Appendix T, Behavioral Health Outpatient and Certain. Other Services Minimum Fee Schedule, is hereby deleted in its entirety and replaced with a new Appendix T attached hereto. APPENDIX D PAYMENT EXHIBIT 1 BASE CAPITATION RATES AND ADD-ONS Contract Year 5 Listed below are the Per Member Per Month (PMPM) Base Capitation Rates for Contract Year 5 (January 1, 2022 through December 31, 2022) (also referred to as Rate Year 2022 or RY22), subject to state appropriation and all necessary federal approvals; Base Capitation Rates do not include EOHHS adjustments described in Sections 4.2.C and 4.2.E. of the Contract. In addition to the Base Capitation Rates tables below, additional tables include the add-ons for the Contract Year for CBHI Services as described in Section 4.5.D, for ABA Services as described in Section 4.5.E, and for SUD Risk Sharing Services as described in Section 4.5.I. The add-ons for CBHI Services, ABA Services and SUD Risk Sharing Services are the same for all Regions and will be added to the Risk Adjusted Capitation Rates as defined in Section 4.2.E. ACO Base Capitation Rates / RC I Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $492.41 $2.97 $1.84 $38.75 $535.97 Greater Boston $503.73 $2.66 $1.88 $35.80 $544.07 Southern $534.18 $4.32 $3.77 $36.79 $579.06 Central $451.96 $2.85 $3.10 $34.31 $492.22 Western $449.75 $2.54 $1.02 $33.77 $487.08 ACO Base Capitation Rates / RC I Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $211.25 $0.02 $4.93 $32.67 $248.87 Greater Boston $209.13 $0.02 $6.63 $30.78 $246.56 Southern $206.76 $0.03 $4.06 $29.60 $240.45 Central $199.95 $0.02 $6.83 $29.04 $235.84 Western $195.98 $0.02 $1.93 $28.92 $226.85 ACO Base Capitation Rates / XX XX Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,820.75 $14.45 $26.11 $101.44 $1,962.75 Greater Boston $1,955.47 $17.20 $25.90 $95.81 $2,094.38 Southern $1,995.16 $18.86 $16.53 $93.61 $2,124.16 Central $1,776.07 $13.38 $23.68 $87.23 $1,900.36 Western $1,552.41 $11.29 $18.83 $77.46 $1,659.99 ACO Base Capitation Rates / XX XX Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $914.01 $0.12 $95.77 $83.79 $1,093.69 Greater Boston $938.33 $0.17 $172.45 $83.87 $1,194.82 Southern $848.42 $0.17 $35.27 $71.99 $955.85 Central $884.12 $0.10 $100.84 $74.26 $1,059.32 Western $641.76 $0.07 $34.25 $57.13 $733.21 ACO Base Capitation Rates / RC IX Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $606.75 $7.45 $6.12 $44.21 $664.53 Greater Boston $585.41 $7.43 $7.92 $39.54 $640.30 Southern $667.04 $10.34 $8.02 $42.69 $728.09 Central $602.99 $7.08 $10.49 $40.00 $660.56 Western $545.95 $7.20 $2.11 $38.13 $593.39 ACO Base Capitation Rates / RC X Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,828.75 $30.94 $4.18 $105.42 $1,969.29 Greater Boston $1,789.97 $38.73 $42.69 $90.31 $1,961.70 Southern $1,877.00 $58.65 $2.59 $89.36 $2,027.60 Central $1,797.20 $44.00 $1.60 $90.29 $1,933.09 Western $1,574.97 $33.75 $3.47 $81.07 $1,693.26 ACO Base Capitation Rates / RC I Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $486.81 $2.97 $1.84 $38.75 $530.37 Greater Boston $499.19 $2.66 $1.88 $35.80 $539.53 Southern $527.77 $4.32 $3.77 $36.79 $572.65 Central $446.91 $2.85 $3.10 $34.31 $487.17 Western $444.14 $2.54 $1.02 $33.77 $481.47 ACO Base Capitation Rates / RC I Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $207.13 $0.02 $4.93 $32.67 $244.75 Greater Boston $206.08 $0.02 $6.63 $30.78 $243.51 Southern $202.86 $0.03 $4.06 $29.60 $236.55 Central $196.44 $0.02 $6.83 $29.04 $232.33 Western $192.08 $0.02 $1.93 $28.92 $222.95 ACO Base Capitation Rates / XX XX Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,792.83 $14.45 $26.11 $101.44 $1,934.83 Greater Boston $1,931.42 $17.20 $25.90 $95.81 $2,070.33 Southern $1,968.60 $18.86 $16.53 $93.61 $2,097.60 Central $1,751.99 $13.38 $23.68 $87.23 $1,876.28 Western $1,530.65 $11.29 $18.83 $77.46 $1,638.23 ACO Base Capitation Rates / XX XX Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $898.24 $0.12 $95.77 $83.79 $1,077.92 Greater Boston $925.18 $0.17 $172.45 $83.87 $1,181.67 Southern $834.08 $0.17 $35.27 $71.99 $941.51 Central $870.32 $0.10 $100.84 $74.26 $1,045.52 Western $630.05 $0.07 $34.25 $57.13 $721.50 ACO Base Capitation Rates / RC IX Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $598.04 $7.45 $6.12 $44.21 $655.82 Greater Boston $576.59 $7.43 $7.92 $39.54 $631.48 Southern $656.70 $10.34 $8.02 $42.69 $717.75 Central $593.88 $7.08 $10.49 $40.00 $651.45 Western $536.14 $7.20 $2.11 $38.13 $583.58 ACO Base Capitation Rates / RC X Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,799.33 $30.94 $4.18 $105.42 $1,939.87 Greater Boston $1,758.29 $38.73 $42.69 $90.31 $1,930.02 Southern $1,840.16 $58.65 $2.59 $89.36 $1,990.76 Central $1,766.23 $44.00 $1.60 $90.29 $1,902.12 Western $1,542.42 $33.75 $3.47 $81.07 $1,660.71 CBHI Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $28.63 Child RC-II $166.85 Child CBHI Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $26.09 Child RC-II $152.39 Child ABA Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $8.83 Child RC-II $206.99 Child ABA Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $7.98 Child RC-II $187.78 Child
