(A)
Completion of the Certification for Payable Abortion (CPA 2)
Form. All providers (i.e., physicians, physician
assistants, certified nurse practitioners, certified nurse midwives, hospitals,
outpatient departments, and ambulatory abortion clinics), must complete a
Certification for Payable Abortion (CPA 2) form and retain the form in the
member's record. To identify those abortions that meet federal reimbursement
standards, the MassHealth agency must secure on the CPA 2 form the
certifications described in 130 CMR 484.006(A)(1), (2), and (3) when
applicable. For all medically necessary abortions not included in 130 CMR
484.006(A)(1), (2), or (3), the certification described in 130 CMR
484.006(A)(4) is required on the CPA 2 form. The provider must indicate on the
CPA 2 form which of the following circumstances is applicable, and shall
complete that portion of the form with the appropriate signatures:
(1)
Life of the Pregnant
Individual Would Be Endangered. The attending provider must
certify that, in their professional judgment, the life of the pregnant
individual would be endangered if the pregnancy were carried to term.
(2)
Severe and Long-lasting
Damage to Pregnant Individual's Physical Health. The attending
provider and another provider must each certify that, in their professional
judgment, severe and long lasting damage to the pregnant individual's physical
health would result if the pregnancy were carried to term. At least one of the
providers must also certify that they are not an "interested provider," defined
as one:
(a) whose income is directly or
indirectly affected by the fee paid for the performance of the abortion;
or
(b) who is the spouse of, or
another relative who lives with, a provider whose income is directly or
indirectly affected by the fee paid for the performance of the
abortion.
(3)
Victim of Rape or Incest. The provider is responsible
for retaining signed documentation from a law enforcement agency or public
health service certifying that the person upon whom the procedure was performed
was a victim of rape or incest which was reported to the agency or service
within 60 days of the incident. (A public health service is defined as either
an agency of the federal, state, or local government that provides health or
medical services; or a rural health clinic, provided that the agency's
principal function is not the performance of abortions.) The documentation must
include the date of the incident, the date the report was made, the name and
address of the victim and of the person who made the report (if different from
victim), and a statement that the report included the signature of the person
who made the report.
(4)
Other Medically Necessary Abortions. The attending
provider must certify that, in their medical judgment, for reasons other than
those described in 130 CMR 484.006(A)(1), (2), and (3), the abortion performed
was necessary in light of all factors affecting the pregnant individual's
health.
(B)
Availability of Certification for Payable Abortion (CPA 2)
Form. A provider may download the form from the Provider Library
at www.mass.gov/masshealth.
