101 CMR, § 446.03

Current through Register 1536, December 6, 2024

Section 446.03 - General Rate Provisions and Payment

(1)Community Health Centers.

(a)General Rate Determination. Rates of payment for services for which 101 CMR 446.03(1) applies are the lowest of

1. the eligible provider's usual fee to patients other than publicly aided individuals;

2. the eligible provider's actual charge submitted; or

3. the schedule of allowable fees set forth in 101 CMR 446.03(1)(c), taking into account appropriate modifiers and any other applicable rate provisions in accordance with 101 CMR 446.03(1).

(b)Defined Terms. Terms used in 101 CMR 446.03(1), that have not been defined elsewhere in 101 CMR 446.00, have the meanings ascribed to those terms in 101 CMR 304.02: Definitions.

(c)Allowable Fee for I&R Services through Alternative Payment Methodology.

1. Governmental units may pay I&R community health centers for I&R services they provide through a weekly, facility-specific, all-inclusive rate established through the alternative payment methodology described in 101 CMR 446.03(1)(c) a. through 2. This rate must be set forth and agreed to by each I&R community health center and the governmental unit through a contract or special conditions amendment to the provider contract, sufficient to cover the following allowable costs associated with the provision of I&R services, as agreed to by the governmental unit and the I&R community health center.

a. The direct labor costs for the clinical care team, staffed appropriately to meet the clinical and administrative needs of the I&R site.

b. The costs to acquire and maintain sufficient amounts of medical supplies necessary to provide I&R services at the I&R site.

c. Appropriate set-up and other one-time costs associated with the provision of I&R services at the I&R site, which may include information technology equipment and services and office supplies.

d. For the costs described in 101 CMR 446.03(1)(c)1. through 2. to be considered allowable, the cost must, at a minimum, be reasonable, directly related to the provision of I&R services, and identified in the contract or special conditions amendment to the I&R community health center's provider contract.

2.Billing and Disbursement of Payment. I&R community health centers must bill the governmental unit for the I&R services provided pursuant to 101 CMR 446.03(1)(c) and a contract or special conditions amendment to the provider contract through weekly invoice. The government unit will pay the I&R community health center for such services weekly, upon receipt of such invoice, consistent with the terms of the contract or special conditions amendment to the provider contract.

(d)Supplemental Payments to Community Health Centers.

1. Subject to federal approval, community health centers that are federally qualified health centers in Massachusetts will receive one-time, health center-specific supplemental payments to account for services rendered during calendar year 2021. The one-time, health center-specific supplemental payment will be paid to each community health center by the end of the second calendar quarter of 2021. A community health center's health center-specific supplemental payment was calculated based on the following components:

a. an amount equal to a portion of the community health center's average monthly claims, based on annualized data from January and February 2020, paid by MassHealth and MassHealth managed care entities, as determined by EOHHS;

b. as applicable, the amount that would have been paid to the community health center, if not for the scheduled decrease to the community health center's 340B supplemental payment under 101 CMR 304.04(3): 340B Transition Supplemental Payments, which took effect on January 1, 2021; and

c. as applicable, an amount determined by EOHHS for the heightened costs faced by community health centers with greater than 100,000 annual individual medical visits, based on annualized data from January and February 2020.

2. The supplemental payments, as described in 101 CMR 446.03(1)(d)1., will equal the following amounts for each community health center:

Community Health Center	Supplemental Payment
Boston Health Care for the Homeless	$4,839,557
Brockton Neighborhood Health Center, Inc.	$2,810,993
Caring Health Center, Inc.	$1,318,873
Charles River Community Health	$666,458
Community Health Center of Cape Cod	$774,741
Community Health Center of Franklin County	$353,940
Community Health Connections Family Health Center	$1,418,345
Community Health Programs CHC	$491,729
Dimock Community Health Center	$876,407
Duffy Health Center	$361,499
Edward M. Kennedy Community Health Center	$1,713,369
Family Health Center of Worcester	$2,545,653
Fenway Community Health Center	$1,700,062
Greater Lawrence Family Health Center, Inc.	$5,340,713
Greater New Bedford Community Health Center	$1,329,984
Harbor Health Services, Inc.	$1,780,265
Harvard Street Neighborhood Health Center	$379,641
Healthfirst Family Care Center, Inc.	$841,430
Hilltown Community Health Centers, Inc.	$295,175
Holyoke Health Center	$2,910,268
Island Health Care	$30,351
Lowell Community Health Center	$2,738,370
Lynn Community Health Center	$3,909,622
Manet Community Health Center	$832,276
Mattapan Community Health Center	$402,987
North End Waterfront Health	$336,460
North Shore Community Health, Inc.	$815,613
Outer Cape Health Services, Inc.	$586,726
South Cove Community Health Center	$1,978,226
Springfield Health Services for the Homeless	$138,746
Stanley Street Treatment and Resources (SSTAR)	$2,832,520
Uphams' Corner Health Center	$715,148
Whittier Street Health Center	$908,376
TOTAL	$48,974,525

(2)Medicine.

