Commonwealth of Massachusetts Subchapter Number and Title Page

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4. PROGRAM REGULATIONS

429.401: Introduction .............................................................................................................. 4-1 429.402: Definitions ................................................................................................................ 4-1 429.403: Eligible Members ..................................................................................................... 4-5 429.404: Provider Eligibility ................................................................................................... 4-5 429.405: Provider Enrollment Process .................................................................................... 4-7 429.406: Required Notifications and Reports ......................................................................... 4-7 429.407: Revocation of Enrollment and Sanctions ................................................................. 4-8 429.408: In-state Providers: Maximum Allowable Fees ......................................................... 4-8 429.409: Out-of-state Providers: Maximum Allowable Fees .................................................. 4-9 429.410: Nonreimbursable Services ........................................................................................ 4-9 429.411: Site Inspections ......................................................................................................... 4-10 429.412: Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Services .......... 4-10 (130 CMR 429.413 through 429.420 Reserved) 429.421: Scope of Services ..................................................................................................... 4-10 429.422: Staff Composition Requirements ............................................................................. 4-14 429.423: Supervision, Training, and Other Staff Requirements ............................................. 4-16 429.424: Qualifications of Staff Authorized to Render Billable Services ................................ 4-17 (130 CMR 429.425 through 429.432 Reserved) 429.433: Coordination of Care ................................................................................................. 4-19 429.434: Schedule of Operations ............................................................................................. 4-19 429.435: Utilization Review Plan ............................................................................................ 4-20 429.436: Recordkeeping Requirements ................................................................................... 4-20 429.437: Written Policies and Procedures ............................................................................... 4-22 429.438: Administration .......................................................................................................... 4-22 429.439: Satellite Clinics ......................................................................................................... 4-23 429.440: Outreach ................................................................................................................... 4-23 429.441: Service Limitations ................................................................................................... 4-23

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

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Provider Manual Series (130 CMR 429.000)

Transmittal Letter Date

Mental Health Center Manual

MHC-53 9/1/2025

429.401: Introduction

130 CMR 429.000 establishes requirements for participation of mental health centers in MassHealth and governs mental health centers operated by freestanding clinics and satellite clinics. All mental health centers participating in MassHealth must comply with the MassHealth regulations, including but not limited to, 130 CMR 429.000 and 130 CMR 450.000: Administrative and Billing Regulations.

429.402: Definitions

The following terms used in 130 CMR 429.000 have the meanings given in 130 CMR 429.402 unless the context clearly requires a different meaning.

Adverse Incident. An occurrence that represents actual or potential serious harm to the well- being of a member, or to others under the care of the mental health center. Adverse incidents may be the result of the actions of a member served, actions of a staff member providing services, or incidents that compromise the health, safety, or operations of the center.

American Society of Addiction Medicine (ASAM). A professional society in the field of addiction medicine that sets diagnostic and dimensional criteria for the delivery of substance use disorder treatment which includes a continuum of five basic levels of care from Early Intervention to Medically Managed Intensive Inpatient Treatment.

Behavioral Health Disorder. Any disorder pertaining to mental health or substance use as defined by the current edition of the Diagnostic and Statistical Manual of Mental Disorders.

Behavioral Health Urgent Care (BHUC) Provider. A center that meets the requirements in 130 CMR 429.404(D).

Case Consultation. Intervention, including scheduled audio-only telephonic, audio-video, or in- person meetings, for behavioral and medical management purposes on a member’s behalf with agencies, employers, or institutions which may include the preparation of reports of the member’s psychiatric status, history, treatment, or progress (other than for legal purposes) for other physicians, agencies, or insurance carriers.

Care Coordination. The organization of a member’s care across multiple services and supports.

Certified Peer Specialist (CPS). A person who has been trained by an agency approved by the Department of Mental Health (DMH) who is self-identified as having lived experience of a mental health disorder and wellness who can effectively share their experiences and serve as a mentor, advocate, or facilitator for a member experiencing a mental health disorder.

Child and Adolescent Needs and Strengths (CANS). A standardized tool that organizes information gathered during behavioral health clinical assessments. A Massachusetts version of the tool has been developed and is intended to be used as a treatment decision support tool for behavioral health providers serving MassHealth members younger than 21 years of age.

Communication Protocol. Formal descriptions of requirements that allow two or more providers to exchange information.

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Co-occurring Disorder. A diagnosis of both a substance use disorder and one or more behavioral health disorders.

Core Discipline. Licensed behavioral health disciplines, including, but not limited to psychiatry, social work, psychology, or psychiatric nursing (including an advanced practice registered nurse), which compose a mental health center's multidisciplinary staff.

