Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

Practitioner Services

Prescription Drugs

Physical Therapy and Other Services

Products and Devices

Transportation Services

Other Services

Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Massachusetts (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes				Fee for service	CN & MN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes			Public Health Clinics not covered	Fee for service	CN & MN
Federally Qualified Health Center Services
Yes				Prospective cost based rate/visit	CN & MN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes	$3/admission	Admissions for specified procedures safely rendered on outpatient basis		Prospective payment/discharge using statewide average cost adjusted for case mix, prospective cost based per diem for specified hospitals/units	CN & MN
Outpatient Hospital Services
Yes				Hospital-specific episode-baed payment/day, excludes physician and lab services	CN & MN
Rehabilitation Services: Mental Health and Substance Abuse
Yes				Fee for service or negotiated rate	CN & MN
Rural Health Clinic Services
Yes				Prospective cost based rate/visit with ancillaries paid fee for service	CN & MN
Practitioner Services
Certified Registered Nurse Anesthetist Services
No
Chiropractor Services
Yes			20 visits/year	Fee for service	CN & MN
Dental Services
Yes		Specified services	Adult exam and cleaning 2/year, root canals limited to anterior teeth	Fee for service	CN & MN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes				Fee for service	CN & MN
Nurse Midwife Services
Yes				Fee for service	CN & MN
Nurse Practitioner Services
Yes				Fee for service	CN & MN
Optometrist Services
Yes		Specified services/items including vision training	1 refractive exam/2 years unless specific diagnostic criteria met	Fee for service	CN & MN
Physician Services
Yes		Specified surgical procedures	1 office, inpatient hospital or home visit/day, 1 nursing facility visit/month	Fee for service	CN & MN
Podiatrist Services
Yes			Limited to services medically necessary for life and safety	Fee for service	CN & MN
Psychologist Services
Yes			Limited to psychological testing and 1 testing session/6 months	Fee for service	CN & MN
Prescription Drugs
Prescription Drugs
Yes	$1/selected generic Rx or selected OTCs,, $3/other generic Rx, $3/brand Rx or other specified OTCs	Specified drugs and drug classes	Specified drugs and drug classes	WAC+5% plus $3.00 dispensing fee; 340B pharmacies paid drug cost plus $3.00 dispensing fee	CN & MN
Physical Therapy and Other Services
Occupational Therapy Services
Yes			20 visits/year	Fee for service	CN & MN
Physical Therapy Services
Yes			20 visits/year	Fee for service	CN & MN
Services for Speech, Hearing and Language Disorders
Yes			35 speech pathology visits/year	Fee for service	CN & MN
Products and Devices
Dentures
Yes		Yes	1 full upper and/or lower denture or 1 partial/7 years, 1 upper and/or lower rebase or reline/3 years, immediate dentures not covered	Fee for service	CN & MN
Eyeglasses
Yes		Specified services/items including special lenses and low-vision aids	1 pair eyeglasses/2 years, minimum diopter correction required for initial and replacement eyeglasses, replacements within 2 years only if eyeglasses lost or unusable, contact lenses and special lenses for specified medical conditions	Fee for service	CN & MN
Hearing Aids
Yes		New or replacement hearing aid costing more than $500, accessories or supplies costing more than $35	1 pair hearing aids/5 years	Fee for service	CN & MN
Medical Equipment and Supplies
Yes		Yes		Fee for service	CN & MN
Prosthetic and Orthotic Devices
Yes			Non-medical items and services not covered	Fee for service	CN & MN
Transportation Services
Ambulance Services
Yes				Fee for service	CN & MN
Non-Emergency Medical Transportation Services
Yes				See service-specific FN	CN & MN
Other Services
Diagnostic, Screening and Preventive Services
Yes				Dependent upon service and billing provider	CN & MN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes				Fee for service	CN & MN
Targeted Case Management
Yes				Fee for service or negotiated rate	CN & MN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes		Services for the following populations: 1, 2, 3 & 4 - See service-specific FN	Dependent upon the services provided	CN & MN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes		Coverage limited by eligibility category	Fee for service using peer groups to set maximum payments	CN & MN - See state-specific FN
Hospice Care
Yes			Prospective rates based on Medicare methodology	CN & MN
Personal Care Services
Yes	Yes		Fee for service	CN & MN
Private Duty Nursing Services
Yes	Yes	112 hours/week	Fee for service	CN & MN
Program of All-Inclusive Care for the Elderly
Yes		See service-specific FN	Capitated payment	CN & MN
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes			Prospective cost based per diem	CN & MN
Inpatient Psychiatric Services, under age 21
Yes			Prospective cost based all-inclusive per diem	CN & MN
Intermediate Care Facility Services for the Mentally Retarded
Yes		Leave days covered if in plan of care, no annual limit	Prospective cost based per diem with limits, facilities not paid for leave days	CN & MN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes		10 hosp leave days/hospitalization, 10 therapeutic leave days/year	Prospective per diem based on case mix adjusted standard payments, higher rates for heavy care residents, cost based payment to pediatric facilities if costs exceed industry benchmarks	CN & MN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State’s Medicaid and SCHIP programs are collectively called MassHealth. In addition to covering the traditional Medicaid population, the State has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to a number of previously uninsured individuals. These waiver-covered groups include low-income workers and their families, working and non-working disabled, individuals with HIV, women with breast or cervical cancer, long-term unemployed adults and children in families with income at or below 200 percent of the federal poverty level (FPL), with coverage of the latter also relying on federal SCHIP authority. MassHealth primarily covers previously uninsured children in families with income at or below 300% of the FPL through SCHIP. Some groups are required to pay monthly premiums; others may receive premium assistance for private insurance coverage; long-term unemployed adults who are covered under MassHealth Essential and MassHealth Basic, receive a narrower package of benefits; and immigrants covered under MassHealth Limited receive emergency services only. Services for members under age 65 are generally provided by managed care organizations; other services are wrapped around and reimbursed directly by the State. Only policies applicable to all populations or related to those services reimbursed directly by the State are reflected on the tables. Some service limitations may apply depending on beneficiary age and coverage type. Copayments are limited to annual maximums of $200 for prescription drugs and $36 for non-pharmacy services per beneficiary.