Rate Provisions

(1) Prospective Payment System (PPS) Methodology. (a) Medical and Behavioral Health PPS Rate for Existing Community Health Centers. Each community health center that is a federally qualified health center (FQHC), enrolled with MassHealth as a community health center as of June 30, 2021, has an individual medical and behavioral health PPS rate established using the community health center’s average total per- visit medical and behavioral health costs from calendar years 1999 and 2000, adjusted by reasonableness and inflated forward by the Medicare Economic Index (MEI). 1999 and 2000 per visit costs were adjusted for reasonableness by bounding PPS rates at the 50th and 75th percentile of 1999 and 2000 costs reported by community health centers that existed at the time and continue to be enrolled with MassHealth as community health centers as of June 30, 2021. The PPS rates for community health centers that were not so enrolled or did not have cost data in 1999 and 2000 were set at the mean PPS rate across all community health centers adjusted for reasonableness and carried forward by the MEI. Community health centers that experienced a change in scope of service, including a change in intensity, type, duration, or amount of service or service delivery that results in a material change in costs per visit will receive an adjustment to their PPS; provided that expenses associated with changes in scope of service may include, but are not limited to, capital expenses. (b) Dental PPS Rate for Existing Community Health Centers. Each community health center that is a FQHC, existing and providing dental services as of June 30, 2021, has an individual dental PPS rate calculated based on its 1999 and 2000 per visit dental costs, and adjusted for reasonableness, the MEI, and changes in scope, in the same manner as the adjustments to the medical and behavioral health PPS rate described in 101 CMR 304.04(1)(a). (c) PPS Rates for New Community Health Centers or Community Health Centers Newly Providing Dental Services. 1. An entity that becomes a community health center that is also a FQHC on or after July 1, 2021, will receive as its initial PPS rate the mean PPS rate of all Massachusetts community health centers that are FQHCs as of the date of the entity’s enrollment as a MassHealth community health center. The initial PPS rate will be effective through the end of the first full state fiscal year of operation as a MassHealth community health center. The community health center must provide EOHHS all relevant and requested cost data from the first year of operation as a community health center. EOHHS will then review the cost data to determine the community health center’s per visit costs, adjusting for reasonableness and bounding the per visit costs at not more than the highest PPS in effect for MassHealth community health centers as of the first day of the entity’s second full state fiscal year of enrollment as a community health center. The medical and behavioral health per visit costs, adjusted for reasonableness, will be the community health center’s individualized medical and behavioral health PPS rate. The dental per visit costs, if applicable, adjusted for reasonableness, will be the community health center’s individualized dental PPS rate. The individualized PPS rates will be effective for dates of service beginning on the first day of the second full state fiscal year of enrollment as a community health center, and will be adjusted thereafter in accordance with 101 CMR 304.04(1)(d). 2. A community health center that is newly providing dental services for the first time will be treated as a new community health center, in accordance with 101 CMR 304.04(1)(c)1., for the sole purpose of establishing a dental PPS rate. (d) PPS Adjustments. PPS rate adjustments occurring on or after January 1, 2022, include: 1. Annual MEI adjustments in effect for dates of services beginning January 1st of each year, as applied to the PPS rate in effect as of December 31st of the previous year. 2. Changes in scope of service adjustments, as follows: a. Community health centers that experienced a change in intensity, type, duration, or scope of service or service delivery that results in a material change in costs per visit may request adjustments to their PPS rates due to changes in scope of service, in a form and manner prescribed by EOHHS via administrative bulletin or other formal written issuance. b. Change in scope of services may result in adjustments up to the higher of 10% above the requesting community health center’s PPS rate in effect as of the date of the request or, if available, the 75th percentile of costs reported through the most recent cost reports submitted after January 1, 2021, by all community health centers as of the date of the request; provided that if no cost reports have been submitted since January 1, 2021, a maximum adjustment of up to 10% above the requesting community health center’s PPS rate in effect as of the date of the request will apply. c. Changes in scope of service may result in a PPS rate adjustment if the incremental change in cost per visit attributable to the changes in scope of service amounts to at least a 3% change in cost per visit as compared to the community health center’s PPS rate as of the date of the request. Request for scope changes may include cumulative changes for up to eighteen months. d. PPS rates effective January 1, 2022, incorporate changes in scope that were implemented on or before December 31, 2020. e. Change in scope adjustments to PPS rates must be approved by EOHHS in order to become effective and EOHHS may