RY26 Psychiatric Hospital Request for Applications.docx

COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

OFFICE OF MEDICAID

ONE ASHBURTON PLACE, 11TH FLOOR

BOSTON, MASSACHUSETTS 02108

PSYCHIATRIC HOSPITAL

REQUEST FOR APPLICATIONS

RATE YEAR 2026

Issued: September 2, 2025 Document #: 26MMEHSPSYCHHOSPITALRFA

TABLE OF CONTENTS

INTRODUCTION

Section 1.1 Procurement Purpose The Massachusetts Executive Office of Health and Human Services (EOHHS), as the single state agency responsible for administering the Massachusetts Medicaid and Children’s Health Insurance Programs (together known as MassHealth), is issuing this Request for Applications (RFA) to solicit applications from eligible, in-state Psychiatric Hospitals wishing to participate as MassHealth providers of Psychiatric Hospital Services as described in Attachment A, the Psychiatric Hospital Contract.

The initial deadline for responses to this RFA is specified in Section 7, RFA Timetable. Responses will be accepted after the initial deadline under the open enrollment process described in Section 6 of the RFA.

Applicants wishing to respond to this RFA must complete and execute the enclosed RFA attachments, including Attachment A. Any existing Psychiatric Hospital Contracts shall terminate on the date of execution.

Section 1.2 Applicant Qualifications and Eligibility EOHHS seeks to contract with all eligible Massachusetts Psychiatric Hospitals to provide Inpatient and Outpatient Services to MassHealth Members, as described in Attachment A, the Psychiatric Hospital Contract, that accept the rates of payment outlined in this RFA in accordance with the reimbursement methodology specified in this RFA as payment in full.

Psychiatric Hospitals, are eligible to apply for a Contract pursuant to this RFA if, in addition to all other requirements specified in the RFA, they:

A. Are licensed by the Massachusetts Department of Mental Health, pursuant to M.G.L.c.19, §19, and 104 CMR 27.00 et seq.;

B. Provide Inpatient Services to MassHealth Members as described in Attachment A in conformance with the requirements set forth in this RFA and all applicable laws;

C. Are enrolled as a MassHealth Provider;

D. Comply with all laws and regulations, rules, provider bulletins, and billing instructions applicable to the participation of Psychiatric Hospitals in the MassHealth program;

E. Are accredited by The Joint Commission or other nationally recognized accreditation agency approved by the Department of Mental Health’s Commissioner;

F. Are Medicare-certified and participate in the Medicare program;

G. Are located in Massachusetts;

H. Utilize a majority of its beds to provide behavioral health services to treat persons whose principal diagnosis is a psychiatric disorder as defined in the current International Classification of Diseases, Clinical Modification (ICD) or the current American Psychiatric Association's Diagnostic and Statistical Manual (DSM);

I. Apply on behalf of all Inpatient Psychiatric Units and Departments; and J. Apply on behalf of all Outpatient Departments if they provide Outpatient Services.

Section 1.3 Contract Term The Contract issued under this RFA shall have an initial term of 12 months, commencing October 1, 2025, or as otherwise specified in Section 8.4 of the Contract. The Contract will apply to Inpatient and Outpatient Psychiatric Services rendered to MassHealth Members pursuant to 130 CMR 425.401, in any contracting Hospital licensed pursuant to M.G.L. c.19, §19. Any Psychiatric Hospital Contract (Attachment A) entered into pursuant to this RFA shall terminate on September 30, 2026 Section 1.4 Definition of Terms The terms or their abbreviations, when capitalized in this RFA and its Attachments, are defined in Section 1 of Attachment A.

PAYMENT

Section 2.1 Payment Rates Psychiatric Hospitals that choose to participate in the MassHealth Program under the terms of the Psychiatric Hospital Contract, shall accept payment at the rates pursuant to Appendix A of Attachment A as payment in full for all Inpatient Services, Outpatient Services, and short term Administratively Necessary Days rendered on and after October 1, 2025, through the term of the Psychiatric Hospital Contract. See Section 4 of Attachment A for payment terms.

