(1)
Prospective Payment System (PPS) Methodology.
(a)
Medical and Behavioral Health
PPS Rate for Existing Community Health Centers. Each community
health center that is a federally qualified health center (FQHC), enrolled with
MassHealth as a community health center as of June 30, 2021, has an individual
medical and behavioral health PPS rate established using the community health
center's average total per-visit medical and behavioral health costs from
calendar years 1999 and 2000, adjusted by reasonableness and inflated forward
by the Medicare Economic Index (MEI). 1999 and 2000 per visit costs were
adjusted for reasonableness by bounding PPS rates at the
50th and 75th percentile
of 1999 and 2000 costs reported by community health centers that existed at the
time and continue to be enrolled with MassHealth as community health centers as
of June 30, 2021. The PPS rates for community health centers that were not so
enrolled or did not have cost data in 1999 and 2000 were set at the mean PPS
rate across all community health centers adjusted for reasonableness and
carried forward by the MEI. Community health centers that experienced a change
in scope of service, including a change in intensity, type, duration, or amount
of service or service delivery that results in a material change in costs per
visit will receive an adjustment to their PPS; provided that expenses
associated with changes in scope of service may include, but are not limited
to, capital expenses.
(b)
Dental PPS Rate for Existing Community Health Centers.
Each community health center that is a FQHC, existing and providing dental
services as of June 30, 2021, has an individual dental PPS rate calculated
based on its 1999 and 2000 per visit dental costs, and adjusted for
reasonableness, the MEI, and changes in scope, in the same manner as the
adjustments to the medical and behavioral health PPS rate described in
101
CMR 304.04(1)(a).
(c)
PPS Rates for New Community
Health Centers or Community Health Centers Newly Providing Dental
Services.
1. An entity that
becomes a community health center that is also a FQHC on or after July 1, 2021,
will receive as its initial PPS rate the mean PPS rate of all Massachusetts
community health centers that are FQHCs as of the date of the entity's
enrollment as a MassHealth community health center. The initial PPS rate will
be effective through the end of the first full state fiscal year of operation
as a MassHealth community health center. The community health center must
provide EOHHS all relevant and requested cost data from the first year of
operation as a community health center. EOHHS will then review the cost data to
determine the community health center's per visit costs, adjusting for
reasonableness and bounding the per visit costs at not more than the highest
PPS in effect for MassHealth community health centers as of the first day of
the entity's second full state fiscal year of enrollment as a community health
center. The medical and behavioral health per visit costs, adjusted for
reasonableness, will be the community health center's individualized medical
and behavioral health PPS rate. The dental per visit costs, if applicable,
adjusted for reasonableness, will be the community health center's
individualized dental PPS rate. The individualized PPS rates will be effective
for dates of service beginning on the first day of the second full state fiscal
year of enrollment as a community health center, and will be adjusted
thereafter in accordance with
101
CMR 304.04(1)(d).
2. A community health center that is newly
providing dental services for the first time will be treated as a new community
health center, in accordance with
101
CMR 304.04(1)(c)1., for the
sole purpose of establishing a dental PPS rate.
(d)
PPS Adjustments.
PPS rate adjustments occurring on or after January 1, 2022, include:
1. Annual MEI adjustments in effect for dates
of services beginning January 1st of each year, as
applied to the PPS rate in effect as of December
31st of the previous year.
2. Changes in scope of service adjustments,
as follows:
a. Community health centers that
experienced a change in intensity, type, duration, or scope of service or
service delivery that results in a material change in costs per visit may
request adjustments to their PPS rates due to changes in scope of service, in a
form and manner prescribed by EOHHS via administrative
bulletin or other formal written issuance.
b. Change in scope of services may result in
adjustments up to the higher of 10% above the requesting community health
center's PPS rate in effect as of the date of the request or, if available, the
75th percentile of costs reported through the most
recent cost reports submitted after January 1, 2021, by all community health
centers as of the date of the request; provided that if no cost reports have
been submitted since January 1, 2021, a maximum adjustment of up to 10% above
the requesting community health center's PPS rate in effect as of the date of
the request will apply.
c. Changes
in scope of service may result in a PPS rate adjustment if the incremental
change in cost per visit attributable to the changes in scope of service
amounts to at least a 3% change in cost per visit as compared to the community
health center's PPS rate as of the date of the request. Request for scope
changes may include cumulative changes for up to 18 months.
d. PPS rates effective January 1, 2022,
incorporate changes in scope that were implemented on or before December 31,
2020.
e. Change in scope
adjustments to PPS rates must be approved by EOHHS in order to become effective
and EOHHS may request additional information as necessary to evaluate the
request. If approved, the PPS rate adjustment will be effective as of the date
of the implementation of the most recent change in scope of service included in
the request, which shall be no sooner than six months prior to the date of
request.
