Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid Rate Year 2027 Acute Hospital Request for Applications Issued: September 15, 2026 Document Number: 27PMEHSACUTEHOSPITAL

TABLE OF CONTENTS

RY2027 Acute Hospital RFA vi Introduction The Massachusetts Executive Office of Health and Human Services (EOHHS) is issuing this Request for Applications (RFA) to solicit applications from eligible, in-state Acute Hospitals wishing to participate as Massachusetts MassHealth Providers. An Acute Hospital’s Contract will apply to covered Acute Hospital Inpatient and Outpatient Services provided to MassHealth Members and recipients of Emergency Aid to the Elderly, Disabled and Children at any Acute Hospital Inpatient Departments, Outpatient Departments, and Satellite Clinics for which a reimbursement method is described in Sections 5 through 8.

EOHHS intends to reimburse Hospitals for Inpatient and Outpatient Services according to the methodologies outlined in this RFA. For out-of-state acute hospital payment, see 130 CMR 450.233, 415.404, and 410.404.

To be a MassHealth Provider of Hospital services other than Emergency Services, a Hospital must accept the rates of payment outlined in this RFA in accordance with the reimbursement methodology specified in this RFA as payment in full. EOHHS will contract with all eligible Hospitals that agree to accept these rates and reimbursement methodologies, and otherwise comply with requirements applicable to Acute Hospitals.

Acceptance of this level of reimbursement, and compliance with all other requirements of this RFA and Contract, including completion and submission of a response to this RFA, is a condition of participation as a Provider in the MassHealth program for provision of non-Emergency Services by Massachusetts Acute Hospitals.

Failure to respond to this RFA by any Massachusetts Acute Hospital may result in its termination as a MassHealth Provider of non-Emergency Services, and in the termination of its Satellite Clinics. However, any inpatient unit within an Acute Hospital for which reimbursement is provided under another contract shall not be terminated as a MassHealth Provider.

RY2027 Acute Hospital RFA Page 2 of 2 Definitions The following terms appearing capitalized throughout this RFA and its appendices shall be defined as follows unless the context clearly indicates otherwise.

30-day Readmissions Policy (30-Day RP) – the MassHealth Acute Hospital 30-day Readmissions Policy, which is a quality-based program intended to encourage participating in-state MassHealth Acute Hospital Providers to establish immediate measures and actions to improve performance in patient care and reduce potentially preventable readmissions.

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 (ACPPs), and Primary Care ACOs.

Accountable Care Partnership Plan (ACPP) – a type of ACO with which the MassHealth agency contracts under its ACO program to provide, arrange for, and coordinate care and certain other medical services to members on a capitated basis and which is approved by the Massachusetts Division of Insurance as a health-maintenance organization (HMO) and which is organized primarily for the purpose of providing health care services.

Adjudicated Payment Amount Per Discharge (APAD) – a Hospital-specific, DRG-specific all-inclusive facility payment for an acute inpatient hospitalization from admission through discharge, which is the complete fee-for-service payment for such acute hospitalization, excluding the additional payment of any inpatient Hospital Outlier Payment. The APAD is not paid for Administrative Days or for Inpatient Services that are paid on a per diem basis under this RFA (for example, Transfer per diem). The APAD is also not payment for LARC Devices or for APAD Carve-Out Drugs, which may be paid separately as described in Section 5.B.8. The APAD is calculated as set forth in Section 5.B.1.

Adjudicated Payment per Episode of Care (APEC) – a Hospital-specific, Episode-specific all-inclusive facility payment for all APEC-Covered Services provided by a Hospital to a MassHealth Member on an outpatient basis in one Episode. The APEC is not payment for those outpatient services described in Section 4.C and Sections 5.C.3 through 5.C.14, as such services are excluded from the definitions of “APEC-Covered Services” and “Episode” under this RFA. The APEC is calculated as set forth in Section 5.C.1.

Adjusted EAPG Weight – the EAPG weight that is multiplied by the Hospital’s Wage Adjusted APEC Outpatient Standard in determining each of the Episode’s claim detail line EAPG payment amounts for purposes of calculating the Episode-Specific Total EAPG Payment. The Solventum (formerly known as 3M) EAPG Grouper’s discounting, consolidation and packaging logic is applied to each of the Episode’s claim detail line MassHealth EAPG Weights to produce the claim detail line’s Adjusted EAPG Weight.

