101 CMR 313.00 — Rates for Freestanding Clinics Providing Abortion and Sterilization Services

Final Adoption Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

1 101 CMR 313.00: RATES FOR FREESTANDING CLINICS PROVIDING ABORTION AND STERILIZATION SERVICES

Section

313.01: General Provisions 313.02: General Definitions 313.03: General Rate Provisions 313.04: Reporting Requirements 313.05: Severability

101 CMR 313.00 Rates for Freestanding Clinics Providing Abortion and Sterilization Services

313.01 General Provisions

313.01: General Provisions

(1) Scope and Purpose. 101 CMR 313.00 governs the rates of payment used by governmental units to pay eligible providers for abortion and sterilization services provided to publicly aided individuals.

(2) Applicable Dates of Service. Rates contained in 101 CMR 313.00 apply for dates of service provided on or after May 1, 2025, unless otherwise indicated.

(3) Coverage. 101 CMR 313.00 and the rates of payment contained in 101 CMR 313.00 apply to abortion and sterilization services rendered by eligible providers in an ambulatory clinic setting. The rates of payment under 101 CMR 313.00 are full compensation for all services rendered.

(4) Disclaimer of Authorization of Services. 101 CMR 313.00 is neither authorization for nor approval of the substantive services for which rates are determined pursuant to 101 CMR 313.00. Governmental units that purchase services from eligible providers 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 reference 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 is no corresponding new code; and (d) codes for entirely new services that require pricing. EOHHS will list these codes and apply individual consideration (IC) reimbursement for these codes until appropriate rates can be developed.

(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 313.00, and as otherwise specified in 101 CMR 313.00.

Final Adoption Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

2

313.02 General Definitions

313.02: General Definitions

As used in 101 CMR 313.00, unless the context clearly otherwise requires, the following terms have the meanings in 101 CMR 313.02.

Ambulatory Abortion or Sterilization Clinic. A state-licensed freestanding ambulatory clinic that provides abortion or sterilization services and which is in compliance with applicable clinic licensure rules and regulations.

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

Eligible Provider. State-licensed freestanding ambulatory abortion or sterilization clinics providing abortion and/or sterilization services which meet 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 and injectables listed in 101 CMR 313.03(5) with IC, payment will be at cost, subject to any documentation requirements of the governmental unit.

Modifier. Listed services and procedures may be modified under certain circumstances. When applicable, the modifying circumstances must be identified by the addition of the appropriate two letter or numeric designation.

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.

313.03 General Rate Provisions

313.03: General Rate Provisions

(1) Rate Determination. Rates of payment for eligible providers of abortion and sterilization services 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 allowable fees set forth in 101 CMR 313.03(5).

(2) Abortion Services. The rates for an induced abortion, physician and clinic services include preoperative evaluation and counseling, laboratory services, surgery, anesthesia, and postoperative care due to complications. The post-abortion visit rate constitutes full compensation for routine follow-up care for abortion patients who return for such care.

Final Adoption Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

3 (3) Sterilization Services. The rates of payment for sterilization services represent full compensation for these services, which include preoperative evaluation and counseling, laboratory services, surgery, anesthesia, and postoperative care.

(4) Modifiers. (a) Modifier -51 Pertains to Multiple Procedures. This modifier must be used to report multiple procedures performed at the same session. The service code for the major procedure or service must be reported without a modifier. The secondary, additional or lesser procedure(s) must be identified by adding the modifier -51 to the end of the service code for the secondary procedure(s). The addition of the modifier -51 to the second and subsequent procedure codes allows 50% of the allowable fee contained in 101 CMR 313.03(5) to be paid to the eligible provider. (b) Modifier -TF – Intermediate Level of Care. Use with procedure codes 59840, 59841, or S2260, if applicable, in accordance with the fee schedules set forth in 101 CMR 313.03(5). (c) Modifier -TG – Complex/High Tech Level of Care. Use with procedure codes 59840, 59841, or S2260, if applicable, in accordance with the fee schedules set forth in 101 CMR 313.03(5). (d) 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

(5) Maximum Allowable Rates.

Code Modifier Allowable Fee Description

55250 $555.69 Vasectomy, unilateral or bilateral (separate procedure), including postoperative semen examination(s) 58600 $862.13 Ligation or transection of fallopian tube(s), abdominal or vaginal approach, unilateral or bilateral 58670 $804.01 Laparoscopy, surgical; with fulguration of oviducts (with or without transection) 58671 $847.03 Laparoscopy, surgical; with occlusion of oviducts by device (eg, band, clip, or Falope ring) 59820 $448.31 Treatment of missed abortion, completed surgically; first trimester (includes physician’s charges and clinic services) 59840 $409.46 Induced abortion, by dilation and curettage (includes physician's charges and clinic services with either I.V. sedation or general anesthesia)

Final Adoption Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

4 Code Modifier Allowable Fee Description

59840 -TF $556.67 Induced abortion, by dilation and curettage (includes physician's charges and clinic services with either I.V. sedation or general anesthesia) 59840 -TG $785.14 Induced abortion, by dilation and curettage (includes physician's charges and clinic services with either I.V. sedation or general anesthesia) 59841 $636.33 Induced abortion, by dilation and evacuation - (includes physician's charges and clinic services) 59841 -TF $1,204.11 Induced abortion, by dilation and evacuation - (includes physician's charges and clinic services) 59841 -TG $1,285.55 Induced abortion, by dilation and evacuation - (includes physician's charges and clinic services) J2790 IC Injection, Rho D immune globulin, human, full dose, 300 mcg (1500 IU) (when required only, reimbursed at the actual wholesale cost of the serum. A copy of the purchase invoice must be submitted with the claim form) S0190 IC Mifepristone, oral, 200 mg S0191 IC Misoprostol, oral, 200 mcg S0199 $501.57 Medically induced abortion by oral ingestion of medication including all associated services and supplies (e.g., patient counseling, office visits, confirmation of pregnancy by HCG, ultrasound to confirm duration of pregnancy, ultrasound to confirm completion of abortion) except drugs S2260 $776.09 Induced abortion, 17 to 24 weeks (includes physician's charges and clinic services) S2260 -TF $1,055.48 Induced abortion, 17 to 24 weeks (includes physician's charges and clinic services) S2260 -TG $1,490.08 Induced abortion, 17 to 24 weeks (includes physician's charges and clinic services)

(6) Services and Payments Covered under Other Regulations. The rates of payment for other abortion and sterilization services not listed in 101 CMR 313.03(5) that are authorized by the purchasing governmental unit will be based on the applicable EOHHS regulations, such as 101 CMR 312.00: Rates for Family Planning Services; 101 CMR 316.00: Rates for Surgery and Anesthesia Services; for 101 CMR 317.00: Rates for Medicine Services; and 101 CMR 318.00: Rates for Radiology Services.

313.04 Reporting Requirements

313.04: Reporting Requirements

(1) Required Reports. Reporting requirements are governed by 957 CMR 6.00: Cost Reporting Requirements.

(2) Penalty for Noncompliance. A 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.

Final Adoption Published in Mass Register: April 25, 2025

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

5 The purchasing governmental unit will notify the provider in advance of its intention to impose a penalty under 101 CMR 313.04(2).

313.05 Severability

313.05: Severability

The provisions of 101 CMR 313.00 are severable. If any provision of 101 CMR 313.00 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 313.00 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

101 CMR 313.00: M.G.L. c.118E.