Code of Massachusetts Regulations
130 CMR - DIVISION OF MEDICAL ASSISTANCE
Title 130 CMR 410.000 - Outpatient hospital services
Section 410.404 - Provider Eligibility
Universal Citation: 130 MA Code of Regs 130.410
Current through Register 1531, September 27, 2024
Payment for the services described in 130 CMR 410.000 is made only to hospital outpatient department and hospital licensed health centers participating in MassHealth on the date of service.
(A) In State.
(1) To participate in MassHealth, acute
hospital outpatient departments and hospital-licensed health centers located in
Massachusetts must
(a) operate under a
hospital license issued to an acute hospital by the Massachusetts Department of
Public Health;
(b) have a signed
provider agreement that specifies a payment methodology with the MassHealth
agency; and
(2) To
participate in MassHealth, chronic disease and rehabilitation hospital
outpatient departments located in Massachusetts must
(a) operate under a hospital license issued
to a CDR hospital by the Massachusetts Department of Public Health or be
operated as a CDR hospital by the Department of Public Health's Bureau of
Public Health Facilities;
(b) have
a signed provider agreement for participation in MassHealth; and
(c) participate in the Medicare
program.
(B) Out of State.
(1)
Out-of-state outpatient hospital services provided to an eligible MassHealth
member are covered in the following instances:
(a) emergency services provided to a
member;
(b) hospital outpatient
hospital services provided to a member whose health would be endangered if the
member were required to travel to Massachusetts;
(c) hospital outpatient hospital services
provided to a member when MassHealth determines on the basis of medical advice
that the medical service is more readily available in the other
state;
(d) it is general practice
for members in a particular locality to use medical resources in another
state;
(e) hospital outpatient
hospital services provided to a member who is authorized to reside or who is
placed out-of-state by the Massachusetts Department of Children and Families or
by a Chapter 766 core team evaluation;
(f) hospital outpatient hospital services
provided to a member who has been authorized by the MassHealth agency to reside
in an out-of-state nursing facility; or
(g) when prior authorization has been
obtained from the MassHealth agency for nonemergency services provided to a
member by an out-of-state hospital outpatient department.
(2) To participate in MassHealth, an
out-of-state hospital outpatient department must obtain a MassHealth provider
number and meet the following criteria:
(a) it
operates under a hospital license from or is approved as a hospital by the
governing or licensing agency in its state, and the hospital licensure is
appropriate to the services it seeks to provide under MassHealth
(i.e., acute hospital or chronic disease and rehabilitation
hospital);
(b) it participates in
the Medicare program; and
(c) it
participates in that state's Medicaid program (or the equivalent).
(3) Payment for out-of-state
outpatient hospital services is made in accordance with
130 CMR
450.233: Rates of Payment to
Out-of-state Providers.
(C) Chronic Disease and Rehabilitation, or Similar Hospitals with Both Out-of-state Inpatient Facilities and In-state Outpatient Facilities.
(1) To participate in MassHealth, chronic
disease, rehabilitation, or similar hospitals with both out-of-state inpatient
facilities and in-state outpatient facilities must meet the following criteria.
(a)
Out-of-state Outpatient
Facilities. The hospital's out-of-state outpatient facilities must
comply with 130 CMR 410.404(B).
(b)
In-state Outpatient Facilities. The hospital's
in-state outpatient facilities must
1. be
appropriately licensed by the Massachusetts Department of Public
Health;
2. have a signed provider
agreement for participation in MassHealth; and
3. participate in Medicare as a
provider-based satellite of the out-of-state hospital.
(2) Payment for outpatient
services at chronic disease and rehabilitation, or similar hospitals with both
out-of-state inpatient facilities and in-state outpatient facilities is made in
accordance with
130
CMR 450.234(B):
Outpatient Services.
Disclaimer: These regulations may not be the most recent version. Massachusetts may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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