Administrative Day (AD) – a day of inpatient hospitalization on which a Member’s care needs can be provided in a setting other than an Acute Hospital, and on which the Member is clinically ready for discharge, but an appropriate institutional or non-institutional setting is not readily available.

Administrative Psychiatric Day – an Administrative Day that is a day of inpatient hospitalization on which a Member’s clinical presentation would typically call for discharge to a lower level of care (e.g., an appropriate community-based location) but an appropriate placement has not yet been secured, the clinical barriers to discharge have been sufficiently addressed and the discharge plan is ready to be executed when an appropriate discharge placement has been secured, and the patient does not require a high degree of clinical resources daily. Administrative Psychiatric Day does not include a day on which a Member is receiving active stabilization efforts or requires inpatient hospital care to prevent further regression of the Member’s condition.

Adult Mobile Crisis Intervention (AMCI) – a community-based Behavioral Health Service available 24 hours per day, 7 days per week, 365 days per year and providing short-term mobile, on-site, face-to-face crisis assessment, intervention, and stabilization to individuals 21 years of age and older experiencing a Behavioral Health Crisis. Services may be provided by a Community Behavioral Health Center (CBHC) in community-based settings outside a CBHC, at a CBHC, or in emergency department sites of services when necessary. Services may also be provided via telehealth. The purpose is to identify, assess, treat, and stabilize the situation and reduce the immediate risk of danger to the individual or others consistent with the individual’s risk management or safety plan, if any. AMCI service is not an outpatient hospital service and is not a payable service under this RFA.

All Patient Refined–Diagnostic Related Group (APR-DRG or DRG) – The All Patient Refined Diagnosis Related Group and Severity of Illness (SOI) assigned using the Solventum APR-DRG Grouper, Version 43, unless otherwise specified.

APAD Base Year – The hospital-specific base year for the APAD is FY21, using the FY21 Massachusetts Hospital cost reports as screened and updated as of March 14, 2023.

APAD Carve-Out Drugs – Drugs designated by EOHHS that are carved out of the APAD payment and separately paid pursuant to Section 5.B.8.b.

APEC Base Year – the APEC Base Year is FY21.

APEC Carve-Out Drugs – Drugs designated by EOHHS that are carved out of the APEC payment and are separately paid pursuant to Section 5.C.9.

APEC-Covered Services – MassHealth-covered Outpatient Services provided by Hospital Outpatient Departments or Satellite Clinics, except those services described in Section 4.C and Sections 5.C.3 through 5.C.14.

APEC Outlier Component – A Hospital-specific, Episode-specific component of the APEC which is calculated by EOHHS as described in Section 5.C.1.b.(2), and added to the Episode-Specific Total EAPG Payment to result in the APEC for that Episode. The APEC Outlier Component may equal $0.

APEC Outpatient Statewide Standard – The outpatient statewide standard determined by EOHHS as described in Section 5.C.1.b.(1).(a).1, that is utilized in the calculation of the APEC.

Baseline ED Psychiatric Services – The following services:

Family support and education.

Screening for substance use disorder (i.e., Screening, Brief Intervention, and Referral to Treatment), including medication-assisted treatment initiation when appropriate.

Referring members to community-based providers for ongoing care after discharge, as necessary.

Observation for those with suicidal ideation and/or homicidal ideation.

Behavioral Health (BH) Contractor – The entity with which EOHHS contracts to provide, arrange for and coordinate Behavioral Health Services to enrolled Members on a capitated basis.

Behavioral Health Crisis – A situation in which an individual demonstrates signs or symptoms of a mental health disorder, substance use disorder, co-occurring mental health and substance use disorder, or co-occurring behavioral health and medical condition that led to significant impairment in the individual’s functioning and/or to behavior that puts the individual at risk of harming themselves, harming others, or being unable to appropriately care for themselves.

Behavioral Health Crisis Management Services – A set of services provided in an Emergency Department or on a medical/surgical floor by qualified clinical professionals to members experiencing a Behavioral Health Crisis in need of ongoing supports on days subsequent to receiving the initial Behavioral Health Crisis Evaluation. The crisis management services include ongoing crisis interventions, ongoing determination and coordination of appropriate disposition, and ongoing required reporting and community collaboration activities.

