CDR RFA Attachment D CDR Hospital Contract RY23.docx

COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

MASSHEALTH PROGRAM CHRONIC DISEASE AND REHABILITATION HOSPITAL CONTRACT

COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

MASSHEALTH PROGRAM

CHRONIC DISEASE AND REHABILITATION HOSPITAL CONTRACT

This Contract, dated as of___________, __, 2022_, is between the Commonwealth of Massachusetts, acting by and through its Executive Office of Health and Human Services (hereinafter “EOHHS”) and

(the Contractor), with a principal place of business (legal name of Contractor) located at:

WHEREAS EOHHS operates and administers the programs of medical assistance and medical benefits under M.G.L. c. 118E, §1 et seq. (hereinafter the MassHealth Program) and serves as the single state agency under 42 U.S.C. §1396 et seq., WHEREAS EOHHS desires to purchase services and goods for eligible Members in the MassHealth Program from participating Hospitals under the terms and conditions set forth herein; and

WHEREAS EOHHS has issued, as of September 8, 2022, a Request for Applications for Chronic Disease and Rehabilitation Hospitals; and, WHEREAS the Contractor desires to furnish Inpatient Services and Outpatient Services to eligible Members in accordance with the legal requirements of the MassHealth Program and the terms of this Contract and to receive payment therefore under the terms and conditions set forth herein.

NOW, THEREFORE, in consideration of the mutual promises herein, the parties agree as follows:

TABLE OF CONTENTS

APPENDICES:

SECTION 1: DEFINITIONS

Accountable Care Organization (ACO) -- an entity that enters into a population-based payment model contract with EOHHS as an accountable care organization, wherein the entity is held financially accountable for the cost and quality of care for an attributed or enrolled member population. ACOs include Accountable Care Partnership Plans, Primary Care ACOs, and MCO-Administered ACOs.

Administrative Day (AD) -- A day of inpatient hospitalization, as defined in 130 CMR 435.402, on which a Member’s care needs can be met in a less-intensive setting than a Chronic Disease and Rehabilitation Hospital and on which the Member is clinically ready for discharge, but an appropriate facility-based or community setting is not readily available.

Administrative Day Per Diem Rate (AD Rate) -- All-inclusive daily payment rate paid to Hospital for AD days. There are two AD payment rates for non-Pediatric CDR Hospitals: one for short-stay Administrative Days and one for long-stay Administrative Days. There is one AD payment rate for Pediatric CDR hospitals.

Behavioral Health Services -- Services provided to Members who are being treated for psychiatric disorders or substance-related disorders.

Center for Health Information and Analysis (CHIA) -- An agency of the Commonwealth of Massachusetts established under M.G.L. c. 12C.

Centers for Medicare and Medicaid Services (CMS) -- The federal agency under the Department of Health and Human Services that is responsible for administering the Medicare and Medicaid programs.

Charge -- The standard fee that a Hospital charges for a Hospital service rendered to a patient, regardless of payer source, and which is required to be filed with CHIA.

Chronic Disease and Rehabilitation Hospital (CDR Hospital) -- A hospital licensed by the Massachusetts Department of Public Health under M.G.L. c.111, §51, with a majority of its beds licensed to provide chronic care services and/or comprehensive rehabilitation services to patients with appropriate medical needs including a hospital licensed with a pediatric specialty. Hospitals with 50 percent or more of their beds licensed as medical/surgical, intensive care, coronary care, burn, maternal (obstetrics) and neonatal intensive care beds (Level III) possess acute hospital licensure and do not meet the definition of a Chronic Disease and Rehabilitation Hospital.

Contractor -- Each Hospital that is selected by EOHHS after submitting a satisfactory application in response to this RFA and that enters into a contract with EOHHS to meet the purposes specified in this RFA.

Department of Public Health (DPH) -- An agency of the Commonwealth of Massachusetts, established under M.G.L. c. 17, §1.

Executive Office of Health and Human Services (EOHHS) -- The executive department of the Commonwealth of Massachusetts established under M.G.L. c. 6A, §2, which through the Department of Elder Affairs and other agencies within the Executive Office, as appropriate, operates and administers the programs of medical assistance and medical benefits under M.G.L. chapter 118E and which serves as the single state agency under section 1902(a)(5) of the Social Security Act.

Hospital Outpatient Department -- A department or unit that operates under the Hospital’s license and provides services to Members on an ambulatory basis.

