(101 CMR 446.03(1) Reserved)

1. (2) Medicine.

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

      1. 1. the eligible provider’s usual fee to patients other than publicly aided individuals;
      2. 2. the eligible provider’s actual charge submitted; or
      3. 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).

   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. 1. the amount of time required to perform the service;
      2. 2. the degree of skill required to perform the service;
      3. 3. the severity or complexity of the patient’s disease, disorder, or disability;
      4. 4. any applicable relative-value studies;
      5. 5. any complications or other circumstances that may be deemed relevant;
      6. 6. the policies, procedures, and practices of other third-party insurers;
      7. 7. the payment rate for prescribed drugs as set forth in 101 CMR 331.00: Prescribed Drugs; and
      8. 8. a copy of the current invoice from the supplier.
   3. (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.

   4. (d) Codes and Modifiers.

      1. 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. 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.

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

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Code Allowable Fee Description of Code 99423 – U9 $870.72 Online digital evaluation and management service, for an established

patient, for up to 7 days, cumulative time during the 7 days; 21 or more minutes.

(Used for COVID-19 remote patient monitoring bundled services provided through any appropriate technology or modality, including up to 7 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.)

1. (f) Allowable Fee for COVID-19 Vaccine and Vaccine Administration. The allowable fees for COVID-19 vaccines and their administration are 100% of the corrresponding 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.
2. 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

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101 CMR 446.00: COVID-19 AND PUBLIC HEALTH EMERGENCY PAYMENT RATES FOR

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Code Description of Code 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

1. (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 corrresponding 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

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

Q0220 SL 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

Q0221 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), 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

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101 CMR 446.00: COVID-19 AND PUBLIC HEALTH EMERGENCY PAYMENT RATES FOR

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Code Description of Code Q0245 SL Injection, bamlanivimab and etesevimab, 2100 mg

Q0247 Injection, sotrovimab, 500 mg

Injection, tocilizumab, for hospitalized adults and pediatric patients (2 years of age and older) with COVID-19 who are receiving systemic

Q0249 corticosteroids and require supplemental oxygen, non-invasive or invasive

mechanical ventilation, or extracorporeal membrane oxygenation (ECMO) only, 1 mg 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

M0220

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 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

M0221

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 Intravenous infusion or subcutaneous injection, casirivimab and imdevimab

M0240 includes infusion or injection, and post administration monitoring,

subsequent repeat doses Intravenous infusion or subcutaneous injection, casirivimab and imdevimab includes infusion or injection, and post administration monitoring in the

M0241 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 Intravenous infusion, casirivimab and imdevimab includes infusion and post

M0243

administration monitoring Intravenous infusion, casirivimab and imdevimab includes infusion and post administration monitoring in the home or residence; this includes a

M0244

beneficiary’s home that has been made provider-based to the hospital during the federal COVID-19 public health emergency

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Code Description of Code

Intravenous infusion, bamlanivimab and etesevimab, includes infusion and

M0245

post administration monitoring Intravenous infusion, bamlanivimab and etesevimab, includes infusion and post administration monitoring in the home or residence; this includes a

M0246

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 (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 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

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

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

      1. 1. the eligible provider’s usual fee to patients other than publicly aided individuals;
      2. 2. the eligible provider’s actual charge submitted; or
      3. 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).
   2. (b) Defined Terms. Terms used in 101 CMR 446.03(3) have the meaning defined in 101 CMR 322.02: General Definitions.
   3. (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.

   (101 CMR 446.03(3)(d) and (e) Reserved)

   1. (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

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members, EOHHS will designate allowable fees via Pharmacy Facts, provider bulletin, or other written issuance, consistent with this section. 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 this section, 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.

(101 CMR 446.03(4) Reserved)

1. (5) Prescribed Drugs.

   1. (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.
   2. (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.
   3. (c) Reporting Requirements. Reporting requirements for 101 CMR 446.03(5) are those in 101 CMR 331.03: Reporting Requirements.

(101 CMR 446.03(6) Reserved)

1. (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.

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

      1. 1. the in-home vaccination provider’s usual fee to patients other than publicly aided individuals;
      2. 2. the in-home vaccination provider’s actual charge submitted; or
      3. 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).
   2. (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.

   3. (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.

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Service Allowable Fee

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