Rate Provisions

(1) Services Included in the Rate. The approved rate includes payment for all care and services that are part of the program of services of an eligible provider, as explicitly set forth in the terms of the purchase agreement between the eligible provider and the purchasing governmental unit(s). (2) Reimbursement as Full Payment. Each eligible provider must, as a condition of acceptance of payment made by any purchasing governmental units for services rendered, accept the approved program rate as full payment and discharge of all obligations for the services rendered. Payment from any other sources will be used to offset the amount of the purchasing governmental unit's obligation for services rendered to the publicly assisted client. (3) Payment Limitations. No purchasing governmental unit may pay less than or more than the approved program rate, except as provided in 101 CMR 346.04(2) and (6). (4) Administrative Adjustment for Extraordinary Circumstances. A method whereby, subject to availability of funds, a purchasing governmental unit may provide additional resource allocations to a qualified provider in response to unusual and unforeseen circumstances that substantially increase the cost of service delivery in ways not contemplated in the development of current rates. It must be demonstrated that such cost increases gravely threaten the stability of service provision such that client or consumer access to necessary services is at risk. The purchasing governmental unit will evaluate the need for the administrative adjustment, determine whether funding is available, and convey that information to EOHHS for review to determine the amount of any adjustment. (5) Approved Rates. The approved rate is the lower of the provider’s charge or amount accepted as payment from another payer or the rate listed in 101 CMR 346.04(5). Refer to purchasers' manuals for special coding instructions and limitations on the number of units. Code Rate Description Inpatient Services H0010 Alcohol and/or drug services; subacute detoxification (residential addiction program inpatient) (Clinically Managed Detoxification Services) H0011 Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) (Medically Monitored Inpatient Detoxification Services Facility) H0011-H9 Alcohol and/or drug services; acute detoxification (residential addiction program inpatient) (court ordered) (Treatment for Civilly Committed Persons Add-on) Residential Services H0018 Behavioral health; short-term residential (nonhospital residential treatment program), per diem (Transitional Support Services) H0018-H9 Behavioral health; short-term residential (nonhospital residential treatment program), per diem (court ordered) (Second Offender-driver Alcohol Education Residential) H0019 Alcohol and/or drug abuse halfway house services, per diem (Residential Rehabilitation), without room and board. H0019-TH Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem (pregnant/parenting individuals’ program) (Pregnant Enhancement for Residential Rehabilitation and Co-occurring Enhanced Residential Rehabilitation) H0019-HD Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem (obstetrical treatment/services, prenatal or postpartum) Code Rate Description (Postpartum Enhancement for Residential Rehabilitation and Co-occurring Enhanced Residential Rehabilitation) H0019-HV Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem (Residential Rehabilitation Child Enhancement) H0019-H9 Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem (court ordered) (Jail Diversion-Phase I) H0006-H9 Alcohol and/or drug services; case management (court ordered) (Jail Diversion-Phase II, per hour) H0019-HR Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem (family/couple with client present) (Family Supportive Housing) H0019-HR Behavioral health; long-term residential (nonmedical, nonacute care in a residential treatment program where stay is typically longer than 30 days), without room and board, per diem (substance abuse program) (Family Residential Treatment) H0047-HR Alcohol and/or drug abuse services, not otherwise specified (family/couple with client present) (Family Residential 2nd Partner Enhancement, per diem) H0019-HH Alcohol and/or drug abuse halfway house services, per diem (Residential Rehabilitation Co-occurring Enhanced for 16 beds) Opioid Treatment Services Medical Services Visit G2067 Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare- enrolled Opioid Treatment Program) G2068 Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare- enrolled Opioid Treatment Program) G2073 $1,838.90 Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology Code Rate Description testing if performed (provision of the services by a Medicare- enrolled Opioid Treatment Program) G2074 Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) G2076 Intake activities, including initial medical examination that is a complete, fully documented physical evaluation and initial assessment by a program physician or a primary care physician, or an authorized healthcare professional under the supervision of a program physician or qualified personnel that includes preparation of a treatment plan that includes the patient’s short-term goals and the tasks the patient must perform to complete the short-term goals; the patient’s requirements for education, vocational rehabilitation, and employment; and the medical, psycho-social, economic, legal, or