Inpatient Per Diem Rate -- An all-inclusive daily rate of payment for any and all Inpatient Services provided to a Member by a Hospital.

Inpatient Services -- Routine and ancillary services that are provided to Members admitted as patients to a Chronic Disease and Rehabilitation Hospital.

Managed Care Organization (MCO) -- A managed care organization, as defined in Section 1903(m) of the Social Security Act, MCOs include MassHealth MCOs, One Care plans and Senior Care Organizations (SCOs) and the PCC Plans.

Managed Care Entity (MCE) – An MCO, One Care Plan, SCO, ACO, or PACE entity which provides or arranges services for enrolled Members under a MassHealth Program contract.

MassHealth Program (MassHealth) -- The medical assistance benefit plans operated and administered by EOHHS pursuant to M.G.L. c. 118E, §1 et seq. and 42 U.S.C. §1396 et seq. (Medicaid).

Member -- A person determined by the MassHealth Program to be eligible for medical assistance benefits under M.G.L. c. 118E, §1 et seq.

One Care -- A health plan or provider-based organization contracted with EOHHS and CMS, and accountable for providing integrated care to individuals age 21 through 64 at the time of enrollment who are eligible for both Medicare and MassHealth Standard or CommonHealth and who do not have any other comprehensive public or private health care coverage. A One Care plan is also known as an Integrated Care Organization (ICO).

Outpatient Cost to Charge Ratio -- A percentage applied to the Charges for Outpatient Services of a Hospital to calculate payment for Outpatient Services provided to Members under the MassHealth Program.

Outpatient Services -- Services provided to Members on an ambulatory basis when rendered in a Hospital Outpatient Department.

Pediatric Chronic Disease and Rehabilitation Hospital (Pediatric CDR Hospital) -- A hospital licensed by the Massachusetts Department of Public Health under M.G.L. c.111, §51, with a majority of its beds licensed to provide chronic care services and/or comprehensive rehabilitation services to patients with appropriate medical needs and licensed with a pediatric specialty that serves solely children and adolescents. Hospitals with 50 percent or more of their beds licensed as medical/surgical, intensive care, coronary care, burn, maternal (obstetrics) and neonatal intensive care beds (Level III) possess acute hospital licensure and do not meet the definition of a Chronic Disease and Rehabilitation Hospital.

Program For All Inclusive Care for the Elderly (PACE) -- PACE provides a complete package of acute and long-term care services to eligible frail elders, as described under Section 1934 of the Social Security Act and federal PACE regulations at 42 CFR 460.

Quality Improvement Project -- An organized effort to address and improve performance in a process and outcome. It involves identifying a particular area for improvement identifying problem areas in the process, proposing specific changes that address the root causes of the problem, implementing the changes, and evaluating the success of such changes.

Rate Year (RY) -- The period beginning October 1 and ending September 30.

Senior Care Options -- A managed care organization that participates in MassHealth under a contract with the MassHealth agency to provide coordinated care and medical services through a comprehensive network to eligible members 65 years of age or older. SCOs are responsible for providing enrolled members with the full continuum of MassHealth-covered services, and for dual eligible members, the full continuum of MassHealth and Medicare covered services.

Third-Party Insurance -- any insurance, including Medicare, that is or may be liable to pay all or part of the Member’s medical claims. Third-Party Insurance includes a MassHealth Member’s own insurance.

Upper Payment Limit -- The term referring to the calculation by which it is determined whether the payment methodology for services provided pursuant to this Contract will result in payments for Inpatient Services and Outpatient Services in the aggregate that are no more than the amount that would be paid under Medicare principles of payment.

SECTION 2: CONTRACTOR RESPONSIBILITIES

The Contractor shall:

1. Furnish Inpatient Services and Outpatient Services to MassHealth Members that conform to the requirements for such Inpatient Services and Outpatient Services as set forth in the MassHealth Program regulations; and shall furnish only those Inpatient Services and Outpatient Services that qualify as medically necessary under the MassHealth Program regulations; and shall furnish only those Inpatient Services and Outpatient Services that conform to the professionally recognized standards of health care within the Commonwealth for the applicable provider type and/or specialty type, or, if appropriate, that conform to the generally accepted standards within the Commonwealth for the trade.

