Massachusetts Regulations
Office of Consumer Affairs and Business Regulation/Division of Insurance

Administrative Bulletin 20-09

101 CMR 613.00: Health Safety Net Eligible Services

101 CMR 614.00: Health Safety Net Payments and Funding

Effective March 12, 2020

Health Safety Net Coverage and Reimbursement Policy for Services Related to Coronavirus Disease 2019 (COVID-19)

Background

The Health Safety Net program serves as the payer of last resort for health care services provided by acute care hospitals and community health centers to qualified uninsured and underinsured residents of Massachusetts. In light of the state of emergency declared in the Commonwealth due to the 2019 novel Coronavirus (COVID-19) outbreak, the Health Safety Net is introducing additional flexibilities for coverage and billing related to COVID-19, as further described in this bulletin. These flexibilities are intended to be consistent with those set forth in MassHealth All Provider Bulletin 289.

This bulletin applies to acute care hospitals and community health centers that are Health Safety Net providers.

The Massachusetts Executive Office of Health and Human Services (EOHHS) is coordinating with federal and local partners to respond to COVID-19. As this situation evolves, EOHHS may issue additional guidance on this topic as informed and directed by the Massachusetts Department of Public Health (DPH) and the federal Centers for Disease Control and Prevention (CDC).

This bulletin shall remain effective for the duration of the state of emergency declared via Executive Order No. 591: Declaration of a State of Emergency to Respond to COVID-19.

Presumptive Determinations

To enhance access to health care services during the COVID-19 outbreak, and notwithstanding 101 CMR 613.04(4): Presumptive Determination, the Health Safety Net will accept a presumptive determination of low-income patient status for a patient, even if the patient has already received such a presumptive determination in the last 12 months. Providers should continue to use the Application for Health Safety Net (HSN) Presumptive Eligibility.

Furthermore, notwithstanding 101 CMR 613.04(7): Eligibility Period and Eligibility Operations Memo 18-02, the Health Safety Net will not place limits on the number of days it will pay for reimbursable health services to patients who are eligible but not enrolled in health insurance through the Health Connector.

Providers will be able to bill the Health Safety Net for services delivered to patients under these enhanced eligibility standards beginning April 1, 2020, for dates of service beginning March 12, 2020.

Billing for COVID-19 Diagnostic Laboratory Services

The Health Safety Net pays providers for medically necessary clinical diagnostic laboratory tests when a qualified clinician orders them. Testing of persons under investigation (PUI) for COVID-19 is available through the Massachusetts State Public Health Laboratory (MA SPHL) when a patient meets clinical and epidemiologic criteria.

MA SPHL does not charge providers for its provision of these laboratory services. Additionally, the Health Safety Net does not pay providers a specimen acquisition fee (including testing supplies) or a specimen transportation fee for lab services to be rendered by MA SPHL.

Health Safety Net providers may bill the Health Safety Net for medically necessary, clinically appropriate COVID-19 lab tests using CPT code 87635 which describes 2019-nCoV Coronavirus, SARA-CoV-2/2019-nCoV (COVID-19) using any technique, multiple types or subtypes. Providers will be able to bill the Health Safety Net for this code beginning April 1, 2020, for dates of service on or after March 12, 2020. The Health Safety Net will adopt the MassHealth rate for this code.

For questions about testing, specimen transport, or control measures, contact the Massachusetts Department of Public Health (DPH) (24/7) at (617) 983-6800. Further information on testing can be found at DPH's website.

Billing for Covered Services Delivered via Telehealth

To mitigate the spread of COVID-19, the Health Safety Net is committed to enabling Health Safety Net patients to remain in their homes to reduce exposure and transmission, to the extent possible, and to preserve health system capacity for the duration of this public health emergency. To that end, and for as long as this bulletin remains effective, the Health Safety Net will permit qualified providers to deliver clinically appropriate, medically necessary Health Safety Net-covered services to Health Safety Net-eligible patients via telehealth (including telephone and live video) in accordance with the standards set forth in Appendix A of this bulletin and notwithstanding any regulation to the contrary.

