Payments to Community Health Centers

(1) General Provisions. (a) The Health Safety Net pays community health centers based on claims submitted to the Health Safety Net office, less applicable cost sharing amount, in accordance with the requirements of 101 CMR 613.00: Health Safety Net Eligible Services and claims specifications determined by the Health Safety Net office. The Health Safety Net office monitors the volume of claims submitted and may adjust or withhold payments if it appears that there has been a substantial change in the provider's service delivery patterns, including, but not limited to, unbundling of services, upcoding, or other billing maximization activities. (b) The Health Safety Net will pay a community health center for prescribed drugs only if the community health center is providing prescribed drugs in accordance with 101 CMR 613.03(2): Reimbursable Health Services. (2) Payments for Services. (a) The Health Safety Net will pay community health centers a Medicare-based rate per patient per day for reimbursable health services unless otherwise specified by the table below. Payment will be either the PPS rate, or the total charges applicable under the PPS rate for services furnished, whichever is less. The PPS rate will be adjusted for geographic differences in the cost of services based on the Medicare FQHC PPS Geographic Adjustment Factors. In addition, the PPS rate will be increased according to 42 CFR 405.2467 when a community health center provides care to a patient that is new to the community health center or to a patient receiving a comprehensive initial visit or an annual wellness visit. (b) The PPS rate applies to individual medical visits, surgical procedures, behavioral health visits including individual diagnostic or treatment services, diagnostic vision care, medical nutrition therapy, diabetes self-management treatment, and tobacco cessation services. Only one visit per patient per day can be billed with the following exceptions: 1. when a behavioral health visit occurs on the same day as a medical visit; or 2. when an illness or injury necessitating a visit occurs on the same day as another visit. (c) For reimbursable health services not included in the PPS rate, the Health Safety Net pays community health centers according to the following table, except for claims for bad debt for urgent care services. Payments for such services are based on the corresponding regulations named in the table. Some reimbursable health services listed in the table may be payable as individual consideration in the regulations named. For individual consideration codes billable to the Health Safety Net, the payment rate is calculated as (total payments made to community health centers by MassHealth for the code) / (total number of claims paid to community health centers by MassHealth for the code) during the source year. If MassHealth payment and claims information for a code is not available for source year, the rate for the code will be based on Medicare fee schedules or other relevant sources. The Health Safety Net pays only for services listed in the HSN CHC Billable Procedure Codes list, in accordance with 101 CMR 613.03: Eligible Services Requirements. Type of Service Payment Rules Payment Source Medical Visit – Urgent Care Payable separately from an individual medical visit. 101 CMR 304.00: Rates for Community Health Centers Pulmonary diagnostic (technical component only) Payable separately only if not occurring on the same day as an individual medical visit. 101 CMR 317.00: Rates for Medicine Services Cardiology diagnostic (technical component only) Payable separately from an individual medical visit. 101 CMR 317.00: Rates for Medicine Services Obstetrical labor and delivery services Payable separately from an individual medical visit 101 CMR 316.00: Rates for Surgery and Anesthesia Services Behavioral health (group treatment, medication management, psychological testing, and methadone services) Payable separately from an individual medical visit. For group treatment and medication visits, rates in 101 CMR 306.00: Rates for Mental Health Services Provided in Community Health Centers and Mental Health Centers; for psychological testing, rates in 101 CMR 329.00: Psychological and Licensed Independent Behavioral Health Clinician Services; Type of Service Payment Rules Payment Source for methadone services, rates in 101 CMR 346.00: Rates for Certain Substance-Related and Addictive Disorders Programs Radiology Payable separately from an individual medical visit. 101 CMR 318.00: Rates for Radiology Services Clinical Laboratory Payable separately from an individual medical visit. 101 CMR 320.00: Rates for Clinical Laboratory Services Dental Payable separately from an individual medical visit. Lesser of allowable charges billed to the HSN, or fees established in 101 CMR 314.00: Rates for Dental Services 340B Pharmacy Services Payment will be reduced by the amount of patient cost-sharing, as applicable under 101 CMR 613.00: Health Safety Net Eligible Services. 101 CMR 331.00: Prescribed Drugs Vision Care (dispensing and repair) Payable separately from an individual medical visit. 101 CMR 315.00: Rates for Vision Care Services and Ophthalmic Materials Family Planning Services Family planning counseling, prescribed drugs, family planning supplies, and related laboratory tests are payable in addition to an individual medical visit. An individual medical visit is not payable for the sole purpose of replenishing a patient's supply of contraceptives. 101 CMR 312.00: Rates for Family Planning Services Preventive Services/Risk Factor Reduction (code 99402) Payable separately from an individual medical visit. 101 CMR 312.00: Rates for Family Planning Services Immunization Visits Payable separately only if not occurring on the same day as an individual medical visit. 101 CMR 317.00: Rates for Medicine Services Vaccines Not Included in the Individual Medical Visit or Payable separately from an individual medical visit. 101 CMR 317.00: Rates for Medicine Services Type of Service Payment Rules Payment Source Supplied by the Department of Public Health (3) Bad Debt Payments for Urgent Care Services. The Health Safety Net pays community health centers at 75% of the payment rates in 101 CMR 614.07(2) for bad debt claims for urgent care services that meet the requirements in 101 CMR 613.00: Health Safety Net Eligible Services. The Health Safety Net pays community health centers only for bad debt claims that are emergency bad debt or bad debt claims for urgent care services.