Couples Therapy. Psychotherapeutic services provided to a couple whose primary issue is the disruption of their marriage, family, or relationship.

Crisis Intervention. An urgent evaluation including assessment of risk, diagnosis, short-term intervention, and rendering of a disposition for a member’s presenting crisis, which may include referral to an existing or new behavioral health provider.

Developmental Assessment. The assessment of developmental status including the administration of developmental testing to assess fine and/or gross motor, language, cognitive level, social, memory, and/or executive functions.

Developmental Testing. The assessment of fine and/or gross motor, language, cognitive level, social, memory, and/or executive functions by standardized developmental instruments, which may include the interpretation and reporting of results.

Diagnostic Evaluation Services. The examination and determination of a member’s physical, psychological, social, economic, educational, and vocational assets and disabilities for the purpose of designing a treatment plan.

Direct and Continuous Supervision. Ongoing supervision provided to unlicensed staff and not independently licensed staff at a frequency of no fewer than one hour of supervision per week for full-time employees. Supervision time may be pro-rated based on scheduled hours for employees employed less than full-time. Direct and continuous supervision must be delivered by an independently licensed staff member or certified peer supervisor who is employed by the agency.

Enhanced Structured Outpatient Addiction Program (E-SOAP). American Society of Addiction Medicine (ASAM) Level 2.1 Intensive Outpatient Services is a program that provides short-term, clinically intensive, structured day and/or evening substance use disorder services. E-SOAP specifically serves specialty populations including homeless members and people at risk of homelessness, pregnant members, and adolescents. E-SOAP services must meet requirements in 130 CMR 418.000: Substance Use Disorder Treatment Services.

Family Consultation. A scheduled meeting with one or more of the parents, legal guardian, or foster parents of a child who is being treated by clinical staff at the center, when the parents, legal guardian, or foster parents are not clients of the center.

Family Therapy. The psychotherapeutic treatment of more than one member of a family simultaneously in the same visit.

Freestanding Clinic. Any institution licensed as a clinic by the Massachusetts Department of Public Health pursuant to M.G.L. c. 111, s. 51, that is not part of a hospital and that possesses its own legal identity, maintains its own patient records, and administers its own budget and

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personnel. Such institutions include mental health centers and community health centers.

Group Therapy. The application of psychotherapeutic or counseling techniques to a group of members, most of whom are not related by blood, marriage, or legal guardianship.

Individual Therapy. Psychotherapeutic services provided to a member.

Intensive Outpatient Program (IOP). A mental health treatment service that provides time- limited, multidisciplinary, multimodal structured treatment in an outpatient setting for members requiring a clinical intensity that exceeds outpatient treatment. Service includes individual, group, and family therapy as well as case management services.

Medication for Addiction Treatment (MAT). Use of a medication approved by the federal Food and Drug Administration (FDA) for the treatment of a substance use disorder.

Medication for Opioid Use Disorder (MOUD). Use of a medication approved by the FDA for the treatment of opioid use disorder.

Medication Visit. A member visit specifically for the prescription, review, and monitoring of medication by a psychiatrist, psychiatric clinical nurse specialist, advanced practice registered nurse, or physician assistant, or administration of prescribed intramuscular medication by a physician, nurse, or physician assistant.

Mental Health Center (Center). An entity that delivers a comprehensive group of diagnostic and psychotherapeutic treatment services to members seeking treatment for mental health disorders, which may include co-occurring substance use disorder, and their families, by an interdisciplinary team under the medical direction of a psychiatrist.

Mental Health Disorder. Any disorder pertaining to mental health as defined by the current edition of the Diagnostic and Statistical Manual of Mental Disorders.

Multiple Family Group Therapy. The treatment of more than one family unit, at the same time in the same visit, by one or more authorized staff members. There must more than one family member present per family unit and at least one of the family members per family unit must be an identified patient of the center.

Neuropsychological Assessment. A battery of performance-based assessments administered by an eligible provider that assesses cognitive functioning and developmental delays, in order to examine the cognitive consequences of brain damage, brain disease, physical, and mental illness, and other conditions that may impact cognitive functioning and achievement of developmental milestones. A neuropsychological assessment may include tests of intelligence, attention and concentration, learning and memory, processing speed, visual spatial perception, language skills, visual motor and fine motor skills, sensory perception, executive functioning, and emotional functioning.

Outreach Program. Mental health and substance use disorder treatment services being delivered by a clinical or paraprofessional staff member of the center off the premises of the mental health center or any of its satellite clinics, including, but not limited to, services in members’ homes or other community environments.