2. For Contractors with at least 100 licensed beds with the Department of Public Health and one or more non-pediatric psychiatric beds as of September 30, 2021, and licensed with the Department of Public Health to provide psychiatric services within the Chronic Disease and Rehabilitation Hospital, EOHHS requires, as of November 1, 2021, for MassHealth members receiving those psychiatric services:

a. An average daily ratio of at least 1 behavioral technician for every 10 patients receiving psychiatric services;

b. An average daily ratio of at least 1 behavioral specialist for every 15 patients receiving psychiatric services;

c. An average daily ratio of at least 1 registered nurse for every 15 patients receiving psychiatric services.

If the Contractor fails to maintain the above listed requirements for MassHealth members utilizing psychiatric beds, EOHHS reserves the right to impose monetary or other sanctions in accordance with 130 CMR 450.238-40.

3. Maintain and retain any records necessary to disclose the extent, quality and medical necessity of services provided to Members, to substantiate any claims for payment submitted by the Provider to the MassHealth Program, or as otherwise required by EOHHS or applicable law. Such records must be, upon request, made available and provided to EOHHS, its designees, the Office of the Attorney General’s Medicaid Fraud Division (MFD), the federal Centers for Medicare & Medicaid Services, and other government agencies as provided in applicable law.

a. The Contractor is required to transition to electronic medical records (EMR) for all inpatient services in its facility by October 1, 2023;

b. If Contractor fails to complete its transition to EMR by the above date, EOHHS may apply a downward adjustment of up to 10% of the Contractor’s inpatient per diem rate.

4. Comply with all applicable billing instructions and provider bulletins issued from time to time by the MassHealth Program.

5. Comply with all applicable state and federal statutes, rules, and regulations governing the MassHealth Program, including, but not limited to, 130 CMR 435.000 et seq. (chronic/rehabilitation hospitals); 130 CMR 410.000 et seq. (hospital outpatient services); and 130 CMR 450.000 et seq. (administrative and billing requirements). All references to statutes and regulations refer to such statutes and regulations as they may be amended from time to time.

SECTION 3: EOHHS RESPONSIBILITIES

EOHHS shall make Contract payments to the Contractor in accordance with the rates of payment and payment provisions set forth in Section 4 and Appendix 1 of this Contract, for all covered Inpatient Services and Outpatient Services actually and properly delivered to eligible Members and properly billed to the MassHealth Program in accordance with the terms of this Contract and in accordance with and subject to all applicable federal and state laws, regulations, rules, billing instructions and provider bulletins, as they may be amended from time to time.

SECTION 4: PAYMENT

Section 4.1: General Provisions The Contractor shall accept payment at the rates pursuant to Appendix 1 of the Contract as payment in full for all Inpatient Services, Outpatient Services, and Administrative Days rendered on and after October 1, 2022 through the term of the Contract.

1. If a CDR Hospital is designated under its DPH license as a “chronic disease hospital,” that CDR Hospital may only admit a MassHealth member if the member meets the LOC (Level of Care) criteria relevant to “chronic disease hospitals,” as specified in MassHealth’s Chronic Disease and Rehabilitation Inpatient Hospital Services regulations at 130 CMR 435.409 Level-of-Care Criteria for Members in Chronic Disease and Massachusetts Department of Public Health Hospitals. If a CDR Hospital is designated under its DPH license as a “rehabilitation hospital,” that CDR Hospital may only admit a MassHealth member if the member meets the LOC criteria relevant to “rehabilitation hospitals,” as specified in MassHealth’s Chronic Disease and Rehabilitation Inpatient Hospital Services regulations at 130 CMR 435.410: Level-of-Care Criteria for Rehabilitation Hospitals.

2. Notwithstanding Section 4.1.a., in certain circumstances, EOHHS (MassHealth) may determine that it is necessary to deny authorization of admission, or withdraw authorization for continued stay, of a member who has both chronic disease and rehabilitation hospital needs from a CDR Hospital:

a. Whose DPH license classifies them as solely a “chronic disease hospital” in situations in which EOHHS’ clinical authorization staff determines that a rehabilitation hospital setting or hospital setting that is both a chronic disease and rehabilitation hospital setting is more appropriate for the member’s medical care needs at that time. Under such circumstances the CDR Hospital shall have the responsibility of transferring the member to an appropriate rehabilitation hospital licensed CDR Hospital or a chronic disease and rehabilitation hospital licensed CDR Hospital.

b. Whose DPH license classifies them as solely a “rehabilitation hospital” in situations in which EOHHS’ clinical authorization staff determine that a chronic disease hospital setting or a hospital setting that is both a chronic disease and rehabilitation hospital setting is more appropriate for the member’s medical care needs at that time. Under such circumstances, the CDR Hospital shall have the responsibility of transferring the member to an appropriate chronic disease licensed CDR Hospital or a chronic disease and rehabilitation hospital licensed CDR hospital.