Behavioral Health Diversionary Services – Those mental health and substance use disorder services provided outside of this RFA as clinically appropriate alternatives to Behavioral Health Inpatient Services, to support an Enrollee returning to the community following a 24-hour acute placement, or to provide intensive support to maintain functioning in the community. There are two categories of Diversionary Services: those services which are provided in a 24-hour facility, and those services which are provided in a non-24-hour setting or facility.

Behavioral Health Crisis Evaluations – An evaluation provided in an Emergency Department or on a medical/surgical floor by qualified clinical professionals to members experiencing a Behavioral Health Crisis during the first calendar day of their readiness to receive such an evaluation. The evaluation includes the initial comprehensive assessment of risk, diagnosis, and treatment needs, the initial crisis interventions, the initial determination and coordination of appropriate disposition, and required reporting and community collaboration activities.

Behavioral Health Services (or Behavioral Health) – Services provided to Members who are being treated for psychiatric disorders or substance use disorders.

Behavioral Health Treatment and Referral Platform (BHTRP) – Technology to support automation of the ED Behavioral Health referral screening, evaluation and referral process, enables the electronic transmission of standardized admissions information, and creates a real-time, transparent view of patients seeking behavioral health treatment for participant organizations.

Calendar Year (CY) – The time period of 12 months beginning on January 1 of any given year and ending on December 31 of the same year.

Casemix – The description and categorization of a hospital’s patient population according to criteria approved by EOHHS including, but not limited to, primary and secondary diagnoses, primary and secondary procedures, illness severity, patient age and source of payment.

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

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

Certified Event Notification Service Vendor or Certified ENS Vendor – An ENS vendor that is certified by EOHHS in compliance with 101 CMR 20.00: Health Information Exchange.

Charge – the uniform price for each specific service within a Revenue Center of an Acute Hospital.

Clinical Laboratory Service – Microbiological, serological, chemical, hematological, biophysical, radio bioassay, cytological, immunohematological, immunological, pathological, or other examinations of materials derived from the human body, to provide information for the assessment of a medical condition or for the diagnosis, prevention, or treatment of any disease.

Coinsurance – a percentage of cost or a fee established by a Third-Party Insurance carrier for a specific service or item for which an individual is responsible when the service or supply is delivered. This cost or fee varies according to the individual’s insurance carrier.

Community-Based Acute Treatment (CBAT) – 24-hour-per-day, seven-day-per-week, staff-secure treatment settings for children and adolescents up to the age of 18 with serious behavioral health disorders that provide short-term crisis stabilization, therapeutic intervention, and specialized programming.

Community-Based Physician – any physician or physician group practice, excluding interns, residents, fellows, and house officers, who is not a Hospital-Based Physician. For purposes of this definition and related provisions, the term physician includes dentists, podiatrists, and osteopaths.

Community Behavioral Health Center (CBHC) – an entity that serves as a hub of coordinated and integrated behavioral health disorder treatment for individuals of all ages, including routine and urgent behavioral health outpatient services, mobile crisis intervention services for adults and youth, and community crisis stabilization services for adults and youth.

Community Crisis Stabilization (CCS) – A community-based program that serves as a medically necessary, less-restrictive alternative to inpatient psychiatric hospitalization when clinically appropriate and provides short-term staff-secure, safe, and structured crisis stabilization and treatment services for individuals 18 years of age and older with mental health and/or substance use disorders. Stabilization and treatment also include the capacity to provide induction onto and bridging for medication for the treatment of opioid use disorders (MOUD) and withdrawal management for opioid use disorders (OUD) as clinically indicated.

Community Partners – entities certified by EOHHS to work with ACOs to ensure integration of care, as further specified by EOHHS. There are two types of CPs – Long-Term Services and Supports CPs (LTSS CPs) and Behavioral Health CPs (BH CPs).

Community Partner Assigned Member – An ACO-enrolled Member who is assigned to a BH or LTSS CP.

Contract (also Hospital Contract or Agreement) – the agreement executed between each selected Hospital and EOHHS, which is contained in Appendix A attached hereto, and incorporates all of the provisions of this RFA. Unless the context indicates that the term “RFA” refers exclusively to the procurement document as such, references to RFA shall constitute references to the Contract (or Agreement).

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.

Copayment – a predetermined fee that the Member is responsible for paying directly to the Provider for specific services.

Critical Access Hospital (CAH) – an Acute Hospital that, prior to October 1, 2026, was certified by CMS and designated as a Critical Access Hospital under 42 U.S.C. 1395i-4, and that continues to maintain that status.