The Health Safety Net is not imposing specific requirements for technologies used to deliver services via telehealth and will allow payment for Health Safety Net covered services delivered through telehealth so long as such services are medically necessary and clinically appropriate and comport with the guidelines set forth in Appendix A of this bulletin. Providers are encouraged to use appropriate technologies to communicate with individuals and should, to the extent feasible, ensure the same rights to confidentiality and security as provided in face-to-face services. Providers must inform patients of any relevant privacy considerations. Rates of payment for services delivered via telehealth will be the same as rates of payment for services delivered via traditional (e.g., in-person) methods set forth in the applicable regulations. Providers must include Place of Service Code 02 when submitting a claim for services delivered via telehealth. Providers will be able to bill the Health Safety Net for these services delivered via telehealth beginning April 1, 2020, for dates of service beginning March 12, 2020.

Furthermore, and notwithstanding any regulation to the contrary, the Health Safety Net will pay providers for clinically appropriate, medically necessary telephone evaluations through the following CPT codes when delivered by physicians: 99441, 99442, 99443; and when delivered by qualified non-physicians: 98966, 98967, 98968.

Providers will be able to bill the Health Safety Net for these telephonic codes beginning April 1, 2020, for dates of service beginning March 12, 2020.

Billing for Home Visits Related to COVID-19

Hospitals and community health centers that are Health Safety Net providers may submit claims to the Health Safety Net for clinically appropriate, medically necessary home visits using the following codes: 99500, 99501, 99502, 99503, 99504, 99505, 99506, 99507, 99509, 99511, 99512, and 99600. For hospitals, these codes will be paid as outpatient services in accordance with 101 CMR 614.06(3): Pricing for Outpatient Services. For community health centers, these codes will be paid at a Prospective Payment System (PPS) Rate in accordance with 101 CMR 614.00. The Health Safety Net will also add these codes to the community health center covered code list available on the HSN Information for Community Health Centers' website. Providers will be able to bill the Health Safety Net for these codes beginning April 1, 2020, for dates of service beginning March 12, 2020.

Billing for COVID-19 Quarantine in a Hospital

There may be instances in which hospitals will need to quarantine Health Safety Net patients infected with COVID-19 for public health reasons or otherwise cannot safely discharge a patient due to COVID-19 exposure or risk, even though these individuals may no longer require an inpatient level of care.

Inpatient hospital providers may bill the Health Safety Net for Health Safety Net patients no longer requiring an inpatient level of care but who must be quarantined in the hospital or otherwise cannot be safely discharged due to COVID-19 by either (1) keeping the patient as an inpatient, switching the patient to administrative day status, and billing accordingly, or (2) discharging the patient from inpatient care, commencing observation services, and billing accordingly. Inpatient hospitals rendering COVID-19-related services to Health Safety Net patients will be paid in accordance with the Medicare Inpatient Prospective Payment System (IPPS) for non-psychiatric claims and the Inpatient Psychiatric Facility Prospective Payment System (IPF-PPS) for psychiatric claims for the current fiscal year.

Updates related to Prescribed Drugs

As described in greater detail in MassHealth's Pharmacy Facts no. 141 and no. 142, the Health Safety Net is allowing additional exceptions to the 30-day supply limitation described in the MassHealth pharmacy regulations 130 CMR 406.411(D): Quantities, effective for dates of service beginning March 14, 2020. Specifically, and notwithstanding the requirements of 130 CMR 406.411(D)(1): Days' Supply Limitations, Health Safety Net providers may dispense up to a 90-day supply of a prescription drug if requested by a Health Safety Net patient or that individual's prescriber as long as sufficient quantity remains on the prescription to support the quantity being filled. This policy does not apply to drugs that require Prescription Monitoring Program (PMP) reporting, antibiotics, schedule IV medications (except for schedule IV benzodiazepines and hypnotics) and certain other drugs designated by MassHealth (e.g., drugs for which quantity limits have been individually established for clinical reasons). If a provider believes that dispensing up to a 90-day supply of any drug not generally subject to this policy would be in the best interest of a Health Safety Net patient, they may call the MassHealth Drug Utilization Review (DUR) program at (800) 745-7318 to request an override.