(e)
PPS Rate Adjustment Notification. Individual community
health center PPS rates will be updated, as adjusted in accordance with
101
CMR 304.04(1)(d), at least
annually and notices will be provided to each individual community health
center each time the community health center's PPS rate is adjusted.
(f)
Authority to Issue Additional
Guidance. EOHHS may provide by administrative bulletin or other
written issuance further detail on the PPS rate calculation methodology,
appeals or dispute procedures, changes in scope of service eligible for PPS
rate adjustments, or the process by which changes in scope of service are
reviewed, considered, and determined.
(2)
Alternative Payment
Methodology (APM). Through the APM, each community health center
will be paid, in the aggregate as calculated on a quarterly basis, an amount at
least equal to what the community health center would have received through the
community health center's individual PPS rates for medical and behavioral
health visits and for dental visits. The total APM is inclusive of the
claims-based APM payments and the reconciliation wrap APM payments, as such
payments are described in
101
CMR 304.04(2).
(a)
1.
Medical and Behavioral Health Services Fee
Schedule.
|
Code |
Allowable
Fee |
Description |
|
99050 |
$52.38 |
Services provided in the office at times other than
regularly scheduled office hours, or days when the office is normally closed
(e.g., holidays, Saturday or Sunday), in addition to basic
service (Bill this code for urgent care provided Monday through Friday from
5:00 P.M. to 6:59 A.M., and Saturday from 7:00 A.M. to Monday 6:59 A.M.) (This
code may be billed in addition to the individual medical visit.) |
|
99381 |
$222.00 |
Initial comprehensive preventive medicine evaluation
and management of an individual, including an age and gender appropriate
history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures, new
patient; infant (age younger than one year) |
|
99382 |
$222.00 |
Initial comprehensive preventive medicine evaluation
and management of an individual, including an age and gender appropriate
history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures; early
childhood (age one through four years) |
|
99383 |
$222.00 |
Initial comprehensive preventive medicine evaluation
and management of an individual, including an age and gender appropriate
history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures; late
childhood (age five through 11 years) |
|
99384 |
$222.00 |
Initial comprehensive preventive medicine evaluation
and management of an individual, including an age and gender appropriate
history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures; adolescent
(age 12 through 17 years) |
|
99385 |
$222.00 |
Initial comprehensive preventive medicine evaluation
and management of an individual, including an age and gender appropriate
history, examination, counseling/anticipatory guidance/risk factor reduction
interventions, and the ordering of laboratory/diagnostic procedures; age 18
through 39 years |
|
99391 |
$222.00 |
Periodic comprehensive preventive medicine
reevaluation and management of an individual, including an age and gender
appropriate history, examination, counseling/anticipatory guidance/risk factor
reduction interventions, and the ordering of laboratory/diagnostic procedures,
established patient; infant (age younger than one year) |
|
99392 |
$222.00 |
Periodic comprehensive preventive medicine
reevaluation and management of an individual, including an age and gender
appropriate history, examination, counseling/anticipatory guidance/risk factor
reduction interventions, and the ordering of laboratory/diagnostic procedures,
established patient; early childhood (age one through four years) |
|
99393 |
$222.00 |
Periodic comprehensive preventive medicine
reevaluation and management of an individual, including an age and gender
appropriate history, examination, counseling/anticipatory guidance/risk factor
reduction interventions, and the ordering of laboratory/diagnostic procedures,
established patient; late childhood (age five through 11 years) |
|
99394 |
$222.00 |
Periodic comprehensive preventive medicine
reevaluation and management of an individual, including an age and gender
appropriate history, examination, counseling/anticipatory guidance/risk factor
reduction interventions, and the ordering of laboratory/diagnostic procedures,
established patient; adolescent (age 12 through 17 years) |
|
99395 |
$222.00 |
Periodic comprehensive preventive medicine
reevaluation and management of an individual, including an age and gender
appropriate history, examination, counseling/anticipatory guidance/risk factor
