1) State: Massachusetts
2) Own or Federal Exchange?

State Exchange called the Massachusetts Health Connector

Health Connectors work with insurers to provide two programs:
o Commonwealth Choice is the online marketplace that helps consumers and businesses
compare health plans and enroll in the one that best meets their needs and budget
o Commonwealth Care offers state-subsidized health plans to eligible Massachusetts
residents. The subsidies are provided on a sliding income scale.
Source: http://www.medicaid.gov/Medicaid-CHIP-Program-Information/By-State/massachusetts.html,
http://www.mass.gov/portal/health-safety/insurance/
3) Medicaid Expansion?



Yes, Massachusetts expanded Medicaid coverage as of January 1, 2014
MassHealth – the name used for Medicaid and Children’s Health Insurance Program (CHIP)
A MassHealth expansion will allow adult residents under age 65, with or without children, with
incomes no greater than 133%* of the Federal Poverty Guidelines (FPG), who are not otherwise
eligible for MassHealth Standard or CommonHealth, to qualify. The new MassHealth eligibility rules
use a 133% FPG income limit and a 5% income disregard. In effect, this makes the income limit equal
to 138% of the FPG.
Source: http://www.massresources.org/health-care-2014.html#changes2014,
http://www.medicaid.gov/AffordableCareAct/Medicaid-Moving-Forward-2014/Downloads/Medicaidand-CHIP-Eligibility-Levels-Table.pdf
4) In all cases – need to designate if rules are associated with Federal or State mandates/coverage
5) What are Medicaid eligibility criteria?

To be eligible for one of the coverages of MassHealth (either Medicaid or CHIP) you 1) must be a
Massachusetts resident, 2) in most cases, you must meet financial eligibility requirements
(explained below), and 3) meet one or more of the categories below:
o a family living with children under the age of 19 years
o
o
o
o
a pregnant woman with or without children
a person who is long-term unemployed
a disabled person
an adult who is working for a qualified employer
o
o
o
o
o
o
o

a person who is HIV positive
a child under the age of 19 years
an adult caretaker relative living with children under 19 years of age when neither
parent is living in the home
elderly (65 or older)
a woman with breast or cervical cancer
a person in need of long-term care
a young adult under age 21 who was in the care and custody of the Department of
Children and Families (DCF/DSS) on his/her 18th birthday
Financial eligibility requirements for MassHealth:
o Asset limit: For most applicants under 65, there are no asset limits. For most people
over 65 and older, and people who are institutionalized or who would be
institutionalized without community-based services, there is an asset limit:
 Countable assets cannot be greater than $2000 for an individual and $3000 for a
couple for MassHealth Standard, Essential, or Limited
 Countable assets cannot be greater than $7080 for an individual and $10,620 for
a couple for MassHealth
 Assets that are not counted include:
 one car per household, if certain conditions are met
 your house if it is in Massachusetts
 assets of anyone receiving SSI
 funeral or burial arrangements (may be limited)
 certain other noncountable assets
 Assets that are counted include:
 other vehicles
 other real estate
 cash, bank accounts, securities
 pensions, annuities, retirement accounts
 There are special asset rules for people who are institutionalized or would be
institutionalized without community-based care.
Sources: http://www.massresources.org/masshealth-general-eligibility.html,
http://aspe.hhs.gov/poverty/14poverty.cfm
6) What kind of coverage is available for mental health care?




MassHealth members with the following coverage types are eligible for mental health and
substance abuse treatment services:
o MassHealth Standard
o MassHealth Basic
o CommonHealth
o MassHealth Family Assistance (Direct Care, and Premium Assistance for HIV members)
o MassHealth Essential
For other coverage types:
o MassHealth Limited and Prenatal members are not covered for non-emergency mental
health or substance abuse treatment services.
o Members with Premium Assistance or Buy-In are covered only if their private insurance
plan includes these services.
o EAEDC recipients are covered for substance abuse treatment services at public
detoxification and outpatient substance abuse treatment centers.
To be covered by MassHealth, mental health services must be medically necessary and must be
provided by health care professionals who meet MassHealth requirements. There are some
limits on the length and frequency of services (shown on website).
Covered mental health services include:
o diagnostic services and psychological testing
o short-term and long-term therapy
o
o
o
o
o
o

