Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 304.00 - Rates For Community Health Centers › Section 304.04 - Rate Provisions

Current through Register 1525, July 5, 2024
(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.