other supportive services that a patient needs, conducted by qualified personnel (provision of the services by a Medicare- enrolled Opioid Treatment Program); list separately in addition to code for primary procedure G2078 Take-home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare-enrolled Opioid Treatment Program); list separately in addition to code for primary procedure. G2079 Take-home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a Medicare-enrolled Opioid Treatment Program); list separately in addition to code for primary procedure. H0020 Alcohol and/or drug services; methadone administration and/or service (provision of the drug by a licensed program) (dose only visit) S1001 Support improved access to MOUD, including methadone, for nursing facility residents with SUDs; allows OTPs to work more closely with nursing facilities to deliver medications directly to residents and reduce the need for daily resident transportation to OTPs Counseling H0004-TF Behavioral health counseling and therapy, per 15 minutes (opioid individual counseling, intermediate level of care, four units maximum per day) H0005-HQ Alcohol and/or drug services; group counseling by a clinician (group setting) (per 45 minutes, opioid group counseling, one unit maximum per day) Code Rate Description H0005-HF Alcohol and/or drug services; group counseling by a clinician (per 90-minute unit) (one unit maximum per day) T1006-HR Alcohol and/or substance abuse services, family/couple counseling (family/couple with client present) (opioid family/couples counseling, per 30 minutes, one unit maximum per day) T1006-HG Alcohol and/or substance abuse services, family/couple counseling (family/couple with client present) (opioid family/couples counseling, per 60 minutes, one unit maximum per day) Ambulatory Services Outpatient Counseling 90882-HF Environmental intervention for medical management purposes on a psychiatric patient’s behalf with agencies, employers, or institutions (substance abuse program) (Consultation with another professional or involved party to clarify and coordinate the treatment of an individual receiving substance- related and addictive disorders treatment services, case consultation, per 30 minutes) H0001 Alcohol and/or drug assessment (per 15 minutes) H0004 Behavioral health counseling and therapy, per 15 minutes (individual counseling) H0005 Alcohol and/or drug services; group counseling by a clinician (per 45 minutes, group counseling, one unit maximum per day) H0005-HG Alcohol and/or drug services group counseling by a clinician (methadone/opioid counseling) (per 90-minute unit) (one unit maximum per day) T1006 See 101 CMR 306.00: Rates for Mental Health Services Provided in Community Health Centers and Mental Health Centers (code 90847) Alcohol and/or substance abuse services; family/couple counseling (per 30 minutes, one unit maximum per day) T1006-HF See 101 CMR 306.00: Rates for Mental Health Services Provided in Community Health Centers and Mental Health Centers (code 90847) Alcohol and/or substance abuse services; family/couple counseling (per 60 minutes, one unit maximum per day) H2019-HF Therapeutic behavioral services, per 15 minutes (substance abuse program) (in-home counseling by a clinician) H2027 Psychoeducational service, per 15 minutes (Educational and motivational nonclinical group, per client) H2016-HM Comprehensive community support program, per diem (Enrolled Client Day) (recovery support service by a recovery advocate trained in Peer Recovery Coaching) Clinical Case Management H0006-HO Alcohol and/or drug services; case management (Substance- related and addictive disorders service by master’s level clinician that uses an evidence-based model that integrates clinical and case management services, per 15 minutes) H0006-HN Alcohol and/or drug services; case management (Substance- related and addictive disorders service by non-master’s level counselor to engage and link client to treatment and community resources, per 15 minutes) H0001-H9 Alcohol and/or drug assessment (court ordered) (per 15 minutes) H0004-H9 Behavioral health counseling and therapy, per 15 minutes (court ordered) (individual counseling) H0005-H9 Alcohol and/or drug services; group counseling by a clinician (court ordered) (per 15 minutes) Day Treatment H2012-HF Behavioral health day treatment (substance abuse program) (3.5 hours) Outpatient Services H0004-HD Behavioral health counseling and therapy, per 15 minutes (pregnant/parenting women's program) (individual counseling) H0005-HD Alcohol and/or drug services; group counseling by a clinician (pregnant/parenting women's program) (per 45 minutes, group counseling, one unit maximum per day) H0005-TH Alcohol and/or drug services group counseling by a clinician (pregnant/parenting women’s program) (per 90-minute unit) (one unit maximum per day) H0006-HD Alcohol and/or drug services; case management (pregnant/parenting women's program) (per 15 minutes) T1006-HD See 101 CMR 306.00: Rates for Mental Health Services Provided in Community Health Centers and Mental Health Centers (code 90847) Alcohol and/or substance abuse services; family/couple counseling (pregnant/parenting women's program) (per 30 minutes, one unit maximum per day) Outpatient Services T1006-TH See 101 CMR 306.00: Rates for Mental Health Services Provided in Community Health Centers and Mental Health Centers (code 90847) Alcohol and/or substance abuse