General Rate Provisions

(1) Rate Determination. Rates of payment for services for which 101 CMR 317.00 applies are the lowest of (a) the eligible provider's usual fee to patients other than publicly aided individuals; (b) the eligible provider's actual charge submitted; or (c) 1. the schedule of allowable fees set forth in 101 CMR 317.04(4), taking into account appropriate modifiers and any other applicable rate provision(s) in accordance with 101 CMR 317.03 or 317.04(1); or 2. for drugs, vaccines, and immune globulins administered in a physician’s office, the fee specified in 101 CMR 317.04(1)(a), taking into account any other applicable rate provision(s) in accordance with 101 CMR 317.04(1). (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): Rate Determination, 101 CMR 317.03(1), 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 317.04 establishes facility setting fees applied to services rendered in a facility when a practice site differential is warranted. (4) The sum of the professional and technical components of an individual procedure will not be greater than the allowable global fee set forth in 101 CMR 317.04(4). (5) Allowable Fee for Certain Eligible Providers. Payment for services provided by eligible providers who are certified nurse practitioners, psychiatric clinical nurse specialists, clinical nurse specialists, physician assistants, registered nurses, tobacco cessation counselors, pharmacies that utilize pharmacists, or other health care professionals certified in accordance with 105 CMR 700.000: Implementation of M.G.L. c. 94C, and home health agencies as specified in 101 CMR 317.02 is 85% of the fees contained in 101 CMR 317.04. 101 CMR 317.03(5) does not apply to the EPSDT add-on code S0302 described in 101 CMR 317.03(7) or for tobacco cessation services, for medical nutrition therapy (97802, 97803, 97804, G0270, G0271), for diabetes self- management training (G0108, G0109), for the administration of behavioral health or developmental screenings (96110, 96127, and related modifiers), or for the perinatal depression screening (S3005 and related modifiers) services listed in 101 CMR 317.04(4). The rates listed in 101 CMR 317.04(4) for tobacco cessation services performed by certain eligible providers already reflect the appropriate rate and no further rate adjustment applies (see codes 99407, 99407-SA, -TD, -TF, -HQ, -U1, -U2, and -U3). (6) Behavioral Health and Developmental Screening Services. Payment for the administration and scoring of standardized behavioral health and developmental screening tools is available to certain eligible providers (physicians, certified nurse midwives, certified nurse practitioners, physician assistants, community health centers, hospital outpatient departments, or such eligible providers employed by a physician or community health center if authorized by the governmental unit) and is allowed for MassHealth purchase only when accompanied by a modifier. Appropriate codes and related modifiers for the standardized behavioral health screening tools are listed in a separate fee table in 101 CMR 317.04(4). For purposes of these modifiers, “Behavioral health need identified” or “Developmental services need identified” means the provider administering the screening tool, in her or his professional judgment, identifies a child with a potential behavioral health or developmental services need. (7) Early and Periodic Screening, Diagnostic and Treatment (EPSDT) Add-on Code. To identify a completed well child office visit including all age-appropriate components of the EPSDT schedule, use code S0302 in addition to the appropriate preventive medicine service in 101 CMR 317.04(4). S0302 is always performed in addition to the primary procedure and must never be reported as a stand-alone code. (8) Services and Payments Covered Under Other Regulations. Rules and reimbursement rates for the Medicine service codes listed in the chart below are contained in other EOHHS regulations, except when an eligible provider that is a licensed physician is billing those codes in conjunction with a medical (non-routine) diagnosis code. Regulation Title Regulation Number Affected Services Rates for Hearing Services 101 CMR 323.00 Audiologic Codes 92590 to 92595 Rates for Vision Care Services and Ophthalmic Materials 101 CMR 315.00 Ophthalmological Service Codes 92002, 92004, 92012, 92014, 92015; Spectacle Service Codes 92340-92342, 92370 and Screening Code 99173 (9) CPT Category III Codes. All medicine-related CPT category III codes are included as a part of 101 CMR 317.00 and have an assigned fee of IC (10) PCC Plan Enhanced Fee. Primary Care Clinicians (PCCs) receive an enhanced rate for certain types of primary and preventive care visits provided to PCC Plan members enrolled with the PCC on the date of service. The enhanced fee specified in 101 CMR 353.03: General Payment Provisions 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. (11) Child and Adolescent Needs and Strengths (CANS): Psychiatric Diagnostic Interview Examination for Children and Adolescents Younger than 21 Years Old. Psychiatrists or psychiatric clinical nurse specialists who complete the CANS for a MassHealth child or adolescent younger than 21 years old during a Psychiatric Diagnostic Interview Examination should bill using procedure code 90791 accompanied by modifier HA.