request additional information as necessary to evaluate the request. If approved, the PPS rate adjustment will be effective as of the date of the implementation of the most recent change in scope of service included in the request, which shall be no sooner than six months prior to the date of the request. (e) PPS Rate Adjustment Notification. Individual community health center PPS rates will be updated, as adjusted in accordance with 101 CMR 304.04(1)(d), at least annually and notices will be provided to each individual community health center each time the community health center’s PPS rate is adjusted. (f) Authority to Issue Additional Guidance. EOHHS may provide by administrative bulletin or other written issuance further detail on the PPS rate calculation methodology, appeals or dispute procedures, changes in scope of service eligible for PPS rate adjustments, or the process by which changes in scope of service are reviewed, considered, and determined. (2) Alternative Payment Methodology (APM). Through the APM, each community health center will be paid, in the aggregate as calculated on a quarterly basis, an amount at least equal to what the community health center would have received through the community health center’s individual PPS rates for medical and behavioral health visits and for dental visits. The total APM is inclusive of the claims-based APM payments and the reconciliation wrap APM payments, as such payments are described in 101 CMR 304.04(2). (a)1. Medical and Behavioral Health Services Fee Schedule. Code Allowable Fee Description Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (e.g., holidays, Saturday or Sunday), in addition to basic service (Bill this code for urgent care provided Monday through Friday from 5:00 P.M. to 6:59 A.M., and Saturday from 7:00 A.M. to Monday 6:59 A.M.) (This code may be billed in addition to the individual medical visit.) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; infant (age younger than one year) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures; early childhood (age one through four years) Code Allowable Fee Description Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures; late childhood (age five through 11 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures; adolescent (age 12 through 17 years) Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures; age 18 through 39 years Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; infant (age younger than one year) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; early childhood (age one through four years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; late childhood (age five through 11 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; age 18 through 39 years Code Allowable Fee Description Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, new patient (CDTM or MTM services, limit of 2 units per calendar year, telehealth permitted as appropriate) Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; initial 15 minutes, established patient (CDTM or MTM services, limit of 1 unit per visit and 6 units per calendar year, telehealth permitted as appropriate) Medication therapy management service(s) provided by a pharmacist, individual, face-to-face with patient, with assessment and intervention if provided; each additional 15 minutes (List separately in addition to code for primary service) (CDTM or MTM services, limit of 3 units per visit and 12 units per calendar year, telehealth permitted as appropriate) G0469 Federally qualified health center (FQHC) visit, mental health, new patient (individual mental health visit, new patient) G0470 Federally qualified health center (FQHC) visit, mental health, established patient (individual mental health visit, established patient) T1015 Clinic visit/encounter, all-inclusive (individual medical visit excludes laboratory and radiology) T1015- HQ Clinic visit/encounter, all-inclusive; group setting (group medical visit excludes laboratory and radiology) T1015- TH Clinic visit/encounter, all-inclusive; obstetrical treatment/services, prenatal or postpartum (nurse-midwife medical visit excludes laboratory and radiology) T1040 Medicaid certified community behavioral health clinic services, per diem (Clinic visit/behavioral health encounter, all-inclusive individual behavioral health visit) T1040- HQ Medicaid certified community behavioral health clinic services, per diem (Clinic visit/behavioral health encounter, all-inclusive behavioral health visit; group setting) G0511 Rural health clinic or federally qualified health center (RHC or FQHC) only, general care management, 20 minutes or more of clinical staff time for chronic care management services or behavioral health integration services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM), per calendar month (Behavioral health integration; applies to all MassHealth community health centers) Code Allowable Fee Description G0512 Rural health clinic or federally qualified health center (RHC or FQHC) only, psychiatric collaborative care model (psychiatric COCM), 60 minutes or more of clinical staff time for psychiatric COCM services directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM) and including services furnished by a behavioral health care manager and consultation with a psychiatric consultant, per calendar month (applies to all MassHealth community health centers) 2. EOHHS will calculate each community health center’s total medical and behavioral health claims-based APM amounts paid in each quarter by summing the community health center’s total amounts received for the services described in 101 CMR 304.04(2)(a)1., including claims paid through MassHealth fee-for-service and claims paid through MassHealth managed care, as those terms are defined in 130 CMR 501.001. This total quarterly medical and behavioral health claims-based APM amount is the amount used to determine the medical and behavioral health reconciliation wrap payment, calculated each quarter under 101 CMR 304.04(2)(c). (b) Dental Services Claims-based APM Payments. 