Section 2.2 Clinical Quality Incentive Payment Psychiatric Hospitals that choose to participate in the MassHealth Program under the terms of the Psychiatric Hospital Contract (Attachment A) may qualify for incentive payments based on clinical quality. See Appendix C of Attachment A for additional information on Clinical Quality Incentive Program Payments.

Section 2.3 Supplemental Payments Psychiatric Hospitals that choose to participate in the MassHealth Program under the terms of the Psychiatric Hospital Contract may qualify for Supplemental Payments. See Attachment A for additional information on Supplemental Payments.

Section 2.4 Non-Covered Services EOHHS will not pay Psychiatric Hospitals under this RFA and accompanying Contract for the following services.

Behavioral Health Contractor:

Psychiatric Hospitals may not bill EOHHS and EOHHS will not pay Psychiatric Hospitals under this RFA for mental health and substance use disorder services provided to MassHealth Members who are enrolled with the Behavioral Health Contractor.

Managed Care Entities (MCEs) and Program for All-Inclusive Care for the Elderly (PACE):

Psychiatric Hospitals may not bill EOHHS, and EOHHS will not pay Psychiatric Hospitals for services provided to MassHealth Members enrolled in an MCE or PACE.

Non-Covered Services:

Psychiatric Hospitals may not bill EOHHS, and EOHHS will not pay Psychiatric Hospitals for non-covered services as defined in applicable laws and regulations including, but not limited to, services described in 130 CMR 425.409 and 434.406.

Hospital Services Reimbursed through Other Contracts or Regulation:

The Commonwealth may institute special program initiatives other than those listed above that provide, through contract and/ or regulation, alternative payment methodologies for hospital services or certain hospital services. In such cases, payment for such services is made pursuant to the contract and/or regulations governing the special program initiative, and not through this RFA and the accompanying Contract.

RFA SUBMISSION REQUIREMENTS

Section 3.1 Contents of Submission Those providers wishing to participate must complete and execute the following RFA attachments, including Attachment A. Each Psychiatric Hospital’s response to this RFA must consist of the following:

Cover Letter The cover letter must be signed by the individual authorized to execute the Psychiatric Hospital Contract (Attachment A) for the applicant and shall contain the name, title, address, email, and telephone number of the individual to be contacted for the purpose of clarifying the response.

Hospital Contract The MassHealth Psychiatric Hospital Contract (Attachment A) will become the MassHealth provider participation contract between EOHHS and each Psychiatric Hospital. Attachment A must be properly completed and signed without modification to terms. EOHHS will sign the contract for the MassHealth Program upon its acceptance of a Psychiatric Hospital’s response.

Application The MassHealth Psychiatric Hospital Application for Participation (Attachment B) shall be completed and signed in accordance with the instructions in Attachment B.

Documentation Each applicant must complete and sign Attachment B.

Certification Each applicant must certify (in Attachment B), as part of its response to this RFA, that the information and supporting documentation are current, correct, and complete.

Clinical Quality Incentive Program Payment Each applicant must submit all information required in Appendix C, and Attachment A in accordance with the timeline in Section 7.

Section 3.2 Responsiveness Each document submitted in response to this RFA must include all information specified to the topic of the document as required by this RFA. EOHHS will evaluate only those materials that are responsive to this RFA and submitted in accord with the instructions in Section 3.

Section 3.3 Submission Instructions and Closing Dates Each Psychiatric Hospital must submit all required documents electronically, as described in Section 3.3.A.

Psychiatric Hospitals currently participating in the MassHealth Program must submit timely, accurate and complete responses to this RFA, including all information specified in the Appendices, by the date and time listed in RFA Section 7, in order to ensure uninterrupted participation in the MassHealth Program.