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Appendix T, Behavioral Health Outpatient and Certain. Other Services Minimum Fee Schedule, is hereby deleted in its entirety and replaced with a new Appendix T attached hereto. APPENDIX D PAYMENT EXHIBIT 1 BASE CAPITATION RATES AND ADD-ONS Contract Year 5 Listed below are the Per Member Per Month (PMPM) Base Capitation Rates for Contract Year 5 (January 1, 2022 through December 31, 2022) (also referred to as Rate Year 2022 or RY22), subject to state appropriation and all necessary federal approvals; Base Capitation Rates do not include EOHHS adjustments described in Sections 4.2.C and 4.2.E. of the Contract. In addition to the Base Capitation Rates tables below, additional tables include the add-ons for the Contract Year for CBHI Services as described in Section 4.5.D, for ABA Services as described in Section 4.5.E, and for SUD Risk Sharing Services as described in Section 4.5.I. The add-ons for CBHI Services, ABA Services and SUD Risk Sharing Services are the same for all Regions and will be added to the Risk Adjusted Capitation Rates as defined in Section 4.2.E. ACO Base Capitation Rates / RC I Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $492.41 501.27 $2.97 3.05 $1.84 1.89 $38.75 $535.97 544.96 Greater Boston $503.73 512.16 $2.66 2.73 $1.88 1.93 $35.80 $544.07 552.62 Southern $534.18 541.23 $4.32 4.44 $3.77 3.87 $36.79 $579.06 586.33 Central $451.96 461.17 $2.85 2.92 $3.10 3.18 $34.31 $492.22 501.58 Western $449.75 447.66 $2.54 2.61 $1.02 1.05 $33.77 $487.08 485.09 ACO Base Capitation Rates / RC I Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $211.25 211.32 $0.02 $4.93 5.01 $32.67 $248.87 249.02 Greater Boston $209.13 209.92 $0.02 $6.63 6.73 $30.78 $246.56 247.45 Southern $206.76 206.49 $0.03 $4.06 4.12 $29.60 $240.45 240.24 Central $199.95 200.86 $0.02 $6.83 6.93 $29.04 $235.84 236.85 Western $195.98 198.93 $0.02 $1.93 1.96 $28.92 $226.85 229.83 ACO Base Capitation Rates / XX XX Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,820.75 1,811.58 $14.45 14.42 $26.11 26.05 $101.44 $1,962.75 1,953.49 Greater Boston $1,955.47 1,939.68 $17.20 17.17 $25.90 25.85 $95.81 $2,094.38 2,078.51 Southern $1,995.16 1,975.47 $18.86 18.82 $16.53 16.49 $93.61 $2,124.16 2,104.39 Central $1,776.07 1,765.89 $13.38 13.36 $23.68 23.63 $87.23 $1,900.36 1,890.11 Western $1,552.41 1,548.89 $11.29 11.27 $18.83 18.79 $77.46 $1,659.99 1,656.41 ACO Base Capitation Rates / XX XX Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $914.01 917.81 $0.12 $95.77 96.27 $83.79 $1,093.69 1,097.99 Greater Boston $938.33 938.60 $0.17 $172.45 173.35 $83.87 $1,194.82 1,195.99 Southern $848.42 848.89 $0.17 $35.27 35.45 $71.99 $955.85 956.50 Central $884.12 894.42 $0.10 $100.84 101.37 $74.26 $1,059.32 1,070.15 Western $641.76 645.14 $0.07 $34.25 34.43 $57.13 $733.21 736.77 ACO Base Capitation Rates / RC IX Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $606.75 609.09 $7.45 7.55 $6.12 6.20 $44.21 $664.53 667.05 Greater Boston $585.41 588.79 $7.43 7.53 $7.92 8.02 $39.54 $640.30 643.88 Southern $667.04 667.86 $10.34 10.47 $8.02 8.13 $42.69 $728.09 729.15 Central $602.99 607.82 $7.08 7.17 $10.49 10.62 $40.00 $660.56 665.61 Western $545.95 551.66 $7.20 7.30 $2.11 2.14 $38.13 $593.39 599.23 ACO Base Capitation Rates / RC X Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,828.75 1,826.08 $30.94 30.88 $4.18 4.17 $105.42 $1,969.29 1,966.55 Greater Boston $1,789.97 1,776.95 $38.73 38.65 $42.69 42.61 $90.31 $1,961.70 1,948.52 Southern $1,877.00 1,853.86 $58.65 58.53 $2.59 $89.36 $2,027.60 2,004.34 Central $1,797.20 1,769.30 $44.00 43.91 $1.60 $90.29 $1,933.09 1,905.10 Western $1,574.97 1,571.76 $33.75 33.68 $3.47 3.46 $81.07 $1,693.26 1,689.97 ACO Base Capitation Rates / RC I Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $486.81 495.57 $2.97 3.05 $1.84 1.89 $38.75 $530.37 539.26 Greater Boston $499.19 507.54 $2.66 2.73 $1.88 1.93 $35.80 $539.53 548.00 Southern $527.77 534.74 $4.32 4.44 $3.77 3.87 $36.79 $572.65 579.84 Central $446.91 456.01 $2.85 2.92 $3.10 3.18 $34.31 $487.17 496.42 Western $444.14 442.08 $2.54 2.61 $1.02 1.05 $33.77 $481.47 479.51 ACO Base Capitation Rates / RC I Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $207.13 207.20 $0.02 $4.93 5.01 $32.67 $244.75 244.90 Greater Boston $206.08 206.86 $0.02 $6.63 6.73 $30.78 $243.51 244.39 Southern $202.86 202.60 $0.03 $4.06 4.12 $29.60 $236.55 236.35 Central $196.44 197.33 $0.02 $6.83 6.93 $29.04 $232.33 233.32 Western $192.08 194.97 $0.02 $1.93 1.96 $28.92 $222.95 225.87 ACO Base Capitation Rates / XX XX Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,792.83 1,783.81 $14.45 14.42 $26.11 26.05 $101.44 $1,934.83 1,925.72 Greater Boston $1,931.42 1,915.81 $17.20 17.17 $25.90 25.85 $95.81 $2,070.33 2,054.64 Southern $1,968.60 1,949.17 $18.86 18.82 $16.53 16.49 $93.61 $2,097.60 2,078.09 Central $1,751.99 1,741.94 $13.38 13.36 $23.68 23.63 $87.23 $1,876.28 1,866.16 Western $1,530.65 1,527.18 $11.29 11.27 $18.83 18.79 $77.46 $1,638.23 1,634.70 ACO Base Capitation Rates / XX XX Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $898.24 901.97 $0.12 $95.77 96.27 $83.79 $1,077.92 1,082.15 Greater Boston $925.18 925.43 $0.17 $172.45 173.35 $83.87 $1,181.67 1,182.82 Southern $834.08 834.53 $0.17 $35.27 35.45 $71.99 $941.51 942.14 Central $870.32 880.47 $0.10 $100.84 101.37 $74.26 $1,045.52 1,056.20 Western $630.05 633.37 $0.07 $34.25 34.43 $57.13 $721.50 725.00 ACO Base Capitation Rates / RC IX Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $598.04 600.35 $7.45 7.55 $6.12 6.20 $44.21 $655.82 658.31 Greater Boston $576.59 579.91 $7.43 7.53 $7.92 8.02 $39.54 $631.48 635.00 Southern $656.70 657.51 $10.34 10.47 $8.02 8.13 $42.69 $717.75 718.80 Central $593.88 598.63 $7.08 7.17 $10.49 10.62 $40.00 $651.45 656.42 Western $536.14 541.75 $7.20 7.30 $2.11 2.14 $38.13 $583.58 589.32 ACO Base Capitation Rates / RC X Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,799.33 1,796.70 $30.94 30.88 $4.18 4.17 $105.42 $1,939.87 1,937.17 Greater Boston $1,758.29 1,745.49 $38.73 38.65 $42.69 42.61 $90.31 $1,930.02 1,917.06 Southern $1,840.16 1,817.46 $58.65 58.53 $2.59 $89.36 $1,990.76 1,967.94 Central $1,766.23 1,738.80 $44.00 43.91 $1.60 $90.29 $1,902.12 1,874.60 Western $1,542.42 1,539.28 $33.75 33.68 $3.47 3.46 $81.07 $1,660.71 1,657.49 CBHI Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $28.63 Child RC-II $166.85 Child CBHI Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $26.09 Child RC-II $152.39 Child ABA Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $8.83 Child RC-II $206.99 Child ABA Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $7.98 Child RC-II $187.78 Child
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Appendix T, Behavioral Health Outpatient and Certain. Other Services Minimum Fee Schedule, is hereby deleted in its entirety and replaced with a new Appendix T attached hereto. APPENDIX D PAYMENT EXHIBIT 1 BASE CAPITATION RATES AND ADD-ONS Contract Year 5 Listed below are the Per Member Per Month (PMPM) Base Capitation Rates for Contract Year 5 (January 1, 2022 through December 31, 2022) (also referred to as Rate Year 2022 or RY22), subject to state appropriation and all necessary federal approvals; Base Capitation Rates do not include EOHHS adjustments described in Sections 4.2.C and 4.2.E. of the Contract. In addition to the Base Capitation Rates tables below, additional tables include the add-ons for the Contract Year for CBHI Services as described in Section 4.5.D, for ABA Services as described in Section 4.5.E, and for SUD Risk Sharing Services as described in Section 4.5.I. The add-ons for CBHI Services, ABA Services and SUD Risk Sharing Services are the same for all Regions and will be added to the Risk Adjusted Capitation Rates as defined in Section 4.2.E. ACO Base Capitation Rates / RC I Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $492.41 537.04 $2.97 3.26 $1.84 2.03 $38.75 $535.97 581.08 Greater Boston $503.73 549.24 $2.66 2.93 $1.88 2.06 $35.80 $544.07 590.03 Southern $534.18 582.81 $4.32 4.75 $3.77 4.14 $36.79 $579.06 628.49 Central $451.96 493.94 $2.85 3.13 $3.10 3.40 $34.31 $492.22 534.78 Western $449.75 481.09 $2.54 2.79 $1.02 1.13 $33.77 $487.08 518.78 ACO Base Capitation Rates / RC I Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $211.25 209.81 $0.02 $4.93 4.95 $32.67 $248.87 247.45 Greater Boston $209.13 207.70 $0.02 $6.63 6.66 $30.78 $246.56 245.16 Southern $206.76 204.35 $0.03 $4.06 4.07 $29.60 $240.45 238.05 Central $199.95 199.82 $0.02 $6.83 6.85 $29.04 $235.84 235.73 Western $195.98 197.22 $0.02 $1.93 1.94 $28.92 $226.85 228.10 ACO Base Capitation Rates / XX XX Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,820.75 1,893.06 $14.45 15.07 $26.11 27.23 $101.44 $1,962.75 2,036.80 Greater Boston $1,955.47 2,026.44 $17.20 17.94 $25.90 27.02 $95.81 $2,094.38 2,167.21 Southern $1,995.16 2,065.65 $18.86 19.67 $16.53 17.24 $93.61 $2,124.16 2,196.17 Central $1,776.07 1,846.74 $13.38 13.96 $23.68 24.70 $87.23 $1,900.36 1,972.63 Western $1,552.41 1,619.34 $11.29 11.78 $18.83 19.64 $77.46 $1,659.99 1,728.22 ACO Base Capitation Rates / XX XX Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $914.01 1,005.25 $0.12 0.13 $95.77 105.65 $83.79 $1,093.69 1,194.82 Greater Boston $938.33 1,029.83 $0.17 0.18 $172.45 190.24 $83.87 $1,194.82 1,304.12 Southern $848.42 931.40 $0.17 0.18 $35.27 38.91 $71.99 $955.85 1,042.48 Central $884.12 982.18 $0.10 0.11 $100.84 111.24 $74.26 $1,059.32 1,167.79 Western $641.76 708.87 $0.07 0.08 $34.25 37.78 $57.13 $733.21 803.86 ACO Base