Effective for dates of service beginning March 14, 2020, the Health Safety Net will also allow early refills of existing prescriptions for drugs as long as at least one refill remains on the prescription. If a provider receives a denial for an early refill, the provider should place a "13" in the Submission Clarification field (NCPDP field 420-DK) to override the denial.

Effective for dates of service beginning March 20, 2020, providers may not require a signature from a Health Safety Net patient upon prescription drug pickup or delivery. In addition, providers are encouraged and allowed to provide prescription drugs to Health Safety Net patients via curbside pickup, courier home delivery, or delivery by mail or other similar parcel delivery. If a signature is otherwise required, the provider may document the waiver of signature by signing the delivery slip or prescription with the phrase "Signature not required related to COVID-19".

Effective for dates of service beginning March 20, 2020, the Health Safety Net is temporarily removing prior authorization (PA) requirements for the following drugs and drug classes.

* Aminoglycoside Agents—Inhaled

* Antibiotics—Oral and Injectable

* Antifungals—Oral and Injectable

* Respiratory Agents—Oral and Inhaled

* Sublocade

Accordingly, and notwithstanding any contrary requirements in the MassHealth Drug List, prescribers do not have to obtain PA for those drugs; and providers should fill and dispense these prescriptions without any PA requirement.

Effective for dates of service beginning March 20, 2020, providers may refill clozapine prescriptions for HSN patients if current lab results cannot be obtained, provided that the pharmacist has consulted with the prescriber, and that such a refill is clinically appropriate in the pharmacist's professional judgment. The provider must document all pertinent details in the patient's records.

Consistent with 130 CMR 406.411(B) and to ensure Health Safety Net patients do not experience gaps in therapy, providers may utilize an emergency override if a claim for a medication is rejected due to lack of PA. The Health Safety Net will pay the pharmacy for at least a 72-hour, nonrefillable supply of the drug dispensed under these circumstances. To obtain an emergency override, pharmacists should contact the MassHealth DUR program at (800) 745-7318 during normal business hours. If outside business hours, providers may submit an emergency override claim with a value of "03" for Level of Service (field 418). After the prescription is adjudicated, the provider should remove the "03" from the level of service field before the next fill.

Effective for dates of service beginning March 20, 2020, the Health Safety Net is temporarily removing the requirement to use brand name ProAir when dispensing an albuterol inhaler. Claims for both branded ProAir inhalers and generic equivalents will be accepted. When dispensing either drug, the pharmacy should enter a DAW code of "0."

Finally, the Health Safety Net is working to identify and extend PAs that are due to expire in the coming weeks. The Health Safety Net anticipates that, where appropriate, these existing PAs will be extended for up to another 60 days from the date of expiration. Notwithstanding this initiative, providers should continue to outreach to prescribers in the event a new prior authorization is required.

Cost Sharing

Effective for dates of service beginning March 12, 2020, and notwithstanding the requirement at 101 CMR 613.04(8), the Health Safety Net will not require Partial Low-Income Patients with MassHealth MAGI Household income or Medical Hardship Family Countable Income greater than 150% and less than or equal to 300% of the FPL to make payments towards their annual deductible.

Other Considerations

Please note that all providers must make diligent efforts to obtain payment first from other resources, including MassHealth, so that the Health Safety Net will be the payer of last resort for Health Safety Net providers.

Additional Information

For the latest MA-specific information, visit the following link: https://www.mass.gov/resource/information-on-the-outbreak-of-coronavirus-disease-2019-covid-19.