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Parent Clinic. The central location of the mental health center, at which most of the administrative, organizational, and clinical services are performed.

Peer Recovery Coach. An individual in addiction recovery who brings lived experience and has completed specialized training to provide nonclinical peer recovery support to members in or seeking recovery. Peer recovery coaches serve as mentors to build hope, explore recovery pathways, and achieve self-directed life goals. Peer recovery coaches also help members navigate systems, overcome barriers, build recovery capital, establish community connections, and link to supportive resources. Peer recovery coaches must meet requirements in 130 CMR 418.000: Substance Use Disorder Treatment Services.

Pharmacotherapy. Therapeutic treatment with pharmaceutical drugs.

Physician. An individual licensed by the Massachusetts Board of Registration in Medicine in accordance with M.G.L. c. 112, § 2.

Preventive Behavioral Health Services. Short-term group interventions, recommended by a physician or other licensed practitioner, practicing within their scope of licensure, that cultivate coping skills and strategies for symptoms of depression, anxiety, and other social/emotional concerns, to prevent the development of behavioral health disorders for children and adolescents younger than 21 years of age.

Psychological Assessment. The use of standardized test instruments and procedures to evaluate aspects of a member’s functioning. Psychological assessment includes intelligence, neuropsychological and developmental, and personality assessments. Test instruments used for psychological assessment must be published, valid, and in general use as defined by listing in the Mental Measurements Yearbook or successor publication, or by conformity to the Standards for Educational and Psychological Testing of the American Psychological Association.

Quality Management Program. A systematic and ongoing process for monitoring, evaluating, and improving the quality and appropriateness of services provided to members, with focused attention on addressing cultural, ethnic, and language differences.

Recovery Support Navigator. A paraprofessional specialist who receives specialized training in the essentials of substance use disorder and evidence-based techniques, such as motivational interviewing, and who supports members in accessing and navigating the substance use disorder treatment system through activities that can include care coordination, case management, and motivational support. Recovery support navigators must meet requirements in 130 CMR 418.000: Substance Use Disorder Treatment Services.

Release of Information (ROI). A document that allows a patient to authorize and revoke what information they want to release from their patient record, who it can be released to, how long it can be released for, and under what statutes and guidelines it is released.

Satellite Clinic. A clinic at a different location from the parent center that operates under the license of and falls under the fiscal, administrative, and personnel management of the parent center.

Structured Outpatient Addiction Program (SOAP): ASAM Level Intensive Outpatient Services. A substance use disorder treatment service that provides short-term, multidisciplinary, clinically

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intensive structured treatment to address the subacute needs of members with substance use disorders and/or co-occurring disorders. These services may be used as a transition service in the continuum of care toward lower intensity outpatient services or accessed directly. SOAP services must meet requirements in 130 CMR 418.000: Substance Use Disorder Treatment Services.

Substance Use Disorder. Any disorder pertaining to substance use as defined by the current edition of the Diagnostic and Statistical Manual of Mental Disorders.

Supervised Clinical Experience. A clinician’s experience providing diagnostic and treatment services to individuals, families, and groups of individuals under the direct and continuous supervision of a qualified independently licensed professional as set forth in 130 CMR 429.423, who is employed by the same agency as the supervisee.

Telehealth. The use of synchronous or asynchronous audio, video, electronic media, or other telecommunications technology, including, but not limited to interactive audio-video technology; remote patient monitoring devices; audio-only telephone; and online adaptive interviews, for the purpose of evaluating, diagnosing, consulting, prescribing, treating, or monitoring of a member’s physical health, oral health, mental health, or substance use disorder condition.

Urgent Behavioral Health Needs. Needs characterized by changes in behavior or thinking, role dysfunction, emerging intent of self-injury, or threats to others. Urgent behavioral health needs do not rise to the level of immediate risk of harm to self or others.

429.403: Eligible Members

(A) MassHealth Members. MassHealth covers mental health center services only when provided to eligible MassHealth members, subject to the restrictions and limitations described in the MassHealth agency’s regulations. Covered services for each MassHealth coverage type are set forth in 130 CMR 450.105: Coverage Types.

(B) Members of the Emergency Aid to the Elderly, Disabled and Children Program. For information on covered services for recipients of the Emergency Aid to the Elderly, Disabled and Children Program, see 130 CMR 450.106: Emergency Aid to the Elderly, Disabled and Children Program.

(C) For information on verifying member eligibility and coverage type, see 130 CMR 450.107: Eligible Members and the MassHealth Card.

