130 CMR, § 410.404

Current through Register 1533, October 25, 2024

Section 410.404 - Provider Eligibility

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.