(a)General Rate Determination. Rates of payment for services for which 101 CMR 446.03(2) applies are the lowest of

1. the eligible provider's usual fee to patients other than publicly aided individuals;

2. the eligible provider's actual charge submitted; or

3. the schedule of allowable fees set forth in 101 CMR 446.03(2)(e), taking into account appropriate modifiers and any other applicable rate provisions in accordance with 101 CMR 446.03(2).

(b)Individual Consideration. Medical services services designated "I.C." are individually considered items. The governmental unit or purchaser analyzes the eligible provider's report of services rendered and charges submitted under the appropriate unlisted services or procedures category. The governmental unit or purchaser determines appropriate payment for procedures designated I.C. in accordance with the following standards and criteria:

1. the amount of time required to perform the service;

2. the degree of skill required to perform the service;

3. the severity or complexity of the patient's disease, disorder, or disability;

4. any applicable relative-value studies;

5. any complications or other circumstances that may be deemed relevant;

6. the policies, procedures, and practices of other third-party insurers;

7. the payment rate for prescribed drugs as set forth in 101 CMR 331.00: Prescribed Drugs; and

8. a copy of the current invoice from the supplier.

(c)Defined Terms. Terms used in 101 CMR 446.03(2) that have not been defined elsewhere in 101 CMR 446.00 have the meanings in 101 CMR 317.02: General Definitions.

(d)Codes and Modifiers.

1. Except as otherwise provided, the codes and modifiers for the services described in 101 CMR 446.03(2) are as defined in 101 CMR 317.04(3): Modifiers and 101 CMR 317.04(4): Fee Schedule.

2. The modifier "SL": State supplied vaccine or antibodies. This modifier is to be applied to codes to identify vaccine or antibodies provided at no cost, whether by the Massachusetts Department of Public Health or other federal or state agency. No payment shall be made for codes with this modifier.

(e)Allowable Fee for Remote Patient Monitoring (RPM) Bundled Services. The following code, modifier, and fee apply for the provision of RPM bundled services.

Code

Allowable Fee

Description of Code

99423 - U9

$870.72

Online digital evaluation and management service, for an established patient, for up to seven days, cumulative time during the seven days; 21 or more minutes.

(Used for COVID-19 remote patient monitoring bundled services provided through any appropriate technology or modality, including up to seven days of daily check-ins for evaluation and monitoring; multidisciplinary clinical team reviews of a member's status and needs; appropriate physician oversight; necessary care coordination; and provision of a thermometer and pulse oximeter for remote monitoring.)

(f)Allowable Fee for COVID-19 Vaccine and Vaccine Administration. The allowable fees for COVID-19 vaccines and their administration are 100% of the corresponding Medicare Part B payment rates, without geographic adjustment. Payment for administration of the COVID-19 vaccine provided by eligible providers who are certified nurse practitioners, certified nurse midwives, psychiatric clinical nurse specialists, clinical nurse specialists, physician assistants, registered nurses, 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 allowable fee. In the event this fee structure conflicts with the rates for the same codes in 101 CMR 317.00: Rates for Medicine Services, then the fee structure in 101 CMR 317.00 will control.

This fee structure applies for the following codes:

Code	Description of Code
90480	Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, single dose
91304	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, recombinant spike protein nanoparticle, saponin-based adjuvant, preservative free, 5 mcg/0.5mL dosage, for intramuscular use
91318	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, 3 mcg/0.2 mL dosage, tris-sucrose formulation, for intramuscular use
91319	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, 10 mcg/0.2 mL dosage, tris-sucrose formulation, for intramuscular use
91320	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use
91321	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 25 mcg/0.25 mL dosage, for intramuscular use
91322	Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, 50 mcg/0.5 mL dosage, for intramuscular use

(g)Allowable Fee for COVID-19 Treatment. The allowable fees for monoclonal antibodies and their administration for the treatment of COVID-19 are 100% of the corresponding Medicare Part B payment rates, without geographic adjustment. Payment for the administration of monoclonal antibodies provided by eligible providers who are certified nurse practitioners, certified nurse midwives, psychiatric clinical nurse specialists, clinical nurse specialists, physician assistants, registered nurses, 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 allowable fee. In the event this fee structure conflicts with the rates for the same codes in 101 CMR 317.00: Rates for Medicine Services, then the fee structure in 101 CMR 317.00 will control.