(D) For limitations on mental health disorder and substance use disorder services provided to members enrolled with a MassHealth managed care provider, see 130 CMR 450.105: Coverage Types and 130 CMR 450.124: Behavioral Health Services.

429.404: Provider Eligibility

(A) In State. Each center operated by a freestanding clinic or a satellite clinic is eligible to participate only if the center is

(1) enrolled as a Medicare provider;

(2) enrolled and actively participating with the MassHealth agency as a billing provider as evidenced by the issuance of a Provider Identification and Service Location (PIDSL) number for the provision of mental health center services at that location; and

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(3) licensed by the Massachusetts Department of Public Health (DPH). The MassHealth agency may waive the clinic licensure requirement for centers that are

(a) operated by a local department of public health; and

(b) comply with 130 CMR 429.404(A)(2).

(B) Out of State. Each out-of-state center operated by a freestanding clinic or satellite clinic is eligible to participate only if the center

(1) meets the following criteria:

(a) if the center is required by its own state's law to be licensed, each center must be licensed by the appropriate state agency under whose jurisdiction it operates;

(b) each center must participate in its own state's medical assistance program or its equivalent; and

(c) each center must have a rate of reimbursement established by the appropriate rate setting regulatory body of its state.

(2) is a Medicare-participating provider;

(3) is enrolled by the MassHealth agency as a provider of mental health center services at that location; and

(4) obtains a MassHealth PIDSL number.

(C) Behavioral Health Urgent Care Provider Eligibility. To be designated as a behavioral health urgent care (BHUC) provider, a center must meet the eligibility requirements in 130 CMR 429.404(A) and the following criteria:

(1) Comply with the regulations in 130 CMR 429.000;

(2) Attest at a time and in a form determined by the MassHealth agency to being able to meet the following requirements:

(a) Appointments.

1. Appointments for diagnostic evaluation services for new clients are available on the same or next day of clinic operation, when clinically indicated based on initial intake;

2. Appointments for all existing clients with an urgent behavioral health need are available on the same or next day of clinic operation;

3. Urgent psychopharmacology appointments and Medication for Addiction Treatment (MAT) evaluations are available within 72 hours of an initial diagnostic evaluation and based on a psychosocial assessment; and

4. All other treatment appointments including follow-up appointments are available within 14 days.

(b) Hours. Meet the requirements in 130 CMR 429.434(D).

(c) Language Capabilities. Maintain the ability to use two-way video communication for translation services, and/or have multilingual staff that align with the language needs of the communities served.

(3) Multiple Clinics. The BHUC provider requirements must be met at the clinic location level.

(D) Each center operated by a freestanding clinic or satellite clinic must meet the requirements in 130 CMR 429.000 to be enrolled by the MassHealth agency.

(E) Payment for services described in 130 CMR 429.000 will be made only to mental health centers participating in MassHealth on the date of service.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

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Provider Manual Series (130 CMR 429.000)

Transmittal Letter Date

Mental Health Center Manual

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429.405: Provider Enrollment Process

(A) A separate, complete application for enrollment as a mental health center must be submitted for each parent clinic and each satellite clinic operated by the parent clinic that operates under a different tax identification number than the parent clinic. The applicant must submit the appropriate provider enrollment application to the MassHealth agency. The MassHealth agency may request additional information or perform a site inspection to evaluate the applicant's compliance with the regulations in 130 CMR 429.000.

(1) Based on the information in the enrollment application, information known to the MassHealth agency about the applicant, and on the findings from any site inspection deemed necessary, the MassHealth agency will determine whether the applicant is eligible for enrollment.

(2) The MassHealth agency will notify the applicant of the determination in writing within 60 days of the MassHealth agency receiving a completed application. An application will not be considered complete until the applicant has responded to all MassHealth requests for additional information, and MassHealth has completed any required site inspection.

(B) If the MassHealth agency determines that the applicant is not eligible for enrollment, the notice will contain a statement of the reasons for that determination, including, but not limited to, incomplete application materials and recommendations for corrective action, if appropriate, so that the applicant may reapply for enrollment once corrective action has been completed.

(C) The enrollment is valid only for the center or centers described in the application and is not transferable to other centers operated at other locations by the applicant. Any additional center established by the applicant at a satellite clinic or other location must separately apply for enrollment and be enrolled with the MassHealth agency to receive payment.

429.406: Required Notifications and Reports

(A) Annual Report. Each mental health center must submit a completed attestation, on forms provided by the MassHealth agency, and file them with the MassHealth agency by September 30 of each year. The center must maintain and provide documentation supporting this attestation upon request by the MassHealth agency. The attestation must include at minimum

(1) a statement that the program has reviewed and updated, as necessary, its written policies and procedures during the reporting period.

