130 CMR 484.00 — Abortion Clinic Services

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title Table of Contents

Page iv

Abortion Clinic Services Manual Transmittal Letter ABR-19

Date 06/10/22

4. PROGRAM REGULATIONS

130 CMR 484.00 Abortion Clinic Services

484.001 Definition of Payable Abortions ... ......................................................................... 4- 1

484.001: Definition of Payable Abortions ... ......................................................................... 4- 1

484.002 Assurance of Recipient Rights................................................................................ 4- 1

484.002: Assurance of Recipient Rights................................................................................ 4- 1

484.003 Participation by MassHealth Agency Staff ............................................................. 4- 1

484.003: Participation by MassHealth Agency Staff ............................................................. 4- 1

484.004 Provider Certification Requirements....................................................................... 4- 1

484.004: Provider Certification Requirements....................................................................... 4- 1

484.005 Reimbursable Abortion-related Services ............................................................... 4- 2

484.005: Reimbursable Abortion-related Services ............................................................... 4- 2

484.006 Report Requirement................................................................................................ 4- 2

484.006: Report Requirement................................................................................................ 4- 2

484.007 Out-of-State Abortions............................................................................................ 4- 3

484.007: Out-of-State Abortions............................................................................................ 4- 3

484.008 Reimbursement for Services ................................................................................... 4- 4

484.008: Reimbursement for Services ................................................................................... 4- 4

484.009 Billing ..................................................................................................................... 4- 4

484.009: Billing ..................................................................................................................... 4- 4

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 484.000) Page 4-1 Abortion Clinic Services Manual Transmittal Letter ABR-19 Date 06/10/22

484.001 Definition of Payable Abortions

484.001: Definition of Payable Abortions

(A) The MassHealth agency pays for abortion services performed in a Department of Public Health licensed clinic when provided to MassHealth recipients (categories of assistance 0, 1, 2, 3, 5, 6, 7, and 8) if all of the following conditions are met: (1) the abortion is a medically necessary abortion, or the abortion is performed upon a victim of rape or incest when such rape or incest has been reported to a law enforcement agency or public health service within 60 days of the incident; (2) the abortion is performed in accordance with law; and (3) the abortion claim is made in accordance with 130 CMR 484.000.

(B) For the purposes of 130 CMR 484.000, a medically necessary abortion is one which, according to the medical judgment of a licensed physician, or, consistent with c. 112, s. 12M and the time limitations established therein a physician assistant, certified nurse practitioner, or certified nurse midwife, is necessary in light of all factors affecting the pregnant individual’s health.

(C) Unless otherwise indicated, all abortions referred to in 130 CMR 484.000 are payable abortions as defined in 130 CMR 484.001(A) and (B).

(D) For information on reimbursable services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program (category of assistance 4), see 130 CMR 450.106: Emergency Aid to the Elderly, Disabled and Children Program.

484.002 Assurance of Recipient Rights

484.002: Assurance of Recipient Rights

No provider shall use any form of coercion in the provision of abortion services. Neither the MassHealth agency nor any provider, nor any agent or employee of a provider, shall mislead any recipient into believing that a decision to have or not to have an abortion will adversely affect the pregnant individual’s entitlement to benefits or services for which the pregnant individual would otherwise be eligible. The MassHealth agency has strict requirements for confidentiality of patient records for abortion services as well as for all other medical services payable under MassHealth.

484.003 Participation by MassHealth Agency Staff

484.003: Participation by MassHealth Agency Staff

Any employee or agent of the MassHealth agency who objects on moral or religious grounds to participation in the furnishing of information or other assistance concerning abortion services to recipients, and who reports such objection to their superiors, shall not be required to participate in such activities. The refusal thereafter of such person to participate in such activities shall not form the basis for any disciplinary or recriminatory action against such person.

484.004 Provider Certification Requirements

484.004: Provider Certification Requirements

(A) Ambulatory Abortion Clinic. An ambulatory abortion clinic must be licensed by the Massachusetts Department of Public Health in compliance with the clinic licensure rules and regulations. In order to receive payment from the MassHealth agency, an ambulatory abortion clinic must be enrolled as a participating provider in MassHealth.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 484.000) Page 4-2 Abortion Clinic Manual Transmittal Letter ABR-19 Date 06/10/22

(B) Hospital. A hospital in which abortions are performed must be licensed by the Massachusetts Department of Public Health in compliance with the hospital licensure rules and regulations. In order to receive payment from the MassHealth agency, a hospital must be enrolled as a participating provider in MassHealth.

(C) Physician. The MassHealth agency pays for abortion services rendered by a physician only in accordance with 130 CMR 433.403 and 130 CMR 433.404.

(D) Physician Assistant. The MassHealth agency pays for abortion services rendered by a physician assistant only in accordance with 130 CMR 433.434.

(E) Certified Nurse Practitioner. The MassHealth agency pays for abortion services rendered by a certified nurse practitioner only in accordance with 130 CMR 433.433.

(F ) Certified Nurse Midwife. The MassHealth agency pays for abortion services rendered by a certified nurse midwife only in accordance with 130 CMR 433.419.

484.005 Reimbursable Abortion-related Services

484.005: Reimbursable Abortion-related Services

(A) The MassHealth agency will reimburse providers for the following abortion-related services when they are provided in conjunction with a payable abortion procedure: (1) pre-operative evaluation and examination; (2) pre-operative counseling; (3) laboratory services, including pregnancy testing, blood type, and Rh factor; (4) Rh o (D) immune globulin (human); (5) anesthesia (general or local); (6) post-operative care; (7) follow-up; and (8) advice on contraception or referral to family planning services.