1. Community health centers may bill 101 CMR 314.00 for dental services rendered in accordance with that regulation. In addition, community health centers may bill the dental enhancement fee established under 101 CMR 314.00 for each separate individual dental visit provided by the community health center; provided that the dental enhancement fee established under 101 CMR 314.00 will be increased by an amount that, when added to such dental enhancement fee, totals $110 when billed to MassHealth by community health centers for MassHealth members (the “CHC dental add-on”); and provided further that the dental enhancement fee and the CHC dental add-on may be billed not more than once per member per day. Hospital-licensed health centers are not eligible for the CHC dental add-on. 2. EOHHS will calculate each community health center’s total MassHealth dental claims-based APM amounts paid in each quarter by summing the community health center’s quarterly MassHealth dental claims paid under 101 CMR 314.00, including dental MassHealth fee-for-service paid claims, claims paid through MassHealth managed care, as defined in 130 CMR 501.001, paid dental enhancement fees, and the quarterly CHC dental add-on paid claims. This total quarterly dental claims-based APM amount is the amount used to determine the dental reconciliation wrap payment, calculated each quarter under 101 CMR 304.04(2)(c). (c) Reconciliation Wrap APM Payments. For each calendar quarter, MassHealth will provide required reconciliation wrap APM payments to community health centers that are Federally Qualified Health Center for the purposes of 42 U.S.C. § 1396a(bb) and that are not hospital licensed health centers. 1. A reconciliation wrap APM payment is required up to the medical and behavioral health PPS, if a community health center’s total quarterly MassHealth medical and behavioral health claims-based APM payments described under 101 CMR 304.04(2)(a)2. are less than what the community health center would have received if it had been paid for such services on a per visit basis through its individual medical and behavioral health PPS rate. Such reconciliation wrap APM payment will equal the difference between the total MassHealth quarterly medical and behavioral health claims-based APM payments and what would have been paid for MassHealth medical and behavioral health visits through the medical and behavioral health PPS rate, in the aggregate, in the calendar quarter. For the purposes of calculating the medical and behavioral health reconciliation wrap APM payment, “visit” will include all individual medical visits, individual mental health visits, individual behavioral health visits, nurse-midwife medical visits, group medical visits, and group behavioral health visits; provided however, that group medical visits and group behavioral health visits will amount to 20% of a visit. 2. A reconciliation wrap APM payment is required for the dental PPS if a community health center’s total MassHealth quarterly dental claims-based APM payments described under 101 CMR 304.04(2)(b)2., are less than what the community health center would have received if it had been paid for such services on a per visit basis through its individual dental PPS rate. Such reconciliation wrap APM payment will equal the difference between the total MassHealth quarterly dental claims-based APM payments and what would have been paid for MassHealth dental visits through the dental PPS rate, in the aggregate, in the calendar quarter. For the purposes of calculating the dental reconciliation wrap APM payment, “visit” will include all individual dental visits. 3. EOHHS will issue an administrative bulletin or other written issuance to clarify or provide further detail on this reconciliation wrap payment process, including but not limited to clarifying the codes corresponding to counting the relevant medical and behavioral health visits and individual dental visits. (3) Other Community Health Center Services. The rates of payment for other community health center services provided to publicly aided individuals and industrial accident patients are based on the applicable regulation and rates of payment for the specific care and services rendered as issued by EOHHS or the governmental unit or purchaser under M.G.L. c. 152 where the schedules of such governmental unit or purchaser under M.G.L. c. 152 have not been superseded by 101 CMR 304.00. Such care and services include, but are not limited to, those furnished by pharmacies, independent clinical laboratories, optometrists, opticians, podiatrists, and other individual practitioners and noninstitutional providers. (4) 340B Transition Supplemental Payments. Subject to federal approval, eligible community health centers will receive monthly supplemental payments in accordance with 101 CMR 304.04(4). (a) Eligibility for the Supplemental Payments. 1. Community health centers for which the calendar year 2016 gross margin earned on drugs purchased through the 340B Drug Pricing Program, as reported to the Center for Health Information and Analysis, is greater than the projected annual impact of the medical visit rate effective October 20, 2017, determined in accordance with 101 CMR 304.04(4)(c)3., will receive supplemental payments in accordance with 101 CMR 304.04(4). 