Rosie D.
Reforming the Mental Health System in Massachusetts

Massachusetts Regulations



Massachusetts’ EPSDT regulations outline the purpose of the federal law and describe the screening, diagnosis and treatment services to which eligible MassHealth members are entitled.  Pursuant to the Rosie D. judgment, these regulations were amended to incorporate behavioral health screening and assessment services, and corresponding payment rates for providers.  These regulatory amendments became effective on December 31, 2007.  See 130 CMR 450.140 et seq.,


Children and adolescents who currently need, but are not receiving medically necessary EPSDT services, including services not covered in MassHealth service codes, regulations and contracts, can utilize 130 CMR 450.144 to request prior authorization for these services.  MassHealth enrolled physicians, nurse practioners or nurse midwifes can submit a written request describing the medical need for the service, and any supporting documentation, to the member’s managed care company, if any, or to Masshealth’s prior authorization unit. 


Fair Hearings


Medicaid recipients may appeal decisions by state officials denying them needed services.  Filing an appeal entitles the recipient to a fair hearing.  This process is most effective when a specific service provider has been identified prior to submission of the request.  Individualized payment rates must be established for such providers, along with specialized Masshealth enrollment procedures.   


Members of a managed care company that provides Medicaid-funded services may appeal service denials though their managed care organization, or MassHealth’s fair hearing process, described at 130 CMR 610.00 et seq.




Persons may be eligible for Medicaid-funded services through different Medicaid coverage catgories.  Each category has its own eligibility criteria and covered services.  Children fall into at least four of these groups.  Separate MassHealth regulations describe the criteria and services available to persons in each coverage category. 


Children in MassHealth Standard and CommonHealth are eligible to receive all new home-based services.  Children with SED in other coverage categories will be eligible for CommonHealth but must transfer to this program.  Children who do not have SED may be eligible for CommonHealth.  Behavioral health screening and mental health evaluations using the CANS are available to all Medicaid members under 21 years of age, regardless of coverage type.  In addition, certain new services, such mobile crisis and in-home therapy, will be available regardless of coverage category.


 Proposed changes to regulations governing MassHealth coverage types, currently described at 130 CMR 450.130, are on hold pending implementation of a state policy decision making Rosie D. home-based services available to Medicaid-eligible children in various coverage categories.    


Supplemental Guidance


Additional information on screening and assessment improvements under Rosie D. can be found in the MassHealth Member Notice.  Answers to specific questions can be obtained by contacting customer service representatives at MassHealth and its individual managed care companies, or by reviewing information on EPSDT and uncovered services contained in the newly revised MassHealth Member Handbook and Provider Fact Sheet.


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