Capitation Rates / RC IX Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $606.75 638.68 $7.45 7.91 $6.12 6.50 $44.21 $664.53 697.30 Greater Boston $585.41 617.69 $7.43 7.89 $7.92 8.41 $39.54 $640.30 673.53 Southern $667.04 700.69 $10.34 10.97 $8.02 8.51 $42.69 $728.09 762.86 Central $602.99 637.57 $7.08 7.52 $10.49 11.13 $40.00 $660.56 696.22 Western $545.95 579.47 $7.20 7.64 $2.11 2.24 $38.13 $593.39 627.48 ACO Base Capitation Rates / RC X Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,828.75 1,943.11 $30.94 32.27 $4.18 4.36 $105.42 $1,969.29 2,085.16 Greater Boston $1,789.97 1,847.01 $38.73 40.39 $42.69 44.52 $90.31 $1,961.70 2,022.23 Southern $1,877.00 1,927.44 $58.65 61.17 $2.59 2.70 $89.36 $2,027.60 2,080.67 Central $1,797.20 1,848.80 $44.00 45.89 $1.60 1.67 $90.29 $1,933.09 1,986.65 Western $1,574.97 1,642.55 $33.75 35.19 $3.47 3.62 $81.07 $1,693.26 1,762.43 ACO Base Capitation Rates / RC I Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $486.81 530.93 $2.97 3.26 $1.84 2.03 $38.75 $530.37 574.97 Greater Boston $499.19 544.29 $2.66 2.93 $1.88 2.06 $35.80 $539.53 585.08 Southern $527.77 575.82 $4.32 4.75 $3.77 4.14 $36.79 $572.65 621.50 Central $446.91 488.42 $2.85 3.13 $3.10 3.40 $34.31 $487.17 529.26 Western $444.14 475.09 $2.54 2.79 $1.02 1.13 $33.77 $481.47 512.78 ACO Base Capitation Rates / RC I Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $207.13 205.72 $0.02 $4.93 4.95 $32.67 $244.75 243.36 Greater Boston $206.08 204.67 $0.02 $6.63 6.66 $30.78 $243.51 242.13 Southern $202.86 200.50 $0.03 $4.06 4.07 $29.60 $236.55 234.20 Central $196.44 196.31 $0.02 $6.83 6.85 $29.04 $232.33 232.22 Western $192.08 193.29 $0.02 $1.93 1.94 $28.92 $222.95 224.17 ACO Base Capitation Rates / XX XX Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,792.83 1,864.03 $14.45 15.07 $26.11 27.23 $101.44 $1,934.83 2,007.77 Greater Boston $1,931.42 2,001.50 $17.20 17.94 $25.90 27.02 $95.81 $2,070.33 2,142.27 Southern $1,968.60 2,038.15 $18.86 19.67 $16.53 17.24 $93.61 $2,097.60 2,168.67 Central $1,751.99 1,821.70 $13.38 13.96 $23.68 24.70 $87.23 $1,876.28 1,947.59 Western $1,530.65 1,596.64 $11.29 11.78 $18.83 19.64 $77.46 $1,638.23 1,705.52 ACO Base Capitation Rates / XX XX Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $898.24 987.91 $0.12 0.13 $95.77 105.65 $83.79 $1,077.92 1,177.48 Greater Boston $925.18 1,015.39 $0.17 0.18 $172.45 190.24 $83.87 $1,181.67 1,289.68 Southern $834.08 915.65 $0.17 0.18 $35.27 38.91 $71.99 $941.51 1,026.73 Central $870.32 966.86 $0.10 0.11 $100.84 111.24 $74.26 $1,045.52 1,152.47 Western $630.05 695.94 $0.07 0.08 $34.25 37.78 $57.13 $721.50 790.93 ACO Base Capitation Rates / RC IX Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $598.04 629.52 $7.45 7.91 $6.12 6.50 $44.21 $655.82 688.14 Greater Boston $576.59 608.38 $7.43 7.89 $7.92 8.41 $39.54 $631.48 664.22 Southern $656.70 689.82 $10.34 10.97 $8.02 8.51 $42.69 $717.75 751.99 Central $593.88 627.93 $7.08 7.52 $10.49 11.13 $40.00 $651.45 686.58 Western $536.14 569.06 $7.20 7.64 $2.11 2.24 $38.13 $583.58 617.07 ACO Base Capitation Rates / RC X Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,799.33 1,911.86 $30.94 32.27 $4.18 4.36 $105.42 $1,939.87 2,053.91 Greater Boston $1,758.29 1,814.31 $38.73 40.39 $42.69 44.52 $90.31 $1,930.02 1,989.53 Southern $1,840.16 1,889.59 $58.65 61.17 $2.59 2.70 $89.36 $1,990.76 2,042.82 Central $1,766.23 1,816.93 $44.00 45.89 $1.60 1.67 $90.29 $1,902.12 1,954.78 Western $1,542.42 1,608.60 $33.75 35.19 $3.47 3.62 $81.07 $1,660.71 1,728.48 CBHI Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $28.63 Child RC-II $166.85 Child CBHI Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $26.09 Child RC-II $152.39 Child ABA Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $8.83 Child RC-II $206.99 Child ABA Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $7.98 Child RC-II $187.78 Child
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Appendix T, Behavioral Health Outpatient and Certain. Other Services Minimum Fee Schedule, is hereby deleted in its entirety and replaced with a new Appendix T attached hereto. APPENDIX D PAYMENT EXHIBIT 1 BASE CAPITATION RATES AND ADD-ONS Contract Year 5 Listed below are the Per Member Per Month (PMPM) Base Capitation Rates for Contract Year 5 (January 1, 2022 through December 31, 2022) (also referred to as Rate Year 2022 or RY22), subject to state appropriation and all necessary federal approvals; Base Capitation Rates do not include EOHHS adjustments described in Sections 4.2.C and 4.2.E. of the Contract. In addition to the Base Capitation Rates tables below, additional tables include the add-ons for the Contract Year for CBHI Services as described in Section 4.5.D, for ABA Services as described in Section 4.5.E, and for SUD Risk Sharing Services as described in Section 4.5.I. The add-ons for CBHI Services, ABA Services and SUD Risk Sharing Services are the same for all