101 CMR 312.00 — Rates for Family Planning Services

Final Adoption Date Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 312.00: RATES FOR FAMILY PLANNING SERVICES

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Section

312.01: General Provisions 312.02: General Definitions 312.03: General Rate Provisions 312.04: Reporting Requirements 312.05: Severability

101 CMR 312.00 Rates for Family Planning Services

312.01 General Provisions

312.01: General Provisions

(1) Scope and Purpose. 101 CMR 312.00 governs the rates of payment used by all governmental units to pay eligible providers which provide family planning services to publicly aided individuals.

(2) Applicable Dates of Service. Rates in 101 CMR 312.00 apply for dates of service provided on or after May 1, 2025 , unless otherwise indicated.

(3) Coverage. 101 CMR 312.00 and the rates of payment in 101 CMR 312.00 apply to family planning services rendered by eligible providers at a family planning agency setting. The rates of payment under 101 CMR 312.00 are full compensation for all services rendered.

(4) Disclaimer of Authorization of Services. 101 CMR 312.00 is not authorization for or approval of the procedures for which rates are determined pursuant to 101 CMR 312.00. Governmental units that purchase care are responsible for the definition, authorization, coverage policies, and approval of the care and services extended to publicly aided individuals.

(5) Coding Updates and Corrections. EOHHS may publish procedure code updates and corrections in the form of an administrative bulletin. Updates may reference coding systems including, but not limited, to the American Medical Association’s Current Procedural Terminology (CPT) and/or the Healthcare Common Procedure Coding System (HCPCS). The publication of such updates and corrections will list: (a) codes for which the code numbers change, with the corresponding cross-references between new codes and the codes being replaced. Rates for such new codes are set at the rate of the code that is being replaced; (b) codes for which the code number remains the same, but the description has changed; (c) deleted codes for which there are no corresponding new codes; and (d) codes for entirely new services that require pricing. EOHHS will list these codes and apply individual consideration (IC) payment for these codes until appropriate rates can be developed.

(6) Administrative Bulletins. EOHHS may issue administrative bulletins to add, delete, or otherwise update codes or modifiers, to clarify its policy on and understanding of substantive provisions of 101 CMR 312.00, and as otherwise specified in 101 CMR 312.00.

Final Adoption Date Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 312.00: RATES FOR FAMILY PLANNING SERVICES

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312.02 General Definitions

312.02: General Definitions

As used in 101 CMR 312.00, unless the context clearly otherwise requires, the following terms have the meanings in 101 CMR 312.02.

Center. The Center for Health Information and Analysis established under M.G.L. c. 12C.

Comprehensive Family Planning Agency. A public or private agency that demonstrates the capability of providing family planning medical services, family planning counseling services, follow-up health care, outreach, and community education.

Eligible Provider. A comprehensive family planning agency which meets such conditions of participation as may be required by a governmental unit purchasing such services.

EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A.

Established Patient. A patient who has received professional services from the provider within the past three years.

Governmental Unit. The Commonwealth, any department, agency, board, or commission of the Commonwealth and any political subdivision of the Commonwealth.

Individual Consideration (IC). For specified drugs, injectables/vaccines, and medical and related supplies that are listed in 101 CMR 312.03(4) with IC, payment will be at cost, subject to any documentation requirements of the governmental unit.

New Patient. A patient who has not received any professional services from the provider within the past three years.

Publicly Aided Individual. A person for whose medical and other services a governmental unit is in whole or in part liable under a statutory program.

Separate Procedure. Some of the listed procedures are commonly performed as an integral part of a total service and, as such, do not warrant a separate identification or payment. When, however, such a procedure is performed independently of, and is not immediately related to other services, it may be listed separately in the procedure description. Thus, when a procedure that is ordinarily a component of a larger procedure is performed alone for a specific purpose, it may be considered a separate procedure. There are certain procedures designated as "(SP)" which are in addition to those procedures designated "separate procedure" by the AMA-CPT coding structure. These "(SP)" procedures were designated "Independent Procedures" (IP) in the former six-digit coding structure.

Final Adoption Date Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 312.00: RATES FOR FAMILY PLANNING SERVICES

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312.03 General Rate Provisions

312.03: General Rate Provisions

(1) Reimbursement as Full Payment. Each eligible provider must, as a condition of payment made by the purchasing governmental unit for services rendered, accept the approved program rate as full payment and discharge of all obligations for the services rendered. Any third-party payments or sliding fees received on behalf of a publicly aided individual reduces, by that amount, the purchasing governmental unit's payment for services rendered to the publicly aided individual.

(2) Rates. Subject to the conditions listed herein, rates of payment for authorized family planning services for which 101 CMR 312.00 applies are the lowest of (a) the eligible provider's usual fee to the general public; (b) the eligible provider’s actual charge submitted; and (c) the schedule of allowable fees listed below in 101 CMR 312.03(4).

(3) Modifiers. (a) 24 – Unrelated evaluation and management service by the same physician or other qualified health care professional during a postoperative period. (b) 25 – Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service. (c) 59 – Distinct procedural service. (d) LT – Left side (used to identify procedures performed on the left side of the body). (e) RT – Right side (used to identify procedures performed on the right side of the body). (f) Modifiers for Provider Preventable Conditions. Below are modifiers for reporting “provider preventable conditions” that are National Coverage Determinations, in accordance with 42 CFR 447.26.