individual, couple, family, and group therapy
medication visits
consultations
crisis intervention and emergency services
home visits
care coordination
All approved plans regardless of Federal or State-run Exchanges must cover the same package of
benefits, called essential health benefits. In Massachusetts, the benefits through Massachusetts
Health Connector include:
1. Outpatient services, such as doctor visits or tests done outside a hospital. This includes
fertility treatments.
2. Emergency services
3. Hospital stays, including weight loss surgery
4. Pregnancy and baby care
5. Mental health and substance abuse services, including behavioral health treatment
6. Prescription drugs, including generic and certain brand-name drugs
7. Rehab and habilitative services, those that help people recover from an accident or
injury and those that help people with developmental issues. In Massachusetts, this
includes physical and occupational therapy for people diagnosed with autism spectrum
disorder, those who have home health care, and those with speech/hearing disorders.
8. Lab tests
9. Preventive and wellness services, along with those that help people manage chronic
conditions. This includes contraceptives, hormone replacement therapy, and wigs for
people who are balding.
10. Services for children, including dental and eye care (but not eyeglasses)
Source: http://www.massresources.org/masshealth-behavioral.html#mentalhealth,
http://www.webmd.com/health-insurance/ma/massachusetts-health-insurance-marketplace?page=2
7) What kind of coverage is available for substance abuse treatment?

To be covered by MassHealth, substance abuse treatment services must be provided by
programs licensed or approved by the Massachusetts Department of Public Health.

The following services are covered:
o methadone treatment programs
o acute inpatient substance abuse treatment services
o substance abuse outpatient counseling, case consultation, and acupuncture
detoxification
o

special services for pregnant women, including intensive outpatient services, enhanced
inpatient services, case management, and day treatment
The Division (of MassHealth) pays only for the following services furnished by substance abuse
treatment programs, in accordance with the regulations of the Massachusetts Department of
Public Health:
(A) the following services provided by freestanding methadone treatment programs, including
methadone detoxification and methadone maintenance programs:
(1) the administration and dispensing of methadone; and
(2) individual, group, and family/couple counseling;
(B) services provided by acute inpatient substance abuse treatment services providers for the
treatment of substance dependency;
(C) the following substance abuse outpatient counseling services:
(1) individual, group, and family/couple counseling;
(2) case consultation; and
(3) acupuncture detoxification, which includes acupuncture treatments and motivational and
supportive services; and
(D) the following special substance abuse treatment services for pregnant recipients:
(1) intensive outpatient program services for pregnant recipients;
(2) day treatment for pregnant recipients;
(3) enhanced acute inpatient substance abuse treatment services for pregnant recipients
(4) case management for pregnant recipients
Source: http://www.massresources.org/masshealth-behavioral.html#mentalhealth,
http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-substanceabuse.pdf
8) Does the state allow the court to order treatment and still have it paid by Medicaid?

The court can order treatment and have it paid by Medicaid if the services are covered by
MassHealth shown in question #7. If the person is not currently covered by Medicaid, he/she
will need to apply and will become covered within 90 days if they are eligible.
9) What happens to the health care coverage when a participant is sanctioned to jail (not prison)?
How many days can someone be incarcerated before s/he loses their coverage?

Federal health programs will not pay for your care, but jails and prisons are responsible for
providing essential health and mental health services to all inmates. You have a constitutional
right to treatment while in jail or prison and can request it. Medicaid does not pay for any
services while you are in jail or prison. Many states will take your name off their Medicaid list
when you are incarcerated and you will have to re-apply when you are out of jail.

Detainees may apply for Medicaid and CHIP at any point. However, if determined eligible for
Medicaid, eligibility must be suspended while incarcerated, and health care services cannot be
covered by Medicaid until release, except for off-site inpatient medical care lasting 24 hours or
more.

Federal Medicaid law and the regulations promulgated by the Centers for Medicare and
Medicaid Services (CMS) govern when and how individuals both lose access to federal Medicaid
when they are incarcerated and when full coverage can be restored or established for released
inmates. These rules are quite complex and are intertwined with rules of other federal benefit
programs.

Medicaid law requires a discontinuation of federal payment for services (known as federal
financial participation, or FFP) once an individual is in a public institution, including a jail or
prison. However, federal rules on Medicaid eligibility are different from those governing
federal payment for services. While the law prohibits federal payment for services furnished to
anyone incarcerated in jail or prison, it does not require that individuals lose their Medicaid
eligibility.

Individuals can retain their status as a Medicaid-eligible person while in jail or prison. States
must use appropriate administrative measures to ensure that no Medicaid claims are filed with
the federal government while the individual is incarcerated, but they can temporarily suspend
an eligible individual from payment status without terminating them totally from the program.
In addition, before terminating someone, states must meet certain federal requirements:
o
States must continue Medicaid to all eligible individuals “until they are found ineligible.”
o
A state cannot terminate an individual from Medicaid until it has conducted a
redetermination of their eligibility, including an ex-parte review.
o
States “have an obligation under federal law to ensure that their computer systems are
not improperly denying enrollment in, or terminating persons from Medicaid.
Source: ACA Jails pdf, http://www.kitsapgov.com/pubdef/Forms/LinkClick.Benefits.pdf,
http://www.bazelon.org/LinkClick.aspx?fileticket=_Ns68MefCJY%3D&tabid=441
10) What happens to an individual’s coverage when they get a new job? (Or lose a job?) Are there any
“grace periods” of coverage?