Deductible – the amount an individual is required to pay in each Calendar Year, as specified in their insurance plan, before any payments are made by the insurer.

Department of Mental Health (DMH) – a department of the Commonwealth of Massachusetts, Executive Office of Health and Human Services.

Department of Public Health (DPH) – a department of the Commonwealth of Massachusetts, Executive Office of Health and Human Services.

Discharge-Specific Case Cost – the product of (1) the Hospital’s MassHealth allowed Charges for a specific discharge, as determined by EOHHS, and (2) the Hospital’s inpatient cost to Charge ratio as calculated by EOHHS using the Hospital’s FY22.

Massachusetts Hospital Cost Report. For applicable discharges, a Hospital’s Charges corresponding to LARC Devices or APAD Carve-Out Drugs are excluded in calculating the Discharge-Specific Case Cost.

Discharge-Specific Outlier Threshold – the sum of the APAD for a specific discharge, as determined by EOHHS, and the inpatient Fixed Outlier Threshold.

DMH-Licensed Bed – a bed in a Hospital that is located in a unit licensed by the Department of Mental Health (DMH), pursuant to 104 CMR 27.00 et seq.

Drugs – Drugs and biologics (including, e.g., cell and gene therapies), or any other similar substance containing one or more active ingredients in a specified dosage form and strength. Each dosage form and strength is a separate Drug.

ED-Presenting Psychiatric Member – A Member who presents to a Hospital’s ED for clinical psychiatric evaluation and treatment.

Electronic Health Record (EHR) – A digital version of a patient's medical history. EHRs are real-time, patient-centered records that make information available instantly and securely to authorized users, often including a patient's medical history, diagnoses, medications, treatment plans, immunization dates, allergies, radiology images, and/or laboratory and test results.

Eligibility Verification System (EVS) [formerly known as the Recipient Eligibility Verification System (REVS)] – the online and telephonic system Hospitals must access to verify eligibility, managed care enrollment, and available third party liability information about Members.

Emergency Aid to the Elderly, Disabled and Children (EAEDC) – the program operated by the Department of Transitional Assistance, pursuant to M.G.L. c. 117A, that furnishes and pays for limited medical services to eligible persons.

Emergency Department (ED) – a Hospital’s Emergency Room or Level I Trauma Center which is located at the same site as the Hospital’s inpatient department, or at a separate site included in the Hospital's DPH license.

Emergency Medical Condition – a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that, in the absence of prompt medical attention, could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine to result in placing the health of a Member or another person or, in the case of a pregnant individual, the health of the individual or their unborn child, in serious jeopardy, serious impairment to body function, or serious dysfunction of any bodily organ or part, or, with respect to a pregnant individual, as further defined in section 1867(e)(1)(B) of the Social Security Act, 42 U.S.C. § 1395dd(e)(1)(B).

Emergency Services – covered Inpatient and Outpatient Services, including Behavioral Health Services, which are furnished to a Member by a Provider that is qualified to furnish such services under Title XIX of the Social Security Act, and are needed to evaluate or stabilize a Member’s Emergency Medical Condition.

Emergency Services Program (ESP) Services – Medically necessary services provided through designated ESP providers, and which are available seven (7) days per week, twenty-four (24) hours per day to provide treatment of any individual who is experiencing a mental health or substance use disorder crisis, or both. An ESP encounter includes, at a minimum, crisis assessment, intervention and stabilization. ESP Services include Mobile Crisis Intervention for members under the age of 21.

Enhanced Ambulatory Patient Group (EAPG) – a group of Outpatient Services that have been bundled for purposes of categorizing and measuring Casemix. It is based on the Solventum’s EAPG Grouper Version 3.18.

Episode – all MassHealth-covered Outpatient Services, except those described in Section 4.C and Sections 5.C.3 through 5.C.14, delivered to a MassHealth Member on a single calendar day, or if the services extend past midnight in the case of Emergency Department or Observation Services, on consecutive days. (See also definition of Observation Services). Additionally, in limited circumstances, APEC-Covered Services delivered to a MassHealth Member during a second distinct and independent visit on the same calendar day may be considered a separate Episode for payment purposes if the services are for unrelated purposes and conditions as determined by EOHHS.

Episode’s Total Allowed Charges – the sum of the MassHealth allowed Charges for all of the claim detail lines with APEC-Covered Services in an Episode that adjudicate to pay, as determined by EOHHS based on a properly submitted APEC claim.

