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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

9 specialty care from other providers, and determine referral requirements for such necessary medical services. (2) Other Medical Services. All medical services to members enrolled in an MCO (except those services not covered under the MassHealth contract with the MCO, family planning services, and emergency services) are subject to the authorization and referral requirements of the MCO. MassHealth members enrolled in an MCO may receive family planning services from any MassHealth family planning provider and do not need an authorization or referral in order to receive such services. Members enrolled with an MCO should contact their MCO for information about covered services, authorization requirements, and referral requirements. (3) Behavioral Health Services. Members who enroll in an MCO receive behavioral health services through that MCO. All behavioral health services to members enrolled in an MCO, except those services not covered under the MassHealth contract with the MCO, are subject to the authorization and referral requirements of the MCO. Members enrolled with an MCO should contact their MCO for information about covered services, authorization requirements, and referral requirements. (4) 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 who participate in managed care under MassHealth 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.

(C) Copayments. Members who are enrolled in MCOs must make copayments in accordance with the MCO’s MassHealth copayment policy. Those MCO copayment policies must (1) be approved by MassHealth; and (2) be consistent with applicable copayment requirements set forth in 130 CMR 450.000: Administrative and Billing Regulations, 130 CMR 506.000: MassHealth: Financial Requirements, and 130 CMR 520.000: MassHealth: Financial Eligibility.

508.005: MassHealth Primary Care Clinician Plan (PCC Plan)

(A) Enrollment in the PCC Plan. (1) Selection Procedure. When a member becomes eligible for managed care, the MassHealth agency notifies the member of the member’s obligation to select a MassHealth managed care provider within the time period specified by the MassHealth agency. To enroll in the PCC Plan, the member must select the PCC Plan and an available primary care clinician (PCC). The MassHealth agency makes available to the member a list of the PCCs in the member’s service area. The member’s service area is determined by the MassHealth agency based on zip codes or geographic area. Service area listings may be obtained from the MassHealth agency. The list of PCCs that the MassHealth agency will make available to members may include those approved as a PCC by MassHealth in accordance with 130 CMR 450.118: Primary Care Clinician (PCC) Plan and who practices within the member’s service area. (2) MassHealth members are assigned to the PCC Plan, may transfer from the PCC Plan, may be disenrolled from a PCC’s panel, and may be re-enrolled in the PCC Plan as described in 130 CMR 508.003(B) through 130 CMR 508.003(E).