Modifier Name Description -PA Surgical or other invasive procedure on wrong body part -PB Surgical or other invasive procedure on wrong patient -PC Wrong surgery or other invasive procedure on patient

Final Adoption Date Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 312.00: RATES FOR FAMILY PLANNING SERVICES

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(4) Schedule of Allowable Fees.

Code Allowable Fee Description 90651 IC Human Papillomavirus vaccine types 6, 11, 16, 18, 31, 33, 45, 52, 58, nonavalent (9vHPV), 2 or 3 dose schedule, for intramuscular use New Patient 99202 $95.14 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 15 minutes must be met or exceeded. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) 99203 $144.55 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) 99204 $210.21 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 45 minutes must be met or exceeded. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) 99205 $265.12 Office or other outpatient visit for the evaluation and management of a new patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 60 minutes must be met or exceeded. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.)

Final Adoption Date Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 312.00: RATES FOR FAMILY PLANNING SERVICES

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Code Allowable Fee Description Established Patient 99211 $37.74 Office or other outpatient visit for the evaluation and management of an established patient that may not require the presence of a physician or other qualified health care professional (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) 99212 $68.06 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and straightforward medical decision making. When using total time on the date of the encounter for code selection, 10 minutes must be met or exceeded. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) 99213 $104.23 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and low level of medical decision making. When using total time on the date of the encounter for code selection, 20 minutes must be met or exceeded. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) 99214 $150.82 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and moderate level of medical decision making. When using total time on the date of the encounter for code selection, 30 minutes must be met or exceeded. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.) 99215 $201.78 Office or other outpatient visit for the evaluation and management of an established patient, which requires a medically appropriate history and/or examination and high level of medical decision making. When using total time on the date of the encounter for code selection, 40 minutes must be met or exceeded. (In addition, visit includes counseling, anticipatory guidance, risk factor reduction, interventions, and the ordering of appropriate laboratory and diagnostic procedures.)

Final Adoption Date Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 312.00: RATES FOR FAMILY PLANNING SERVICES

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Code Allowable Fee Description Preventive Medicine Services 99384 $110.46 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; adolescent (age 12 through 17 years) 99385 $110.46 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 18-39 years 99386 $123.75 Initial comprehensive preventive medicine evaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, new patient; 40-64 years 99394 $95.86 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; adolescent (age 12 through 17 years) 99395 $96.34 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 18-39 years 99396 $102.56 Periodic comprehensive preventive medicine reevaluation and management of an individual including an age and gender appropriate history, examination, counseling/anticipatory guidance/risk factor reduction interventions, and the ordering of laboratory/diagnostic procedures, established patient; 40-64 years 99402 $71.15 Preventive medicine counseling and/or risk factor reduction intervention(s) provided to an individual (separate procedure); approximately 30 minutes Allowable Medical and Related Supplies S4993

$11.33 Contraceptive pills for birth control

Final Adoption Date Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 312.00: RATES FOR FAMILY PLANNING SERVICES

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Code Allowable Fee Description All Other Medical and Related Supplies S4989 IC Contraceptive intrauterine device (e.g., Progestasert IUD), including implants and supplies A4261 IC Cervical cap for contraceptive use A4266 $9.77 Diaphragm for contraceptive use (includes applicator and contraceptive cream or jelly) A4267 $0.19 Contraceptive supply, condom, male, each A4268 $2.14 Contraceptive supply, condom, female, each A4269 $4.10 Contraceptive supply, spermicide (e.g., foam, gel), each (per tube or package) (includes contraceptive sponges) J1050 IC Injection, medroxyprogesterone acetate, 1 mg J3490-FP IC Unclassified Drugs (service provided as part of a Medicaid family planning program) (may be used by other governmental purchasers of family planning services) J7296 IC Levonorgestrel-releasing intrauterine contraceptive system, (Kyleena), 19.5 mg J7297 IC Levonorgestrel-releasing intrauterine contraceptive system (Liletta), 52 mg J7298 IC Levonorgestrel-releasing intrauterine contraceptive system (Mirena), 52 mg J7300 IC Intrauterine copper contraceptive J7301 IC Levonorgestrel-releasing intrauterine contraceptive system (Skyla), 13.5 mg J7303 IC Contraceptive supply, hormone containing vaginal ring, each J7304 IC Contraceptive supply, hormone containing patch, each J7307 IC Etonogestrel (contraceptive) implant system, including implant and supplies Medical and Surgical Procedures 11976 $158.16 Removal, implantable contraceptive capsules 11981 $261.55 Insertion, drug-delivery implant (ie, bioresorbable, biodegradable, non- biodegradable)

(5) Other Family Planning Services. The rates of payment for other family planning services

not listed in 101 CMR 312.03(4) that are authorized by the purchasing governmental unit will be based on the applicable EOHHS regulations such as 101 CMR 313.00: Rates for Freestanding Clinics Providing Abortion and Sterilization Services; 101 CMR 316.00: Rates for Surgery and

Final Adoption Date Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 312.00: RATES FOR FAMILY PLANNING SERVICES

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Anesthesia Services; 101 CMR 317.00: Rates for Medicine Services; 101 CMR 318.00: Rates for Radiology Services; and 101 CMR 320.00: Rates for Clinical Laboratory Services.

312.04 Reporting Requirements

312.04: 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 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 312.04(2).

312.05 Severability

312.05: Severability

The provisions of 101 CMR 312.00 are severable. If any provision of 101 CMR 312.00 or application of any provision to an applicable individual, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of 101 CMR 312.00 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

101 CMR 312.00: M.G.L. c.118E.