Episode-Specific Case Cost – the product of (1) the Episode’s Total Allowed Charges, and (2) the Hospital’s FY22 outpatient cost-to-charge ratio, as calculated by EOHHS using the Hospital’s FY22 Massachusetts Hospital Cost Report.

Episode-Specific Outlier Threshold – the sum of (1) the Episode-Specific Total EAPG Payment, as determined by EOHHS, and (2) the Fixed Outpatient Outlier Threshold.

Episode-Specific Total EAPG Payment – an Episode-specific payment amount, which summed with the APEC Outlier Component (as applicable) results in the APEC for that Episode. The Episode-Specific Total EAPG Payment is calculated as set forth in Section 5.C.1.b.(1).

Event Notification Service (ENS) – A specialized form of Health Information Exchange (HIE) alerts for existing care providers that occurs after admissions, discharges, and transfers (ADT) to and from Emergency Departments (EDs), hospitals and post-acute care facilities. ADT alerts can include some clinical data through a Certified ENS Vendors.

Excluded Units – Non-Acute Units as defined in this section; any unit which has a separate license from the Hospital; psychiatric and substance use disorder units; and non-distinct observation units.

Executive Office of Health and Human Services (EOHHS) – the single state agency that is responsible for the administration of the MassHealth Program, pursuant to M.G.L. c. 118E and Titles XIX and XXI of the Social Security Act and other applicable laws and waivers.

Expedited Psychiatric Inpatient Admission (EPIA) – The escalation protocol for securing appropriate placement for individuals awaiting psychiatric placement longer than 24 hours.

Fiscal Year (FY) – The time period of 12 consecutive months, typically beginning on October 1 of any Calendar Year and ending on September 30 of the immediately following Calendar Year, but which 12-month consecutive month period may vary by Hospital (e.g. a Hospital may have an FY beginning on July 1 of any Calendar Year and ending on June 30 of the immediately following Calendar Year).

Fixed Outlier Threshold (inpatient) – the Fixed Outlier Threshold for purposes of calculating any inpatient Hospital Outlier Payment is $42,430.

Fixed Outpatient Outlier Threshold – the Fixed Outpatient Outlier Threshold for purposes of calculating the APEC Outlier Component is $4,460.

Freestanding Pediatric Acute Hospital – an Acute Hospital which limits admissions primarily to children and which qualifies as exempt from the Medicare prospective payment system regulations.

Gross Patient Service Revenue (GPSR) – the total dollar amount of a Hospital’s Charges for services rendered in a fiscal year.

Health Information Exchange (HIE) – A secure connection which allows health care professionals and patients to appropriately access and share a patient’s medical information. The Mass HIway is a secure Health Information Exchange (HIE) for all healthcare systems in Massachusetts.

High Medicaid Volume Freestanding Pediatric Acute Hospital – the Freestanding Pediatric Acute Hospital with the largest volume of inpatient discharges in fiscal year 2019, as determined by EOHHS using Massachusetts hospital cost report data.

High Medicaid Volume Safety Net Hospital – an Acute Hospital which had a ratio of Medicaid inpatient days to total inpatient days that was greater than 45% in FY14, based on the Hospital’s FY14 403 cost report.

Hospital (also Acute Hospital – any Hospital licensed under M.G.L. c. 111, § 51 and which meets the eligibility criteria set forth in Section 3 of this RFA.

Hospital at Home – Inpatient Hospital Services provided in a Member’s home or residence in accordance with MassHealth’s Acute Inpatient Hospital Bulletin 180, or any successor bulletins thereto.

Hospital-Based Physician – Any physician or physician group practice (excluding interns, residents, fellows, and house officers) who contracts with a Hospital to provide Hospital Services to Members at a site for which the hospital is otherwise eligible for reimbursement under this RFA. For purposes of this definition and related provisions, the term physician includes dentists, podiatrists, and osteopaths. Nurse practitioners, nurse midwives, physician assistants, and other allied health professionals are not Hospital-Based Physicians.

Hospital Discharge Data (HDD) – Hospital discharge filings for FY21 provided and verified by each hospital, submitted to CHIA and screened and updated by CHIA as of April 7, 2023. HDD is used for determining Casemix as part of the APAD rate development, as set forth in Section 5.B.1.