2. Community health centers for which the calendar year 2016 gross margin earned on drugs purchased through the 340B Drug Pricing Program, as reported to the Center for Health Information and Analysis, is lower than or equal to the projected annual impact of the medical visit rate effective October 20, 2017, determined in accordance with 101 CMR 304.04(4)(c)3., will not receive supplemental payments in accordance with 101 CMR 304.04(4). (b) Frequency and Duration of Supplemental Payments. 1. Supplemental payments will be made to eligible community health centers on a monthly basis. 2. Supplemental payments will be made for 75 months, beginning with October 2017. (c) Calculation of Monthly Supplemental Payment Amounts for the First 12 Months of Payment. For each of the 12 months beginning with October 2017, a monthly supplemental payment will be made to eligible community health centers in an amount calculated in accordance with 101 CMR 304.04(4)(c). The amount of the monthly supplemental payment is calculated for each eligible community health center as follows: 1. Historical annual medical visit rate revenue is determined from claims data submitted by the community health center and MassHealth managed care organizations. 2. Projected annual medical visit rate revenue is calculated for the 12-month period beginning October 1, 2017, using the medical visit rate effective October 20, 2017, and medical visit claims and encounters, excluding behavioral health claims and encounters, including claims billed directly to the MassHealth Medicaid Management Information System (MMIS) by community health centers for state fiscal year 2015 and MassHealth managed care organization encounters for federal fiscal year 2016. 3. Projected annual impact of the medical visit rate effective October 20, 2017, is determined by subtracting historical annual medical visit rate revenue determined in accordance with 101 CMR 304.04(4)(c)1. from projected annual medical visit rate revenue determined in accordance with 101 CMR 304.04(4)(c)2. 4. Projected annual impact of the medical visit rate effective October 20, 2017, determined in accordance with 101 CMR 304.04(4)(c)3. is subtracted from calendar year 2016 gross margin earned on drugs purchased through the 340B Drug Pricing Program, as reported to the Center for Health Information and Analysis. 5. The projected annual medical visit rate revenue determined in accordance with 101 CMR 304.04(4)(c)2. is multiplied by 0.75. 6. The lower of the amount calculated in accordance with 101 CMR 304.04(4)(c)4. and the amount calculated in accordance with 101 CMR 304.04(4)(c)5. is divided by 12 to determine the community health center’s monthly supplemental payment amount for the 12 months beginning with October 2017. (d) Calculation of Monthly Supplemental Payment Amounts for Subsequent Months. For the 63 months beginning with October 2018, monthly supplemental payments will be made to eligible community health centers in an amount calculated in accordance with 101 CMR 304.04(4)(d). Monthly supplemental payment amounts are calculated for each eligible community health center in accordance with the following. 1. The community health center’s average monthly supplemental payment amount for the 27 months beginning with October 2018 is equivalent to the community health center’s monthly supplemental payment amount for the 12 months beginning with October 2017 calculated in accordance with 101 CMR 304.04(4)(c)6. 2. The community health center’s average monthly supplemental payment amount for the 12 months beginning with January 2021 is the product of the community health center’s monthly supplemental payment amount for the 12 months beginning with October 2017 calculated in accordance with 101 CMR 304.04(4)(c)6. and 0.75. 3. The community health center’s average monthly supplemental payment amount for the 12 months beginning with January 2022 is the product of the community health center’s monthly supplemental payment amount for the 12 months beginning with October 2017 calculated in accordance with 101 CMR 304.04(4)(c)6. and 0.50. 4. The community health center’s average monthly supplemental payment amount for the 12 months beginning with January 2023 is the product of the community health center’s monthly supplemental payment amount for the 12 months beginning with October 2017 calculated in accordance with 101 CMR 304.04(4)(c)6. and 0.25. (e) Impact on Allowable Fees in Subsequent Periods. Subject to promulgation of further rate setting regulations as may be necessary to implement this provision, for each of the four 12- month periods beginning in or around January 2021, January 2022, January 2023, and January 2024, the allowable fees described in 101 CMR 304.04(2)(a) will be increased such that aggregate expenditures for such allowable fees in each period will increase over such expenditures from the previous 12-month period by 25 % of the amount of aggregate expenditures for the 340B transition supplemental payments, as determined by EOHHS, in the 12-month period beginning October 2017 described in 101 CMR 304.04(4)(c), based on projected utilization, as determined by EOHHS. (f) Authority to Issue Additional Guidance. EOHHS reserves the right to issue an administrative bulletin on these supplemental payment provisions including, but not limited to, an administrative bulletin to implement changes in the payment amounts and dates to account for any period during which 101 CMR 304.00 is in effect and MassHealth Managed Care Organizations (MCOs) continue to cover 340B drugs for MassHealth members.