Section 4.2: Payments for Inpatient Services Inpatient Services will be paid using a Hospital-specific Inpatient Per Diem Rate as listed in Appendix 1 of the Contract. The Inpatient Per Diem Rate is an all-inclusive daily rate paid for any and all Inpatient Services provided by the Contractor to a Member, with the exception of any and all Administrative Days that shall be paid in accordance with Section 4.5 below.

Section 4.3: Payments for Outpatient Services Outpatient Services will be paid using a Hospital-specific Outpatient Cost-to-Charge Ratio as listed in Appendix 1 of the Contract, and subject to the payment limitations described in Section 4.4. The Outpatient Cost-to-Charge Ratio is a fixed percentage that is applied to the Contractor’s Charge for an Outpatient Service.

Section 4.4: Payment Limitations for Certain Outpatient Services

1. Laboratory Services: The maximum allowable payment for laboratory services shall be at the lowest of the following:

a. The amount listed in the most current applicable Clinical Laboratory Services fee schedule at 101 CMR 320.00 or successor regulation, and the Surgery & Anesthesia fee schedule at 114.3 CMR 16.00 or successor regulation (available at the State House Bookstore and at http://www.mass.gov/eohhs/).

b. The Contractor’s usual and customary charge; or

c. The amount that would be recognized under 42 U.S.C. §1395l(h) for tests performed for a person with Medicare Part B benefits.

2. Dental Services: Claims for outpatient dental services will be paid in accordance with regulations 130 CMR 420.000 et seq. Dental services will be paid at the lower of the most current dental rates at 101 CMR 314.00 or successor regulation (available at the State House Bookstore and at http://www.mass.gov/eohhs/), or the Contractor’s usual and customary charge.

Section 4.5: Payment for Administrative Days The Contractor will be paid for Administrative Days using either a facility-specific short-stay or statewide standard long-stay Administrative Day Per Diem Rate (AD Rate) as listed in Appendix 1 of the Contract. The long-stay AD rate will apply when a Member’s care needs is clinically ready for discharge, but an appropriate facility-based or community setting is not readily available, and the member has been at an Administrative Day level of care for greater than 180 days. The long-stay AD rate does not apply to Pediatric CDR Hospitals. AD Rates are all-inclusive daily rates. As stated in the MassHealth program regulations, the first 45 administrative days of a member’s admission or continued stay are not reimbursable. However, if the Contractor is able to document appropriate discharge planning efforts for individual MassHealth members in Rate Year 2023, EOHHS may issue quality performance incentive payments as described in Appendix 3: Quality Performance Incentive and Supplemental Payments.

Section 4.6: Quality Performance Incentive Payments or Supplemental Payments The Contractor may qualify to receive quality performance incentive payments or supplemental payments under this Contract and as specified in Appendix 3.

SECTION 5: ADDITIONAL PAYMENT AND REPORTING PROVISIONS

All payments under this Contract are subject to the following provisions, as well as all other rules and regulations governing service limitations, claims payment, billing and claims processing procedures, utilization control requirements and all other conditions of participation established by the MassHealth Program.

Section 5.1: Services Requiring Prior Approval The MassHealth Program will not pay the Contractor for an Inpatient Service or Outpatient Service when the Contractor is required, but fails, to obtain prior approval for the service from the MassHealth Program. It is the responsibility of the Contractor to obtain the necessary prior approval.

Section 5.2: Payments in the Event of Third-Party Coverage MassHealth payments will be made to the Contractor according to the third-party liability provisions at 130 CMR 450.316-450.318 and 130 CMR 450.321.