Hospital-Licensed Health Center (HLHC) – A Satellite Clinic that (1) meets MassHealth requirements for reimbursement as an HLHC as provided at 130 CMR 410.413; and (2) is approved by and enrolled with MassHealth’s Provider Enrollment Unit as an HLHC.

Induction (or Initiation) – The process of initial dosing with medication treatment for OUD, until the patient reaches a state of stability.

Inflation Factors for Capital Costs – For price changes between RY04 and RY18 and between RY19 and RY24, the inflation factors for capital costs are the factors used by CMS to update capital payments made by Medicare, and are based on the CMS Capital Input Price Index. For price changes between RY18 and RY19, the inflation factors for capital costs are the factors used by CMS to update capital payments made by Medicare and are based on the CMS Capital Input Price Index, plus a RY19 capital enhancement factor of 0.9%. The Inflation Factors for Capital Costs between RY04 and RY24 are as follows:

· 0.7% reflects the price changes between RY04 and RY05

· 0.7% reflects the price changes between RY05 and RY06

· 0.8% reflects the price changes between RY06 and RY07

· 0.9% reflects the price changes between RY07 and RY08

· 0.7% reflects the price changes between RY08 and RY09

· 1.4% reflects the price changes between RY09 and RY10

· 1.5% reflects the price changes between RY10 and RY11

· 1.5% reflects the price changes between RY11 and RY12

· 1.2% reflects the price changes between RY12 and RY13

· 1.4% reflects the price changes between RY13 and RY14

· 1.5% reflects the price changes between RY14 and RY15

· 1.3% reflects the price changes between RY15 and RY16

· 0.9% reflects the price changes between RY16 and RY17

· 1.3% reflects the price changes between RY17 and RY18

· 2.1108% reflects the price changes between RY18 and RY19

· 1.5% reflects the price changes between RY19 and RY20

· 1.5% reflects the price changes between RY20 and RY21

· 1.0% reflects the price changes between RY21 and RY22

· 1.7% reflects the price changes between RY22 and RY23

· 3.5% reflects the price changes between RY23 and RY24 Inflation Factors for Operating Costs – For price changes between RY04 and RY07, and between RY08 and RY24, a blend of the Center for Medicare and Medicaid Services (CMS) market basket and the Massachusetts Consumer Price Index (CPI) in which the CPI replaces the labor-related component of the CMS market basket to reflect conditions in the Massachusetts economy. For price changes between RY07 and RY08, the inflation factor for operating costs is the CMS market basket. The Inflation Factors for Operating Costs between RY04 and RY24 are as follows:

· 1.186% reflects price changes between RY04 and RY05

· 1.846% reflects price changes between RY05 and RY06

· 1.637% reflects price changes between RY06 and RY07

· 3.300% reflects price changes between RY07 and RY08

· 3.000% reflects price changes between RY08 and RY09 for the period October 1, 2008, through December 6, 2008

· 1.424% reflects price changes between RY08 and RY09 for the period December 7, 2008, through September 30, 2009

· 0.719% reflects the price changes between RY09 and RY10

· 1.820% reflects the price changes between RY10 and RY11

· 1.665% reflects the price changes between RY11 and RY12

· 1.775% reflects the price changes between RY12 and RY13

· 1.405% reflects the price changes between RY13 and RY14

· 1.611% reflects the price changes between RY14 and RY15

· 1.573% reflects the price changes between RY15 and RY16

· 1.937% reflects the price changes between RY16 and RY17

· 2.26% reflects the price changes between RY17 and RY18

· 2.183% reflects the price changes between RY18 and RY19

· 2.236% reflects the price changes between RY19 and RY20

· 1.854% reflects the price changes between RY20 and RY21

· 1.433% reflects the price changes between RY21 and RY22

· 2.451% reflects the price changes between RY22 and RY23

· 2.599% reflects the price changes between RY23 and RY24 Inpatient Admission – the admission of a Member to an Acute Hospital for the purpose of receiving Inpatient Services in that Hospital.

Inpatient Services – medical services, including Behavioral Health Services, provided to a Member admitted to an Acute Hospital or Hospital at Home services provided in a Member’s home or residence in accordance with MassHealth’s Acute Inpatient Hospital Bulletin 180, or any successor bulletins thereto. Payment rules regarding Inpatient Services are found in 130 CMR Parts 415 and 450, the regulations referenced therein, Appendix F to the MassHealth Acute Inpatient Hospital Manual, MassHealth billing instructions, and this RFA.

