Chapter 118E

Section 1 Duties of office
Section 2 Established authority
Section 2A Director of dental services
Section 3 to 5 Repealed, 2003, 26, Sec. 308
Section 6 Medical care advisory committee; member; staff; report from office of Medicaid
Section 7 Powers
Section 8 Definitions
Section 8A Definitions for Secs. 13C to 13K and Secs. 64 to 70
Section 9 Eligibility
Section 9A MassHealth; beneficiaries; eligibility; payment; information applications
Section 9B Repealed, 2013, 35, Sec. 25
Section 9C Medical insurance reimbursement programs; definitions; eligibility; expenditures; submission of plans
Section 9D Senior care options initiative; senior care organizations; enrollment choices; advisory committee; report
Section 9E Application for authority; implementation of measures; waiver of measures due to hardship
Section 9F Duals demonstration; review of request for financial solvency
Section 10 Medical care assistance program for pregnant women and infants
Section 10A Required coverage for abortion, abortion-related care, prenatal care, childbirth and postpartum care
Section 10A 1/2 MassHealth standard coverage for pregnant or postpartum residents
Section 10B Required coverage for newborn hearing screening tests
Section 10C Required coverage for items medically necessary for the diagnosis or treatment of diabetes
Section 10D Required coverage for treatment of breast and cervical cancer
Section 10E Healthy start program; medical assistance for pregnant women and infants; eligibility; types of assistance; protection from billing and collection practices
Section 10F Health care services for dependent and adopted youths; funding; types of services; eligibility; program reports; no entitlement
Section 10G Coverage for children under age 18 for cleft lip and cleft palate
Section 10H Coverage for medically necessary treatments for persons younger than 21 years old diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist
Section 10H 1/2 Coverage for treatment of Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis services
Section 10H.5 Coverage for treatment of Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis services
Section 10I Coverage for administration of all federal Food and Drug Administration approved drugs for opioid or alcohol dependence treatment
Section 10J Coverage for medical or drug treatments to correct or repair disturbances of body composition caused by HIV associated lipodystrophy syndrome
Section 10K Coverage for certain services and contraceptive methods
Section 10L Filling of remaining portion of prescription for covered drug that is a narcotic substance earlier filled in lesser quantity
Section 10M Coverage for tobacco use cessation counseling and products
Section 10N Urgent care facilities; referrals; primary care providers
Section 10O Coverage for mental health acute treatment, community-based acute treatment and intensive community-based acute treatment
Section 10P Coverage for mental health or substance use disorder services delivered through psychiatric collaborative care model
Section 10Q Coverage for annual mental health wellness examination
Section 10R Coverage for noninvasive prenatal screening
Section 10S Coverage for postpartum depression and major depressive disorder screenings conducted pursuant to section 247 of chapter 111
Section 10T Coverage for the provision of medically necessary pasteurized donor human milk and donor human milk-derived products
Section 10U Coverage of doula services
Section 10V Coverage for universal postpartum home visiting services
Section 10W Coverage for diagnostic examinations for breast cancer screening; digital breast tomosynthesis screening, MRIs and ultrasounds
Section 10X Coverage for prescribed, ordered or dispensed opioid antagonists
Section 10Y Coverage for the provision of services by a recovery coach
Section 10Z Coverage for identified generic and brand name drug used to treat diabetes, asthma, and certain heart conditions
Section 11 Cooperation with federal authorities
Section 12 Policies; procedures; rules and regulations; contracts
Section 12A Pharmaceutical drugs; negotiation of supplemental rebate agreements
Section 13 Rate changes; review
Section 13A Non-acute hospitals; rates and terms of payment
Section 13B Hospital rate increases; quality standards and benchmarks
Section 13C Establishment of rates of payment for health care services
Section 13D Duties of ratemaking authority; criteria for establishing rates
Section 13D 1/2 Minimum payment rates to be paid to providers of behavioral health services delivered in community behavioral health centers by managed care entities; annual review and reporting
Section 13E Appeals of interim or final rates
Section 13E 1/2 Contractual arrangements with acute and non-acute hospitals
Section 13F Contracts between acute and non-acute hospital service providers and office of Medicaid
Section 13G Hospital assets not to be considered as resources for purpose of establishing rates
Section 13H Recipients of benefits under chapter 117A
Section 13I Patients with foreign residency
Section 13J Health maintenance organizations; contracting rights
Section 13K Adjustment of facility's rate
Section 13L Restriction of hospital access to discounted purchase of prescription drugs
Section 14 Nursing home negotiated rate contracts
Section 14A Reimbursement to nursing homes for admissions to acute care and chronic disease or rehabilitation hospitals
Section 15 Medicaid benefits; rules and regulations; managed care; personal expenses
Section 16 Primary and supplemental medical care and assistance program for residents with disabilities; assistance program for chronically ill persons or persons with disabilities forced to leave employment or substantially reduce work hours
Section 16A Medical care and assistance program for children with disabilities
Section 16A 1/2 Costs incurred for medical programs projected to exceed available appropriations; notice
Section 16B Repealed, 1996, 203, Sec. 16
Section 16C Child health insurance program; medical benefits; eligibility
Section 16D Aliens or persons residing in United States under color of law; benefits
Section 17 Reimbursements for non-generic drugs
Section 17A Emergency services provided to beneficiaries for emergency medical conditions
Section 18 Medical insurance purchases for persons eligible for assistance
Section 19 Prior approval of medical services; methods; rules and regulations; posttreatment examinations