Section 5.3: Reporting Requirements The Contractor shall furnish ownership, licensure, financial, and statistical documents relating to MassHealth participation, services, and payment, as required by EOHHS and other governmental entities. This shall include, but is not limited to, state and federal cost reports, charge books, audited financial statements, and provider enrollment information. If the Contractor does not furnish required information within the applicable time period, or within a reasonable extension of time approved in writing by EOHHS or other governmental entity, the Contractor may have a 5% reduction applied to its Inpatient Per Diem rate beginning on the day following the date the information is due. The reduction shall be applied for each day of non-compliance. The reduction shall increase in a cumulative manner at the rate of 5% for each month of non-compliance. For example, the downward adjustment to the Contractor’s Inpatient Per Diem for the first month of noncompliance would equal 5%. If the requested documentation were not received for another month, the downward adjustment to the Contractor’s Inpatient Per Diem for the second month would equal 10%. The adjustment shall not, in any case, exceed 50% of the Inpatient Per Diem Rate.

Section 5.4: Upper Payment Limits and Federal Approval If any portion of the Contractor’s payment methodology or this Contract or any amount paid pursuant to the Contract is not approved or is the basis of a disallowance by CMS, such payments made to the Contractor by the MassHealth Program in excess of the federally approved methodology or amounts will be deemed an overpayment and the MassHealth Program may recoup, or offset such overpayments against future payments.

If any payments made pursuant to this Contract exceed any applicable federal Hospital-specific payment limits, including, but not limited to, charge limits, upper payment limits, and limits based on federally approved payment methods, such amounts will be deemed an overpayment and the MassHealth Program may recoup, or offset such overpayments against future payments.

If any payments made pursuant to this Contract exceed applicable federal aggregate payment limits, the MassHealth Program may exercise its discretion to apportion disallowed amounts among the affected Hospitals, and to recoup from, or offset against future payments to such Hospitals, or to otherwise restructure payments in accordance with approved payment methods.

Section 5.5: Billing Requirements The Contractor shall bill all Inpatient Services and Outpatient Services on the appropriate electronic format except where otherwise indicated by the MassHealth Program in applicable regulations, billing instructions or provider bulletins.

Claims for inpatient and outpatient services must itemize the services provided, and must include appropriate HCPCS codes and units of service. Any service billed without an HCPCS code will be denied, or subject to recoupment.

National Drug Code Requirement: NDC units and appropriate descriptors are required when submitting outpatient claims for drugs payable by an HCPCS Level II code. Such claims that do not have this information will be denied, or subject to recoupment.

Section 5.6: Additional Billing Requirements In billing for services provided under this Contract, the Contractor shall:

1. Not bill the MassHealth Program under this Contract for behavioral health services provided to Members who are enrolled with the MassHealth behavioral health contractor. The provision of behavioral health and substance use treatment for members not enrolled with the MassHealth behavioral health contractor are included in the all-inclusive day rate set forth in Section 4.2, above. Further, upon admission, MassHealth members served must be screened for potential behavioral health and substance use issues. If a member indicates a history of or current behavioral health or substance use concern, clinically appropriate assessments must be administered. Based on the results of said assessments, appropriate behavioral health and substance use services must be provided, including providing for behavioral health and substance use needs in discharge planning.

2. Not bill the MassHealth Program for services provided to Members enrolled in an MCE where such services are covered by the MCE’s contract with the MassHealth Program.

3. Not bill the MassHealth Program for non-covered services as defined in applicable law and regulations, including but not limited to, services described in 130 CMR 410.405, 130 CMR 435.407, 435.408, and 435.413.

4. Not bill the MassHealth Program under this Contract, for services provided by: (i) any unit within the Contractor’s Hospital which has a separate license, such as a skilled nursing unit, or (ii) any unit that is licensed to provide services other than chronic disease or comprehensive rehabilitation services, such as a psychiatric unit.

5. Not bill the MassHealth program when other special program initiatives give rise to other contracts or regulations that provide for alternative payment methodologies for Contractor services, or part of the Contractor’s services.

SECTION 6: QUALITY MEASURES

The Contractor shall comply with the quality measures of this Contract, in doing so, the Contractor shall:

1. Submit all information required in Appendix 2 of this Contract, by the dates specified in Appendix 2;

2. Designate a representative to act as a quality improvement liaison between the Contractor and the MassHealth Program for the duration of the Contract. The representative will:

a. Receive and respond to all inquiries and requests from the MassHealth Program, in accordance with Appendix 2, in the time frames and format specified by representatives of the MassHealth Program;

b. Represent the Contractor on all matters pertaining to Appendix 2. The quality improvement liaison will be authorized and empowered to represent the Contractor regarding all aspects of the quality issues;

c. Monitor the Contractor’s compliance with the terms of Appendix 2 of this Contract;

d. Meet with representatives of the MassHealth Program on a periodic or as-needed basis and resolve issues that arise;

e. Identify Contractor representatives with the appropriate knowledge and authority to coordinate activities and communicate with the MassHealth Program regarding the Quality Improvement section in Appendix 2; and

f. Coordinate requests and activities from the MassHealth Program to ensure that the Contractor’s staff with appropriate expertise (i.e., clinical, management, data, etc.) participate in MassHealth activities and respond to requests by representatives of the MassHealth Program.