This fee structure applies for the following codes:

Code	Description of Code
Q0220 SL	Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available COVID-19 vaccine is not recommended due to a history of severe adverse reaction to a COVID-19 vaccine(s) and/or covid-19 vaccine component(s), 300 mg
Q0221SL	Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 600 mg
Q0222	Injection, bebtelovimab, 175 mg
Q0240 SL	Injection, casirivimab and imdevimab, 600 mg
Q0243 SL	Injection, casirivimab and imdevimab, 2400 mg
Q0244 SL	Injection, casirivimab and imdevimab, 1200 mg
Q0245 SL	Injection, bamlanivimab and etesevimab, 2100 mg
Q0247	Injection, sotrovimab, 500 mg
Q0249	Injection, tocilizumab, for hospitalized adults and pediatric patients (two years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg
M0220	Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available COVID-19 vaccine is not recommended due to a history of severe adverse reaction to a COVID-19 vaccine(s) and/or COVID-19 vaccine component(s), includes injection and post administration monitoring
M0221	Injection, tixagevimab and cilgavimab, for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available COVID-19 vaccine is not recommended due to a history of severe adverse reaction to a COVID-19 vaccine(s) and/or COVID-19 vaccine component(s), includes injection and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider based to the hospital during the federal COVID-19 public health emergency
M0222	Intravenous injection, bebtelovimab, includes injection and post administration monitoring
M0223	Intravenous injection, bebtelovimab, includes injection and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the federal COVID-19 public health emergency
M0240	Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses
M0241	Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence, this includes a beneficiary's home that has been made provider-based to the hospital during the federal COVID-19 public health emergency, subsequent repeat doses
M0243	Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring
M0244	Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the federal COVID-19 public health emergency
M0245	Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring
M0246	Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the federal COVID-19 public health emergency
M0247	Intravenous infusion, sotrovimab, includes infusion and post administration monitoring
M0248	Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the federal COVID-19 public health emergency
M0249	Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (two years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose
M0250	Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (two years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose

(h)Allowable Fee for COVID-19 Vaccine and Vaccine Administration Applicable for Dates of Service on or after September 22, 2021. The following code and fee applies for the listed COVID-19 vaccines and their administration.

Code

Allowable Fee

Description of Code

0004A

$45.87

Pfizer-BioNTech COVID-19 Vaccine (Purple Cap)

Administration - Booster (ADM SARSCOV2 30MCG/0.3ML BST)

(i)Allowable Fee for COVID-19 Vaccine and Vaccine Administration Applicable for Dates of Service on or after October 20, 2021. The following codes and fees apply for the listed COVID-19 vaccines and their administration.

Code	Allowable Fee	Description of Code
0034A	$45.87	Janssen COVID-19 Vaccine Administration - Booster[ ( (ADM SARSCOV2 VAC AD26.5ML B)
91306 SL	$0.00	Moderna COVID-19 Vaccine (Low Dose) (SARSCOV2 VAC 50MCG/0.25ML IM)
0064A	$45.87	Moderna COVID-19 Vaccine (Low Dose) Administration - Booster (ADM SARSCOV2 50MCG/0.25MLBST)

(j)Allowable Fee for COVID-19 Vaccine and Vaccine Administration Applicable for Dates of Service on or after October 29, 2021. The following codes and fees apply for the listed COVID-19 vaccines and their administration.

Code	Allowable Fee	Description of Code
91307 SL	$0.00	Pfizer-BioNTech COVID-19 Pediatric Vaccine (Orange Cap)
0071A	$45.87	Pfizer-BioNTech COVID-19 Pediatric Vaccine (Orange Cap) - Administration - First dose (ADM SARSCV2 10MCG TRS-SUCR 1)
0072A	$45.87	Pfizer-BioNTech COVID-19 Pediatric Vaccine (Orange Cap) - Administration - Second dose (ADM SARSCV2 10MCG TRS-SUCR 2)

(k)Allowable Fee for COVID-19 Vaccine and Vaccine Administration Applicable for Dates of Service on or after January 3, 2022. The following codes and fees apply for the listed COVID-19 vaccines and their administration.

