101 CMR 444.00 — Rates for Certain Substance Use Disorder Services

Final Adoption Date Published in Mass Register: March 28, 2025

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101 CMR 444.00: RATES FOR CERTAIN SUBSTANCE USE DISORDER SERVICES Section

444.01: General Provisions 444.02: Definitions 444.03: Reporting Requirements 444.04: Rate Provisions 444.05: Severability

101 CMR 444.00 Rates for Certain Substance Use Disorder Services

444.01 General Provisions

444.01: General Provisions

(1) Scope and Purpose. 101 CMR 444.00 governs rates of payment for opioid treatment and other substance use disorder services to be used by all governmental units making payment to eligible providers of certain substance use disorder services to publicly assisted clients. The rates for health care services set forth in 101 CMR 444.00 also apply to individuals covered by M.G.L. c.152 (the Workers' Compensation Act).

(2) Applicable Dates of Service. Rates contained in 101 CMR 444.00 apply for dates of service provided on or after March 28, 2025.

(3) Disclaimer of Authorization of Services. 101 CMR 444.00 is neither authorization for nor approval of the substantive services for which rates are determined pursuant to 101 CMR 444.00. Governmental units that purchase services from eligible providers are responsible for the definition, authorization, and approval of services extended to publicly assisted clients.

(4) Coding Updates and Corrections. EOHHS may publish procedure code updates and corrections in the form of an administrative bulletin. The publication of such updates and corrections will list: (a) codes for which only the code numbers change, with the corresponding cross references between existing and new codes; (b) deleted codes for which there are no corresponding new codes; and (c) codes for entirely new services that require pricing. EOHHS will list these codes and apply individual consideration (IC) reimbursement for these codes until appropriate rates can be developed.

444.02 Definitions

444.02: Definitions As used in 101 CMR 444.00, terms shall have the following meanings, unless the context requires otherwise. Meaning of Terms. As used in 101 CMR 444.00, unless the context requires otherwise, terms have the following meanings. Center. The Center for Health Information and Analysis established under M.G.L. c. 12C. Eligible Provider. Any individual, group, partnership, trust, corporation, or other legal entity that offers services for purchase by a governmental unit and that meets the conditions of purchase or licensure that have been or may be adopted by a purchasing governmental unit.

Final Adoption Date Published in Mass Register: March 28, 2025

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EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A. Established Charge. The lowest fee that is charged or accepted as payment by the eligible provider to the general public or any third-party payer, other than a governmental unit, for the provision of services. Fees based upon the client's ability to pay, as in the case of a sliding fee scale, and fees subject to EOHHS review and approval are not deemed to be established charges. Governmental Unit. The Commonwealth, any board, commission, department, division, or agency of the Commonwealth and any political subdivision of the Commonwealth. Individualized Treatment and Stabilization Services. Acute Treatment Services (ASAM Level 3.7) and Clinical Stabilization Services (ASAM Level 3.5) provided in an appropriately licensed facility and in accordance with all applicable specifications. Medical Evaluation. A history, physical examination, and assessment of mental status that incorporates the principles of The American Society of Addiction Medicine completed within 24 hours of admission to Individualized Treatment and Stabilization Services and Opioid Treatment Programs and as needed based on clinical presentation. Opioid Treatment Program (OTP). A program that provides opioid treatment services. An opioid treatment program must be federally certified by the Substance Abuse Mental Health Services Administration and must be licensed as an opioid treatment program by the Department of Public Health under 105 CMR 164.000: Licensure of Substance Use Disorder Treatment Programs. Opioid treatment programs must conform to the federal opioid treatment standards set forth in 42 CFR 8.12: Federal Opioid Treatment Standards. Opioid Treatment Services. Supervised assessment and treatment of an individual, using FDA- approved medications (including methadone, buprenorphine, buprenorphine/naloxone, and naltrexone), along with a comprehensive range of medical and rehabilitative services, when clinically necessary, to alleviate the adverse medical, psychological, or physical effects incident to opiate use disorders. This term encompasses withdrawal management and maintenance treatment. Publicly Assisted Client. A person who receives program services for which a governmental unit is liable, in whole or in part, under a statutory program of financial assistance. Purchasing Governmental Unit. A governmental unit that has purchased or is purchasing service units from an eligible provider. Recovery Support Navigator. A paraprofessional or peer specialist who receives specialized training in the essentials of substance use disorder and evidence-based techniques such as motivational interviewing, and who supports members in accessing and navigating the substance use disorder treatment system through activities that can include care coordination, case management, and motivational support.