Regions and will be added to the Risk Adjusted Capitation Rates as defined in Section 4.2.E. ACO Base Capitation Rates / RC I Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $492.41 523.08 $2.97 3.04 $1.84 1.89 $38.75 $535.97 566.76 Greater Boston $503.73 517.56 $2.66 2.72 $1.88 1.92 $35.80 $544.07 558.00 Southern $534.18 552.68 $4.32 4.42 $3.77 3.85 $36.79 $579.06 597.74 Central $451.96 473.93 $2.85 2.91 $3.10 3.16 $34.31 $492.22 514.31 Western $449.75 456.54 $2.54 2.59 $1.02 1.05 $33.77 $487.08 493.95 ACO Base Capitation Rates / RC I Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $211.25 226.73 $0.02 $4.93 4.95 $32.67 $248.87 264.37 Greater Boston $209.13 226.95 $0.02 $6.63 6.66 $30.78 $246.56 264.41 Southern $206.76 214.58 $0.03 $4.06 4.07 $29.60 $240.45 248.28 Central $199.95 207.39 $0.02 $6.83 6.85 $29.04 $235.84 243.30 Western $195.98 207.16 $0.02 $1.93 1.94 $28.92 $226.85 238.04 ACO Base Capitation Rates / XX XX Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,820.75 1,891.78 $14.45 14.76 $26.11 26.67 $101.44 $1,962.75 2,034.65 Greater Boston $1,955.47 2,046.07 $17.20 17.57 $25.90 26.46 $95.81 $2,094.38 2,185.91 Southern $1,995.16 2,050.26 $18.86 19.26 $16.53 16.88 $93.61 $2,124.16 2,180.01 Central $1,776.07 1,836.80 $13.38 13.67 $23.68 24.19 $87.23 $1,900.36 1,961.89 Western $1,552.41 1,613.72 $11.29 11.53 $18.83 19.24 $77.46 $1,659.99 1,721.95 ACO Base Capitation Rates / XX XX Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $914.01 958.26 $0.12 $95.77 98.39 $83.79 $1,093.69 1,140.56 Greater Boston $938.33 1,005.12 $0.17 $172.45 177.17 $83.87 $1,194.82 1,266.33 Southern $848.42 867.03 $0.17 $35.27 36.23 $71.99 $955.85 975.42 Central $884.12 921.03 $0.10 $100.84 103.60 $74.26 $1,059.32 1,098.99 Western $641.76 711.87 $0.07 0.08 $34.25 35.19 $57.13 $733.21 804.27 ACO Base Capitation Rates / RC IX Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $606.75 624.11 $7.45 7.46 $6.12 6.13 $44.21 $664.53 681.91 Greater Boston $585.41 603.00 $7.43 7.44 $7.92 7.93 $39.54 $640.30 657.91 Southern $667.04 670.96 $10.34 10.35 $8.02 8.03 $42.69 $728.09 732.03 Central $602.99 614.13 $7.08 7.09 $10.49 10.50 $40.00 $660.56 671.72 Western $545.95 546.39 $7.20 7.21 $2.11 $38.13 $593.39 593.84 ACO Base Capitation Rates / RC X Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,828.75 1,927.77 $30.94 31.60 $4.18 4.27 $105.42 $1,969.29 2,069.06 Greater Boston $1,789.97 1,816.74 $38.73 39.56 $42.69 43.61 $90.31 $1,961.70 1,990.22 Southern $1,877.00 1,996.68 $58.65 59.91 $2.59 2.65 $89.36 $2,027.60 2,148.60 Central $1,797.20 1,836.55 $44.00 44.94 $1.60 1.63 $90.29 $1,933.09 1,973.41 Western $1,574.97 1,608.76 $33.75 34.47 $3.47 3.55 $81.07 $1,693.26 1,727.85 ACO Base Capitation Rates / RC I Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $486.81 517.14 $2.97 3.04 $1.84 1.89 $38.75 $530.37 560.82 Greater Boston $499.19 512.90 $2.66 2.72 $1.88 1.92 $35.80 $539.53 553.34 Southern $527.77 546.06 $4.32 4.42 $3.77 3.85 $36.79 $572.65 591.12 Central $446.91 468.64 $2.85 2.91 $3.10 3.16 $34.31 $487.17 509.02 Western $444.14 450.85 $2.54 2.59 $1.02 1.05 $33.77 $481.47 488.26 ACO Base Capitation Rates / RC I Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $207.13 222.31 $0.02 $4.93 4.95 $32.67 $244.75 259.95 Greater Boston $206.08 223.64 $0.02 $6.63 6.66 $30.78 $243.51 261.10 Southern $202.86 210.54 $0.03 $4.06 4.07 $29.60 $236.55 244.24 Central $196.44 203.75 $0.02 $6.83 6.85 $29.04 $232.33 239.66 Western $192.08 203.03 $0.02 $1.93 1.94 $28.92 $222.95 233.91 ACO Base Capitation Rates / XX XX Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,792.83 1,862.78 $14.45 14.76 $26.11 26.67 $101.44 $1,934.83 2,005.65 Greater Boston $1,931.42 2,020.91 $17.20 17.57 $25.90 26.46 $95.81 $2,070.33 2,160.75 Southern $1,968.60 2,022.97 $18.86 19.26 $16.53 16.88 $93.61 $2,097.60 2,152.72 Central $1,751.99 1,811.90 $13.38 13.67 $23.68 24.19 $87.23 $1,876.28 1,936.99 Western $1,530.65 1,591.11 $11.29 11.53 $18.83 19.24 $77.46 $1,638.23 1,699.34 ACO Base Capitation Rates / XX XX Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $898.24 941.76 $0.12 $95.77 98.39 $83.79 $1,077.92 1,124.06 Greater Boston $925.18 991.12 $0.17 $172.45 177.17 $83.87 $1,181.67 1,252.33 Southern $834.08 852.37 $0.17 $35.27 36.23 $71.99 $941.51 960.76 Central $870.32 906.68 $0.10 $100.84 103.60 $74.26 $1,045.52 1,084.64 Western $630.05 698.93 $0.07 0.08 $34.25 35.19 $57.13 $721.50 791.33 ACO Base Capitation Rates / RC IX Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $598.04 615.16 $7.45 7.46 $6.12 6.13 $44.21 $655.82 672.96 Greater Boston $576.59 593.92 $7.43 7.44 $7.92 7.93 $39.54 $631.48 648.83 Southern $656.70 660.56 $10.34 10.35 $8.02 8.03 $42.69 $717.75 721.63 Central $593.88 604.85 $7.08 7.09 $10.49 10.50 $40.00 $651.45 662.44 Western $536.14 536.57 $7.20 7.21 $2.11 $38.13 $583.58 584.02 ACO Base Capitation Rates / RC X Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,799.33 