130 CMR, § 435.404 - Provider Eligibility

(A) Introduction. Payment for the services described in 130 CMR 435.000 will be made only to chronic-disease and rehabilitation hospitals participating in MassHealth as of the date of service.

(B) In State. To participate in MassHealth, a chronic-disease or rehabilitation hospital located in Massachusetts must:

(1) be licensed or operated by the Massachusetts Department of Public Health or the Massachusetts Department of Mental Health as a chronic-disease or rehabilitation hospital or unit;

(2) accept payment according to the methods and amounts as described in 130 CMR 435.405 as payment in full for services; and

(3) participate in the Medicare program.

(C) Out of State.

(1) Out-of-state chronic-disease or rehabilitation hospitalization is reimbursable on a prior-authorization basis only. The Division will consider a prior-authorization request submitted by an out-of-state chronic-disease or rehabilitation hospital only under one of the following circumstances.

(a) The hospital is located in Connecticut, Maine, New Hampshire, New York, Rhode Island, or Vermont, is within 50 miles of the Massachusetts border, and provides services to a member who resides in a Massachusetts community near the border of that state.

(b) The hospital provides services to a member who is authorized to reside out of state by the Massachusetts Department of Social Services.

(c) The hospital provides a member with services that are not available from comparable resources in Massachusetts, that are generally acceptable medical practice, and that can be expected to benefit the member significantly.

(2) To participate in MassHealth, an out-of-state chronic-disease or rehabilitation hospital must obtain a MassHealth provider number and meet the following criteria:

(a) be approved as a chronic-disease or rehabilitation hospital by the governing or licensing agency in its state;

(b) participate in the Medicare program; and

(c) participate in that state's medical assistance program.

(D) Managed-care Program. To participate in the chronic-disease and rehabilitation hospital managed-care program, a hospital must comply with 130 CMR 435.404(B) and must agree, by contract with the MassHealth agency, to provide or arrange and pay for all services covered by MassHealth, except acute-hospital services, for all MassHealth members who are inpatients of the chronic-disease or rehabilitation hospital and who participate in the hospital's managed-care program.

Notes

130 CMR, § 435.404