3. Actively participate in Quality Improvement Projects as requested by EOHHS; and

4. Participate in such meetings regarding quality improvement as EOHHS deems necessary.

SECTION 7: PROVIDER PREVENTABLE CONDITIONS

Section 7.1: Introduction Under Section 2702 of the Patient Protection and Affordable Care Act (ACA) (Pub. L. 111-148) (the ACA), and corresponding federal regulations at 42 C.F.R. 447.26, Hospitals must report “provider preventable conditions” to Medicaid agencies; and Medicaid agencies are prohibited from paying Hospitals for services resulting from a “provider preventable condition” in violation of the federal requirements. EOHHS has implemented policies that conform to the federal requirements. The following provisions and payment methods governing “provider preventable conditions” apply to the Contractor, and the Contract must comply with such provisions.

As part of the MassHealth “provider preventable conditions” policy, certain of the “serious reportable events” designated by the Massachusetts Department of Public Health (DPH) pursuant to its regulations at 105 CMR 130.332, as they pertain to MassHealth members, shall be excepted from the requirement that the Contractor shall not charge or seek reimbursement for the event, as described in Section 8 below. The excepted “serious reportable events” are any “serious reportable events” designated by DPH pursuant to its regulations at 105 CMR 130.332 which are not identified in Appendix U of the Contractor’s Chronic Disease and Rehabilitation Inpatient and Chronic Disease and Rehabilitation Outpatient Hospital MassHealth provider manuals. The Contractor shall bill and report, and related payment adjustments shall be made for, these excepted “serious reportable events” as “provider preventable conditions” in accordance with this Section 7 governing Provider Preventable Conditions. The Contractor also shall continue to perform the documented review process and determination for these events, as further described in Section 8 below, solely for the purpose of reporting to DPH. The remaining “serious reportable events” identified in Appendix U of the Contractor’s Chronic Disease and Rehabilitation Inpatient and Chronic Disease and Rehabilitation Outpatient Hospital MassHealth provider manuals shall be governed entirely by the Serious Reportable Event provisions in Section 8 below.

Section 7.2: Definitions The following definitions apply to this Section 7:

1. Provider Preventable Condition (PPC) – a condition that meets the definition of a “Health Care Acquired Condition” or “Other Provider Preventable Condition” as defined by CMS in federal regulations at 42 C.F.R. 447.26(b).

2. Health Care Acquired Conditions (HCACs) – conditions occurring in an inpatient hospital setting, which Medicare designates as hospital-acquired conditions (HACs) pursuant to Section 1886(d)(4)(D)(ii) and (iv) of the Social Security Act (SSA), with the exception of deep vein thrombosis (DVT)/pulmonary embolism (PE) as related to total knee replacement or hip replacement surgery in pediatric and obstetric patients.

3. Other Provider Preventable Condition (OPPC) – a condition that meets the requirements of “Other Provider Preventable Condition” pursuant to 42 C.F.R. 447.26(b). OPPCs may occur in any health care setting and are divided into two sub-categories:

a. National Coverage Determinations (NCDs) – The NCDs are mandatory OPPCs under 42 C.F.R. 447.26(b) and consist of the following:

i. Wrong surgical or other invasive procedure performed on a patient;

ii. Surgical or other invasive procedure performed on the wrong body part;

iii. Surgical or other invasive procedure performed on the wrong patient.

For each of i. through iii. above, the term “surgical or other invasive procedure” is as defined in CMS Medicare guidance on NCDs.

b. Additional Other Provider Preventable Condition (Additional OPPCs) – Additional OPPCs are state-defined OPPCs that meet the requirements of 42 C.F.R. 447.26(b). EOHHS has designated certain conditions as Additional OPPCs.