Electronic Submission The Hospital must complete all necessary documentation, including all necessary signatures, compile such documentation, and submit via email to PsychiatricHospitalRFA@mass.gov. Only the following forms of signature will be accepted:

1. Electronic Signature. If using an electronic signature, the signature must be visible and must be accompanied by the signatory’s printed legal name and title, the printed legal name of the psychiatric hospital represented by the signatory, and the signature date. Typed text of a name not generated by a digital tool such as Adobe Sign or DocuSign, even in computer-generated cursive script, or an electronic symbol, are not acceptable forms of electronic signature. Acceptable forms of electronic signature as are follows:

· Electronic signature affixed using a digital tool such as Adobe Sign or DocuSign (Preferred method); or

· Hand drawn using a mouse or finger if working from a touch screen device; or

· An uploaded picture of the signatory’s hand drawn signature.

2. Scanned Ink Signature. Acceptable traditional “wet signature” of ink on paper. The authorized signature must print, sign and date the signature page. The signed signature page must then be scanned and returned as part of the electronic submission.

SECTION 4 RESPONSE REVIEW AND PROVIDER SELECTION

EOHHS will review all responses submitted in accordance with the terms of this RFA. Each application will be reviewed to determine whether the Program Participation Requirements in Section 5 have been met. Those applicants meeting all of the Program Participation Requirements will be awarded a Contract and may participate as a Psychiatric Hospital provider in the MassHealth Program.

Any submission determined to be non-responsive to any requirement of this RFA may be rejected. EOHHS may determine that noncompliance is insubstantial and can be corrected. In such cases, EOHHS may, at its discretion, seek clarification, allow the applicant to make corrections, and/or allow the applicant to submit additional information. All such responses to EOHHS requests for clarification must be in writing, unless otherwise specified by EOHHS. Those applicants who do not meet the entire Program Participation Requirements in RFA Section 5 may be disqualified from participation in the MassHealth Program as Psychiatric Hospital providers.

SECTION 5 PROGRAM PARTICIPATION REQUIREMENTS

A Psychiatric Hospital may not be awarded a Contract effective October 1, 2025, if it fails to meet any one of the following criteria:

Section 5.1 Proper Submission Each Hospital must submit a complete response in accordance with all applicable instructions to the designated address by the deadlines established in this RFA. (See Sections 6 and 7 of this RFA.)

Section 5.2 Qualifications The Hospital must be an eligible applicant in accordance with Section 1.2 of the RFA.

Section 5.3 Acceptance of Agreement Attachment A, the Psychiatric Hospital Contract, is the Contract that will be awarded pursuant to this RFA. The applicant must accept the provisions of Attachment A without revision by signing the last page of Attachment A.

Section 5.4 Documentation Each applicant must provide the required documentation and information regarding institutional status in Attachment B.

Section 5.5 Certification The applicant must complete Attachment B and certify that all information and documentation required to be on file with the MassHealth Program is current, correct, and complete.

Section 5.6 Clinical Quality Incentive Program The applicant must provide the documentation and information regarding quality as required in Appendix C to Attachment A and must otherwise comply with all requirements related to the clinical quality incentive program as set forth in Section 6 of the Contract and in Appendix C to Attachment A. Failure to do so may affect the applicant’s future participation in the MassHealth Program.

SECTION 6 RFA INFORMATION

Section 6.1 Issuing Office Commonwealth of Massachusetts Executive Office of Health and Human Services MassHealth Office of Accountable Care and Behavioral Health One Ashburton Place, 10th floor Boston, MA 02108 Section 6.2 Inquiries Prospective applicants may submit written business and contractual questions concerning this RFA, as well as any other additional information concerning this RFA, no later than date listed in Section 7, RFA Timetable, to the address specified in RFA Section 6.1. Inquiries may be e-mailed to the following address: PsychiatricHospitalRFA@mass.gov. The Bid Solicitation Q&A functionality in COMMBUYS will be also used for this RFA; emailing Applicant questions to the RFA Contact Person is preferred.

