(A) MassHealth
members participate in managed care pursuant to
130 CMR
508.001: MassHealth Member
Participation in Managed Care. MassHealth members may be excluded from
participating in managed care pursuant to
130
CMR 508.002: MassHealth Members
Excluded from Participation in Managed Care.
(B) MassHealth managed care provides for the
management of medical care, including primary care, behavioral health services,
and other medical services. MassHealth members who participate in managed care
obtain services as follows:
(1) Members who
enroll with an MCO obtain services in accordance with
130 CMR
508.004(B):
Obtaining Services when Enrolled in an MCO.
(2) Members who enroll with the PCC Plan
obtain services in accordance with
130 CMR
508.005(B):
Obtaining Services when Enrolled with the PCC Plan.
(3) Members who enroll with an Accountable
Care Partnership Plan obtain services in accordance with
130 CMR
508.006(A)(2):
Obtaining Services when Enrolled in an Accountable Care Partnership
Plan.
(4) Members who
enroll with a Primary Care ACO obtain services in accordance with
130 CMR
508.006(B)(2):
Obtaining Services when Enrolled in a Primary Care
ACO.
(5) Members who
enroll with an ICO obtain services in accordance with
130 CMR
508.007(C):
Obtaining Services when Enrolled in an ICO. Members who enroll
in the Duals Demonstration Program may continue to receive services from their
current providers who accept current Medicare or Medicaid fee-for-service
provider rates during a continuity-of-care period. A continuity-of-care period
is a period beginning on the date of enrollment into the Duals Demonstration
Program and extends to either of the following:
(a) up to 90 days, unless the comprehensive
assessment and the individualized-care plan are completed sooner and the
enrollee agrees to the shorter time period; or
(b) until the comprehensive assessment and the individualized-care
plan are complete.
(6)
Members who enroll with a SCO obtain services in accordance with
130 CMR
508.008(C):
Obtaining Services when Enrolled in a SCO.
(7) Members who are Native Americans (within
the meaning of "Indians" as defined at
42 U.S.C.
1396u-2) or Alaska Natives and who
participate in managed care may choose to receive covered services from an
Indian health-care provider. All participating MCOs, Accountable Care
Partnership Plans, SCOs and ICOs must provide payment for such covered services
in accordance with the provisions of
42 U.S.C.
1396u-2(h) and
comply with all other provisions of
42 U.S.C.
1396u-2(h).
For the purposes of 130 CMR 450.117(B)(7), the term Indian health-care provider
means a health care program, including contracted health services, operated by
the Indian Health Service or by an Indian tribe, Tribal Organization, or Urban
Indian Organization as those terms are defined in § 4 of the Indian Health
Care Improvement Act (25 U.S.C. 1603)
.
(C) Members who
participate in managed care are identified on EVS. (See
130 CMR
450.107.) For members who participate in
managed care, this system will give the name and telephone number of the
MassHealth managed care provider, the behavioral health contractor, the SCO, or
the ICO, as applicable. The MassHealth agency pays for services provided to
MassHealth members who participate in managed care as described in
130 CMR 450.105
and
450.118.
(D) The MassHealth agency may impose
sanctions on MassHealth managed care providers, the behavioral health
contractor, SCOs, and ICOs pursuant to the terms of the MassHealth agency's
contracts with those entities. If EOHHS is required to provide a
pre-termination hearing pursuant to 42 CFR Part 438 , EOHHS shall provide the
contractor with such hearing in accordance with
42 CFR
438.710 and
130 CMR
450.241 through 247.
