Appendix J, Sub. Capitation Program Rates for Primary Care Entities, is hereby deleted and replaced with the attached Appendix J. Amendment #2A to PCACO Contract APPENDIX J SUB-CAPITATION PROGRAM RATES FOR PRIMARY CARE ENTITIES Contract Year 1 Listed below are the Per Member Per Month (PMPM) Primary Care Entity (PCE) Primary Care Sub-Capitation Rates, developed by EOHHS, for Contract Year 1 (April 1, 2023, through December 31, 2023) (also referred to as Rate Year 2023 or RY23). The table below sets forth PMPM amounts by PCE, across all Regions and Rating Categories. Please refer to Section 2.14.A.1.h for information on how the Contractor shall pay each PCE during the Contract Year. PCE-specific Primary Care Sub-Capitation Rates April 1, 2023 – December 31, 2023 (RY23) PCE (as defined by EOHHS) PCE SUB- CAPITATION RATE COMPONENT: BASE SUB- CAPITATION RATE PCE SUB- CAPITATION RATE COMPONENT: TIER ENHANCED PAYMENT TOTAL PCE SUB- CAPITATION RATE (see Section 2.14.A.1.h) (per member per month) (per member per month) (per member per month) 010562299 $ 18.94 $ 4.99 $ 23.93 010652163 $ 19.75 $ 4.05 $ 23.80 010805320 $ 16.33 $ 4.01 $ 20.34 020424098 $ 13.90 $ 4.12 $ 18.02 030375949 $ 25.94 $ 4.00 $ 29.94 042547627 $ 20.42 $ 12.90 $ 33.32 042619517 $ 56.03 $ 11.16 $ 67.19 042699646 $ 17.56 $ 4.11 $ 21.67 042702637 $ 21.54 $ 4.93 $ 26.47 042740173 $ 21.23 $ 12.73 $ 33.96 042752365 $ 17.30 $ 4.19 $ 21.49 042800066 $ 21.56 $ 4.33 $ 25.89 042870059 $ 20.43 $ 4.03 $ 24.46 042993314 $ 18.69 $ 4.04 $ 22.73 043005401 $ 19.18 $ 4.01 $ 23.19 PCE-specific Primary Care Sub-Capitation Rates April 1, 2023 – December 31, 2023 (RY23) PCE (as defined by EOHHS) PCE SUB- CAPITATION RATE COMPONENT: BASE SUB- CAPITATION RATE PCE SUB- CAPITATION RATE COMPONENT: TIER ENHANCED PAYMENT TOTAL PCE SUB- CAPITATION RATE (see Section 2.14.A.1.h) (per member per month) (per member per month) (per member per month) 043013890 $ 23.41 $ 12.90 $ 36.31 043106457 $ 20.08 $ 4.95 $ 25.03 043174401 $ 13.48 $ 4.28 $ 17.76 043240936 $ 16.28 $ 4.97 $ 21.25 043286529 $ 24.03 $ 4.06 $ 28.09 043288315 $ 16.34 $ 4.12 $ 20.46 043326112 $ 27.17 $ 4.96 $ 32.13 043405594 $ 12.25 $ 4.08 $ 16.33 043438404 $ 17.36 $ 4.15 $ 21.51 043472701 $ 17.80 $ 4.27 $ 22.07 043520680 $ 14.85 $ 4.05 $ 18.90 043531275 $ 10.81 $ 4.23 $ 15.04 043543416 $ 15.46 $ 4.08 $ 19.54 043567594 $ 25.97 $ 4.08 $ 30.05 043567824 $ 26.37 $ 4.92 $ 31.29 043630666 $ 21.42 $ 4.98 $ 26.40 134262532 $ 15.08 $ 4.03 $ 19.11 200144352 $ 16.33 $ 4.11 $ 20.44 201817107 $ 19....
Appendix J, Sub. Capitation Program Rate for Primary Care Entities, is hereby deleted and replaced with the attached Appendix J. APPENDIX A Exhibit 1: Services Included in TCOC Calculations Denotes a service included in TCOC Calculations Each of the Services listed below will be included in Total Cost of Care (TCOC) calculations, except for those listed as Services Not Included in TCOC Calculations or listed as Excluded Services. MassHealth reserves the right to amend or modify this list, including but not limited to further defining the services listed below as well as adding or removing services. Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Acupuncture Treatment Acute Inpatient Hospital Ambulatory Surgery/Outpatient Hospital Care Audiologist Behavioral Health Services (see below) Breast Pumps and Breast Milk Storage Bags Certain COVID-19 Specimen Collection and Testing (until May 11, 2023) Chiropractic Services Chronic, Rehabilitation Hospital or Nursing Facility Services, up to 100 days per Contract Year, except stays in Commonwealth designated COVID-19 nursing facility, see non-TCOC Included Services in Exhibit 2. Emergency Related Dental Services Diabetes Self-Management Training Dialysis Durable Medical Equipment and Medical/Surgical Supplies 1) Durable Medical Equipment 2) Medical/Surgical Supplies Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services Early Intervention Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Emergency Services Family Planning Fluoride Varnish Hearing Aids Home Health Services Hospice Infertility, related to an underlying medical condition Laboratory MassHealth Coordinating Aligned, Relationship-centered Enhanced Support (CARES) for Kids Medical Nutritional Therapy Orthotics Oxygen and Respiratory Therapy Equipment Pharmacy (Please see Exhibit 2 for categories of Pharmacy that are not included in TCOC calculations.) Physician (primary and specialty) Podiatry Preventive Pediatric Health Screening and Diagnostic Services Prosthetic Services and Devices Radiology and Diagnostic Tests Remote Patient Monitoring (RPM) 1) RPM 2) COVID-19 RPM School Based Health Center Services Therapy 1) Physical 2) Occupational Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus 3) Speech and Hearing Tobacco Cessation Services Transportation (emerg...