Code	Allowable Fee	Description of Code
91305 SL	$0.00	Pfizer-BioNTech COVID-19 Vaccine Pre-Diluted (Gray Cap) (SARSCOV2 VAC 30 MCG TRS-SUCR)
0051A	$45.87	Pfizer-BioNTech COVID-19 Vaccine Pre-Diluted (Gray Cap) Administration - First dose (ADM SARSCV2 30MCG TRS-SUCR 1)
0052A	$45.87	Pfizer-BioNTech COVID-19 Vaccine Pre-Diluted (Gray Cap) Administration - Second dose (ADM SARSCV2 30MCG TRS-SUCR 2)
0053A	$45.87	Pfizer-BioNTech COVID-19 Vaccine Pre-Diluted (Gray Cap) Administration - Third dose (ADM SARSCV2 30MCG TRS-SUCR 3)
0054A	$45.87	Pfizer-BioNTech COVID-19 Vaccine Pre-Diluted (Gray Cap) Administration - Booster (ADM SARSCV2 30MCG TRS-SUCR B)
0073A	$45.87	Pfizer-BioNTech COVID-19 Pediatric Vaccine (Orange Cap) - Administration - Third dose (ADM SARSCV2 10MCG TRS-SUCR 3)

(l)Allowable Fee for COVID-19 Vaccine and Vaccine Administration Applicable for Dates of Service on or after March 22, 2022. The following codes and fees apply for the listed COVID-19 vaccines and their administration.

Code	Allowable Fee	Description of Code
D1708	$45.87	D1708 Pfizer-BioNTech COVID-19 vaccine administration - third dose (SARSCOV2 COVID-19 VAC mRNA 30mcg/0.3mL IM DOSE 3)
D1709	$45.87	D1709 Pfizer-BioNTech Covid-19 vaccine administration - booster dose (SARSCOV2 COVID-19 VAC mRNA 30mcg/0.3mL IM DOSE BOOSTER)
D1710	$45.87	D1710 Moderna COVID-19 vaccine administration -third dose (SARSCOV2 COVID-19 VAC mRNA 100mcg/0.5mL IM DOSE 3)
D1711	$45.87	D1711 Moderna COVID-19 vaccine administration -booster dose (SARSCOV2 COVID-19 VAC mRNA 50mcg/0.25mL IM DOSE BOOSTER)
D1712	$45.87	D1712 Janssen COVID-19 vaccine administration -booster dose (SARSCOV2 COVID-19 VAC Ad26 5x1010 VP/0.5mL IM DOSE BOOSTER)
D1713	$45.87	D1713 Pfizer-BioNTech COVID-19 vaccine administration tris-sucrose pediatric - first dose (SARSCOV2 COVID-19 VAC mRNA 10mcg/0.2mL tris-sucrose IM DOSE 1)
D1714	$45.87	D1714 Pfizer-BioNTech COVID-19 vaccine administration tris-sucrose pediatric - second dose (SARSCOV2 COVID-19 VAC mRNA 10mcg/0.2mL tris-sucrose IM DOSE 2)

(m)Allowable Fee for COVID-19 Vaccine and Vaccine Administration Applicable for Dates of Service on or after March 29, 2022. The following codes and fees apply for the listed COVID-19 vaccines and their administration.

Code	Allowable Fee	Description of Code
91309 SL	$0.00	Moderna Covid-19 Vaccine (Aged 6 years through 11 years or aged 18 years and older) (Blue Cap with purple border) 50MCG/0.5ML (SARSCOV2 VAC 50MCG/0.5ML IM)
0094A	$45.87	Moderna Covid-19 Vaccine (Aged 18 years and older) (Blue Cap with purple border) 50MCG/0.5ML Administration - Booster (ADM SARSCOV2 50MCG/0.5 MLBST)

(n)Allowable Fee for COVID-19 Vaccine and Vaccine Administration Applicable for Dates of Service on or after May 17, 2022. The following code and fee applies for the listed COVID-19 vaccine and its administration.

Code	Allowable Fee	Description of Code
0074A	$45.87	Pfizer-BioNTech COVID-19 Pediatric Vaccine (Orange Cap) - Administration - Booster (ADM SARSCV2 10MCG TRS-SUCR B)

(o)Allowable Fee for COVID-19 Vaccine and Vaccine Administration Applicable for Dates of Service on or after June 17, 2022. The following codes and fees apply for the listed COVID-19 vaccines and their administration.

