130 CMR, § 508.002

Current through Register 1533, October 25, 2024

Section 508.002 - MassHealth Members Excluded from Participation in Managed Care

(A)MassHealth Managed Care Provider. The following MassHealth members are excluded from participation with a MassHealth managed care provider:

(1) a member who has Medicare;

(2) a member who has access to other health insurance that meets the basic-benefit level as defined in 130 CMR 501.001: Definition of Terms;

(3) a member who is 65 years of age or older. Such member may voluntarily enroll in a senior care organization (SCO) in accordance with the requirements at 130 CMR 508.008(A);

(4) a member in a nursing facility, chronic disease or rehabilitation hospital, intermediate care facility for individuals with intellectual disabilities (ICF/ID), or a state psychiatric hospital for other than a short-term rehabilitative stay;

(5) a member who is eligible solely for

(a) MassHealth Limited; or

(b) Children's Medical Security Plan (CMSP);

(6) a member who is receiving medical services through the Emergency Aid to the Elderly, Disabled and Children (EAEDC) Program pursuant to 130 CMR 450.106: Emergency Aid to the Elderly, Disabled and Children Program;

(7) a member who is receiving hospice care through MassHealth on a fee-for-service basis, or who is terminally ill as documented by a medical prognosis of a life expectancy of six months or less; and

(8) a member who has presumptive eligibility.

(B)SCO. The following MassHealth members 65 years of age or older are excluded from participating in a senior care organization (SCO):

(1) A member who has access to other health insurance, with the exception of Medicare, that meets the basic-benefit level as defined in 130 CMR 501.001: Definition of Terms;

(2) a member who does not live in the designated service area of a SCO;

(3) a member in a chronic disease or rehabilitation hospital or ICF/ID;

(4) a member who is not eligible for MassHealth Standard;

(5) a member who has presumptive eligibility;

(6) a member who is diagnosed as having end-stage renal disease;

(7) a member who is enrolled in a home- and community-based services waiver, except the Home- and Community-based Services Waiver-frail Elder as described at 130 CMR 519.007(B): Home- and Community-based Services Waiver-frail Elder; and

(8) a member who is a refugee described at 130 CMR 522.002: Refugee Resettlement Program.

(C)ICO. The following MassHealth members who are enrolled in Medicare Parts A and B and are eligible for Medicare Part D are excluded from participation in an integrated care organization (ICO):

(1) a member who has other health insurance, with the exception of Medicare, that meets the basic-benefit level as defined in 130 CMR 501.001: Definition of Terms;

(2) a member in an ICF/ID;

(3) a member who is not eligible for MassHealth Standard or CommonHealth;

(4) a member who has presumptive eligibility;

(5) a member who is enrolled in a home- and community-based services waiver; and

(6) a member who is a refugee described at 130 CMR 522.002: Refugee Resettlement Program.