General Rate Provisions

(1) Services or Functions Included in the Rate. The approved rate includes payment for care and services or functions listed in 101 CMR 309.03(4) that are part of the PCA program under 130 CMR 422.401 through 130 CMR 422.423 subject only to the terms of the purchase agreement between the eligible provider and the purchasing governmental unit. (2) Reimbursement as Full Payment. Each eligible provider must, as a condition of acceptance of payment made by the purchasing governmental unit for services rendered, accept the approved program rate as full payment and discharge of all obligations for services rendered. Any third- party payments received on behalf of a publicly aided consumer will reduce, by that amount, the amount of the purchasing governmental unit’s obligation for services rendered to the consumer. (3) Payment Limitation. Except as provided in 101 CMR 309.03(2), no purchasing governmental unit may pay less than, or more than, the approved program rate. (4) Rates of Payment for PCM Functions Effective July 1, 2023. Code Modifier Rate Unit Description $265.41 Per Session Work related or medical disability examination by other than the treating physician that includes: completion of a medical history commensurate with the patient’s condition; performance of an examination commensurate with the patient’s condition; formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; development of future medical treatment plan; and completion of necessary documentation/certificates and report (initial evaluation of a member to determine the need, and extent of the need, for PCA services) (per evaluation). TS $152.54 Per Session Work related or medical disability examination by other than the treating physician that includes: completion of a medical history commensurate with the patient’s condition; performance of an examination commensurate with the patient’s condition; formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; development of future medical treatment plan; and completion of necessary documentation/certificates and report (code with modifier for reevaluations). Code Modifier Rate Unit Description T1023 $120.92 Per Session Screening to determine the appropriateness of consideration of an individual for participation in a specified program, project, or treatment protocol, per encounter (per session charge for intake and orientation services provided to a member who does not yet have PA for PCA services) (maximum three sessions). T2022 $58.99 Per Member per Month Case management per month. (Current PA for PCA services required for each member.) Use this code to bill administrative (per member per month). Bill code on the first of month. During a transfer, both PCM agencies may bill for the month the transfer took place (one-month limit). T2022 $0 Per Session Case management per month. (Current PA for PCA services required for each member.) Use to bill for required quarterly comprehensive (in person) functional skills training (FST) visits during the first year of approved PCA services. (Bill on the date FST was delivered.) (Bill code once in each calendar year quarter only.) Cannot be billed on the same date as T2022 U2, U3, U4, U5, or another unit of T2022 U1 was billed. T2022 $0 Per Session Case management per month. (Current PA for PCA services required for each member.) Use to bill for required annual comprehensive (in person) FST (limit one per year). (Bill on date FST was delivered.) Cannot be billed on the same date as T2022 U3, U4, U5, or another unit of T2022 U2 was billed. T2022 $0 Per Session Case management per month. (Current PA for PCA services required for each member.) Use to bill for FST (in person) within ten days of identifying a new surrogate. (Bill on date FST was delivered.) Cannot be billed on same date as T2022 U1, U2, U3, U4, or another unit of T2022 U5 was billed. May bill only once during a calendar year, regardless of multiple surrogate changes. This code does not apply to administrative proxy changes. T2022 $0 Per Session Case management per month. (Current PA for PCA services required for each member.) Use to bill for issue-focused (in person) FST. (Bill on date FST was delivered.) Cannot be billed on same date as T2022 U1, U2, U5, or another unit of T2022 U3 was billed. T2022 $0 Per Session Case management per month. (Current PA for PCA services required for each member.) Use to bill for issue-focused (telephone contact with FST delivery) FST. (Bill on date FST was delivered.) Cannot be billed on same date as T2022 U1, U2, or U5 was billed. (5) PCA Rates. The rates for PCA services consist of the employer expense component and the PCA wage component. (a) Rates. The rates of payment for PCA services are established in accordance with the provisions of any collective bargaining agreement under M.G.L. c. 150E and as authorized by the MassHealth program regulations at 130 CMR 422.413: Payment for PCA Services. (b) PCA Wage Component. Beginning on the effective date of a collective bargaining agreement, the PCA wage component is based on amounts established by the collective bargaining agreement. (c) Employer Expense Component. The employer expense component is the sum of the employer mandated contribution for each statutorily required tax and benefit. Each mandated contribution amount is calculated by multiplying the PCA wage component by the percentage required by statute, regulation, or other official document. EOHHS issues specific rates in an administrative bulletin that lists rates in time increments that conform to the definitions of the procedure codes authorized for payment by the MassHealth agency. The employer expense component for mandated employer expenses is subject to audit and may be adjusted in accordance with provisions of the fiscal intermediary contract with the purchasing agency.