444.03 Reporting Requirements

444.03: Reporting Requirements (1) Required Reports. Reporting requirements are governed by 957 CMR 6.00: Cost Reporting Requirements. (2) Penalty for Noncompliance. 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 101 CMR 444.03(2).

Final Adoption Date Published in Mass Register: March 28, 2025

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(3) An eligible provider that was paid by a governmental unit for opioid treatment services provided in a prior fiscal year, and whose program operated for the entire prior fiscal year must submit the following information to the Operational Services Division and/or to the Center for Health Information and Analysis as required: a. An annual Uniform Financial Statements and Independent Auditor's Report (UFR) completed in accordance with:

1. the filing requirements and schedule of 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services; and
2. any special instructions appearing in the UFR Audit & Preparation Manual, that may require that certain providers distinguish certain programs by filing separate UFR Schedule Bs for each program; and b. Any cost report supplemental schedule or any additional information requested by the Center within the timeframe specified by the Center on the request.

444.04 Rate Provisions

444.04: Rate Provisions (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) Rates 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 is used to offset the amount of the purchasing governmental unit's obligation for services rendered to the publicly assisted client. (3) Rates of Payment. Payment rates under 101 CMR 444.00 must be the lower of: (a) the eligible provider's usual charge to the general public; or (b) the schedule of allowable rates for services provided by substance use disorder treatment programs as set forth in 101 CMR 444.04(4)(a) and (b). (4) Payment Limitations. No purchasing governmental unit may pay less than or more than the approved program rate except as provided in 101 CMR 444.04(2). (a) Allowable fees for dates of service on or after March 28, 2025 through June 30, 2025:

Code Rate Unit Description G2067 $190.82 Per Week Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) G2068 $227.96 Per Week Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program)

Final Adoption Date Published in Mass Register: March 28, 2025

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Code Rate Unit Description G2073 $1,209.57 Per Week Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) G2074

$149.34

Per Week Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare- enrolled Opioid Treatment Program) G2076 $165.73 Per Initial Visit Intake activities, including initial medical examination that is a complete, fully documented physical evaluation and initial assessment by a program physician or a primary care physician, or an authorized healthcare professional under the supervision of a program physician or qualified personnel that includes preparation of a treatment plan that includes the patient’s short-term goals and the tasks the patient must perform to complete the short-term goals; the patient’s requirements for education, vocational rehabilitation, and employment; and the medical, psycho-social, economic, legal, or other supportive services that a patient needs, conducted by qualified personnel (provision of the services by a Medicare-enrolled Opioid Treatment Program); list separately in addition to code for primary procedure G2078 $31.77 Per Week Take-home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare-enrolled Opioid Treatment Program); list separately in addition to code for primary procedure. G2079 $68.92 Per Week Take-home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a Medicare-enrolled Opioid Treatment Program); list separately in addition to code for primary procedure. H2015-HF $17.54 Per 15- Minutes Comprehensive community support services, per 15 minutes (Recovery Support Navigator) H2036-HK $919.21 Per Diem Alcohol and/or other drug treatment program, per diem (Individualized Treatment and Stabilization, Tier 1) H2036-HF $667.22 Per Diem Alcohol and/or other drug treatment program, per diem (Individualized Treatment and Stabilization, Tier 2) H0015 $121.90

Per Diem Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3.5 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling, crisis intervention, and activity therapies or education (Structured Outpatient Addiction Program, 3.5 hours, not to exceed two units a day).