reduction interventions, and the ordering of laboratory/diagnostic procedures,
established patient; age 18 through 39 years |
|
99605 |
$52.00 |
Medication therapy management service(s) provided by
a pharmacist, individual, face-to-face with patient, with assessment and
intervention if provided; initial 15 minutes, new patient (CDTM or MTM
services, limit of two units per calendar year, telehealth permitted as
appropriate) |
|
99606 |
$34.00 |
Medication therapy management service(s) provided by
a pharmacist, individual, face-to-face with patient, with assessment and
intervention if provided; initial 15 minutes, established patient (CDTM or MTM
services, limit of one unit per visit and six units per calendar year,
telehealth permitted as appropriate) |
|
99607 |
$24.00 |
Medication therapy management service(s) provided by
a pharmacist, individual, face-to-face with patient, with assessment and
intervention if provided; each additional 15 minutes (List separately in
addition to code for primary service) (CDTM or MTM services, limit of three
units per visit and 12 units per calendar year, telehealth permitted as
appropriate) |
|
G0469 |
$216.00 |
Federally qualified health center (FQHC) visit,
mental health, new patient (individual mental health visit, new
patient) |
|
G0470 |
$216.00 |
Federally qualified health center (FQHC) visit,
mental health, established patient (individual mental health visit, established
patient) |
|
T1015 |
$216.00 |
Clinic visit/encounter, all-inclusive (individual
medical visit excludes laboratory and radiology) |
|
T1015-HQ |
$43.20 |
Clinic visit/encounter, all-inclusive; group setting
(group medical visit excludes laboratory and radiology) |
|
T1015-TH |
$216.00 |
Clinic visit/encounter, all-inclusive; obstetrical
treatment/services, prenatal or postpartum (nurse-midwife medical visit
excludes laboratory and radiology) |
|
T1040 |
$140.00 |
Medicaid certified community behavioral health clinic
services, per diem (Clinic visit/behavioral health encounter, all-inclusive
individual behavioral health visit) |
|
T1040-HQ |
$28.00 |
Medicaid certified community behavioral health clinic
services, per diem (Clinic visit/behavioral health encounter, all-inclusive
behavioral health visit; group setting) |
|
G0511 |
$56.98 |
Rural health clinic or federally qualified health
center (RHC or FQHC) only, general care management, 20 minutes or more of
clinical staff time for chronic care management services or behavioral health
integration services directed by an RHC or FQHC practitioner (physician, NP,
PA, or CNM), per calendar month (Behavioral health integration; applies to all
MassHealth community health centers) |
|
G0512 |
$124.07 |
Rural health clinic or federally qualified health
center (RHC or FQHC) only, psychiatric collaborative care model (psychiatric
COCM), 60 minutes or more of clinical staff time for psychiatric COCM services
directed by an RHC or FQHC practitioner (physician, NP, PA, or CNM) and
including services furnished by a behavioral health care manager and
consultation with a psychiatric consultant, per calendar month (applies to all
MassHealth community health centers) |
2.
EOHHS will calculate each community health center's total medical and
behavioral health claims-based APM amounts paid in each quarter by summing the
community health center's total amounts received for the services described in
101
CMR 304.04(2)(a)1.,
including claims paid through MassHealth fee-for-service and claims paid
through MassHealth managed care, as those terms are defined in
130
CMR 501.001: Definition of
Terms. This total quarterly medical and behavioral health claims-based
APM amount is the amount used to determine the medical and behavioral health
reconciliation wrap payment, calculated each quarter under
101
CMR 304.04(2)(c).
(b)
Dental Services
Claims-based APM Payments.
1.
Community health centers may bill
101 CMR
314.00 for dental services rendered in accordance with
that regulation. In addition, community health centers may bill the dental
enhancement fee established under
101 CMR
314.00 for each separate individual dental visit
provided by the community health center; provided that the dental enhancement
fee established under
101 CMR
314.00 will be increased by an amount that, when added
to such dental enhancement fee, totals $110 when billed to MassHealth by
community health centers for MassHealth members (the "CHC dental add-on"); and
provided further that the dental enhancement fee and the CHC dental add-on may
be billed not more than once per member per day. Hospital-licensed health
centers are not eligible for the CHC dental add-on.