(B) Reimbursement for all of the above abortion-related services, with the exception of Rh o (D) immune globulin (human), is included in the all-inclusive abortion fees for ambulatory abortion clinics, as established by the Massachusetts Center for Health Information and Analysis. For other providers (i.e., physicians, physician assistants , certified nurse practitioners, certified nurse midwives, hospitals, and outpatient departments), the MassHealth agency shall make payment for any of the above abortion-related services in accordance with the fee schedule appropriate to the provider's category (see 130 CMR 484.008).

484.006 Report Requirement

484.006: Report Requirement

(A) Completion of the Certification for Payable Abortion (CPA-2) Form. All providers (i.e., physicians, physician assistants, certified nurse practitioners, certified nurse midwives, hospitals, outpatient departments, and ambulatory abortion clinics), must complete a Certification for Payable Abortion (CPA-2) form and retain the form in the member’s record. To identify those abortions that meet federal reimbursement standards, the MassHealth agency must secure on the CPA-2 form the certifications described in 130 CMR 484.006(A)(1), (2), and (3) when applicable. For all medically necessary abortions not included in 130 CMR 484.006(A)(1), (2), or (3), the certification described in 130 CMR 484.006(A)(4) is required on the CPA-2 form. The provider must indicate on the CPA-2 form which of the following circumstances is applicable, and shall complete that portion of the form with the appropriate signatures:

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 484.000) Page 4-3 Abortion Clinic Services Manual Transmittal Letter ABR-19 Date 06/10/22

(1) Life of the Pregnant Individual Would Be Endangered. The attending provider must certify that, in their professional judgment, the life of the pregnant individual would be endangered if the pregnancy were carried to term. (2) Severe and Long-las ting Damage to Pregnant Individual’s Physical Health. The attending provider and another provider must each certify that, in their professional judgment, severe and long-lasting damage to the pregnant individual’s physical health would result if the pregnancy were carried to term. At least one of the providers must also certify that they are not an "interested provider," defined herein as one (a) whose income is directly or indirectly affected by the fee paid for the performance of the abortion; or (b) who is the spouse of, or another relative who lives with, a provider whose income is directly or indirectly affected by the fee paid for the performance of the abortion. (3) Victim of Rape or Incest. The provider is responsible for retaining signed documentation from a law enforcement agency or public health service certifying that the person upon whom the procedure was performed was a victim of rape or incest which was reported to the agency or service within 60 days of the incident. (A public health service is defined as either an agency of the federal, state, or local government that provides health or medical services; or a rural health clinic, provided that the agency's principal function is not the performance of abortions.) The documentation must include the date of the incident, the date the report was made, the name and address of the victim and of the person who made the report (if different from victim), and a statement that the report included the signature of the person who made the report. (4) Other Medic ally Necessary Abortions. The attending provider must certify that, in their medical judgment, for reasons other than those described in 130 CMR 484.006(A)(1), (2), and (3), the abortion performed was necessary in light of all factors affecting the pregnant individual’s health.

(B) Availability of Certification for Payable Abortion (CPA-2) Form. A provider may download the form from the Provider Library at www.mass.gov/masshealth.

484.007 Out-of-State Abortions

484.007: Out-of-State Abortions

(A) A facility located outside of Massachusetts is eligible to receive reimbursement for abortion services provided to Massachusetts recipients only if it is licensed by the governing or licensing agency in its state to perform abortions. An out-of-state facility must obtain a Massachusetts Medical Assistance provider number before it may receive such reimbursement from the MassHealth agency.

(B) The MassHealth agency will pay for a nonemergency abortion performed in an out-of-state facility only if it is a payable abortion and if prior authorization has been requested from and granted by the MassHealth agency. (1) The recipient or a referral agency may request prior authorization by telephone or in writing. The request should be made to: MassHealth, Prior Authorization Unit, ATTN: Prior Authorization, 100 Hancock Street, 6 th Floor, Quincy, MA, 02171 Tel.: (800) 862-8341. The facility may also make the prior authorization request. (2) If the MassHealth agency grants a prior authorization request, it will issue a prior authorization number directly to the out-of-s tate facility. In order to receive payment for an out-of-state abortion which requires prior authorization, the facility must enter the approved prior authorization number on the claim form. (3) The MassHealth agency will grant a prior authorization request only when the abortion service needed by the recipient is not available in a Massachusetts facility.

Commonwealth of Massachusetts MassHealth Provider Manual Series Subchapter Number and Title 4 Program Regulations (130 CMR 484.000) Page 4-4 Abortion Clinic Manual Transmittal Letter ABR-19 Date 06/10/22

(C) Consistent with regulations governing other aspects of MassHealth, the MassHealth agency grants an exception to the prior authorization requirement for recipients who live in communities near the borders of the states of Connecticut, New Hampshire, New York, Rhode Island, or Vermont. Such recipients may seek abortion services at facilities in these states when the location of the out-of-state facility is closer to the recipient's residence than the nearest Massachusetts abortion facility which provides equivalent services and which is eligible to participate in MassHealth.

484.008 Reimbursement for Services

484.008: Reimbursement for Services

A provider of abortion services claiming reimbursement from the MassHealth agency must bill according to the fee schedule appropriate to its provider category.

484.009 Billing

484.009: Billing

Refer to 130 CMR 450.000: Administrative and Billing for billing regulations applicable to all providers. Providers of abortion services must bill the MassHealth agency on the appropriate claim form, in accordance with the billing instructions.

REGULATORY AUTHORITY

130 CMR 484.000: M.G.L. c. 118E, §§ 7 and 12.