Code	Allowable Fee	Description of Code
91308 SL	$0.00	Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) (SARSCOV2 VAC 3MCG TRS-SUCR)
0081A	$45.87	Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration -First dose (ADM SARSCOV2 3MCG TRS-SUCR 1)
0082A	$45.87	Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration -Second dose (ADM SARSCOV2 3MCG TRS-SUCR 2)
0083A	$45.87	Pfizer-BioNTech Covid-19 Pediatric Vaccine (Aged 6 months through 4 years) (Maroon Cap) Administration -Third dose (ADM SARSCOV2 3MCG TRS-SUCR 3)
0091A	$45.87	Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - First dose (ADM SARSCOV2 50 MCG/.5 ML1ST)
0092A	$45.87	Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - Second dose (ADM SARSCOV2 50 MCG/.5 ML2ND)
0093A	$45.87	Moderna Covid-19 Pediatric Vaccine (Aged 6 years through 11 years) (Blue Cap with purple border) Administration - Third dose (ADM SARSCOV2 50 MCG/.5 ML3RD)
91311 SL	$0.00	Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) 250MCG/0.25ML (SARSCOV2 VAC 25MCG/0.25ML IM)
0111A	$45.87	Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - First dose (ADM SARSCOV2 25MCG/0.25ML1ST)
0112A	$45.87	Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - Second dose (ADM SARSCOV2 25MCG/0.25ML2ND)
0113A	$45.87	Moderna Covid-19 Pediatric Vaccine (Aged 6 months through 5 years) (Blue Cap with magenta border) Administration - Third dose (ADM SARSCOV2 25MCG/0.25ML3RD)

(p)Allowable Fee for COVID-19 Vaccine and Vaccine Administration Applicable for Dates of Service on or after July 13, 2022. The following codes and fees apply for the listed COVID-19 vaccines and their administration.

Code	Allowable Fee	Description of Code
91304 SL	$0.00	Novavax Covid-19 Vaccine, Adjuvanted (Aged 12 years and older) (SARSCOV2 VAC 5MCG/0.5ML IM)
0041A	$45.87	Novavax Covid-19 Vaccine, Adjuvanted Administration -First Dose (ADM SARSCOV2 5MCG/0.5ML 1ST)
0042A	$45.87	Novavax Covid-19 Vaccine, Adjuvanted Administration -Second Dose ADM SARSCOV2 5MCG/0.5ML 2ND

(q)Allowable Fee for COVID-19 Vaccine and Vaccine Administration Applicable for Dates of Service on or after August 31, 2022. The following codes and fees apply for the listed COVID-19 vaccines and their administration.

Code	Allowable Fee	Description of Code
91313 SL	$0.00	Moderna COVID-19 Vaccine, Bivalent Product (Aged 18 years and older) (Dark Blue Cap with gray border) (SARSCOV2 VAC BVL 50MCG/0.5ML)
0134A	$45.87	Moderna COVID-19 Vaccine, Bivalent (Aged 18 years and older) (Dark Blue Cap with gray border) Administration - Booster Dose (ADM SARSCV2 BVL 50MCG/.5ML B)
91312 SL	$0.00	Pfizer-BioNTech COVID-19 Vaccine, Bivalent Product (Aged 12 years and older) (Gray Cap) (SARSCOV2 VAC BVL 30MCG/0.3M)
0124A	$45.87	Pfizer-BioNTech COVID-19 Vaccine, Bivalent (Gray Cap) Administration - Booster Dose (ADM SARSCV2 BVL 30MCG/.3ML B)

(r)Allowable Fee for COVID-19 Treatment Applicable for Dates of Service on or after May 6, 2021. The following codes and fees apply for the listed COVID-19 treatment services.

Code	Allowable Fee	Description of Code
Q0243 SL	$0.00	Injection, casirivimab and imdevimab, 2400 mg
M0243	$450.00	Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring
M0244	$750.00	Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the federal COVID-19 public health emergency
Q0245 SL	$0.00	Injection, bamlanivimab and etesevimab, 2100 mg
M0245	$450.00	Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring
M0246	$750.00	Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the federal COVID-19 public health emergency

(s)Allowable Fee for COVID-19 Treatment Applicable for Dates of Service on or after May 26, 2021. The following codes and fees apply for the listed COVID-19 treatment services.

Code	Allowable Fee	Description of Code
Q0247	$2,394.00	Injection, sotrovimab, 500 mg
M0247	$450.00	Intravenous infusion, sotrovimab, includes infusion and post administration monitoring
M0248	$750.00	Intravenous infusion, sotrovimab, includes infusion and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the federal COVID-19 public health emergency

(t)Allowable Fee for COVID-19 Treatment Applicable for Dates of Service on or after June 3, 2021. The following codes and fees apply for the listed COVID-19 treatment service.

Code	Allowable Fee	Description of Code
Q0244 SL	$0.00	Injection, casirivimab and imdevimab, 1200 mg

(u)Allowable Fee for COVID-19 Treatment Applicable for Dates of Service on or after June 24, 2021. The following codes and fees apply for the listed COVID-19 treatment services.

