Covered services

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For materials and information concerning Dental services, look under the Dental subcategory.

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MassHealth Fair Hearing Decisions

Office of Medicaid Board of Hearings
MassHealth has started posting fair hearing decisions on its website. As of February 2024, there are over 2400 decisions from July -Sept 2023 currently posted with a filtering feature by topic. 

New MassHealth Unit for Problem Cases

MassHealth
New Escalation Protocol for Problem MassHealth Cases: The Service Solution Unit (SSU) MassHealth is standing up a new process to “escalate” problem MassHealth cases after initial attempts to resolve an issue with MassHealth Customer Service or the MassHealth Enrollment Center or other units…

Comments on Proposed MassHealth 1115 Amendments

MLRI, CHLPI, HCFA
In August 2023 MassHealth proposed 8 amendments to the current 1115 demonstration, with an opportunity to comment by Sept 9, 2023 including proposals to:  Provide 12-months continuous eligibility for all adults (continuous eligibility for children is already required as of Jan 1,…

MassHealth Managed Care Options in 2023

Various
On April 1, 2023 MassHealth members subject to mandatory managed care will have a new set of managed care options. These changes do not apply to people 65 or over or Medicare beneficiaries with voluntary managed options in SCO or One Care, or to other MassHealth members with MassHealth secondary to…

MassHealth Managed Care Contracts

MassHealth
At this website MassHealth has posted its contracts with its managed care plans including the MCOs, the ACOs, the Behavioral Health Partnership, and the One Care and SCO plans. When researching the scope of covered services for a beneficiary enrolled in a managed care plan, the contract may have…

CCA One Care Coverage Exceptions for non-covered benefits

Various
In Feb 2022 CCA updated and published its Medical Necessity Guidelines for otherwise NonCovered Services (PDF is attached) & posted it here: https://www.commonwealthcarealliance.org/ma/wp-content/uploads/2023/01/Non-Covered-Benefit-MNG-100_20230124.pdf Thanks to Central West Justice…

Benefits Included in MassHealth by Coverage Type 2022

MLRI
Attached is a Table prepared by MLRI of the different kinds of services and service providers that are available under the various MassHealth coverage types described in MassHealth eligibility regulations & cross referencing to MassHealth fee for service regulations. It's been updated…

MassHealth Dental program resources

MassHealth
For general information on dental services in MassHealth, CMSP and the Health Safety Net, visit this MassHealth website https://www.mass.gov/info-details/learn-about-masshealth-dental-benefits For legal advocates the starting point is in the MassHealth Dental Regulations, they are…

State-funded Family Assistance and MassHealth Standard for Immigrants

Office of Medicaid
MassHealth Family Assistance provides coverage for different groups including 100% state-funded coverage for certain lawfully present and PRUCOL immigrants who are not eligible for federally reimbursed Medicaid. Until recently, Family Assistance included few long term services and supports.…

MassHealth Monthly Copay Caps

MassHealth
MassHealth mailed notices to members about a monthly cap on copayments beginning July 1, 2021 that will reduce the amount of copayments people with multiple prescriptions per month will have to pay.  However, the wording of the notice has led to widespread confusion with many people thinking…

New Brokerage System for MassHealth PT-1 Nonemergency Transportation July 1, 2021

Office of Medicaid
MassHealth members in Standard, CommonHealth and CarePlus are eligible for non-emergency transportation assistance to get to and from their appointments with MassHealth providers if  they cannot use public transportation due to a disability or medical condition or because there…

Medicaid revises policy on home health aides & DME in response to advocacy letter

Office of Medicaid; MLRI, HLA, DLC & GBLS
In August 2018 legal advocates wrote to the Medicaid director identifying several ways that current MassHealth regulations and policies on home health aide services and durable medical equipment (DME) are out of compliance with federal Medicaid regulations and harming our clients. We outlined the…

EPSDT & MassHealth

Vicky Pulos
Medicaid's "Early and Periodic Screening, Diagnosis and Treatment" (EPSDT) benefit for children is a powerful tool advocates can use to help children and youth under age 21 enrolled in MassHealth Standard or CommonHealth get the health benefits they need. This memo provides citations…

Continuity of Care in MassHealth Managed Care after March 1, 2018

Office of Medicaid and Others
March 1, 2018 over 1 million members will be moving to new kinds of health plans. This affects individual under age 65 with MassHealth as their only coverage. Individuals should have received notice of the change from MassHealth and their new plans. There are protections in place to try to avoid…

Pharmacy Facts

Office of Medicaid
Attached is very helpful issue of a publication MassHealth regularly distributes to participating pharmacies. The March 15, 2018 issue makes clear that pharmacies may not charge a MassHealth member more than the allowed co-payment if payment is "available from MassHealth" and that payment…

MassHealth Restructuring Web Page

MassHealth
Bookmark this page for materials on changes in the MassHealth delivery and payment system. It currently includes copies  of the Model contracts with new Accountable Care Organizations that will be providing services starting March 1, 2018 and includes a powerpoint presentation on new behavioral…

Advocates' Comments to EOHHS on 1115 Proposal

MLRI and others
In July 2017 EOHHS released for public comment proposed amendments to the MassHealth 1115 demonstration. The proposals among other things would lower the income standard for parents/caretakers and other non-disabled adults, deny MassHealth to non-disabled adults with access to Student Health…

Letter to Secretary Opposing Managed Care Lock-In

Vicky Pulos and others
This is a letter signed by legal aid and disability rights organizations to Sec. Sudders opposing the administration's proposal to go to a 12-month lock in for MassHealth beneficiaries who enroll in a Managed Care Organization. 

