Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 346.00 - Rates for Certain Substance-related and Addictive Disorders Programs › Section 346.04 - General Provisions

Current through Register 1525, July 5, 2024
(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
$438.61
Alcohol and/or drug services; subacute detoxification
							 (residential addiction program inpatient) (Clinically Managed Detoxification
							 Services)
H0011
$568.09
Alcohol and/or drug services; acute detoxification
							 (residential addiction program inpatient) (Medically Monitored Inpatient
							 Detoxification Services Facility)
H0011-H9
$39.44
Alcohol and/or drug services; acute detoxification
							 (residential addiction program inpatient) (court ordered) (Treatment for
							 Civilly Committed Persons Add-on)
Residential Services
H0018
$228.58
Behavioral health; short-term residential
							 (nonhospital residential treatment program),
per diem
(Transitional Support Services)
H0018-H9
$191.29
Behavioral health; short-term residential
							 (nonhospital residential treatment program),
per diem
(court
							 ordered) (Second Offender-driver Alcohol Education Residential)
H0019
$179.04
Alcohol and/or drug abuse halfway house services,
per diem
(Residential Rehabilitation), without room and
							 board.
H0019-TH
$43.77
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 women's program) (Residential Rehabilitation Pregnant
							 Enhancement)
H0019-HD
$99.83
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) (Residential Rehabilitation
							 Postpartum Enhancement)
H0019-HV
$49.92
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
$265.77
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
$72.84
Alcohol and/or drug services; case management (court
							 ordered) (Jail Diversion-Phase II, per hour)
H0019-HR
$249.31
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
$412.17
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
$64.11
Alcohol and/or drug abuse services, not otherwise
							 specified (family/couple with client present) (Family Residential
							 2nd  Partner Enhancement,
per
							 diem
)
H0019-HH
$291.80
Alcohol and/or drug abuse halfway house services,
per diem
(Residential Rehabilitation Co-occurring Enhanced for
							 16 beds)
Opioid Treatment Services
Medical Services Visit
H0020
$11.26
Alcohol and/or drug services; methadone
							 administration and/or service (provision of the drug by a licensed program)
							 (dose only visit)
Counseling
H0004-TF
$20.11
Behavioral health counseling and therapy, per 15
							 minutes (opioid individual counseling, intermediate level of care, four units
							 maximum per day)
H0005-HQ
$17.64
Alcohol and/or drug services; group counseling by a
							 clinician (group setting) (per 45 minutes, opioid group counseling, one unit
							 maximum per day)
H0005-HF
$35.28
Alcohol and/or drug services; group counseling by a
							 clinician (per 90-minute unit) (one unit maximum per day)
T1006-HR
$40.52
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
$81.04
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
$57.85
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
$28.94
Alcohol and/or drug assessment (per 15
							 minutes)
H0004
$28.94
Behavioral health counseling and therapy, per 15
							 minutes (individual counseling)
H0005
$26.04
Alcohol and/or drug services; group counseling by a
							 clinician (per 45 minutes, group counseling, one unit maximum per
							 day)
H0005-HG
$52.09
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 of Payment 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 of Payment 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)
H2015-HF
$15.88
Comprehensive community support services, per 15
							 minutes (substance abuse program) (Telephone Recovery support service by a
							 counselor trained in evidence-based model)
H2019-HF
$24.05
Therapeutic behavioral services, per 15 minutes
							 (substance abuse program) (in-home counseling by a clinician)
H2027
$4.64
Psychoeducational service, per 15 minutes
							 (Educational and motivational nonclinical group, per client)
H2016-HM
$19.70
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
$28.94
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
$18.21
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
$28.94
Alcohol and/or drug assessment (court ordered) (per
							 15 minutes)
H0004-H9
$28.94
Behavioral health counseling and therapy, per 15
							 minutes (court ordered) (individual counseling)
H0005-H9
$8.68
Alcohol and/or drug services; group counseling by a
							 clinician (court ordered) (per 15 minutes)
Day Treatment
H2012-HF
$104.44
Behavioral health day treatment (substance abuse
							 program) (3.5 hours)
Outpatient Services
H0004-HD
$28.94
Behavioral health counseling and therapy, per 15
							 minutes (pregnant/parenting women's program) (individual
							 counseling)
H0005-HD
$26.04
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
$52.09
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
$18.21
Alcohol and/or drug services; case management
							 (pregnant/parenting women's program) (per 15 minutes)
Outpatient Services
T1006-HD
See 101 CMR 306.00:
Rates of Payment 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
T1006-TH
See 101 CMR 306.00:
Rates of Payment 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
$104.44
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
$104.44
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
$16.49
Adult Housing Stability Support
Enrolled Client Day
$33.18
Family Housing Stability Support
Enrolled Client Day
$43.82
Youth Housing Stability Support
Month
$3,316
House Manager Add-on
Month
$4,573
Outreach and Staffing Supports
Enrolled Client Day
$58.14
Low Threshold
N/A
I.C.
Extraordinary Circumstances/Flex Funding
Month
$20,194
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
$1,112
$630
$324
B
Monthly per slot
$1,337
$816
$515
Triage, Engagement, and Assessment Services
							 Add-on Rates
Unit
Rate
Peer Service Coordinator Add-on Rate
Hourly
$26.09
Social Worker LCSW Add-on Rate
Hourly
$46.58
Care Coordinator Add-on Rate
Hourly
$26.09
Direct Care Staff Add-on Rate
Hourly
$26.09
Support Staff Add-on Rate
Hourly
$26.09
Service
Unit
Monthly Rate
Federally Qualified Health Centers (FQHCs)
							 Services
Per Client
$66.69
Office-based Opioid Treatment Programs (OBOTs)
							 Outpatient Clinic Services
Per Client
$86.60
Office-based Opioid Treatment Programs (OBOTs)
							 Hospital Services
Per Client
$178.77
Service
Level
Monthly Rate
Federally Qualified Health Centers (FQHCs)
							 Start-up
Level 1
$9,915
Level 2
$14,516
Service
Tier
Monthly Rate
Recovery Support Centers
Tier 1
$39,489
Tier 2
$49,072
Tier 3
$59,844
Recovery Support Center Add-on
							 Rates
FTE
Monthly Rate
Direct Service Staff Add-on Rate
1.0
$4,131
Direct Service Staff Add-on Rate
0.5
$2,066
Recovery Coach Specialist Staff Add-on
							 Rate
1.0
$5,168
Recovery Coach Specialist Staff Add-on
							 Rate
0.5
$2,584
(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(5), 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(5)(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(5)(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.
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				image
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.
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				image
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.
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				image
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(5)) by the
			 maximum number of points per performance indicator (10).
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				image
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.
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				image
(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.
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				image
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.
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				image
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(5)(c);
2. the number of P4P eligible provider
			 clients served during the measurement period; and
3. the per member payment amount that is
			 calculated as per
			 101
			 CMR 346.04(4).
P4P Eligible Provider Total Performance Indicator Payment
				Amount = (P4P Eligible Provider Performance Score) x (number of P4P Eligible
				Provider clients served) x (Per Member Payment Amount)