Insurance Payment – a payment received from any entity or individual legally responsible for paying all or part of the medical claims of MassHealth Members. Sources of payments include, but are not limited to: commercial health insurers, Medicare, MCOs, personal injury insurers, automobile insurers, and Workers’ Compensation.

Liability – the obligation of an individual to pay, pursuant to the individual’s Third-Party Insurance, for the services or items delivered (i.e., Coinsurance, Copayment or Deductible).

Long-Acting Injectable (LAI) Antipsychotics – Antipsychotic medications that are administered through intramuscular injection and provide medication coverage for a period of weeks to months. LAI Antipsychotics does not refer to the administration of the medications. The EOHHS-designated LAI Antipsychotics are identified on the Long-Acting Injectable Antipsychotic Medications Administered in Inpatient Psychiatry Units document maintained on the MassHealth Drug List (MHDL). The MassHealth Drug List is published on the MassHealth website at .

Long-Acting Reversible Contraception (LARC) Device – Long-acting reversible contraception (LARC) device refers, specifically, to intrauterine devices and contraceptive implants. LARC Device does not refer to the procedure, itself.

Managed Care Organization (MCO) – any entity with which EOHHS contracts to provide Primary Care and certain other medical services, including Behavioral Health Services, to Members on a capitated basis and which meets the definition of an MCO as set forth in 42 CFR Part 438.2. MCOs include “traditional” MCOs, Senior Care Organizations (SCOs) and Accountable Care Partnership Plans (ACPPs). In addition, MCOs include One Care plans for all purposes under this RFA, except for Sections 4.A.2, 4.B.4, 5.D.1 and Section 7. When historical MCO data is used in a methodology, the term MCO will also include CarePlus MCOs, to the extent CarePlus MCOs existed during the period for which the MCO data is used in such methodology, as applicable.

Marginal Cost Factor – The Marginal Cost Factor is 60% (inpatient) and 60% (outpatient).

MassHealth (also Medicaid) – the medical assistance program administered by EOHHS to furnish and pay for medical services pursuant to M.G.L. c. 118E and Titles XIX and XXI of the Social Security Act, and any approved waivers of such provisions.

MassHealth DRG Weight – The MassHealth relative weight developed by EOHHS for each unique combination of APR-DRG and severity of illness (SOI). See Chart C to Appendix C for the MassHealth DRG Weights.

MassHealth EAPG Weight – The MassHealth relative weight developed by EOHHS for each unique EAPG (See Chart D to Appendix D for the RY27 MassHealth EAPG Weights for the APEC methodology). The Solventum EAPG Grouper’s discounting, consolidation and packaging logic is applied to each of the Episode’s claim detail line MassHealth EAPG Weights to produce the claim detail line’s Adjusted EAPG Weight as part of the APEC payment methodology. See also the definition of “Adjusted EAPG Weight.”

Mass HIway – A secure statewide network that facilitates the transmission of healthcare data and health information among providers, hospitals, and other healthcare entities as allowed by applicable state and federal laws.

Medicaid Management Information System (MMIS) – The state-operated system of automated and manual processes, certified by CMS, that meets the federal guidelines in Part 11 of the State Medicaid Manual, used to process Medicaid claims from providers of medical care and services furnished to Members, and to retrieve and produce service utilization and management information for program administration and audit purposes.

Medication for the Treatment of Opioid Use Disorder (OUD) – Use of a medication approved by the FDA for the treatment of an opioid use disorder.

Member – A person determined by EOHHS to be eligible for medical assistance under the MassHealth program.

Mobile Crisis Intervention (MCI) – Services provided by designated ESP providers to members under age 21. MCI services include a short-term mobile, on-site, and face-to-face therapeutic service provided for youth experiencing a Behavioral Health Crisis and for the purpose of identifying, assessing, treating, and stabilizing the situation and reducing the immediate risk of danger to the youth or others consistent with the youth’s risk management/safety plan, if any. Mobile Crisis Intervention utilizes a multidisciplinary model, with both professional and paraprofessional staff. Services are available 24 hours a day, 7 days a week.

Non-Acute Unit – A chronic care, rehabilitation, or skilled nursing facility unit within a Hospital.