2. EOHHS will calculate each community health
center's total MassHealth dental claims-based APM amounts paid in each quarter
by summing the community health center's quarterly MassHealth dental claims
paid under
101 CMR
314.00, including dental MassHealth fee-for-service
paid claims, claims paid through MassHealth managed care, as defined in
130
CMR 501.001, paid dental enhancement fees,
and the quarterly CHC dental add-on paid claims. This total quarterly dental
claims-based APM amount is the amount used to determine the dental
reconciliation wrap payment, calculated each quarter under
101
CMR 304.04(2)(c).
(c)
Reconciliation
Wrap APM Payments. For each calendar quarter, MassHealth will
provide required reconciliation wrap APM payments to community health centers
that are Federally Qualified Health Center for the purposes of
42 U.S.C. §
1396a(bb) and that are not
hospital licensed health centers.
1. A
reconciliation wrap APM payment is required up to the medical and behavioral
health PPS, if a community health center's total quarterly MassHealth medical
and behavioral health claims-based APM payments described under
101
CMR 304.04(2)(a)2. are less
than what the community health center would have received if it had been paid
for such services on a per visit basis through its individual medical and
behavioral health PPS rate. Such reconciliation wrap APM payment will equal the
difference between the total MassHealth quarterly medical and behavioral health
claims-based APM payments and what would have been paid for MassHealth medical
and behavioral health visits through the medical and behavioral health PPS
rate, in the aggregate, in the calendar quarter. For the purposes of
calculating the medical and behavioral health reconciliation wrap APM payment,
"visit" will include all individual medical visits, individual mental health
visits, individual behavioral health visits, nurse-midwife medical visits,
group medical visits, and group behavioral health visits; provided however,
that group medical visits and group behavioral health visits will amount to 20%
of a visit.
2. A reconciliation
wrap APM payment is required for the dental PPS if a community health center's
total MassHealth quarterly dental claims-based APM payments described under
101
CMR 304.04(2)(b)2., are less
than what the community health center would have received if it had been paid
for such services on a per visit basis through its individual dental PPS rate.
Such reconciliation wrap APM payment will equal the difference between the
total MassHealth quarterly dental claims-based APM payments and what would have
been paid for MassHealth dental visits through the dental PPS rate, in the
aggregate, in the calendar quarter. For the purposes of calculating the dental
reconciliation wrap APM payment, "visit" will include all individual dental
visits.
3. EOHHS will issue an
administrative bulletin or other written issuance to clarify or provide further
detail on this reconciliation wrap payment process including, but not limited
to, clarifying the codes corresponding to counting the relevant medical and
behavioral health visits and individual dental visits.
(3)
Other Community
Health Center Services. The rates of payment for other community
health center services provided to publicly aided individuals and industrial
accident patients are based on the applicable regulation and rates of payment
for the specific care and services rendered as issued by EOHHS or the
governmental unit or purchaser under M.G.L. c. 152 where the schedules of such
governmental unit or purchaser under M.G.L. c. 152 have not been superseded by
101 CMR
304.00. Such care and services include, but are not
limited to, those furnished by pharmacies, independent clinical laboratories,
optometrists, opticians, podiatrists, and other individual practitioners and
noninstitutional providers.
(4)
340B Transition Supplemental Payments. Subject to
federal approval, eligible community health centers will receive monthly
supplemental payments in accordance with
101
CMR 304.04(4).
(a)
Eligibility for the
Supplemental Payments.
1.
Community health centers for which the calendar year 2016 gross margin earned
on drugs purchased through the 340B Drug Pricing Program, as reported to the
Center for Health Information and Analysis, is greater than the projected
annual impact of the medical visit rate effective October 20, 2017, determined
in accordance with
101
CMR 304.04(4)(c)3., will
receive supplemental payments in accordance with
101
CMR 304.04(4).
2. Community health centers for which the
calendar year 2016 gross margin earned on drugs purchased through the 340B Drug
Pricing Program, as reported to the Center for Health Information and Analysis,
is lower than or equal to the projected annual impact of the medical visit rate
effective October 20, 2017, determined in accordance with
101
CMR 304.04(4)(c)3., will not
receive supplemental payments in accordance with
101
CMR 304.04(4).
(b)
Frequency and
Duration of Supplemental Payments.
1. Supplemental payments will be made to
eligible community health centers on a monthly basis.
2. Supplemental payments will be made for 75
months, beginning with October 2017.