Code	Allowable Fee	Description of Code
Q0249	$6.57	Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg
M0249	$450.00	Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, first dose
M0250	$450.00	Intravenous infusion, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic corticosteroids and require supplemental oxygen, non-invasive or invasive mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, includes infusion and post administration monitoring, second dose

(v)Allowable Fee for COVID-19 Treatment Applicable for Dates of Service on or after July 31, 2021. The following codes and fees apply for the listed COVID-19 treatment services.

Code	Allowable Fee	Description of Code
Q0240 SL	$0.00	Injection, casirivimab and imdevimab, 600 mg
M0240	$450.00	Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring, subsequent repeat doses
M0241	$750.00	Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the home or residence, this includes a beneficiary's home that has been made provider-based to the hospital during the COVID-19 public health emergency, subsequent repeat doses

(w)Allowable Fee for COVID-19 Treatment Applicable for Dates of Service on or after December 8, 2021. The following codes and fees apply for the listed COVID-19 treatment services.

Code	Allowable Fee	Description of Code
Q0220 SL	$0.00	Injection, tixagevimab and cilgavimab, for the preexposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available COVID-19 vaccine is not recommended due to a history of severe adverse reaction to a COVID-19 vaccine(s) and/or covid-19 vaccine component(s), 300 mg
M0220	$150.50	Injection, tixagevimab and cilgavimab, for the preexposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available COVID-19 vaccine is not recommended due to a history of severe adverse reaction to a COVID-19 vaccine(s) and/or COVID-19 vaccine component(s), includes injection and post administration monitoring
M0221	$250.50	Injection, tixagevimab and cilgavimab, for the preexposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available COVID-19 vaccine is not recommended due to a history of severe adverse reaction to a COVID-19 vaccine(s) and/or COVID-19 vaccine component(s), includes injection and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the COVID-19 public health emergency

(x)Allowable Fee for COVID-19 Treatment Applicable for Dates of Service on or after February 11, 2022. The following codes and fees apply for the listed COVID-19 treatment services.

Code	Allowable Fee	Description of Code
Q0222 SL	$0.00	Injection, bebtelovimab, 175 mg
M0222	$350.50	Intravenous injection, bebtelovimab, includes injection and post administration monitoring
M0223	$550.50	Intravenous injection, bebtelovimab, includes injection and post administration monitoring in the home or residence; this includes a beneficiary's home that has been made provider-based to the hospital during the covid-19 public health emergency

(y)Allowable Fee for COVID-19 Treatment Applicable for Dates of Service on or after April 24, 2022. The following code and fee applies for the listed COVID-19 treatment service.

Code	Allowable Fee	Description of Code
Q0221 SL	$0.00	Injection, tixagevimab and cilgavimab, for the preexposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 600 mg

(z)Allowable Fee for COVID-19 Treatment Applicable for Dates of Service on or after April 1, 2022. The following code and fee applies for the listed COVID-19 treatment services.

Code	Allowable Fee	Description of Code
J0248	$5.51	Injection, remdesivir, 1 mg

(aa)Allowable Fee for COVID-19 Treatment Applicable for Dates of Service on or after August 15, 2022. The following code and fee applies for the listed COVID-19 treatment service.

Code	Allowable Fee	Description of Code
Q0222	$2394.00	Injection, bebtelovimab, 175 mg

(3)Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment, and Supplies.

(a)General Rate Determination. Rates of payment for services for which 101 CMR 446.03(3) applies are the lowest of

1. the eligible provider's usual fee to patients other than publicly aided individuals;

2. the eligible provider's actual charge submitted; or

3. the schedule of allowable fees set forth in 101 CMR 446.03(3)(f) and (g), taking into account appropriate modifiers and any other applicable rate provisions in accordance with 101 CMR 446.03(3).

(b)Defined Terms. Terms used in 101 CMR 446.03(3) have the meaning defined in 101 CMR 322.02: General Definitions.

(c)Codes and Modifiers. Except as otherwise provided, the codes and modifiers for the DME services described in 101 CMR 446.03(3) are as defined in 101 CMR 322.03(13): Modifiers and 101 CMR 322.06: Allowable Fees and Rate Schedule.

(d)Allowable Fee for Distribution of Personal Protective Equipment (PPE).

1. Authorization for the provision of, and billing and payment for, distribution of PPE to certain MassHealth members is governed by an executed special conditions amendment to a MassHealth DME provider's provider contract.

2. The fee and modifier in 101 CMR 446.03(3)(d)2. apply for distribution of PPE.

Code	Allowable Fee	Description of Code
E1399U9	$40.00	Durable medical equipment, miscellaneous. (Used for PPE distribution services, specifically the packaging, preparing, and delivering or shipping of a two-week supply PPE kit to an authorized individual during the COVID-19 public health emergency)

(e)Allowable Fee for Nonsterile Gloves. The following fee in 101 CMR 446.03(3)(e) is in effect for nonsterile gloves.