Observation Services – Outpatient Hospital Services provided anywhere in an Acute Inpatient Hospital or Hospital Outpatient Department to evaluate a Member’s condition and determine the need for admission to an Acute Hospital, prior to relocating the Member home or to another non-hospital setting. Observation Services are provided under the order of a physician, consist of the use of a bed and intermittent monitoring by professional licensed clinical staff, and may be provided for more than 24 hours. Payment rules regarding Observation Services are found in 130 CMR 410.414, Appendix E to the MassHealth Acute Outpatient Hospital Manual, MassHealth billing instructions, and this RFA.

One Care: MassHealth plus Medicare (One Care plan) – a health plan or provider-based organization contracted with EOHHS and CMS, and accountable for providing integrated care to individuals aged 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).

Outlier Payment (inpatient) – a hospital-specific, discharge-specific inpatient Hospital payment made in addition to the APAD for qualifying discharges in accordance with Section 5.B.2.

Outpatient Department (also Hospital Outpatient Department) – a department or unit located at the same site as the Hospital’s inpatient facility, or at a School-Based Health Center that operates under the Hospital’s license and provides services to Members on an ambulatory basis. Hospital Outpatient Departments include day surgery units, Primary Care clinics, specialty clinics, and Emergency Departments.

Outpatient Services (also Outpatient Hospital Services) – medical services, including Behavioral Health Services, provided to a Member on an outpatient basis, by or under the direction of a physician or dentist, in a Hospital Outpatient Department or Satellite Clinic for which a reimbursement method is specified in Section 5.C. Such services include, but are not limited to, Emergency Services, Primary Care services, Observation Services, ancillary services, and day surgery services. Payment rules regarding services provided to Members on an outpatient basis are found in 130 CMR Parts 410 and 450, Appendix E to the MassHealth Acute Outpatient Hospital Manual, MassHealth billing instructions, and this RFA.

Participating PCP – See definition of Primary Care ACO Participating Primary Care Provider.

Patient – a person receiving health care services from a hospital.

Pay-for-Performance Program for Acute Hospitals (P4P) – This refers to the pay-for-performance program formerly set forth in Section 7 of the RFA.

Primary Care – all health care services customarily furnished by or through a general practitioner, family physician, internal medicine physician, obstetrician/gynecologist, pediatrician, certified nurse practitioner, certified nurse midwife, or other eligible primary care provider to the extent the furnishing of those services is legally authorized in the Commonwealth.

Primary Care ACO – a type of ACO with which the MassHealth agency contracts under its ACO program.

Primary Care ACO Participating Primary Care Provider (Participating PCP) – a physician, independent certified nurse practitioner, group practice organization, community health center, Hospital-Licensed Health Center, Acute Hospital Outpatient Department, or other eligible providers, who serve as a Participating PCP with a Primary Care ACO.

Primary Care Clinician (PCC) – a physician, independent certified nurse practitioner, group practice organization, community health center, Hospital-Licensed Health Center, Acute Hospital Outpatient Department, or other eligible MassHealth providers with an executed MassHealth PCC Plan Provider contract.

Primary Care Clinician Plan (PCC Plan) – a comprehensive managed care plan, administered by EOHHS, through which enrolled MassHealth Members receive Primary Care, Behavioral Health, and other medical services. See 130 CMR 450.118.

Provider – an individual or entity that has a written contract with EOHHS to provide medical goods or services to Members.

Psychiatric Per Diem – a statewide per diem payment for Behavioral Health Services provided to members in DMH-Licensed beds who are not enrolled with the BH Contractor or MCO.

Psychiatric Per Diem Base Year – the base year for the psychiatric per diem is FY04, using FY04 -403 cost reports as screened and updated as of March 10, 2006.

Qualified Behavioral Health Professional –A qualified behavioral health professional shall include a: (i) licensed physician who specializes in the practice of psychiatry; (ii) licensed psychologist; (iii) licensed independent clinical social worker; (iv) licensed certified social worker; (v) licensed mental health counselor; (vi) licensed physician assistant who practices in the field of psychiatry (vii) advanced practice registered nurse who practices in the field of psychiatry, including but not limited to a licensed nurse practitioner or licensed psychiatric clinical nurse specialist; or (viii) healthcare provider qualified within the scope of the individual’s license to conduct an evaluation of a mental health condition, including an intern, resident or fellow pursuant to the policies and practices of the hospital and medical staff.

Quality and Equity Performance Initiatives – data-driven systemic efforts, anchored on measurement-driven activities, including…