services; family/couple counseling (pregnant/parenting women's program) (per 60 minutes, one unit maximum per day) Day Treatment H1005 Prenatal care, at-risk enhanced service package (includes H1001-H1004) (prenatal care, at-risk enhanced service, antepartum management, care coordination, education, follow- up home visit, individual counseling, per hour) H1005-HQ Prenatal care, at-risk enhanced service package (includes H1001-H1004) (group setting) (prenatal care, at-risk enhanced service, antepartum management, care coordination, education, follow-up home visit, day treatment, per 3.5 hours) Supportive Case Management Services Unit Rate Service Enrolled Client Day Adult Housing Stability Support Enrolled Client Day Family Housing Stability Support Enrolled Client Day Youth Housing Stability Support Month House Manager Add-on Month Outreach and Staffing Supports Enrolled Client Day Low Threshold N/A IC Extraordinary Circumstances/Flex Funding Month School-based Targeted Prevention Program Program Model Unit Base Rate Engagement Staffing Rate Engagement Staffing Rate, Day Program only Triage, Engagement, and Assessment Services A Monthly per slot $690 $355 B Monthly per slot $933 $583 Triage, Engagement, and Assessment Services Add-on Rates Unit Rate Peer Service Coordinator Add-on Rate Hourly Social Worker LCSW Add-on Rate Hourly Care Coordinator Add-on Rate Hourly Direct Care Staff Add-on Rate Hourly Support Staff Add-on Rate Hourly Service Unit Monthly Rate Federally Qualified Health Centers (FQHCs) Services Per Client Office-based Opioid Treatment Programs (OBOTs) Outpatient Clinic Services Per Client Office-based Opioid Treatment Programs (OBOTs) Hospital Services Per Client Service Level Monthly Rate Federally Qualified Health Centers (FQHCs) Start- up Level 1 Level 2 Service Tier Monthly Rate Recovery Support Centers Tier 1 Tier 2 Tier 3 Recovery Support Center Add-on Rates FTE Monthly Rate Direct Service Staff Add-on Rate 1.0 Direct Service Staff Add-on Rate 0.5 Recovery Coach Specialist Staff Add-on Rate 1.0 Recovery Coach Specialist Staff Add-on Rate 0.5 (6) Pay for Performance (P4P) Incentive Payments. Subject to a purchasing governmental unit’s determination of the availability of funds, P4P providers receive incentive payments through the Pay for Performance (P4P) Program as defined by the purchasing governmental unit and as follows. (a) Performance Indicators. Each performance indicator is calculated to produce aggregate numbers that will be used to establish baseline information, attainment thresholds, and performance benchmarks, relative to the distribution of P4P eligible providers. Performance indicator rates are calculated by dividing the numerator by the denominator for each measure to obtain a percentage. A measure’s denominator is the number of clients served by a P4P eligible provider who are eligible for the performance measure and the numerator is the subset of the denominator who meet the measure’s specific performance criteria. (b) Payment Eligibility. To be eligible for payment for a performance indicator, a P4P eligible provider must 1. be an eligible provider as of a certain date, the date to be established by the purchasing governmental unit on an annual basis; and 2. have a minimum number (minimum to be established by the purchasing governmental unit) of clients who must meet specific performance indicator criteria during the date range for which performance is being measured. (c) Performance Score. For each performance indicator for which the P4P eligible provider is eligible per 101 CMR 346.04(6), P4P eligible providers will earn points for either achieving a benchmark or for improving their performance over their previous year’s performance. Points will be awarded to a P4P eligible provider for each indicator, according to the methodologies in 101 CMR 346.04(6)(c). 1. Attainment Points. P4P eligible providers may earn points based on where the P4P eligible provider’s performance falls, relative to the attainment threshold and to the benchmark set for each performance indicator. The attainment threshold is set at the median of all P4P eligible providers’ performance rates. The benchmark is set at the 75th percentile of all P4P eligible providers’ performance rates. P4P eligible providers will receive attainment points between the range of zero and ten for each performance indicator, as noted in 101 CMR 346.04(6)(c). a. If a P4P eligible provider’s performance rate is below the attainment threshold, it will receive zero attainment points. b. If a P4P eligible provider’s performance rate is greater than or equal to the benchmark, it will receive ten attainment points. c. If a P4P eligible provider’s performance rate is below the benchmark, but at or above the attainment threshold, the P4P eligible provider will receive anywhere from one to up to, but less than, ten attainment points, as calculated using the following formula. P4P Eligible Provider’s Attainment Points = ) ( ) ( ) ( ) ' ( +    − −   Threshold Attainment Rate Benchmark Threshold Attainment Rate e Performanc s ATP 2. Improvement Points. P4P eligible providers may earn improvement points if the P4P eligible provider has demonstrated improvement from its previous year’s performance rate. The P4P eligible provider’s improvement points will be calculated based on the following formula. P4P Eligible Provider’s Improvement Points = ) Pr ' ( ) ( ) Pr ' ( ) ' (    − −   Rate e Performanc