101 CMR 319.00 — Rates for Doula Services

Final Adoption Date Published in Mass Register: December 8, 2023

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 319.00: RATES FOR DOULA SERVICES

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Section

319.01: General Provisions 319.02: Definitions 319.03: General Rate Provisions and Payment 319.04: Reporting Requirements 319.05: Severability

101 CMR 319.00 Rates for Doula Services

319.01 General Provisions

319.01: General Provisions

(1) Scope and Purpose. 101 CMR 319.00 governs the rates of payments used by all governmental units in making payments to eligible doula providers for doula services rendered to publicly aided individuals.

(2) Applicable Dates of Service. Rates contained in 101 CMR 319.00 are effective for dates of service provided on and after December 8, 2023, unless otherwise indicated.

(3) Coverage. The rates of payment contained in 101 CMR 319.00, or determined in accordance with the provisions of 101 CMR 319.00, are full compensation for doula services rendered to publicly aided individuals as well as for any related administrative or supervisory duties in connection with the provision of services, without regard to where these services are rendered.

(4) Disclaimer of Authorization of Services. 101 CMR 319.00 is not authorization for or approval of the procedures for which rates are determined pursuant to 101 CMR 319.00. Governmental units that purchase care are responsible for the definition, authorization, coverage policies, and approval of care and services provided to publicly aided individuals.

(5) Coding Updates and Corrections. EOHHS may publish service 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). 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 (I.C.) 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 319.00, and as otherwise specified in 101 CMR 319.00.

Final Adoption Date Published in Mass Register: December 8, 2023

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 319.00: RATES FOR DOULA SERVICES

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319.02 Definitions

319.02: Definitions

Terms used in 101 CMR 319.00 have the meanings set forth in 101 CMR 319.02. The descriptions and five-digit codes included in 101 CMR 319.00 utilize the Healthcare Common Procedure Code System (HCPCS) for Level I and Level II coding. Level 1 CPT-4 codes are obtained from the Physicians’ 2023 Current Procedural Terminology® by the American Medical Association (AMA), unless otherwise specified. Level II codes are obtained from 2023 HCPCS maintained jointly by the Centers for Medicare & Medicaid Services (CMS), the Blue Cross and Blue Shield Association, and the Health Insurance Association of America. HCPCS is a listing of descriptive terms and identifying codes and modifiers for reporting medical services and procedures performed by physicians and other healthcare professionals, as well as associated non- physician services. 101 CMR 319.00 includes only HCPCS numeric and alpha-numeric identifying codes and modifiers for reporting medical services and procedures that were selected by EOHHS. Any use of CPT outside the fee schedule should refer to the Physicians’ 2023 Current Procedural Terminology®.

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

Doula. A qualified professional who provides non-medical emotional, informational, and physical support to individuals and families during pregnancy, delivery, and the post-pregnancy period.

Eligible Doula Provider. (1) A provider of doula services who meets the conditions of participation of a governmental unit purchasing such services. (2) MassHealth providers of doula services must satisfy the provider eligibility requirements set forth in 130 CMR 463.000: Doula Services and 130 CMR 450.000: Administrative and Billing Regulations.

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

Governmental Unit. The Commonwealth of Massachusetts or any of its departments, agencies, boards, commissions, or political subdivisions.

Individual Consideration (I.C.). Doula services that are authorized but not listed in 101 CMR 319.00, doula services performed in unusual circumstances, and services whose fees are designated by the letters "I.C." are individually considered items. The governmental unit or purchaser analyzes the eligible provider’s operative report, which must contain a diagnosis, a pertinent medical history, a description of the services rendered, and the length of time spent with the patient. In making the determination of whether the service is appropriately classified as an individually considered item the following criteria are used: (1) policies, procedures, and practices of other third-party purchasers of care, both governmental and private; (2) the severity and complexity of the patient's disorder or disability; (3) prevailing provider ethics and accepted practice; and (4) time, degree of skill, and cost including equipment cost required to perform the procedure(s).

Final Adoption Date Published in Mass Register: December 8, 2023

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 319.00: RATES FOR DOULA SERVICES

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Labor and Delivery. Childbirth or delivery of a fetus following pregnancy, inclusive of all pregnancy outcomes.

Modifiers. Listed services may be modified under certain circumstances. When applicable, the modifying circumstances must be identified by the addition of the appropriate two-digit number or letters.

Perinatal. The period encompassing pregnancy and labor and delivery, through 12 months following delivery, inclusive of all pregnancy outcomes.

Publicly Aided Individual. A person who receives health care and services for which a governmental unit is in whole or in part liable under a statutory program of public assistance.

319.03 General Rate Provisions and Payment

319.03: General Rate Provisions and Payment

(1 ) Individual Consideration and Nonlisted Procedures. Rates of payment for doula services that are authorized but not listed in 101 CMR 319.00, services performed in unusual circumstances, and services whose fees are designated by the letters “I.C.” are determined on an individual consideration basis.

(2) Fee Schedule. Certain doula services are not associated with CPT codes that have a service- specific description, and therefore must be billed for by using a CPT code that represents unlisted services (Unlisted Service Code) in accordance with the fee schedule below. For such doula services, the doula service associated with each Unlisted Service Code is identified in the parenthetical description of the code description section of the fee schedule below.

Code Rate Code Description 99600 $100 Unlisted home visit service or procedure. (Perinatal visit up to 60 minutes.) 99600 TF $150 Unlisted home visit service or procedure. (Perinatal visit from 61 minutes up to 90 minutes. This service must be identified by adding the modifier TF to the parent service code.) 99199 $900 Unlisted special service, procedure or report. (Labor and delivery support.)

(3) Perinatal Visit Payments. For MassHealth providers of doula services, the payment for perinatal visits will not exceed $800 per perinatal period per member, with the exception of payment for additional perinatal visits for which a provider receives prior authorization in accordance with 130 CMR 463.000.

Final Adoption Date Published in Mass Register: December 8, 2023

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 319.00: RATES FOR DOULA SERVICES

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319.04 Reporting Requirements

319.04: 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 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 319.04(2).

319.05 Severability

319.05: Severability

The provisions of 101 CMR 319.00 are severable. If any provision of 101 CMR 319.00 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 319.00 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

101 CMR 319.00: M.G.L. c. 118E.