EOHHS will review inquiries received before this deadline and will identify questions for which written answers will be prepared. Any written answers of general interest will be posted on COMMBUYS (see RFA Section 6.6 for information on COMMBUYS). EOHHS will not be responding to questions individually on COMMBUYS.

Section 6.3 Anticipated Date of Contractor Selection EOHHS anticipates initial selection of Contractors by the date specified in Section 7, RFA Timetable.

Section 6.4 Anticipated Date of Contract Commencement EOHHS anticipates that the Hospital Contracts shall be effective as of October 1, 2025.

Section 6.5 Addendum or Withdrawal of RFA If it becomes necessary to revise any part of this RFA, or if additional data is necessary to clarify any of its provisions, a supplement shall be provided to prospective applicants who have received a copy of the RFA. EOHHS reserves the right to amend the RFA at any time and to terminate this procurement in whole or in part at any time.

Section 6.6 COMMBUYS COMMBUYS is the official source of information for this RFA and is publicly accessible at no charge at www.commbuys.com. The RFA, and any RFA attachments and amendments, are all components of the RFA, and are incorporated into the RFA and any resulting contract.

Applicants are solely responsible for obtaining and completing required attachments that are identified in this RFA and for obtaining all information distributed for this RFA via COMMBUYS.

It is also each applicant’s responsibility to check COMMBUYS for:

· Any amendments, addenda or modifications to this RFA; and

· Any RFA Q&A records that may be posted related to this RFA.

The Commonwealth accepts no responsibility and will provide no accommodation to applicants who submit a response based on an out-of-date RFA or on information received from a source other than COMMBUYS. Applicants may not alter (manually or electronically) the RFA language or any RFA component files. Modifications to the body of the RFA, specifications, terms and conditions, or which change the intent of this RFA are prohibited and may disqualify a response.

COMMBUYS Subscription. Applicants may elect to obtain a free COMMBUYS subscription which provides value-added features, including automated email notification associated with postings and modifications to COMMBUYS records.

The COMMBUYS system introduces new terminology, which applicants must be familiar with in order to conduct business with the Commonwealth. To view this terminology and to learn more about the COMMBUYS system, please visit the COMMBUYS Resource Center.

Section 6.7 Applicant Communications Applicants are prohibited from communicating directly with any employee of EOHHS about this RFA, except as specified in this RFA, and no other individual federal or State employee or representative is authorized to provide any information or respond to any question or inquiry concerning this RFA. Applicants may contact the contact person for this RFA in the event this RFA is incomplete, or the Applicant is having trouble obtaining any documents or attachments electronically through COMMBUYS. Applicants may request a copy of the RFA, or any of its components, by contacting the RFA contact person named below.

Section 6.8 Public Records All applications and related documents submitted in response to this RFA are public records under the Massachusetts Public Records Law, M.G.L. c. 66, §10, and M.G.L. c. 4, §7, regarding public access to such documents. Statements inconsistent with those statutes will be disregarded.

Section 6.9 Limitations This RFA does not commit EOHHS to award a Contract, to pay any costs incurred in the preparation of the application, or to procure or contract for services or supplies. EOHHS reserves the right to accept or reject any and all applications received as a result of this RFA, or to cancel this RFA in any part or in its entirety if it is in the best interest of the MassHealth Program to do so. To the extent that the methodologies require State Plan approval by the Centers for Medicare and Medicaid Services (CMS), Contracts are subject to such approval. EOHHS reserves the right to amend the reimbursement methodology as necessary to meet federal requirements.

Section 6.10 Cost of Application No costs or expenses incurred by applicants in submitting a response to this RFA shall be borne by the Commonwealth.

Section 6.11 Return of Application or Materials The Commonwealth shall be under no obligation to return any materials submitted by an applicant in response to this RFA.