Code	Allowable Fee	Description of Code
A4927	$11.00	Gloves, non-sterile, per 100

(f)Allowable Fee for Over-the-counter Diagnostic Tests for SARS-CoV-2. For over-the-counter diagnostic tests for SARS-CoV-2 supplied through pharmacies to MassHealth members, EOHHS may set allowable fees no higher than $12.00 per test. EOHHS may set the allowable fee for particular tests below $12.00 per test, so long as the allowable fee is equal to or greater than the lowest retail rate available to MassHealth members in Massachusetts. For over-the-counter tests supplied through pharmacies for MassHealth members, EOHHS will designate allowable fees via Pharmacy Facts, provider bulletin, or other written issuance, consistent with 101 CMR 446.03(3)(f). The $12.00 maximum allowable fee per test rate may be adjusted via administrative bulletin if guidance from the federal Departments of Labor, Health and Human Services, or the Treasury changes regarding rates payable by commercial plans.

(g)Allowable Fee for Formula and Thickening Agents. For formula and thickening agents dispensed through pharmacies to MassHealth members, the allowable fee is the wholesale acquisition cost. For purposes of 101 CMR 446.03(3)(g), the wholesale acquisition cost means the manufacturer's price published in a national price compendium or other publicly available source or an adjusted list price.

(h)Reporting Requirements. Reporting requirements for 101 CMR 446.03(3) are those in 101 CMR 322.04: Reporting Requirements.

(4)Ambulance and Wheelchair Van Services.

(a)General Rate Determination. Rates of payment for services for which 101 CMR 446.03(4) applies are the lowest of

1. the eligible provider's usual fee to patients other than publicly aided individuals;

2. the eligible provider's actual charge submitted; or

3. the schedule of allowable fees set forth in 101 CMR 446.03(4)(c), taking into account appropriate modifiers and any other applicable rate provisions in accordance with 101 CMR 446.03(4).

(b)Defined Terms. Terms used in 101 CMR 446.03(4) that have not been defined elsewhere in 101 CMR 446.00 have the meanings in 101 CMR 327.02: General Definitions.

(c)Allowable Fees for Ambulance and Wheelchair Van Services. The following code and allowable fee applies, notwithstanding the definition of "trip" in 101 CMR 327.02: General Definitions.

Code	Allowable Fee	Description of Code
A0998	$157.88	Ambulance response and treatment, no transport (Used for medically necessary visits to patients to obtain and transport specimens for COVID-19 diagnostic testing)
A0120	$100.00	Nonemergency transportation: mini-bus, mountain area transports, or other transportation systems. (Each way. Used only for non-emergency wheelchair van transport for a person under investigation or known to have COVID-19.)

(d)Billing Certification. Each eligible provider who submits an invoice to a governmental unit for authorized ambulance services must certify the accuracy of the level of services provided, as listed on its invoice.

(e)Reporting Requirements. Reporting requirements under 101 CMR 446.03(4) are those in 101 CMR 327.05: Reporting Requirements.

(5)Prescribed Drugs.

(a)Defined Terms. Terms used in 101 CMR 446.03(5) that have not been defined elsewhere in 101 CMR 446.00 have the meanings in 101 CMR 331.02: General Definitions.

(b)Delivery Fee. Eligible providers will receive a payment adjustment to the professional dispensing fee when medications are delivered to a personal residence (including homeless shelters). The payment adjustment will be the lower of the provider's usual and customary charge for prescription delivery or $8.00, and will be made only when the MassHealth agency is the primary payer. Payment of this fee by MassHealth will occur only in such circumstances as is designated by Pharmacy Facts, provider bulletin, or other written issuance from the MassHealth agency.

(c)Reporting Requirements. Reporting requirements for 101 CMR 446.03(5) are those in 101 CMR 331.03: Reporting Requirements.

(6)Testing Services.

(a)General Rate Determination. Rates of payment for services under which 101 CMR 446.03(6) applies are the lowest of

1. the eligible provider's usual and customary charge to patients, other than publicly aided individuals;

2. the eligible provider's actual charge submitted; or

3. the schedule of allowable fees set forth in 101 CMR 446.03(6)(d) through (f), taking into account appropriate modifiers and any other applicable rate provisions in accordance with 101 CMR 446.03(6).

(b)Defined Terms. Terms used in 101 CMR 446.03(6), that have not been defined elsewhere in 101 CMR 446.00, have the meanings in 101 CMR 320.02: Definitions.