(2) a statement that the program has completed ongoing review of staffing licensure and license eligibility, including licensure verification with specific attention to provider administrative and clinical management staff;(3) a statement describing the current language capacities, capacity to provide services to specialized populations, and utilization of evidenced-based modalities of the program;

(4) a statement that that the center is in compliance with 130 CMR 429.000; and

(5) any other information that the MassHealth agency may request.

(B) Staffing and Personnel Reports. Each center must provide additional staffing or personnel information as requested by the MassHealth agency.

(C) For each CANS assessment conducted, each center must report data collected during the assessment to the MassHealth agency, in the manner and format specified by the MassHealth agency.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

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Provider Manual Series (130 CMR 429.000)

Transmittal Letter Date

Mental Health Center Manual

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(D) Adverse Incident Reports. Each center must report adverse incidents to the MassHealth agency within 24 hours of discovery of the incident, or, if the incident occurs on a holiday or weekend, on the next business day, in a format specified by the MassHealth agency.

(E) Each center must inform the MassHealth agency within 15 days of any citation or loss of licensure or accreditation issued to the center by another agency, including, but not limited to, DPH, an out-of-state provider’s relevant state licensing agency, the Joint Commission, or the Commission on Accreditation of Rehabilitation Facilities (CARF), or changes to or loss of Medicare participation and enrollment.

(F) Each center must comply with all reporting requirements that may pertain to the practice, facility, or staffing of the center as directed by the MassHealth agency.

429.407: Revocation of Enrollment and Sanctions

(A) The MassHealth agency has the right to review a mental health center's continued compliance with the conditions for enrollment referred to in 130 CMR 429.405 and the reporting requirements in 130 CMR 429.406 upon reasonable notice and at any reasonable time during the center's hours of operation. The MassHealth agency has the right to revoke the enrollment, subject to any applicable provisions of 130 CMR 450.000: Administrative and Billing Regulations, if such review reveals that the center has failed to or ceased to meet such conditions.

(B) If the MassHealth agency determines that there exists good cause for the imposition of a lesser sanction than revocation of enrollment, it may withhold payment, temporarily suspend the center from participation in MassHealth, or impose some other lesser sanction as the MassHealth agency sees fit, pursuant to the processes in 130 CMR 450.000: Administrative and Billing Regulations, as applicable.

429.408: In-state Providers: Maximum Allowable Fees

(A) The MassHealth agency pays for mental health center services with rates set by EOHHS, subject to the conditions, exclusions, and limitations in 130 CMR 429.000. EOHHS fees for mental health center services are in 101 CMR 306.00: Rates for Mental Health Services Provided in Community Health Centers and Mental Health Centers.

(1) If the center has a sliding scale charge structure, the maximum published charges will be considered the center’s usual charge to the general public, provided the following conditions are met:

(a) the center's full charges must be published in a fee schedule;

(b) the center's revenues must be based on the application of full charges with allowances noted for reduction of fees;

(c) the center's procedure for reduction of fees must be in accordance with written policies; and

(d) the center must maintain sufficient information to document the amount of the reductions.

(2) Centers designated as BHUC providers pursuant to 130 CMR 429.404(A) may bill for the provision of these services according to rates in 101 CMR 306.00: Rates for Mental Health Center Services Provided in Community Health Centers and Mental Health Centers.

Commonwealth of Massachusetts Subchapter Number and Title Page

MassHealth 4. Program Regulations

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Provider Manual Series (130 CMR 429.000)

Transmittal Letter Date

Mental Health Center Manual

MHC-53 9/1/2025

(B) Administrative Operations. Payment by the MassHealth agency for mental health center services includes payment for administrative operations and for all aspects of service delivery not explicitly included in 130 CMR 429.000, such as, but not limited to

(1) completion of member registration and intake, which may be completed on a telephonic or walk-in basis, and must include collecting and recording at least the minimally required member information necessary to facilitate diagnostic evaluation services, including the members’ presenting concern, and for referral to an appropriate provider or service;

(2) communication with members or other parties that may include processes for appointment reminders or coordination of care;

(3) staff supervision or consultation with another staff member within the mental health center;

(4) providing information for the coordination of referrals; and

(5) recordkeeping.

429.409: Out-of-state Providers: Maximum Allowable Fees

Payment to a mental health center located out of state must be in accordance with the applicable rate schedule of its state's medical assistance program, or its equivalent, and is always subject to the applicable conditions, exclusions, and limitations in 130 CMR 429.000.