Section 6.12 RFA Contact Kate Agyeman Deputy Director of Contracting and Operations MassHealth Office of Accountable Care and Behavioral Health 1 Ashburton Place, 10th Floor Boston, MA 02108 PsychiatricHospitalRFA@mass.gov Section 6.13 Reasonable Accommodation Applicants with disabilities or hardships that seek reasonable accommodations, which may include the receipt of RFA information in an alternative format, must submit a written statement to the RFA contact person describing the Applicant’s disability and the requested accommodation. EOHHS reserves the right to reject unreasonable requests.

Section 6.14 Privacy and Security of Health Information Applicants shall comply with all state and federal laws and regulations relating to confidentiality, privacy, and security of health information including but not limited to rules and regulations of CMS and EOHHS. EOHHS may require specific written assurance and further agreements regarding the security and privacy of protected health information that are deemed necessary to implement and comply with standards under the Health Insurance Portability and Accountability act of 1996 (HIPAA) as implemented in 45 CFR, parts 160 and 164.

Section 6.15 Open Enrollment This is an “open enrollment” RFA. After the initial enrollment period, EOHHS will reopen the RFA at EOHHS’ discretion to accept RFA responses from additional applicants. Any Hospital that submits a response after the initial response deadline and in response to a subsequent open enrollment period must follow the same submission instructions set forth in Section 3, RFA, Submission Requirements. Such responses shall be reviewed and evaluated as described in Section 4, RFA, Response Review and Provider Selection. All Contracts awarded as a result of this RFA, regardless of start date, shall expire on September 30, 2026, unless otherwise extended in accordance with Section 8 of the Attachment A.

SECTION 1

SECTION 2

SECTION 3

RFA TIMETABLE

EOHHS reserves the right, at its sole discretion, to adjust this schedule as it deems necessary. Notification of any adjustment to the RFA Timetable shall be posted on COMMBUYS.

RY2026 Psychiatric Hospital RFA 2

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

MASSHEALTH PROGRAM

PSYCHIATRIC HOSPITAL RFA

ATTACHMENT A

PSYCHIATRIC HOSPITAL CONTRACT

Rate Year 2026

Attachment A – RY2026 Psychiatric Hospital Contract A-2

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

MASSHEALTH PROGRAM

PSYCHIATRIC HOSPITAL CONTRACT

This Contract, dated as of October 1, 2025, is between the Commonwealth of Massachusetts, acting by and through the Executive Office of Health and Human Services (hereinafter “EOHHS”), and

(Legal name of Contractor) (hereinafter the “Contractor”), with a principal place of business located at:

(Address of Psychiatric Hospital) 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; and Whereas, EOHHS desires to purchase services and goods for eligible Members in the MassHealth Program from participating Psychiatric Hospitals under the terms and conditions set forth herein; and Whereas, EOHHS has issued, as of September 2, 2025, a Request for Applications for Psychiatric Hospitals; and Whereas, the Contractor desires to furnish Inpatient Services and may desire to furnish Outpatient Services to eligible MassHealth 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 set forth herein, the parties agree as follows

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 (ACPPs), Primary Care ACOs, and MCO-Administered 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.

Administratively Necessary Days (AND) – a day of inpatient hospitalization, as defined in 130 CMR 425.402, on which a Member’s care needs can be met in a less intensive setting than a Psychiatric Hospital, and on which the Member is clinically ready for discharge to a lower level of care, but an appropriate institutional or non-institutional setting is not readily available.

Administratively Necessary Day Per Diem Rate (AND Rate) – an all-inclusive daily rate of payment paid to Hospitals for the ongoing provision of appropriate clinical care until the date of discharge.

Adverse Incident – an occurrence that represents actual or potential serious harm to the well-being of a Member, or to others under the care of a provider. Adverse Incidents may be the result of the actions of a Member served, actions of a staff member providing services, incidents that compromise the health and safety of the Member receiving treatment at the program, or the operations of the provider.

