General Rate Provisions

(1) Rate Determination. Rates of payment for services for which 101 CMR 316.00 applies are the lowest of (a) the eligible provider's usual fee to patients other than publicly aided patients; (b) the eligible provider's actual charge submitted; or (c) the allowable fees in accordance with 101 CMR 316.04 (for anesthesia services), or the schedule of allowable fees set forth in 101 CMR 316.05 (for surgical services), as applicable, and taking into account appropriate modifiers and any other applicable rate provision(s) in accordance with 101 CMR 316.03. (2) Supplemental Payment. (a) Eligibility. An eligible provider who is a physician, certified nurse practitioner, physician assistant, or CRNA is eligible for a supplemental payment for services to publicly aided individuals eligible under Titles XIX and XXI of the Social Security Act if the following conditions are met: 1. the eligible provider is employed by a nonprofit group practice that was established in accordance with St.1997 c.163 and is affiliated with a Commonwealth-owned medical school; 2. such nonprofit group practice must have been established on or before January 1, 2000, in order to support the purposes of a teaching hospital affiliated with and appurtenant to a Commonwealth-owned medical school; and 3. the services are provided at a teaching hospital affiliated with and appurtenant to a Commonwealth-owned medical school. (b) Payment Method. This supplemental payment may not exceed the difference between 1. payments to the eligible provider made pursuant to the rates applicable under 101 CMR 316.03(1), 101 CMR 317.03(1): Rate Determination, and 101 CMR 318.03(1): Rate Determination; and 2. the federal upper payment limit established by the Centers for Medicare & Medicaid Services. (3) Rate Variations Based on Practice Site. Payments for certain services provided by individual eligible providers that can be routinely furnished in physicians’ offices are reduced when such services are furnished in facility settings. 101 CMR 316.05 establishes facility setting fees applied to services rendered in a facility when a practice site differential is warranted. (4) Allowable Fee for Certain Eligible Providers. Payment for services provided by eligible providers who are certified nurse practitioners, clinical nurse specialists, psychiatric clinical nurse specialists, and physician assistants as specified in 101 CMR 316.02, is 85% of the fees contained in 101 CMR 316.05. (5) Global Surgical Package. The payment for a surgical procedure includes a standard package of preoperative, intraoperative, and postoperative services. Reimbursement for these procedures includes payment for services related to the surgery when furnished by the eligible provider who performs the surgery. The services included in the global surgical package may be furnished in any setting, e.g., in hospitals, ASCs, physicians' offices. Included in the global fee are preoperative period of one day for major surgery and the postoperative period of 90 days for major surgery, as determined by the Centers for Medicare & Medicaid Services (CMS). The postoperative period for minor surgery is either 0 or 10 days depending on the procedure, as determined by CMS. Visits to a patient in an intensive care or critical care unit are also included if made by the surgeon. (6) Obstetrical Services. Obstetrical fees contained in 101 CMR 316.05 are intended to include only the procedure or procedures performed and care to the publicly aided patient while hospitalized with the exception of global delivery (59400, 59510, 59610, 59618). Outpatient antepartum and postpartum obstetrical care may be billed under the appropriate medical procedure code in accordance with 101 CMR 317.00: Rates for Medicine Services. Medical problems complicating labor and delivery management or medical complications of pregnancy may require additional resources or services and should be identified by utilizing the appropriate procedure codes in 101 CMR 317.00: Rates for Medicine Services in addition to the procedure codes for maternity care listed in 101 CMR 316.05. (7) Casts and Appliances. All maximum allowable fees include the initial application of a cast, traction device, or similar appliance. (8) CPT Category III Codes. All surgery-related CPT category III codes are included as a part of 101 CMR 316.00 and have an assigned fee of I.C. (9) PCC Plan Enhanced Fee. Primary Care Clinicians (PCCs) receive an enhanced rate for certain types of primary and preventive care visits provided to their PCC Plan members enrolled with the PCC on the date of service. The enhanced fee specified in 101 CMR 353.03(A) is added to the rate for the procedure code billed. The MassHealth agency pays PCCs an enhanced fee for delivering primary care services in accordance with the terms of the PCC provider contract. (10) Primary Care ACO-participating PCPs Enhanced Fee. Primary Care ACO-participating Primary Care Providers (participating PCPs) receive an enhanced rate for certain types of primary and preventive care visits provided to Primary Care ACO members enrolled with the participating PCP on the date of service. The enhanced fee specified in 101 CMR 353.03(B) is added to the rate for the procedure code billed. The MassHealth agency pays participating PCPs an enhanced fee for delivering primary care services in accordance with the terms of the participating PCP contract. (11) Multiple Endoscopy Procedures. When multiple endoscopy procedures are performed through the same endoscope, payment is made for the endoscopy with the highest rate plus the difference between the next highest rate and the base endoscopy. When two related endoscopies and an unrelated endoscopy are performed, the special endoscopic payment rules apply to the related endoscopies. Unrelated endoscopic procedures are treated as a separate surgery and reimbursed using the payment rules for multiple surgery claims.