(c)
Calculation of Monthly
Supplemental Payment Amounts for the First 12 Months of Payment.
For each of the 12 months beginning with October 2017, a monthly supplemental
payment will be made to eligible community health centers in an amount
calculated in accordance with
101
CMR 304.04(4)(c). The amount
of the monthly supplemental payment is calculated for each eligible community
health center as follows:
1. Historical
annual medical visit rate revenue is determined from claims data submitted by
the community health center and MassHealth managed care
organizations.
2. Projected annual
medical visit rate revenue is calculated for the 12-month period beginning
October 1, 2017, using the medical visit rate effective October 20, 2017, and
medical visit claims and encounters, excluding behavioral health claims and
encounters, including claims billed directly to the MassHealth Medicaid
Management Information System (MMIS) by community health centers for state
fiscal year 2015 and MassHealth managed care organization encounters for
federal fiscal year 2016.
3.
Projected annual impact of the medical visit rate effective October 20, 2017,
is determined by subtracting historical annual medical visit rate revenue
determined in accordance with
101
CMR 304.04(4)(c)1. from
projected annual medical visit rate revenue determined in accordance with
101
CMR 304.04(4)(c)2.
4. Projected annual impact of the medical
visit rate effective October 20, 2017, determined in accordance with
101
CMR 304.04(4)(c)3. is
subtracted from calendar year 2016 gross margin earned on drugs purchased
through the 340B Drug Pricing Program, as reported to the Center for Health
Information and Analysis.
5. The
projected annual medical visit rate revenue determined in accordance with
101
CMR 304.04(4)(c)2. is
multiplied by 0.75.
6. The lower of
the amount calculated in accordance with
101
CMR 304.04(4)(c)4. and the
amount calculated in accordance with
101
CMR 304.04(4)(c)5. is
divided by 12 to determine the community health center's monthly supplemental
payment amount for the 12 months beginning with October
2017.
(d)
Calculation of Monthly Supplemental Payment Amounts for Subsequent
Months. For the 63 months beginning with October 2018, monthly
supplemental payments will be made to eligible community health centers in an
amount calculated in accordance with
101
CMR 304.04(4)(d). Monthly
supplemental payment amounts are calculated for each eligible community health
center in accordance with the following.
1.
The community health center's average monthly supplemental payment amount for
the 27 months beginning with October 2018 is equivalent to the community health
center's monthly supplemental payment amount for the 12 months beginning with
October 2017 calculated in accordance with
101
CMR 304.04(4)(c)6.
2. The community health center's average
monthly supplemental payment amount for the 12 months beginning with January
2021 is the product of the community health center's monthly supplemental
payment amount for the 12 months beginning with October 2017 calculated in
accordance with
101
CMR 304.04(4)(c)6. and
0.75.
3. The community health
center's average monthly supplemental payment amount for the 12 months
beginning with January 2022 is the product of the community health center's
monthly supplemental payment amount for the 12 months beginning with October
2017 calculated in accordance with
101
CMR 304.04(4)(c)6. and
0.50.
4. The community health
center's average monthly supplemental payment amount for the 12 months
beginning with January 2023 is the product of the community health center's
monthly supplemental payment amount for the 12 months beginning with October
2017 calculated in accordance with
101
CMR 304.04(4)(c)6. and
0.25.
(e)
Impact on Allowable Fees in Subsequent Periods.
Subject to promulgation of further rate setting regulations as may be necessary
to implement this provision, for each of the four 12-month periods beginning in
or around January 2021, January 2022, January 2023, and January 2024, the
allowable fees described in
101
CMR 304.04(2)(a) will be
increased such that aggregate expenditures for such allowable fees in each
period will increase over such expenditures from the previous 12-month period
by 25% of the amount of aggregate expenditures for the 340B transition
supplemental payments, as determined by EOHHS, in the 12-month period beginning
October 2017 described in
101
CMR 304.04(4)(c), based on
projected utilization, as determined by EOHHS.
(f)
Authority to Issue Additional
Guidance. EOHHS reserves the right to issue an administrative
bulletin on these supplemental payment provisions including, but not limited
to, an administrative bulletin to implement changes in the payment amounts and
dates to account for any period during which
101 CMR
304.00 is in effect and MassHealth Managed Care
Organizations (MCOs) continue to cover 340B drugs for MassHealth
members.