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 Services – services provided to MassHealth Members who are being treated for psychiatric disorders or substance-related disorders.

Behavioral Health Treatment and Referral Platform (BH TRP) – technology that supports 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.

Bureau of Substance Addiction Services (BSAS) – the division within the Department of Public Health responsible for licensure and regulatory oversight of substance use disorder treatment programs and counselors across the Commonwealth of Massachusetts.

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 which oversees states’ Medical Assistance programs and states’ Children Health Insurance Programs (CHIP) under Titles XIX and XXI of the Social Security Act and waivers thereof.

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 standard fee that a Hospital charges for Psychiatric Hospital services provided to a patient, regardless of payer source, which must be filed with the CHIA.

Clinical Quality Incentive Program (CQI) – a program which provides incentive payment to qualifying Contractors based on their performance on identified quality measures. The program is structured to address and improve performance in identified areas, through review of performance data. Qualifying Contractors can earn a range of attainment and improvement quality points based on measure performance rate, relative to achieving attainment threshold or goal benchmarks and improvement targets.

Contractor – each Hospital that submits a satisfactory application in response to the Psychiatric Hospital RFA and that enters into a Contract with EOHHS to meet the purposes specified in the Psychiatric Hospital RFA.

Department of Children and Families (DCF) – an agency of the Commonwealth of Massachusetts established under M.G.L. c. 18B, §1 et seq.

Department of Developmental Services (DDS) – an agency of the Commonwealth of Massachusetts established under M.G.L. c. 19B, §1 et seq.

Department of Mental Health (DMH) – an agency of the Commonwealth of Massachusetts established under M.G.L. c. 19, §1 et seq.

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

Department of Youth Services (DYS) – an agency of the Commonwealth of Massachusetts established under M.G.L. c. 18A, §1 et seq.

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.

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.

Event Notification Service (ENS) – 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 vendor.

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 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.

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

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.

Hospital Contract (Contract) – the agreement between a participating Psychiatric Hospital and EOHHS executed to accomplish the purposes specified in the Psychiatric Hospital RFA.

Hospital Fiscal Year-(HFY) – the fiscal year used by an individual hospital.

Hospital Outpatient Department – a department or unit that operates under the Hospital and is accredited by The Joint Commission or other Centers for Medicare and Medicaid Services approved deeming authority, as required, that provides services to MassHealth Members on an ambulatory basis.

Inpatient Per Diem Rate – a daily rate of payment for any and all Inpatient Services provided to a MassHealth Member by the Psychiatric Hospital, paid in addition to the Per Inpatient Admission Rate.

Individual Consideration (I.C.) – payment rates to eligible providers for services authorized in accordance with the Contract, but not listed in Contract or authorized services performed in exceptional circumstances are determined on an individual consideration basis by the governmental unit or purchaser under M.G.L. c. 152: Workers’ Compensation upon receipt of a bill that describes the services rendered. The determination of rates of payment for authorized individual consideration procedures are in accordance with the following criteria:

i. time required to perform the service;

ii. degree of skill required for service rendered;

iii. severity and/or complexity of the client's disorder or disability;

iv. policies, procedures, and practices of other third-party purchasers of care; and

v. such other standards and criteria as may be adopted from time to time by EOHHS pursuant to the contract.

Inpatient Psychiatric Supplemental Payment – a payment type calculated based on inpatient psychiatric admissions claims data using methodology described in Appendix I. To qualify for the Inpatient Psychiatric Supplemental Payment, a hospital must operate an inpatient site providing inpatient services licensed by DMH as of October 1, 2025.

Inpatient Service – psychiatric care and treatment provided under the direction of a psychiatrist to a MassHealth Member admitted as an inpatient to a Psychiatric Hospital.

Inpatient Site – the place at which the Psychiatric Hospital provides Inpatient Services.