1,896.78 $30.94 31.60 $4.18 4.27 $105.42 $1,939.87 2,038.07 Greater Boston $1,758.29 1,784.58 $38.73 39.56 $42.69 43.61 $90.31 $1,930.02 1,958.06 Southern $1,840.16 1,957.55 $58.65 59.91 $2.59 2.65 $89.36 $1,990.76 2,109.47 Central $1,766.23 1,804.90 $44.00 44.94 $1.60 1.63 $90.29 $1,902.12 1,941.76 Western $1,542.42 1,575.51 $33.75 34.47 $3.47 3.55 $81.07 $1,660.71 1,694.60 CBHI Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $28.63 Child RC-II $166.85 Child CBHI Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $26.09 Child RC-II $152.39 Child ABA Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $8.83 Child RC-II $206.99 Child ABA Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $7.98 Child RC-II $187.78 Child
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Appendix T, Behavioral Health Outpatient and Certain. Other Services Minimum Fee Schedule, is hereby deleted in its entirety and replaced with a new Appendix T attached hereto. APPENDIX D PAYMENT EXHIBIT 1 BASE CAPITATION RATES AND ADD-ONS Contract Year 5 Listed below are the Per Member Per Month (PMPM) Base Capitation Rates for Contract Year 5 (January 1, 2022 through December 31, 2022) (also referred to as Rate Year 2022 or RY22), subject to state appropriation and all necessary federal approvals; Base Capitation Rates do not include EOHHS adjustments described in Sections 4.2.C and 4.2.E. of the Contract. In addition to the Base Capitation Rates tables below, additional tables include the add-ons for the Contract Year for CBHI Services as described in Section 4.5.D, for ABA Services as described in Section 4.5.E, and for SUD Risk Sharing Services as described in Section 4.5.I. The add-ons for CBHI Services, ABA Services and SUD Risk Sharing Services are the same for all Regions and will be added to the Risk Adjusted Capitation Rates as defined in Section 4.2.E. ACO Base Capitation Rates / RC I Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $492.41 513.62 $2.97 3.13 $1.84 1.94 $38.75 $535.97 557.44 Greater Boston $503.73 524.59 $2.66 2.80 $1.88 1.98 $35.80 $544.07 565.17 Southern $534.18 555.54 $4.32 4.55 $3.77 3.97 $36.79 $579.06 600.85 Central $451.96 475.12 $2.85 3.00 $3.10 3.26 $34.31 $492.22 515.69 Western $449.75 458.72 $2.54 2.67 $1.02 1.08 $33.77 $487.08 496.24 ACO Base Capitation Rates / RC I Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $211.25 222.46 $0.02 $4.93 5.27 $32.67 $248.87 260.42 Greater Boston $209.13 221.11 $0.02 $6.63 7.09 $30.78 $246.56 259.00 Southern $206.76 217.86 $0.03 $4.06 4.34 $29.60 $240.45 251.83 Central $199.95 211.19 $0.02 $6.83 7.30 $29.04 $235.84 247.55 Western $195.98 209.76 $0.02 $1.93 2.07 $28.92 $226.85 240.77 ACO Base Capitation Rates / XX XX Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,820.75 1,826.10 $14.45 14.54 $26.11 26.27 $101.44 $1,962.75 1,968.35 Greater Boston $1,955.47 1,954.21 $17.20 17.31 $25.90 26.06 $95.81 $2,094.38 2,093.39 Southern $1,995.16 1,991.17 $18.86 18.97 $16.53 16.63 $93.61 $2,124.16 2,120.38 Central $1,776.07 1,779.46 $13.38 13.46 $23.68 23.83 $87.23 $1,900.36 1,903.98 Western $1,552.41 1,577.61 $11.29 11.36 $18.83 18.95 $77.46 $1,659.99 1,685.38 ACO Base Capitation Rates / XX XX Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $914.01 912.14 $0.12 $95.77 $83.79 $1,093.69 1,091.82 Greater Boston $938.33 934.28 $0.17 $172.45 $83.87 $1,194.82 1,190.77 Southern $848.42 844.32 $0.17 $35.27 $71.99 $955.85 951.75 Central $884.12 896.08 $0.10 $100.84 $74.26 $1,059.32 1,071.28 Western $641.76 642.73 $0.07 $34.25 $57.13 $733.21 734.18 ACO Base Capitation Rates / RC IX Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $606.75 591.51 $7.45 7.33 $6.12 6.02 $44.21 $664.53 649.07 Greater Boston $585.41 571.75 $7.43 7.32 $7.92 7.79 $39.54 $640.30 626.40 Southern $667.04 650.88 $10.34 10.17 $8.02 7.89 $42.69 $728.09 711.63 Central $602.99 590.35 $7.08 6.97 $10.49 10.32 $40.00 $660.56 647.64 Western $545.95 535.86 $7.20 7.09 $2.11 2.08 $38.13 $593.39 583.16 ACO Base Capitation Rates / RC X Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,828.75 1,841.52 $30.94 31.13 $4.18 4.21 $105.42 $1,969.29 1,982.28 Greater Boston $1,789.97 1,783.87 $38.73 38.96 $42.69 42.95 $90.31 $1,961.70 1,956.09 Southern $1,877.00 1,860.78 $58.65 59.01 $2.59 2.61 $89.36 $2,027.60 2,011.76 Central $1,797.20 1,784.48 $44.00 44.27 $1.60 1.61 $90.29 $1,933.09 1,920.65 Western $1,574.97 1,584.63 $33.75 33.95 $3.47 3.49 $81.07 $1,693.26 1,703.14 ACO Base Capitation Rates / RC I Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $486.81 507.78 $2.97 3.13 $1.84 1.94 $38.75 $530.37 551.60 Greater Boston $499.19 519.87 $2.66 2.80 $1.88 1.98 $35.80 $539.53 560.45 Southern $527.77 548.88 $4.32 4.55 $3.77 3.97 $36.79 $572.65 594.19 Central $446.91 469.81 $2.85 3.00 $3.10 3.26 $34.31 $487.17 510.38 Western $444.14 453.00 $2.54 2.67 $1.02 1.08 $33.77 $481.47 490.52 ACO Base Capitation Rates / RC I Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $207.13 218.12 $0.02 $4.93 5.27 $32.67 $244.75 256.08 Greater Boston $206.08 217.89 $0.02 $6.63 7.09 $30.78 $243.51 255.78 Southern $202.86 213.75 $0.03 $4.06 4.34 $29.60 $236.55 247.72 Central $196.44 207.48 $0.02 $6.83 7.30 $29.04 $232.33 243.84 Western $192.08 205.58 $0.02 $1.93 2.07 $28.92 $222.95 236.59 ACO Base Capitation Rates / XX XX Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,792.83 1,798.10 $14.45 14.54 $26.11 26.27 $101.44 $1,934.83 1,940.35 Greater Boston $1,931.42 1,930.16 $17.20 17.31 $25.90 26.06 $95.81 $2,070.33 2,069.34 Southern $1,968.60 1,964.66 $18.86 18.97 $16.53 16.63 $93.61 $2,097.60 2,093.87 Central $1,751.99 1,755.33 $13.38 13.46 $23.68 23.83 $87.23 $1,876.28 1,879.85 Western $1,530.65 1,555.50 $11.29 11.36 $18.83 18.95 $77.46 $1,638.23 1,663.27 ACO Base Capitation Rates / XX XX Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $898.24 896.40 $0.12 $95.77 $83.79 $1,077.92 1,076.08 Greater Boston $925.18 921.18 $0.17 $172.45 $83.87 $1,181.67 1,177.67 Southern $834.08 830.04 $0.17 $35.27 $71.99 $941.51 937.47 Central $870.32 882.11 $0.10 $100.84 $74.26 $1,045.52 1,057.31 Western $630.05 631.01 $0.07 $34.25 $57.13 $721.50 722.46 ACO Base Capitation Rates / RC IX Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $598.04 583.02 $7.45 7.33 $6.12 6.02 $44.21 $655.82 640.58 Greater Boston $576.59 563.13 $7.43 7.32 $7.92 7.79 $39.54 $631.48 617.78 Southern $656.70 640.79 $10.34 10.17 $8.02 7.89 $42.69 $717.75 701.54 Central $593.88 581.42 $7.08 6.97 $10.49 10.32 $40.00 $651.45 638.71 Western $536.14 526.23 $7.20 7.09 $2.11 2.08 $38.13 $583.58 573.53 ACO Base Capitation Rates / RC X Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,799.33 1,811.90 $30.94 31.13 $4.18 4.21 $105.42 $1,939.87 1,952.66 Greater Boston $1,758.29 1,752.29 $38.73 38.96 $42.69 42.95 $90.31 $1,930.02 1,924.51 Southern $1,840.16 1,824.25 $58.65 59.01 $2.59 2.61 $89.36 $1,990.76 1,975.23 Central $1,766.23 1,753.72 $44.00 44.27 $1.60 1.61 $90.29 $1,902.12 1,889.89 Western $1,542.42 1,551.89 $33.75 33.95 $3.47 3.49 $81.07 $1,660.71 1,670.40 CBHI Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $28.63 Child RC-II $166.85 Child CBHI Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $26.09 Child RC-II $152.39 Child ABA Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $8.83 Child RC-II $206.99 Child ABA Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $7.98 Child RC-II $187.78 Child
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Appendix T, Behavioral Health Outpatient and Certain. Other Services Minimum Fee Schedule, is hereby deleted in its entirety and replaced with a new Appendix T attached hereto. APPENDIX D PAYMENT EXHIBIT 1 BASE CAPITATION RATES AND ADD-ONS Contract Year 5 Listed below are the Per Member Per Month (PMPM) Base Capitation Rates for Contract Year 5 (January 1, 2022 through December 31, 2022) (also referred to as Rate Year 2022 or RY22), subject to state appropriation and all necessary federal approvals; Base Capitation Rates do not include EOHHS adjustments described in Sections 4.2.C and 4.2.E. of the Contract. In addition to the Base Capitation Rates tables below, additional tables include the add-ons for the Contract Year for CBHI Services as described in Section 4.5.D, for ABA Services as described in Section 4.5.E, and for SUD Risk Sharing Services as described in Section 4.5.I. The add-ons for CBHI Services, ABA Services and SUD Risk Sharing Services are the same for all Regions and will be added to the Risk Adjusted Capitation Rates as defined in Section 4.2.E. ACO Base Capitation Rates / RC I Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $492.41 488.80 $2.97 2.95 $1.84 1.83 $38.75 $535.97 532.33 Greater Boston $503.73 498.60 $2.66 2.65 $1.88 1.87 $35.80 $544.07 538.92 Southern $534.18 553.17 $4.32 4.30 $3.77 3.75 $36.79 $579.06 598.01 Central $451.96 468.51 $2.85 2.83 $3.10 3.08 $34.31 $492.22 508.73 Western $449.75 440.46 $2.54 2.52 $1.02 $33.77 $487.08 477.77 ACO Base Capitation Rates / RC I Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $211.25 212.01 $0.02 $4.93 5.01 $32.67 $248.87 249.71 Greater Boston $209.13 209.87 $0.02 $6.63 6.74 $30.78 $246.56 247.41 Southern $206.76 210.95 $0.03 $4.06 4.12 $29.60 $240.45 244.70 Central $199.95 203.80 $0.02 $6.83 6.94 $29.04 $235.84 239.80 Western $195.98 202.44 $0.02 $1.93 1.96 $28.92 $226.85 233.34 ACO Base Capitation Rates / XX XX Adult Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,820.75 1,893.06 $14.45 14.84 $26.11 26.80 $101.44 $1,962.75 2,036.14 Greater Boston $1,955.47 2,005.73 $17.20 17.66 $25.90 26.59 $95.81 $2,094.38 2,145.79 Southern $1,995.16 2,038.84 $18.86 19.36 $16.53 16.97 $93.61 $2,124.16 2,168.78 Central $1,776.07 1,819.32 $13.38 13.74 $23.68 24.31 $87.23 $1,900.36 1,944.60 Western $1,552.41 1,606.72 $11.29 11.59 $18.83 19.33 $77.46 $1,659.99 1,715.10 ACO Base Capitation