Section 7.3: Contractor Reporting of PPCs to EOHHS

1. Appendix V of the MassHealth Chronic Disease and Rehabilitation Inpatient Hospital and Chronic Disease and Rehabilitation Outpatient Hospital MassHealth provider manuals identifies those PPCs that apply to the Hospital for inpatient and outpatient hospital services. EOHHS may also provide this information to Hospitals through provider bulletins, or other written statements of policy, and all such documentation, including without limitation Appendix V, may be amended from time to time.

2. The Contractor shall report the occurrence of a PPC and PPC-related services through MMIS claims submissions to MassHealth. Contractor reporting of PPCs, and related claims submissions, must be conducted in accordance with applicable MassHealth regulations, provider manuals and billing instructions, including without limitation as set forth in Appendix V of the MassHealth Chronic Disease and Rehabilitation Inpatient Hospital and Chronic Disease and Rehabilitation Outpatient Hospital provider manual, respectively. EOHHS may also provide such instructions through provider bulletins, or other written statements or policy, and all such documentation, including without limitation, Appendix V, may be amended from time to time.

3. In accordance with state and federal statutes, rules and regulations governing the MassHealth program, including but not limited to 130 CMR 435.000 et seq. (Chronic Disease and Rehabilitation Inpatient Hospitals); 130 CMR 410.000 et seq. (Chronic Disease and Rehabilitation Outpatient Hospitals); and 130 CMR 450.000, et seq. (administrative and billing requirements), EOHHS may request additional information from the Contractor which EOHHS deems necessary to facilitate its review of any PPC or to carry out payment, provider enrollment, quality or other routine functions of the MassHealth program, and the Contractor must comply with the request. EOHHS may use this information, as well as the reports provided pursuant to Section 7.6, in reviewing any PPC and in applying any payment adjustment as set forth in Section 7.4.

Section 7.4: Payment Adjustments for Provider Preventable Conditions

1. Inpatient Hospital Services – For inpatient hospital services, when the Contractor reports a PPC that the Contractor indicates was not present on admission, EOHHS will reduce payments to the Contractor as follows:

a. Inpatient Per Diem Payment. For inpatient services for which the Contractor would be paid the Inpatient Per Diem rate:

i. MassHealth will not pay the Inpatient Per Diem if the Contractor reports that only PPC-related services were delivered on that day, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

ii. MassHealth will pay the Inpatient Per Diem if the Contractor reports that non-PPC related services were also delivered on that day, but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

b. Administrative Per Diem (AD) Rate. For inpatient services for which the Contractor would be paid the AD rate:

i. MassHealth will not pay the AD rate if the Contractor reports that only PPC-related services were delivered on that day, and will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

ii. MassHealth will pay the AD rate if the Contractor reports that non-PPC- related services were also delivered on that day, but will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

c. Follow-up Care in the same Hospital. If the Contractor reports that it provided follow-up inpatient hospital services that were solely the result of a previous PPC (inpatient or outpatient) that occurred while the member was being cared for at a facility covered under the same hospital license, MassHealth will not pay for the reported follow-up services. If the Contractor reports that non-PPC- related services were provided during the follow-up stay, payment will be made, but MassHealth will exclude all reported PPC-related costs/services when determining future year payment rates that are calculated using a data source that would otherwise include the PPC.

Section 7.5: Additional Requirements The Contractor agrees to take such action as is necessary in order for EOHHS to comply with all federal and state laws, regulations, and policy guidance relating to the reporting and non-payment of provider preventable conditions, including without limitation Section 2702 of the ACA. In addition, should EOHHS, in its sole discretion, deem it necessary to further amend this RFA and Contract to implement any such laws, the Contractor agrees that, notwithstanding any other provision in this RFA and Contract, EOHHS may terminate the Contractor’s Contract immediately upon written notice in the event the Contractor fails to agree to any such amendment.

Section 7.6: Reporting to the Massachusetts Department of Public Health In addition to complying with Sections 7.1 through 5 above, for any PPC that is also a “serious reportable event (SRE)” as designated by the Massachusetts Department of Public Health (DPH) pursuant to its regulations at 105 CMR 130.332, the Contractor must also continue to report the occurrence of the PPC as an SRE to DPH, and perform the documented review process as set forth in and in accordance with DPH regulations at 105 CMR 130.332(B) and (C). The Contractor must also provide copies of such reports to EOHHS and any other responsible third-party payer and inform the patient as required by and in accordance with DPH regulations at 105 CMR 130.332(B) and (C). The copies to MassHealth must be sent to:

PPC/Serious Reportable Event Coordinator MassHealth Utilization Management Department 100 Hancock Street, 6th Floor Quincy, MA 02171

Notwithstanding such reporting and documented review process as set forth in 105 CMR 130.332(B) and (C), provider claims to MassHealth and related payment methods for PPCs, including without limitation, those that also constitute a DPH-designated SRE, are governed by this Section 7 and not Section 8, below.