Final Adoption Date Published in Mass Register: March 28, 2025

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Code Rate Unit Description H0015-TF $176.15 Per Diem Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3.5 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling, crisis intervention, and activity therapies or education (Enhanced Structured Outpatient Addiction Program, 3.5 hours, not to exceed 2 units a day.)

(b) Allowable fees for dates of service on or after July 1, 2025:

Code Rate Description G2067 See 101 CMR 346.00: Rates for Certain Substance-Related and Addictive Disorders Programs Medication assisted treatment, methadone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing, if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) G2068 See 101 CMR 346.00: Rates for Certain Substance-Related and Addictive Disorders Programs Medication assisted treatment, buprenorphine (oral); weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) G2073 See 101 CMR 346.00: Rates for Certain Substance-Related and Addictive Disorders Programs Medication assisted treatment, naltrexone; weekly bundle including dispensing and/or administration, substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare-enrolled Opioid Treatment Program) G2074 See 101 CMR 346.00: Rates for Certain Substance-Related and Addictive Disorders Programs Medication assisted treatment, weekly bundle not including the drug, including substance use counseling, individual and group therapy, and toxicology testing if performed (provision of the services by a Medicare- enrolled Opioid Treatment Program)

Final Adoption Date Published in Mass Register: March 28, 2025

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Code Rate Description G2076 See 101 CMR 346.00: Rates for Certain Substance-Related and Addictive Disorders Programs Intake activities, including initial medical examination that is a complete, fully documented physical evaluation and initial assessment by a program physician or a primary care physician, or an authorized healthcare professional under the supervision of a program physician or qualified personnel that includes preparation of a treatment plan that includes the patient’s short-term goals and the tasks the patient must perform to complete the short-term goals; the patient’s requirements for education, vocational rehabilitation, and employment; and the medical, psycho-social, economic, legal, or other supportive services that a patient needs, conducted by qualified personnel (provision of the services by a Medicare-enrolled Opioid Treatment Program); list separately in addition to code for primary procedure G2078 See 101 CMR 346.00: Rates for Certain Substance-Related and Addictive Disorders Programs Take-home supply of methadone; up to 7 additional day supply (provision of the services by a Medicare-enrolled Opioid Treatment Program); list separately in addition to code for primary procedure. G2079 See 101 CMR 346.00: Rates for Certain Substance-Related and Addictive Disorders Programs Take-home supply of buprenorphine (oral); up to 7 additional day supply (provision of the services by a Medicare-enrolled Opioid Treatment Program); list separately in addition to code for primary procedure. H2015-HF $17.54 Comprehensive community support services, per 15 minutes (Recovery Support Navigator) H2036-HK $919.21 Alcohol and/or other drug treatment program, per diem (Individualized Treatment and Stabilization, Tier 1) H2036-HF $667.22 Alcohol and/or other drug treatment program, per diem (Individualized Treatment and Stabilization, Tier 2) H0015 $121.90 Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3.5 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education (Structured Outpatient Addiction Program) H0015-TF $176.15 Alcohol and/or drug services; intensive outpatient (treatment program that operates at least 3.5 hours/day and at least 3 days/week and is based on an individualized treatment plan), including assessment, counseling; crisis intervention, and activity therapies or education (Enhanced Structured Outpatient Addiction Program)

Final Adoption Date Published in Mass Register: March 28, 2025

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444.05 Severability

444.05: Severability The provisions of 101 CMR 444.00 are severable. If any provision of 101 CMR 444.00 or application of such provision to any eligible provider or fiscal intermediary is held invalid or unconstitutional, such determination will not affect the validity or constitutionality of any remaining provisions of 101 CMR 444.00 or application of such provisions to eligible providers or fiscal intermediaries in circumstances other than those held invalid. REGULATORY AUTHORITY 101 CMR 444.00: M.G.L. c 118E.