Rates / XX XX Child Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $914.01 995.83 $0.12 0.13 $95.77 104.84 $83.79 $1,093.69 1,184.59 Greater Boston $938.33 1,032.50 $0.17 0.18 $172.45 188.78 $83.87 $1,194.82 1,305.33 Southern $848.42 950.53 $0.17 0.18 $35.27 38.61 $71.99 $955.85 1,061.31 Central $884.12 971.89 $0.10 0.11 $100.84 110.39 $74.26 $1,059.32 1,156.65 Western $641.76 705.26 $0.07 0.08 $34.25 37.50 $57.13 $733.21 799.97 ACO Base Capitation Rates / RC IX Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $606.75 582.24 $7.45 7.22 $6.12 5.93 $44.21 $664.53 639.60 Greater Boston $585.41 567.46 $7.43 7.20 $7.92 7.68 $39.54 $640.30 621.88 Southern $667.04 640.49 $10.34 10.01 $8.02 7.77 $42.69 $728.09 700.96 Central $602.99 588.75 $7.08 6.86 $10.49 10.16 $40.00 $660.56 645.77 Western $545.95 536.25 $7.20 6.98 $2.11 2.05 $38.13 $593.39 583.41 ACO Base Capitation Rates / RC X Effective January 1, 2022 – June 30, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,828.75 1,944.97 $30.94 31.76 $4.18 4.29 $105.42 $1,969.29 2,086.44 Greater Boston $1,789.97 1,818.07 $38.73 39.75 $42.69 43.83 $90.31 $1,961.70 1,991.96 Southern $1,877.00 1,929.23 $58.65 60.21 $2.59 2.66 $89.36 $2,027.60 2,081.46 Central $1,797.20 1,824.90 $44.00 45.17 $1.60 1.64 $90.29 $1,933.09 1,962.00 Western $1,574.97 1,640.81 $33.75 34.64 $3.47 3.56 $81.07 $1,693.26 1,760.08 ACO Base Capitation Rates / RC I Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $486.81 483.25 $2.97 2.95 $1.84 1.83 $38.75 $530.37 526.78 Greater Boston $499.19 494.11 $2.66 2.65 $1.88 1.87 $35.80 $539.53 534.43 Southern $527.77 546.54 $4.32 4.30 $3.77 3.75 $36.79 $572.65 591.38 Central $446.91 463.28 $2.85 2.83 $3.10 3.08 $34.31 $487.17 503.50 Western $444.14 434.96 $2.54 2.52 $1.02 $33.77 $481.47 472.27 ACO Base Capitation Rates / RC I Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $207.13 207.87 $0.02 $4.93 5.01 $32.67 $244.75 245.57 Greater Boston $206.08 206.81 $0.02 $6.63 6.74 $30.78 $243.51 244.35 Southern $202.86 206.97 $0.03 $4.06 4.12 $29.60 $236.55 240.72 Central $196.44 200.22 $0.02 $6.83 6.94 $29.04 $232.33 236.22 Western $192.08 198.40 $0.02 $1.93 1.96 $28.92 $222.95 229.30 ACO Base Capitation Rates / XX XX Adult Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,792.83 1,864.05 $14.45 14.84 $26.11 26.80 $101.44 $1,934.83 2,007.13 Greater Boston $1,931.42 1,981.06 $17.20 17.66 $25.90 26.59 $95.81 $2,070.33 2,121.12 Southern $1,968.60 2,011.70 $18.86 19.36 $16.53 16.97 $93.61 $2,097.60 2,141.64 Central $1,751.99 1,794.65 $13.38 13.74 $23.68 24.31 $87.23 $1,876.28 1,919.93 Western $1,530.65 1,584.21 $11.29 11.59 $18.83 19.33 $77.46 $1,638.23 1,692.59 ACO Base Capitation Rates / XX XX Child Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $898.24 978.64 $0.12 0.13 $95.77 104.84 $83.79 $1,077.92 1,167.40 Greater Boston $925.18 1,018.04 $0.17 0.18 $172.45 188.78 $83.87 $1,181.67 1,290.87 Southern $834.08 934.47 $0.17 0.18 $35.27 38.61 $71.99 $941.51 1,045.25 Central $870.32 956.72 $0.10 0.11 $100.84 110.39 $74.26 $1,045.52 1,141.48 Western $630.05 692.39 $0.07 0.08 $34.25 37.50 $57.13 $721.50 787.10 ACO Base Capitation Rates / RC IX Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $598.04 573.89 $7.45 7.22 $6.12 5.93 $44.21 $655.82 631.25 Greater Boston $576.59 558.91 $7.43 7.20 $7.92 7.68 $39.54 $631.48 613.33 Southern $656.70 630.56 $10.34 10.01 $8.02 7.77 $42.69 $717.75 691.03 Central $593.88 579.85 $7.08 6.86 $10.49 10.16 $40.00 $651.45 636.87 Western $536.14 526.61 $7.20 6.98 $2.11 2.05 $38.13 $583.58 573.77 ACO Base Capitation Rates / RC X Effective July 1, 2022 – December 31, 2022 REGION NON-HIGH COST DRUG / NON-HCV MEDICAL COMPONENT HCV COMPONENT NON-HCV HIGH COST DRUG COMPONENT ADMINISTRATIVE COMPONENT TOTAL BASE CAPITATION RATE (per member per month) (per member per month) (per member per month) (per member per month) (per member per month) Northern $1,799.33 1,913.70 $30.94 31.76 $4.18 4.29 $105.42 $1,939.87 2,055.17 Greater Boston $1,758.29 1,785.88 $38.73 39.75 $42.69 43.83 $90.31 $1,930.02 1,959.77 Southern $1,840.16 1,891.38 $58.65 60.21 $2.59 2.66 $89.36 $1,990.76 2,043.61 Central $1,766.23 1,793.45 $44.00 45.17 $1.60 1.64 $90.29 $1,902.12 1,930.55 Western $1,542.42 1,606.91 $33.75 34.64 $3.47 3.56 $81.07 $1,660.71 1,726.18 CBHI Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $28.63 Child RC-II $166.85 Child CBHI Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 CBHI Add-On to Risk Adjusted Capitation Rates PMPM RC-I $26.09 Child RC-II $152.39 Child ABA Add-On to Risk Adjusted Capitation Rates Effective January 1, 2022 – June 30, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $8.83 Child RC-II $206.99 Child ABA Add-On to Risk Adjusted Capitation Rates Effective July 1, 2022 – December 31, 2022 ABA Add-On to Risk Adjusted Capitation Rates PMPM RC-I $7.98 Child RC-II $187.78 Child
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