(c)Individual Consideration (I.C.). Unlisted procedures and laboratory tests designated I.C. are individually considered items. The eligible provider's bill for such a test must be accompanied by a brief report of the procedure or test performed and the eligible provider's usual and customary charge for that procedure or test. Determination of appropriate payments for procedures and tests designated I.C. are in accordance with the following standards and criteria:

1. time required to perform the procedure;

2. degree of skill required in the procedure performed;

3. severity or complexity of the patient's disease, disorder, or disability;

4. policies, procedures, and practices of other third-party purchasers of care;

5. prevailing medical-laboratory ethics and accepted custom of the medical laboratory community; and

6. such other standards and criteria as may be adopted by EOHHS. In no event may an eligible provider bill or be paid in excess of the usual and customary charge for the service.

(d)Allowable Fees for Certain Individual COVID-19 Testing Services - Not Including Laboratory Analysis. The allowable fees in 101 CMR 446.03(6)(d) apply for the listed COVID-19 testing services performed by an eligible provider at a mobile testing site where the eligible provider is not required to perform, pay for, or contract for the laboratory analysis.

Allowable Fee	Description of Service
$20.81	Ordering, resulting, and follow-up counseling services, per COVID-19 test completed by an eligible mobile testing vendor where the provider is not required to perform, pay for, or contract for the laboratory analysis
$60.00	COVID-19 specimen collection completed by an mobile testing vendor, including test administration or observation, and specimen transport services, per hour, per staff member

(e)Allowable Fees for Certain Individual COVID-19 Testing Services - Including Laboratory Analysis. The allowable fees in 101 CMR 446.03(6)(e) apply for the listed COVID-19 testing services where the eligible provider is required to perform, pay for, or contract for the laboratory analysis.

Allowable Fee	Description of Service
$144.27	Site-based or mobile COVID-19 testing service administered or observed by an eligible provider, including specimen collection, laboratory processing, ordering, resulting, and follow-up counseling services, per test
Individual Consideration	Self-administered COVID-19 testing service completed by an eligible provider, including transport of testing materials, laboratory processing, ordering, resulting, and follow-up counseling services, per test

(f)Allowable Fees for Certain Pooled COVID-19 Testing Services - Including Laboratory Analysis.

1. Effective for dates of service on or after February 4, 2021, governmental units may pay eligible providers for pooled COVID-19 testing services, including laboratory analysis, through a per-pool rate and a rate for individual testing, if any, provided by the pooled testing provider as part of a pooled testing program. The rates must be set forth and agreed to by each eligible provider and the governmental unit through a contract or special conditions amendment to the provider contract. Specimen collection costs, specimen transport costs, and administrative fees may be billed separately from testing services.

2. Eligible providers must bill the governmental unit for the pooled COVID-19 testing services provided pursuant to 101 CMR 446.03(6)(f) and a contract or special conditions amendment to the provider contract, consistent with the terms of the contract or special conditions amendment to the provider contract. The governmental unit will pay the eligible provider for such services, upon receipt of such invoice, consistent with the terms of the contract or special conditions amendment to the provider contract.

(g)Billing Certification. Each eligible provider who submits an invoice to a governmental unit for authorized services under 101 CMR 446.03(6) must certify to the accuracy of the level of services provided, as listed on its invoice.

(7)Allowable Fee for In-home Vaccination Services and Waste Prevention Vaccinations Provided Pursuant to a Contract Between an In-home Vaccination Provider and a Governmental Unit.

(a)General Rate Determination. Rates of payment for services for which 101 CMR 446.03(7) applies are the lowest of

1. the in-home vaccination provider's usual fee to patients other than publicly aided individuals;

2. the in-home vaccination provider's actual charge submitted; or

3. the schedule of allowable fees set forth in 101 CMR 446.03(7)(c), taking into account appropriate modifiers and any other applicable rate provisions in accordance with 101 CMR 446.03(7).

(b)Defined Terms. Terms used in 101 CMR 446.03(7) that have not been defined elsewhere in 101 CMR 446.00 have the meanings ascribed to those terms in the contract between the in-home vaccination provider and the governmental unit.

(c)Allowable Fee for In-home Vaccination Services and Waste Prevention Vaccinations Provided by In-home Vaccination Providers. The following fees apply for the listed in-home vaccination services and waste prevention vaccinations rendered by in-home vaccination providers.

Service	Allowable Fee
In-home vaccination services rendered to eligible residents, inhome vaccination services rendered to eligible additional individuals, or waste prevention vaccinations administered to other vaccinable individuals	$150.00 per COVID-19 vaccine dose administered