The latest Centers for Disease Control and Prevention (CDC) guidance for healthcare professionals is available at the following link: https://www.cdc.gov/coronavirus/2019-ncov/hcp/index.html.

Questions

If you have any questions about the information in this bulletin, please contact the Health Safety Net at (800) 609-7232, or email your inquiry to HSNHelpdesk@state.ma.us.

Appendix A

Guidelines for Use of Telehealth to Deliver Covered Services

Terminology

For the purposes of this bulletin, the following terms are used as defined below.

Distant site is the site where the practitioner providing the service is located at the time the service is provided. While all applicable licensure and programmatic requirements apply to the delivery of the service, there are no additional geographic or facility restrictions on distant sites for services delivered via telehealth.

Originating site is the location of the member at the time the service is being provided. There are no geographic or facility restrictions on originating sites.

Billing and Payment Rates for Services

Providers must include the Place of Service (POS) Code 02 when submitting a claim for services delivered via telehealth. Rates of payment for services delivered via telehealth will be the same as rates of payment for services delivered via traditional (e.g., in-person) methods set forth in the applicable regulations.

Providers may not bill the Health Safety Net a facility fee for distant or originating sites.

Additional Requirements for Prescribing

A provider may prescribe medications via telehealth as otherwise described in this bulletin and in accordance with the following requirements.

1. Providers must comply with all applicable state and federal statutes and regulations governing medication management and prescribing services when delivering these services via telehealth.

2. Providers who deliver prescribing services via telehealth must maintain policies for providing patients with timely and accurate prescriptions by use of mail, phone, e-prescribing and/or fax. Providers must document prescriptions in the patient's medical record consistent with in-person care.

Requirements for Telehealth Encounters

Providers must adhere to and document the following best practices when delivering services via telehealth.

1. Providers must properly identify the patient using, at a minimum, the patient's name, date of birth, and place of residence. If the patient has a MassHealth ID, providers should obtain that, as well.

2. Providers must disclose and validate the provider's identity and credentials, such as the provider's license, title, and, if applicable, specialty and board certifications.

3. For an initial appointment with a new patient, the provider must review the patient's relevant medical history and any available medical records with the patient before initiating the delivery of the service.

4. For existing provider-patient relationships, the provider must review the patient's medical history and any available medical records with the patient during the service.

5. Prior to each patient appointment, the provider must ensure that the provider is able to deliver the service to the same standard of care and in compliance with licensure regulations and requirements, programmatic regulations, and performance specifications related to the service (e.g., accessibility and communication access) using telehealth as is applicable to the delivery of the services in person. If the provider cannot meet this standard of care or other requirements, the provider must direct the patient to seek in-person care. The provider must make this determination prior to the delivery of each service.

6. To the extent feasible, providers must ensure the same rights to confidentiality and security as provided in face-to-face services. Providers must inform members of any relevant privacy considerations.

7. Providers must follow consent and patient information protocol consistent with those followed during in-person visits.

8. Providers must inform patients of the location of the provider rendering services via telehealth (i.e., distant site) and obtain the location of the patient (i.e., originating site).

9. The provider must inform the patient of how the patient can see a clinician in-person in the event of an emergency or as otherwise needed.

Documentation and Record Keeping

Providers delivering services via telehealth must meet all health records' standards required by the applicable licensing body as well as any applicable regulatory and program specifications required by the Health Safety Net. This includes storage, access, and disposal of records.

In addition to complying with all applicable Health Safety Net regulations pertaining to documentation of services, providers must include a notation in the medical record that indicates that the service was provided via telehealth, the technology used, and the physical location of the distant and the originating sites. The provider must also include the CPT code for the service rendered via telehealth in the patient's medical record.

The Health Safety Net may audit provider records for compliance with all regulatory requirements, including record keeping and documentation requirements, and may apply appropriate sanctions to providers who fail to comply.