130 CMR, § 450.119

Current through Register 1536, December 6, 2024

Section 450.119 - Primary Care ACOs

(A)

(1)Role of Primary Care ACO. Each Primary Care ACO is contracted with the MassHealth agency to coordinate and manage care for enrolled members.

(2)Role of Primary Care ACO's Participating Primary Care Provider (participating PCP). The participating PCPs are the principal source of care for members who are enrolled in a Primary Care ACO. All services for which such a member is eligible, except those listed in 130 CMR 450.119(I), are payable only when provided by the member's participating PCP, or when the participating PCP has referred the member to another MassHealth provider.

(3)Role of Primary Care ACO's Referral Circle. Each Primary Care ACO may establish a referral circle of providers pursuant to its contract with the MassHealth agency.

(B)Provider Eligibility. Providers who wish to enroll as participating PCPs must be participating providers in MassHealth, must complete a participating PCP application, which is subject to approval by the MassHealth agency, and must meet the requirements of the participating PCP contract. The following provider types may apply to the MassHealth agency to become participating PCPs:

(1) individual physicians who have current admitting privileges to at least one MassHealth participating Massachusetts acute hospital that participates in MassHealth or who meet 130 CMR 450.119(F)(1), and who are board-eligible or board-certified in family practice, pediatrics, internal medicine, obstetrics, gynecology, or obstetrics/gynecology, or who meet 130 CMR 450.119(F)(2);

(2) independent nurse practitioners who have a collaborative arrangement with a MassHealth-participating physician who meets the criteria of 130 CMR 450.119(B)(1);

(3) community health centers (freestanding or hospital-licensed) with at least one physician on staff who meets the criteria of 130 CMR 450.119(B)(1);

(4) acute hospital outpatient departments with at least one physician on staff who meets the criteria of 130 CMR 450.119(B)(1);

(5) group practices with at least one physician or nurse practitioner who

(a) is enrolled and approved by the MassHealth agency as a participating provider in that group;

(b) meets the requirements of 130 CMR 450.119(B)(1) or (2); and

(c) has signed the participating PCP contract; and

(6) providers who are enrolled as PCCs pursuant to 130 CMR 450.118(G).

(C)Community Health Center Participation. When a community health center is a participating PCP, it must assign each enrollee to an individual practitioner who meets the requirements of 130 CMR 450.119(B)(1) or (2).

(D)Hospital Outpatient Department Participation. When a hospital outpatient department is a participating PCP, it must assign each enrollee to an attending physician who meets the requirements of 130 CMR 450.119(B)(1) or (2).

(E)Group Practice Participation. When a group practice participates as a participating PCP, the group practice

(1) may claim an enhanced fee only for services provided by those individual practitioners within the group who meet the requirements of 130 CMR 450.119(B)(1) or (2); and

(2) must assign each enrollee to an individual practitioner who meets the criteria under 130 CMR 450.119(B)(1) or (2).

(F)Waiver of Eligibility Requirements. The MassHealth agency may, if necessary to ensure adequate member access to services, and under the following circumstances, allow an individual physician to enroll as a participating PCP or as a physician in a group practice participating PCP notwithstanding the physician's inability to meet certain eligibility requirements set forth in 130 CMR 450.119(B)(1).

(1) Upon written request from a physician, the MassHealth agency may waive the requirement that an individual physician or a physician in a group practice have admitting privileges to at least one MassHealth-participating Massachusetts acute hospital, if the physician demonstrates to the MassHealth agency's satisfaction that the physician:

(a) practices in an area that is too distant to adequately respond to emergencies at the nearest acute hospital or where lack of admitting privileges is common for physicians practicing in that area;

(b) admits exclusively to acute hospitals that employ one or more physicians to care for their inpatient census, provided that the hospital's medical director agrees to admit and care for the physician's patients through the use of such physicians employed by the hospital; or

(c) establishes a collaborative relationship with a physician participating in MassHealth who has admitting privileges at the acute hospital closest to the requesting physician's office and who will assume responsibility for admitting the requesting physician's managed care members to that hospital when necessary.

(2) Upon written request from a physician, the MassHealth agency may waive the requirement that the individual physician or physician in a group practice is board-eligible or board-certified in family practice, pediatrics, internal medicine, obstetrics, gynecology, or obstetrics/gynecology, if the physician is board-eligible or board-certified in another medical specialty, and otherwise meets the requirements of 130 CMR 450.119.

(G)Rate of Payment. The MassHealth agency pays participating PCPs an enhanced fee for primary care services, in accordance with the terms of the participating PCP contract.

(H)Termination.

(1) If the MassHealth agency determines that a participating PCP has failed to fulfill any of the obligations stated in the MassHealth agency's regulations or participating PCP contract, the MassHealth agency may terminate the participating PCP contract in accordance with its terms. To the extent required by law, a pretermination hearing will be held in substantial conformity with the procedures set forth in 130 CMR 450.238 through 450.248.

(2) If the MassHealth agency determines that an individual practitioner within a participating PCP group practice has failed to fulfill any of the obligations stated in the MassHealth agency's regulations or the participating PCP contract, the MassHealth agency may terminate the participating PCP contract pursuant to 130 CMR 450.119(H)(1), or require the group practice to stop assigning enrollees to such practitioner and to reassign existing enrollees to other practitioners in the group who meet the requirements of 130 CMR 450.119(B)(1) or (2).

(I)Referral for Services.