Section 20 Application; forms; application by institution
Section 21 Inquiry by department; notification of applicant; agreement
Section 21A Medical assistance eligibility of an institutionalized spouse
Section 22 Third party payments; repayment; assignment; subrogation
Section 23 Subrogation rights; health insurance benefits; garnishment of wages
Section 23A Financial institutions; request for deposit and withdrawal records; penalty
Section 24 Repealed, 1996, 450, Sec. 157
Section 25 Exempt income and resources
Section 25A Determination of eligibility for Qualified Medicare Beneficiary, Specified Low-Income Medicare Beneficiary and Qualified Individual programs; consideration of certain income or assets
Section 26 Identification card
Section 27 Redetermination of eligibility
Section 28 Disposal of resources at less than fair market value; period of ineligibility; transfers for sole benefit of individual age 65 or older
Section 29 Transfer of interest in real property; notice
Section 30 Time of payment
Section 31 Adjustment or recovery of payments
Section 32 Provision of death certificate and probate petition to division; liability of estate beneficiaries; claims against estate; sale or transfer of property subject to lien or claim
Section 32A Repealed, 2005, 6, Sec. 14
Section 33 Long term care insurance purchasers; liability for medical assistance paid
Section 34 Liens and encumbrances
Section 35 Reimbursement for covered claims; submission of information
Section 36 Eligible providers; responsibility for overpayments
Section 37 Distribution of rules, regulations to providers; administrative sanctions
Section 38 Submission of bills by providers; appeals for erroneous denials; overpayments; civil collection actions
Section 38A Retroactive claims denials for behavioral health services
Section 39 False representations, failure to disclose; penalty
Section 40 False statements or representations by providers; penalty
Section 41 Bribery or rebates; penalty
Section 41A Repealed, 2001, 177, Sec. 27
Section 42 Excess charges; penalty
Section 43 Health care facilities; additional charges as precondition for admission or continuance; penalty
Section 44 Civil remedies; limitations
Section 45 Venue; actions relating to false claims
Section 46 Availability of other remedies
Section 46A Providers; submission of claims for payment not in compliance with policies and procedures of medical assistance program; proof of clerical or administrative error
Section 47 Persons aggrieved; written notification of denial of requested benefits or services; right to hearing; investigation; decision; rehearing; notice
Section 47A Benefits available only to otherwise eligible individuals showing lawful presence in the United States or meeting applicable federal requirements necessary to qualify for benefits for which the commonwealth receives federal reimbursement
Section 48 Board of hearings
Section 49 Use and disclosure of information
Section 50 Contract for administrative functions; underwriting of program
Section 51 Utilization review of care and services; data processing and collection procedures; liability in civil actions
Section 51A Step therapy protocol clinical review criteria; prescription coverage
Section 52 Maintenance of standards for providers; development of new programs
Section 53 Covered services
Section 54 Wellness program for MassHealth enrollees
Section 55 Repealed, 2008, 451, Sec. 75
Section 56 Controlled substance management program for MassHealth enrollees
Section 57 to 60 [There are no 118E:57 to 118E:60.]
Section 61 Availability of benefits to persons recognized as a spouse under laws of the commonwealth
Section 62 Acceptance and recognition of information submitted pursuant to coding standards and guidelines required; use of standardized claim formats
Section 63 Assessment per non–Medicare reimbursed patient day
Section 64 Definitions for Secs. 64 through 69
Section 65 Health safety net office
Section 66 Health Safety Net Trust Fund
Section 67 Liability of acute hospital to fund
Section 67A Nonpublic ambulance services; liability; uniform assessment; enforcement
Section 68 Managed care organization services assessment; calculation of liability; payment to health safety net trust fund
Section 69 Reimbursements to hospitals and community health centers for health services provided to uninsured and underinsured individuals
Section 69A Repealed, 2024, 140, Sec. 131
Section 70 Definitions for Secs. 70 through 75
Section 71 PCA quality home care workforce council
Section 72 Duties of workforce council; PCA recruitment, training and referral resources; lists of PCAs
Section 73 Rights of consumers regarding PCAs; public employee status for limited purposes; collective bargaining
Section 74 PCA quality home care workforce council; scope of power and authority
Section 75 Performance reviews
Section 76 Designation of another governmental unit to perform functions set forth in Secs. 13C through 13K and 64 through 75
Section 77 Office of Medicaid to attribute members to primary care providers
Section 78 Employer healthcare coverage form
Section 79 Coverage for health care services delivered via telehealth by a contracted health care provider; right in in-person services; copayment or coinsurance; rate of payment; standards of care
Section 80 Sickle cell disease; executive office review; content of report
Section 81 Mental health and substance use disorder benefits; benefits for children and adolescents under the age of 19 for the diagnosis and treatment of mental, behavioral, emotional or substance use disorders substantially interfering with or limiting the functioning and social interactions of such child or adolescent; consent to disclosure of information
Section 82 Requirement that division meets parity requirements described under federal Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity Act of 2008 and related guidance or regulations
Section 83 Dispensing of OTC oral contraceptive to MassHealth member or HSN patient by licensed pharmacist
Section 84 Dispensing of a prenatal vitamin to MassHealth member or HSN patient by licensed pharmacist
Section 85 Establishment of Medicaid rates for licensed skilled nursing facilities
Section 86 Skilled nursing facility rate add–on programs; bariatric care; 1–on–1 staffing of at-risk residents
Section 87 Payment to state agencies for claims related to Medicaid

Chapter 118E

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Chapter 118E: DIVISION OF MEDICAL ASSISTANCE