FAQ: MassHealth - NEW Coverage of Applied Behavior Analysis Services for Children with Autism Spectrum Disorder

Mass Advocates for Children and MLRI
The Autism Omnibus Act requires MassHealth to cover medically necessary ABA services for children with autism under age 21.  ABA services are now available to MassHealth members. The attached “Frequently Asked Questions” explain how to get coverage now through the…

MassHealth coverage of electronic tablets dedicated to use as Augmentative and Alternative Communication (AAC)

MAC
Attached is the fact sheet regarding MassHealth new coverage of electronic tablets (such as iPads) dedicated to use as Augmentative and Alternative Communication (AAC).along with related software, when medically necessary for communication.    Please help distribute to families,…

DMA Provider Regulations including covered services

MassHealth

EPSDT-A Guide for States: Coverage in the Medicaid Benefit for Children & Adolescents

Centers for Medicare and Medicaid Services
The Centers for Medicare & Medicaid Services (CMS) has just published a Guide to the Early Periodic Screening, Diagnosis and Treatment benefits for children and youth under age 21 in Medicaid. The 38 page EPSDT Guide was written in collaboration with the National Health Law…

Advocates Guide: Medicaid Long Term Services & Supports 101: Emerging Opportunities & Challenges

National Senior Citizens Law Center
Medicaid is the single largest purchaser of long-term services and supports (LTSS) in the United States. The current legal and political landscape presents both great opportunities to expand low-income individuals’ ability to receive needed LTSS services at home, and tremendous challenges for…

Parents' How-To Guide to Children's Mental Health Services in Massachusetts

Boston Bar Association/ Children's Hospital Boston
Link to the Boston Bar Association for a copy of the third edition of this guide to mental health services for children.  According to the BBA, "[t]he Guide is designed to help parents in Massachusetts find the child mental health services and resources their children need.Practical…

Children's Mental Health-Rosie D. website

Link to the website maintained by the lawyers for the class of children with serious emotional disturbances in the Rosie D. MassHealth lawsuit with information on relief available to the class.

Notice of Feb 2009 change in MassHealth/HSN Copays

MassHealth
Notice sent to MassHealth & Health Safety Net recipients that most copays for generic drugs increased from $1 to $2 on Feb 1, 2009; also contains reminder that pharmacy can't refuse to provide drugs to MassHealth member unable to afford copay.

Proposed Durable Medical Equipment Rules

MassHealth has proposed many changes to DME rules. Comments due May 23, but Office of Medicaid plans to issue new notice May 30 with public hearing later in June.

Children's Rights to Medical Services under EPSDT

MLRI
Summary of the rights of children under age 21 to early, periodic screening, diagnostic and treatement (EPSDT) services under Medicaid (MassHealth). UPDATE: Please note the address of the Board of Hearings has changed since the attached Memo was written. The address of the MassHealth Board of…

Notice to Members of New & Restored Benefits

This is the notice MassHealth mailed to members telling them about the July 1 2006 benefit improvements; more detailed information for providers and emergency rules are now or will soon be posted at https://www.mass.gov/topics/masshealth

MassHealth Changes on July 1, 2006

Changes in MassHealth effective July 1 include: restoration of optional benefits to adults; new smoking cessation benefit; increase in income eligibility for children & youth under age 19 to 300% of poverty, and implementation of federal rules requiring US citizens to verify citizenship &…

Rosie D Experts Summary

CPR has summarized the reports and findings of the expert witnesses in Rosie D v. Romney into a single report on The Status of Home-Based Services for Massachusetts Children with Serious Emotional Disturbance. A PDF version.

Rosie D. -- Summary of Opinion

Steven Schwartz, CPR
A summary of the US District Court's 98 page opinion in Rosie D. v. Romney. For copies of the decisions, as well as pleadings, memoranda and other papers filed in connection with the litigation, go to the Rosie D website, www.rosied.org

Rosie D. trial summary

A 3 page summary of the cliams and the trial in Rosie D v. Romney leading to the US District Court's finding that the state's EPSDT services for children with serious emotional disturbance violate the Medicaid law.

Practice Memo: Services Available to non-citizens denied MassHealth Long Term Care Services

Updated 2007 version intentended for health care providers

New DMA Regulations Re: Pharmacy Co-Payments

DMA
Effective January 1, 2003, co-payments are increasing from $.50 to $2.00 for MassHealth recipients, unless they fall under an exception.

Rosie D. v. Swift

1st Circuit
The 1st Circuit held that the 11th Amendment does not protect state officials from federal law suits for prospective relief under the Medicaid Act.

Provider Bulletin 101: MassHealth Limited Scope of Coverage

Massachusetts Behavioral Health Partnership web page

The Massachusetts Behavioral Health Partnership, usually referred to as "The Partnership" is the managed care organization which manages the mental health and substance abuse services package for MassHealth recipients in the PCC program. The Partnership also contracts with various MCOs…