130 CMR, § 433.455

Current through Register 1533, October 25, 2024

Section 433.455 - Abortion Services

(A)Payable Services.

(1) The MassHealth agency pays for an abortion service if both of the following conditions are met:

(a) the abortion is a medically necessary abortion, or the abortion is performed upon a victim of rape or incest when such rape or incest has been reported to a law enforcement agency or public health service within 60 days of the incident; and

(b) the abortion is performed in accordance with law.

(2) For the purposes of 130 CMR 433.455, a medically necessary abortion is one which, according to the medical judgment of a licensed physician, or, consistent with M.G.L. c. 112, § 12M and the time limitations established therein a physician assistant, certified nurse practitioner, or certified nurse midwife, is necessary in light of all factors affecting the pregnant individual's health.

(3) Unless otherwise indicated, all abortions referred to in 130 CMR 433.455 are payable abortions as defined in 130 CMR 433.455(A)(1) and (2).

(B)Assurance of Member Rights. A provider must not use any form of coercion in the provision of abortion services. The MassHealth agency, any provider, any agent or employee of a provider must not mislead any member into believing that a decision to have or not to have an abortion will adversely affect the member's entitlement to benefits or services for which the member would otherwise be eligible. The MassHealth agency has strict requirements for confidentiality of member records for abortion services as well as for all other medical services covered by MassHealth.

(C)Certification for Payable Abortion Form. All providers (i.e., physicians, physician assistants, nurse practitioners, or nurse midwives) must complete a Certification for Payable Abortion (CPA 2) form and retain the form in the member's record. (Instructions for obtaining the CPA-2 form are in Appendix A of all provider manuals.) 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 433.455(C)(1), (2), and (3), when applicable. For all medically necessary abortions not included in 130 CMR 433.455(C)(1), (2), or (3), the certification described in 130 CMR 433.455(C)(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 must 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 herein as one whose income is directly or indirectly affected by the fee paid for the performance of the abortion; or 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 submitting with the claim form 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 that 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 the 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 433.455(C)(1), (2), and (3), the abortion performed was necessary in light of all factors affecting the pregnant individual's health.