(1)Referral Requirement. All services provided by a clinician or provider other than the Primary Care ACO member's participating PCP require referral from the member's participating PCP in order to be payable, unless the service is exempted under 130 CMR 450.119(I)(5). This referral requirement also applies to services delivered by individual practitioners who are part of a group practice participating PCP and who have not been identified by the group practice as providers who may be assigned Primary Care ACO members under 130 CMR 450.119(E). In order to make a referral, participating PCPs must follow the processes described in the participating PCP contract.

(2)Time Frames for Referral. Whenever possible, the participating PCP should make the referral before the member's receipt of the service. However, the participating PCP may issue a referral retroactively if the participating PCP determines that the service was medically necessary at the time of receipt.

(3)Payment for Services Requiring Referral. The MassHealth agency pays a provider other than the member's participating PCP for services that require a participating PCP referral only when a referral has been submitted by the member's participating PCP.

(4)Services Requiring Referrals. See130 CMR 450.105 for a list of the services covered for each MassHealth coverage type and applicable program regulations for descriptions of covered services and specific service limitations. Prior-authorization requirements are described in 130 CMR 450.303, 450.144(A)(2), and applicable program regulations and subregulatory publications. Payment for services is subject to all conditions and restrictions of MassHealth including, but not limited to, the scope of covered services for a member's coverage type, service limitations, and prior-authorization requirements.

(5)Exceptions to Services Requiring Referrals. Notwithstanding 130 CMR 450.119(I)(4), the following services provided by a clinician or other provider other than the member's participating PCP do not require a referral from the member's participating PCP in order to be payable:

(a) abortion services;

(b) annual gynecological exams;

(c) clinical laboratory services;

(d) diabetic supplies;

(e) durable medical equipment (items, supplies, and equipment) described in 130 CMR 409.000: Durable Medical Equipment Services;

(f) fiscal intermediary services as described in 130 CMR 422.419(B): The Fiscal Intermediary;

(g) fluoride varnish administered by a physician or other qualified medical professional;

(h) functional skills training provided by a MassHealth personal care management agency as described in 130 CMR 422.421(B): Functional Skills Training;

(i) HIV pre- and post-test counseling services;

(j) HIV testing;

(k) hospitalization

1.Elective Admissions. All elective admissions are exempt from the PCC referral requirement and are subject to the MassHealth agency's admission screening requirements at 130 CMR 450.208(A). The hospital must notify the member's PCC within 48 hours following an elective admission;

2.Nonelective Admissions. Nonelective admissions are exempt from the PCC referral requirement. The hospital must notify the member's PCC within 48 hours following a nonelective admission;

(l) obstetric services for pregnant and postpartum members are provided up to the end of the month in which the 60-day period following the termination of pregnancy ends;

(m) oxygen and respiratory therapy equipment;

(n) pharmacy services (prescription and over-the-counter drugs);

(o) radiology and other imaging services with the exception of magnetic resonance imaging (MRI), computed tomography (CT) scans, positron emission tomography (PET) scans, and imaging services conducted at an independent diagnostic testing facility (IDTF), which do require a referral;

(p) services delivered by a behavioral health (mental health and substance abuse) provider (including inpatient and outpatient psychiatric services);

(q) services delivered by a dentist;

(r) services delivered by a family planning service provider, for members of childbearing age;

(s) services delivered by a hospice provider;

(t) services delivered by a limited service clinic;

(u) services delivered in a nursing facility;

(v) services delivered in an urgent care clinic;

(w) services delivered by an anesthesiologist;

(x) services delivered in an intermediate care facility for individuals with intellectual disabilities (ICF/ID);

(y) services delivered to a homeless member outside of the participating PCP's office pursuant to 130 CMR 450.119(J);

(z) services delivered to diagnose and treat sexually transmitted diseases;

(aa) services delivered to treat an emergency condition;

(bb) services provided under a home- and community-based waiver;

(cc) sterilization services when performed for family planning services;

(dd) surgical pathology services;

(ee) tobacco-cessation counseling services;

(ff) transportation to covered care;

(gg) vision care in the following categories (see Subchapter 6 of the Vision Care Manual): visual analysis frames, single vision prescriptions, bifocal prescriptions, and repairs;

(hh) medication assisted treatment (MAT) for opioid use disorder; and

(ii) additional services provided to members by providers in the member's Primary Care ACO's referral circle pursuant to the MassHealth agency's contract with the Primacy Care ACO.

(J)Services to Homeless Members. To provide services to homeless members according to 130 CMR 450.119(I)(5)(y), the provider must furnish written evidence of demonstrated experience in delivering medical care in a nonmedical setting, and request, in writing, designation from the MassHealth agency that the participating PCP is approved to provide services to homeless members. The MassHealth agency retains the right to approve or disapprove such a request or revoke an approval of such a request at any time.

(K)Recordkeeping and Reporting.

(1)Participating PCP Recordkeeping Requirement. The participating PCP must document all referrals in the member's medical record by recording the following:

(a) the date of the referral;

(b) the name of the provider to whom the member was referred;

(c) the reason for the referral;

(d) number of visits authorized; and

(e) copies of the reports required by 130 CMR 450.119(K)(2).

(2)Reporting Requirements. The participating PCP who made the referral must obtain from the provider who furnished the service the results of the referred visit by telephone and in writing whenever legally possible.

(L)Other Program Requirements. Payment for services provided to members enrolled with a MassHealth managed care provider is subject to all conditions and restrictions of MassHealth, including all applicable prerequisites for payment.

(M)Participating PCP Contracts. Providers that are participating PCPs are bound by and liable for compliance with the terms of the most recent participating PCP contract issued by the MassHealth agency, including amendments to the contract, as of the effective date specified in the participating PCP contract or amendment.