If a person has insurance through the Marketplace, getting or losing a job will not affect an
individual’s coverage. The person will need to update their information on the Marketplace
when changes occur because subsidies will be adjusted.

If a person has insurance through their job and lose the job, COBRA continuation coverage may
be available. COBRA, which generally applies to employers with 20 or more employees, allows
the individual and his/her family to continue the same group health coverage. An individual’s
cost for coverage may be higher than what the individual was paying before (and is usually
higher than the cost for coverage under special enrollment in a spouse’s plan), but generally the
cost is lower than that for private, individual health insurance coverage. The plan should send a
notice regarding the availability of COBRA coverage. After this notice is provided, the individual
generally has 60 days to elect coverage and it is then available retroactive to the loss of
coverage. COBRA coverage typically lasts 18 months, but may last longer in certain
circumstances.

Once someone is enrolled in Medicaid, they must renew their eligibility at least once a year or
when there is a change in their circumstances, such as an increase or decrease in any public
assistance.
Source: http://www.dol.gov/ebsa/newsroom/fsjobloss.html
11) Are there restrictions related to treatment providers for probationers, substance abuse, or mental
health treatment? Will only certain providers be covered?

Restrictions for substance abuse:
o
There are limits on the length and frequency of counseling, consultation, and
acupuncture detoxification sessions.
(A) Methadone Treatment Programs.
(1) Payment for administering or dispensing methadone is limited to one dose per recipient per
day. Payment for dispensing a take-home supply is limited to a maximum six days’ supply.
(2) Payment for counseling services is limited to four sessions (individual, group, or
family/couple) per recipient per week.
(B) Acute Inpatient Substance Abuse Treatment Services. The Division will pay for acute
inpatient substance abuse treatment services delivered in conformance with the standards and
patient placement criteria issued and enforced by the Massachusetts Department of Public
Health’s Bureau of Substance Abuse Services.
(C) Substance Abuse Outpatient Counseling Programs.
(1) Counseling. Payment for counseling services is limited to a maximum of 24 sessions
(individual, group, or family/couple) per recipient per calendar year.
(2) Case Consultation.
(a) The Division will pay a provider only for case consultation that lasts at least 30 minutes.
Payment is limited to a maximum of one hour per session, once every three months.
(b) The Division will pay for case consultation only when telephone contact, written
communication, and other nonreimbursable forms of communication clearly will not suffice.
Such circumstances must be documented in the recipient’s record. Such circumstances are
limited to situations in which both the substance abuse treatment provider and the other
provider are actively involved in treatment or management programs with the recipient (or
family members) and where a lack of face-to-face communication would impede a coordinated
treatment program.
(c) The Division will not pay for court testimony.
(3) Acupuncture Detoxification.
(a) The Division will pay for outpatient acupuncture detoxification sessions, which may include
acupuncture treatments and motivational and supportive services. A provider may not bill
separately for these components.
(b) Acupuncture treatments must be performed by an acupuncturist licensed by the
Massachusetts Board of Registration in Medicine in a substance abuse outpatient facility
licensed by the Massachusetts Department of Public Health.
(c) Payment for acupuncture detoxification sessions is limited to a maximum of six treatments
per recipient per week for the first two weeks and a maximum of three treatments per recipient
per week thereafter. Each session must last at least 45 minutes and no more than 60 minutes.
(d) All recipients seeking acupuncture detoxification services must be screened to ensure that
acupuncture treatment is not medically contraindicated. If the screening determines that
acupuncture treatment is medically contraindicated, the provider should assist the individual in
obtaining an alternative form of treatment. The screening may be performed by a physician
assistant, a nurse practitioner, or a registered nurse. The recipient is appropriate for
acupuncture detoxification services if the screening determines that the recipient:
(i) has no history of seizures, delirium tremens, or other life-threatening withdrawal
symptoms; and
(ii) is oriented to time, place, and person
Source: http://www.massresources.org/masshealth-behavioral.html#mentalhealth,
http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-substanceabuse.pdf
12) Can treatment courts designate or select particular providers -ie those with experience and good
reputations treating substance-addicted probationers?

A team of court staff and mental health professionals works together to develop treatment
plans and are primarily responsible for overseeing operations of the program and managing
supervision of the drug court participants. The providers must meet all of the requirements
from #14.
Source: https://www.ncjrs.gov/pdffiles1/bja/205621.pdf
13) Is there coverage for residential substance abuse treatment? What are the parameters?


Yes, MassHealth pays for services provided by acute inpatient substance abuse treatment
services providers for the treatment of substance dependency.
The Division will pay for acute inpatient substance abuse treatment services delivered in
conformance with the standards and patient placement criteria issued and enforced by the
Massachusetts Department of Public Health’s Bureau of Substance Abuse Services.
Source: http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-substanceabuse.pdf
14) What is the process and what are the regulations for treatment providers to be able to
participate?

