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130 CMR: DIVISION OF MEDICAL ASSISTANCE

Trans. by E.L. 260 Rev. 07/17/2026

130 CMR 508.000: MASSHEALTH: MANAGED CARE REQUIREMENTS

12 agency. To enroll in a Primary Care ACO, the member must select a Primary Care ACO and an available PCP that participates with the Primary Care ACO the member has selected. The MassHealth agency makes available to the member a list of PCPs that are participating with each Primary Care ACO. The list of PCPs that the MassHealth agency will make available to members may include those approved as a PCP in accordance with 130 CMR 450.119: Primary Care ACOs and who practices within the member’s service area. (b) MassHealth members are assigned to Primary Care ACOs, may transfer from Primary Care ACOs, may be disenrolled from Primary Care ACOs, and may be re- enrolled in Primary Care ACOs as described in 130 CMR 508.003(B) through 130 CMR 508.003(E). (2) Obtaining Services when Enrolled in a Primary Care ACO. (a) Primary Care. When the member selects or is assigned to a Primary Care ACO, the member's selected or assigned PCP will deliver the member's primary care, determine if the member needs medical or other specialty care from other providers, and make referrals for such necessary medical services. (b) Other Medical Services (excluding Behavioral Health). All medical services, except those services listed in 130 CMR 450.119: Primary Care ACOs and those provided by providers in a Primary Care ACO’s referral circle, require a referral or authorization from the member's primary care provider. MassHealth members enrolled in a Primary Care ACO may receive those services listed in 130 CMR 450.119, for which they are otherwise eligible, without a referral from their PCP. (c) Behavioral Health Services. All members enrolled with a Primary Care ACO receive behavioral health (mental health and substance use disorder) services, except those services not covered under the MassHealth contract with the behavioral health contractor, through the MassHealth behavioral health contractor as follows: 1. Nonemergency Behavioral Health Services. Behavioral health services, except for emergency services, may be obtained only from a provider that has entered into an agreement with the MassHealth behavioral health contractor. The MassHealth behavioral health contractor is responsible for authorizing or denying behavioral health services based on the member's medical need for those services. 2. Emergency Behavioral Health Services. Members may obtain emergency behavioral health services from any qualified participating MassHealth provider as well as any provider that has entered into an agreement with the MassHealth behavioral health contractor. (d) Native Americans and Alaska Natives. Individuals who are Native Americans (within the meaning of "Indians" as defined at 42 U.S.C. 1396u-2) or Alaska Natives may choose to receive covered services from an Indian health care provider. Such Indian health-care providers may participate in MassHealth subject to applicable provisions of 130 CMR 450.000: Administrative and Billing Regulations. (3) Copayments. Members enrolled in Primary Care ACOs must make copayments in accordance with MassHealth copayment requirements set forth in 130 CMR 450.000, 130 CMR 506.000, and 130 CMR 520.000.

508.007: One Care Plans