Payment for Primary Care Clinician Plan Services and Primary Care ACO Participating Primary Care Provider Services

Final Adoption May 14, 2021

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 353.00: PAYMENT FOR PRIMARY CARE CLINICIAN PLAN SERVICES AND PRIMARY CARE ACO PARTICIPATING PRIMARY CARE PROVIDER SERVICES

Section 353.01: General Provisions 353.02: General Definitions 353.03: General Payment Provisions 353.04: Filing and Reporting Requirements 353.05: Severability

353.01: General Provisions

(1) Scope and Purpose. .00 governs certain payments to Primary Care Clinicians (PCCs) for Primary Care Clinician (PCC) services provided to MassHealth members as part of the MassHealth PCC Plan, and to Primary Care ACO-participating Primary Care Providers (participating PCPs) for participating PCP services provided to members enrolled in MassHealth Primary Care ACOs. The enhancement rate payments described in .00 are in addition to payments issued under the Acute Hospital Request for Applications, and 101 CMR 304.00: Rates for Community Health Centers; 101 CMR 316.00: Surgery and Anesthesia Services; 101 CMR 317.00: Medicine; and 101 CMR 318.00: Radiology.

(2) Disclaimer of Authorization of Services. .00 is not authorization for or approval of the procedures for which payments are determined pursuant to 101 CMR 353.00. Purchasing agencies and insurers are responsible for the definition, authorization, and approval of care and services extended to publicly aided individuals.

(3) Administrative Bulletins. EOHHS may issue administrative bulletins to clarify its policy on and understanding of substantive provisions of .00.

353.02: General Definitions

Meaning of Terms. Terms used in .00 will have the meaning ascribed in .02.

Accountable Care Organization (ACO). An entity that enters into a population-based payment model contract with EOHHS as an accountable care organization, wherein the entity is held financially accountable for the cost and quality of care for an attributed or enrolled member population. ACOs include Accountable Care Partnership Plans, Primary Care ACOs, and MCO-administered ACOs.

Center. The Center for Health Information and Analysis established under M.G.L. c. 12C.

EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A.

Final Adoption May 14, 2021

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

.00: PAYMENT FOR PRIMARY CARE CLINICIAN PLAN SERVICES AND PRIMARY CARE ACO PARTICIPATING PRIMARY CARE PROVIDER SERVICES

Primary Care ACO. A type of ACO with which the MassHealth agency contracts under its ACO program.

Primary Care Clinician (PCC). Any MassHealth provider that participates as a primary care provider for MassHealth members enrolled in the PCC Plan, as described in 130 CMR 450.118: Primary Care Clinician (PCC) Plan.

Publicly Aided Individual. A person whose medical and other services is paid for in whole or in part by the Commonwealth of Massachusetts or any of its departments, agencies, boards, commissions, or political subdivisions.

353.03: General Payment Provisions

(A) 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. Ten dollars is added to the fee 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.

(B) 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. Ten dollars is added to the fee for the procedure code 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.

353.04: Penalty for Noncompliance with Filing and Reporting Requirements

The purchasing governmental unit may impose a penalty in the amount of up to 15% of its payments to any provider that fails to submit required information. The purchasing governmental unit will notify the provider in advance of its intention to impose a penalty under .04.

353.05: Severability

The provisions of .00 are severable, and if any provision of 101 CMR 353.00 or application of such provision to any community service agency or any circumstances shall be held to be invalid or unconstitutional, such invalidity shall not be construed to affect the validity or constitutionality of any remaining provisions of 101 CMR 353.00 or application of such provisions to community service agencies or circumstances other than those held invalid.

REGULATORY AUTHORITY

.00: M.G.L. c. 118E.