Year evious s ATP Rate Benchmark Rate e Performanc Year evious s ATP Rate e Performanc s ATP 3. P4P Eligible Provider Awarded Points. For each performance indicator, the awarded points are the higher of the attainment or improvement points earned by the P4P eligible provider. In no event will the number of points awarded exceed ten for each performance indicator. Each performance indicator’s awarded points are then summed across all the indicators a P4P eligible provider is eligible for to determine the total awarded points for a P4P eligible provider. P4P Eligible Provider’s Awarded Points = (Points Awarded Indicator 1) + (Points Awarded Indicator 2) + ………(Points Awarded Indicator N) 4. P4P Eligible Provider Potential Points. The total potential points for a P4P eligible provider is determined by multiplying the number of performance indicators the P4P eligible provider is eligible for (see 101 CMR 346.04(6)) by the maximum number of points per performance indicator (10). Potential Points = (Number of Performance Indicators for which a P4P Eligible Provider is Eligible) X 10 5. P4P Eligible Provider Performance Score. The P4P eligible provider’s performance score reflects a percentage between 0% and 100%. The P4P eligible provider awarded points is divided by the P4P eligible provider potential points to obtain the P4P eligible provider performance score based on the following formula. P4P Eligible Provider Performance Score = (P4P Eligible Provider Awarded Points) / (P4P Eligible Provider Potential Points) (d) Per Client Payment Amount. The per client payment amount is determined as follows. The per client payment amount is determined by dividing the aggregate dollar figure determined by the purchasing governmental unit(s) to be available for incentive payments by the statewide adjusted clients calculated as described below. Per Client Payment Amount = Aggregate Dollar Amount Available for Incentive Payments Statewide Adjusted Clients 1. Statewide Adjusted Clients. The statewide adjusted clients figure is calculated by summing over all P4P eligible providers, each P4P eligible provider’s adjusted clients number. Statewide Adjusted Clients = (P4PEP 1 Adjusted Clients) + (P4PEP 2 Adjusted Clients) + …… (P4PEP N Adjusted Clients) 2. P4P Eligible Provider Adjusted Clients. Each P4P eligible provider’s number of clients served during the measurement period is multiplied by the P4P eligible provider’s performance score to derive the “adjusted clients” figure. (e) P4P Eligible Provider Total Performance Indicator Payment Amount. A P4P eligible provider’s performance indicator incentive payment is calculated as the product of 1. the P4P eligible provider’s performance score calculated as per 101 CMR 346.04(6)(c); 2. the number of P4P eligible provider clients served during the measurement period; and 3. the per client payment amount that is calculated as per 101 CMR 346.04(6)(d). P4P Eligible Provider Total Performance Indicator Payment Amount = (P4P Eligible Provider Performance Score) x (number of P4P Eligible Provider clients served) x (Per Client Payment Amount) (7) Publicly Assisted Client Mix Factor for Certain Services with Rates Established at 101 CMR 346.00. The publicly assisted client mix factor described in 101 CMR 346.04(7) is effective for dates of service on and after July 1, 2025, and applies as described in 101 CMR 346.04(7)(a) through (d). (a) Calculation of Publicly Assisted Client Mix. The publicly assisted client mix is an individual provider’s bed days attributable to publicly assisted clients divided by the total bed days for clinically managed detoxification services and medically monitored inpatient detoxification services described at 101 CMR 346.04(7)(c) and expressed as a percentage of publicly assisted client bed days. For the purposes of 101 CMR 346.04(7), “bed day” means a date of service, or portion thereof, during which a service recipient is inpatient and on which the provider furnishes the inpatient services described at 101 CMR 346.04(7)(c). (b) Applicable Provider Rate. The applicable rate for each provider of services described at 101 CMR 346.04(7)(c) is based on each provider's publicly assisted client mix calculated in accordance with 101 CMR 346.04(7)(a) and as determined by EOHHS. Applicable provider rates are as follows: 1. Base Rate: the rate established at 101 CMR 346.04(5) 2. Tier 1 Rate: the base rate multiplied by a publicly assisted client mix factor of 1.05 3. Tier 2 Rate: the base rate multiplied by a publicly assisted client mix factor of 1.07 (c) Rates for Certain Inpatient Services Subject to Publicly Assisted Client Mix Factor. The publicly assisted client mix factors with associated applicable provider rates described at 101 CMR 346.04(7)(b) apply to the following inpatient services with rates established at 101 CMR 346.04(5): 1. H0011 (medically monitored inpatient detoxification services facility); and 2. H0010 (clinically managed detoxification services). (d) Administrative Bulletins. EOHHS may issue administrative bulletins to establish the period and source of data used by EOHHS to determine the publicly assisted client mix in accordance with 101 CMR 346.04(7)(a); the criteria for the applicable provider rate, including the publicly assisted client mix that is attributable to each applicable provider rate in accordance with 101 CMR 346.04(7)(b); and to clarify substantive provisions of 101 CMR 346.04(7).