130 C.M.R. 415.408 – Nonpayable Services

The following are not payable:

(A) drugs and durable medical equipment prescribed for take-home use that are readily available from pharmacies or medical providers;
(B) the cost of any treatment or testing provided to a member who is an inpatient at another hospital, whether of the member or of a specimen from the member. Payment will be made to the hospital where the member is an inpatient and not to the provider where this treatment or testing occurs;
(C) leaves of absence;
(D) research or the provision of experimental, unproven, cosmetic, or otherwise medically unnecessary procedures or treatments;
(E) cosmetic surgery;
(F) the provision of whole blood (however, administrative and processing costs associated with the provision of blood and its derivatives are reimbursable);
(G) private hospital rooms, except when the member is being treated for an infectious disease that requires a private room, or in other circumstances in which a private room would be medically necessary; and
(H) the treatment of male or female infertility (including, but not limited to, laboratory tests, drugs, and procedures associated with such treatment); however, MassHealth does pay for the diagnosis of male or female infertility.

415.409: Sterilization Services: Introduction

(A) Covered Services. The MassHealth agency pays for sterilization services performed by a licensed physician in an acute inpatient hospital for a member only if all of the following conditions are met.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

4-4b

Provider Manual Series (130 CMR 415.000)

Transmittal Letter Date

Acute Inpatient Hospital Manual

AIH-52 01/02/15

(1) The member has voluntarily given informed consent for the sterilization procedure in the manner and at the time described in 130 CMR 415.410, and such consent is documented in the manner described in 130 CMR 415.411.
(2) The member is at least 18 years old at the time consent is obtained.
(3) The member is not a mentally incompetent individual or an institutionalized individual.
(B) Assurance of Member Rights. A provider must not use any form of coercion in the provision of sterilization services. The MassHealth agency, any provider, or any agent or employee of a provider, must not mislead any member into believing that a decision to have or not have a sterilization will adversely affect the member's entitlement to benefits or services for which the member would otherwise be eligible. The MassHealth agency has strict requirements for confidentiality of member records for sterilization services as well as for all other medical services covered by MassHealth.
1. (C) Retroactive Eligibility. The MassHealth agency does not pay for a sterilization performed during the period of a member's retroactive eligibility unless all conditions for payment listed in 130 CMR 415.409(A) are met.

415.410: Sterilization Services: Informed Consent

A member's consent for sterilization will be considered informed and voluntary only if such consent is obtained in accordance with the requirements specified in 130 CMR 415.410(A) and (B), and such consent is documented as specified in 130 CMR 415.411.

(A) Informed Consent Requirements.
1. (1) The person who obtains consent (a physician, nurse, or counselor, for example) must orally provide all of the following information and advice to the member requesting sterilization:
  1. (a) advice that the member is free to withhold or withdraw consent for the procedure at any time before the sterilization without affecting the right to future care or treatment and without loss of any federal or state-funded program benefits to which the member otherwise might be entitled;
  2. (b) a description of available alternative methods of family planning and birth control;
  3. (c) advice that the sterilization procedure is considered irreversible;
  4. (d) a thorough explanation of the specific sterilization procedure to be performed;
  5. (e) a full description of the discomforts and risks that may accompany or follow the procedure, including an explanation of the type and possible effects of any anesthetic to be used;
  6. (f) a full description of the benefits or advantages that may be expected as a result of the sterilization; and
  7. (g) advice that the sterilization will not be performed for at least 30 days, except under the circumstances specified in 130 CMR 415.410(B)(1).
2. (2) The person who obtains consent must also
  1. (a) offer to answer any questions the member may have about the sterilization procedure;
  2. (b) give the member a copy of the consent form;
  3. (c) make suitable arrangements to ensure that the information and advice required by 130 CMR 415.410(A)(1) are effectively communicated to any member who is blind, deaf, or otherwise handicapped;