SECTION 8: SERIOUS REPORTABLE EVENTS

Section 8.1: Introduction The following Serious Reportable Event (“SRE”) provisions reflect and further EOHHS’ commitment to value-based purchasing and to helping to ensure safer and cost-effective care delivery to MassHealth members by encouraging Hospitals to establish measures and actions to actively improve performance in patient care safety and to avoid preventable errors.

Section 8.2: Applicability

Section 8.3: Reporting and Non-Payment for Serious Reportable Events Subject to the applicability provision in Section 8.2 above:

1. The Contractor is prohibited from charging or seeking reimbursement from MassHealth for services that are made necessary by, or are provided as a result of, a serious reportable event occurring on premises covered under the Contractor’s Hospital license that was preventable, within the Contractor’s control, and unambiguously the result of a system failure as described in DPH regulations. Non-reimbursable services include:

a. All services provided during the inpatient stay during which a preventable SRE occurred, from the date the SRE occurred through discharge, not to exceed 60 days;

b. All services provided during the outpatient visit during which a preventable SRE occurred; and

c. All services provided during readmissions and follow-up outpatient visits as a result of a non-billable SRE provided:

i. at a facility under the same license as the Hospital at which a non-billable SRE occurred; or

ii. on the premises of a separately licensed Hospital with common ownership or a common corporate parent of the Hospital at which a non-billable SRE occurred;

d. Charges for services, including co-payments or deductibles, deemed non-billable to EOHHS are not billable to the Member.

e. The non-payment provision of this RFA also applies to third-party liability and cross-over payments by EOHHS.

f. A Hospital not involved in the occurrence of a preventable SRE that also does not meet the criteria of subsection c above, and that provides inpatient or outpatient services to a patient who previously incurred an SRE, may bill EOHHS for all medically necessary services provided to the patient following a preventable SRE.

PPC/Serious Reportable Event Coordinator MassHealth Utilization Management Department 100 Hancock Street, 6th Floor Quincy, MA 02171

EOHHS will review any documentation submitted by the Contractor and shall decide whether to make full, partial, or no payment for such services. Any such request and supporting documentation must be mailed to the contact identified in Section 8.3 herein. EOHHS shall make an SRE payment determination and send it in writing to the Contractor, which shall describe any applicable right of appeal under 130 CMR 450.241 or 130 CMR 450.323.

SECTION 9: ADDITIONAL TERMS AND CONDITIONS

Section 9.1 Capitalized Terms All capitalized terms shall have the meanings as defined Section 1 of this Contract.

Section 9.2: Notification The Contractor shall notify EOHHS in writing of:

Section 9.3: Federally Required Disclosures The Contractor shall comply with the disclosure requirements set forth at 42 CFR 455.100 et seq. and 42 CFR 1002.3(a), including, without limitation, submitting within 35 days after the date of a request by the United States Secretary of Health and Human Services or MassHealth, full and complete information related to business transactions as set forth in 42 CFR § 455.105. For purposes of making disclosures to EOHHS as required by 42 CFR 455.100 et seq. and 42 C.F.R. 1002.3, the Contractor agrees to: (a) use any form required by EOHHS for such purpose, unless otherwise directed by EOHHS; (b) fully and accurately complete any such EOHHS-supplied form (or such portions thereof as directed by EOHHS); and (c) sign, date and return the form to EOHHS within the required time period. The Contractor should refer to 42 C.F.R. 455.100 et seq. and 42 C.F.R. 1002.3, as necessary.

EOHHS may immediately terminate this Contract in whole or in part if the Contractor fails to comply with this section or due to the information contained in the Contractor’s disclosures. In addition, the Contractor shall not be entitled to payment for any MassHealth services for which EOHHS reasonably determines federal reimbursement is not available. Any such payments shall constitute an overpayment as defined in 130 CMR 450.235. Under such circumstances, EOHHS may also exercise its authority under 130 CMR 450.238 et seq. to impose sanctions.

Section 9.4: Contract Term For Contractors responding to the RFA by the close of the initial enrollment period…