The eligibility requirements for providers of substance abuse treatment services are as follows.
(A) In State. The following requirements apply when the provider is located in Massachusetts.
(1) Methadone Treatment Program. A provider who furnishes methadone detoxification and
methadone maintenance services must be licensed as a methadone treatment program by the
Massachusetts Department of Public Health under its regulations at 105 CMR 750.000.
(2) Acute Inpatient Substance Abuse Treatment Services. A provider who furnishes acute
inpatient substance abuse treatment services must be licensed or approved, or both, as a
provider of acute inpatient substance abuse treatment services by the Massachusetts
Department of Public Health pursuant to its regulations at 105 CMR 160.000 and 161.000.
(3) Substance Abuse Outpatient Counseling Program. A provider who furnishes substance abuse
outpatient counseling services must be licensed by the Massachusetts Department of
Public Health to provide such services under its regulations at 105 CMR 162.000. These services
include counseling services and acupuncture detoxification.
(4) Special Services for Pregnant Members. A provider who furnishes intensive outpatient, day
treatment, or case management services must be approved by the Massachusetts
Department of Public Health to provide each of those services under its regulations at 105
CMR 162.000. A provider who furnishes enhanced acute inpatient substance abuse treatment
services must be approved by the Massachusetts Department of Public Health to provide such
services under its regulations at 105 CMR 160.000 and 161.000.
(B) Out of State. To participate in MassHealth, an out-of-state substance abuse treatment
program must obtain a MassHealth provider number and meet the following criteria:
(1) the program must be licensed as a methadone treatment program, acute inpatient
substance abuse treatment program, or substance abuse outpatient counseling program by the
appropriate state agency under whose jurisdiction it operates;
(2) the program must participate in its own state’s Medical Assistance Program or its equivalent;
(3) the program must have a rate of reimbursement established by the appropriate rate setting
regulatory body of its state; and
(4) the program must be one that recipients in a particular locality use for medical services as a
general practice.
Source: http://www.mass.gov/eohhs/docs/masshealth/regs-provider/regs-substanceabuse.pdf
15) Is dental care covered?

MassHealth:
o
o

MassHealth dental benefits for adults (21 or older) include:
 complete checkup (once with each new dental provider)
 regular checkups (twice per 12-month period)
 cleanings (twice per 12-month period)
 radiographs (X-rays)
 extractions
 emergency dental care
 certain types of oral surgery (such as biopsies)
 composite fillings for the 12 teeth at the front of the mouth
 starting in 2014, fillings for all teeth
The Massachusetts legislature has approved MassHealth coverage for adult dental
fillings in the 2014 budget, but has not restored full dental benefits for adults. Starting in
2014, MassHealth Dental for adults will cover diagnostic and preventive services (such
as checkups, cleanings, and x-rays), extractions, emergency treatment, and all dental
fillings.
Massachusetts Health Connector (Marketplace):
o Dental care is an option, but is not included in the basic plan (except for children). Up to
$3,000 is provided for dental care due to accidental injury NOT related to
chewing/biting.
Source: http://www.massresources.org/health-care-2014.html#masshealthdental
16) What is the basic primary medical care coverage? Are well-women check-ups included? Is birth
control included?

Well-women check-ups and contraceptives are included for all states, regardless if the exchange
is Federal or State-run.

All Qualified Health Plans (through the Marketplace) must include 10 essential benefits:
1. Outpatient services, such as doctor visits or tests done outside a hospital. This includes
fertility treatments.
2. Emergency services
3. Hospital stays, including weight loss surgery
4. Pregnancy and baby care
5. Mental health and substance abuse services, including behavioral health treatment
6. Prescription drugs, including generic and certain brand-name drugs
7. Rehab and habilitative services, those that help people recover from an accident or
injury and those that help people with developmental issues. In Massachusetts, this
includes physical and occupational therapy for people diagnosed with autism spectrum
disorder, those who have home health care, and those with speech/hearing disorders.
8. Lab tests
9. Preventive and wellness services, along with those that help people manage chronic
conditions. This includes contraceptives, hormone replacement therapy, and wigs for
people who are balding.
10. Services for children, including dental and eye care (but not eyeglasses)
Source: http://www.webmd.com/health-insurance/ma/massachusetts-health-insurancemarketplace?page=2
18) How does family member coverage work?

Go to the healthcare.gov website, choose your state, will take you to Massachusetts Health
Connector website, apply for family coverage. All of the plans will cover the 10 essential benefits
listed above. On the first step, if you and your family is not eligible for subsides through the
Health Connector website, it will take you to MassHealth Medicaid website to apply for family
coverage. Because Massachusetts expanded Medicaid, there will not be anyone who falls into
the coverage gap.
Source: www.healthcare.gov