Current through Register 1531, September 27, 2024
(A) The MassHealth
agency does not pay for any of the following services:
(1) nonmedical services, such as social,
educational, and vocational services;
(2) cosmetic surgery;
(3) canceled or missed
appointments;
(4) telephone
conversations and consultations;
(5) court testimony;
(6) research or the provision of
experimental, unproven, or otherwise medically unnecessary procedures or
treatments, specifically including, but not limited to, sex-reassignment
surgery, thyroid cartilage reduction and any other related surgeries and
treatments, including pre- and post-sex-reassignment surgery hormone therapy.
Notwithstanding the preceding sentence, the MassHealth agency will continue to
pay for post-sex-reassignment surgery hormone therapy for which it had been
paying immediately prior to May 15, 1993;
(7) the provision of whole blood; however,
administrative and processing costs associated with the provision of blood and
its derivatives are covered; and
(8) the treatment of male or female
infertility (including, but not limited to, laboratory tests, drugs, and
procedures associated with such treatment); however, MassHealth does pay for
the diagnosis of infertility.
(B) The MassHealth agency does not pay for
mental health services such as, but not limited to, the following
(see
130 CMR
410.472) :
(1) vocational rehabilitation
services;
(2) sheltered
workshops;
(3) recreational
services (play therapy, the use of play activities with a child in an
identified treatment setting as an alternative to strictly verbal expression of
conflicts and feelings, is not considered a recreational service and is
covered);
(4) life-enrichment
services; and
(5) alcohol or drug
drop-in centers.
(C) The
MassHealth agency does not pay for pharmacy services such as, but not limited
to, the following (see130 CMR 406.000: Pharmacy
Services):
(1) any drug used for the
treatment of obesity;
(2) cough and
cold preparations;
(3)
less-than-effective drugs; and
(4)
drugs related to the treatment of male or female infertility.
(D) The MassHealth agency does not
pay for certain vision care services and materials as specified in 130 CMR
402.000: Vision Care Services.
(E) The MassHealth agency does not pay an
independent practitioner for services provided to members in an outpatient
department except when that practitioner has an active provider number issued
by the MassHealth agency and meets one of the following criteria.
(1) The practitioner serves in an attending,
visiting, or supervisory role at the hospital where the services are provided,
is legally responsible for the management of the member's care, is physically
present and actively involved in the treatment for which payment is claimed,
and provides a service for which the MassHealth agency pays an independent
practitioner when provided in an outpatient hospital setting. Supervisory
surgeons must be scrubbed and physically present during the major portion of an
operation.
(2) The independent
practitioner, if serving as a salaried intern, resident, fellow, or house
officer, provides services during off-duty hours at an institution that does
not pay his or her salary.
(3) The
independent practitioner receives a salary from an institution for
administrative or teaching services, but not for delivery of care, and provides
direct medical care to a member that meets the conditions set forth in 130 CMR
410.405(E)(1).