The Joint Commission – a national, private accrediting body for health care organizations, including mental health facilities.

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 itself. The EOHHS-designated LAIs are identified on the Long-Acting Injectable Antipsychotic Medications Administered in Inpatient Psychiatry Units maintained on the MassHealth Drug List (MHDL). The MassHealth Drug List is published on the MassHealth website at MassHealth Drug List - Health and Human Services Managed Care Organization (MCO) – an 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. In addition, MCOs include Accountable Care Partnership Plans, One Care plans and Senior Care Organizations (SCOs) for all purposes under this Contract.

Managed Care Entity (MCE) – an MCO or the Behavioral Health Contractor which provides or arranges services for enrolled Members under a MassHealth Program contract.

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. The Mass HIway is a Health Information Exchange (HIE) for all healthcare systems in Massachusetts.

Massachusetts Rehabilitation Commission (MRC) – a commission of the Commonwealth of Massachusetts, established under M.G.L. c. 6, §74.

MassHealth Program (MassHealth) – the medical assistance benefit plans operated and administered by EOHHS pursuant to M.G.L. c. 118E, §1 et seq. and Titles XIX and XXI of the Social Security Act, and any approved waivers of such provisions.

MassHealth Member (Member) – a person determined by the MassHealth Program to be eligible for medical assistance under M.G.L. 118E, §1 et seq.

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

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.

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

Outpatient Service – services provided to MassHealth Members on an ambulatory basis when rendered in a Psychiatric Hospital Outpatient Department.

Per Inpatient Admission Rate – a rate paid per inpatient admission based on criteria met upon Member admission, paid in addition to the inpatient per diem rate.

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

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.

Psychiatric Inpatient Hospital (Psychiatric Hospital) – a hospital licensed by the Department of Mental Health (DMH) pursuant to M.G.L. c. 19, §19.

Psychiatric Services – for purposes of this Contract, these are the behavioral health services provided to MassHealth Members who are being treated for psychiatric disorders or substance–related disorders.

Qualified Behavioral Health Provider – a Qualified Behavioral Health Provider, 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 nurses who practice in the field of psychiatry, including but not limited to licensed nurse practitioners and licensed psychiatric clinical nurse specialists; 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.

Query and Retrieve – a method utilized in the Health Information Exchange (HIE) to allow providers to search for and retrieve patient information that was made accessible by other care providers, public agencies, and other sources.

Rate Year (RY) – generally, the period beginning October 1 and ending September 30. RY 2026 will begin on October 1, 2025, and will end on September 30, 2026.

Senior Care Options – a comprehensive health plan implemented by EOHHS in collaboration with CMS for the purpose of delivering and coordinating all Medicare- and Medicaid-covered benefits for individuals aged 65 and over who are eligible for MassHealth Standard or are eligible for MassHealth Standard and Medicare The Senior Care Options plan provides services to Members through a senior care organization (SCO) and its network of providers.

Specialty Inpatient Psychiatric Service for Children/Adolescents with Neurodevelopmental Disorders – intensive level of specialized inpatient psychiatric care for youth with severe behavioral manifestations of Autism Spectrum Disorders (ASD)/Intellectual Disabilities (ID) and co-occurring mental health conditions. In addition to all the clinical service components required within Psychiatric Inpatient Hospitals, pursuant to this Contract, Specialty Inpatient Psychiatric Services for Children/Adolescents with Neurodevelopmental Disorders must be supported by specially-trained staff. Additionally, specialized components of services include specialized treatment milieu, clinical expertise, clinical interventions, and evidence-based practices and procedures.

Specialty Inpatient Psychiatric Service for Eating Disorders – an intensive level of specialized inpatient psychiatric care for adults and youth with eating disorder diagnoses who require acute psychiatric and medical stabilization. In addition to all clinical service components required within Psychiatric Inpatient Hospitals, pursuant to this Contract, as set forth in the MassHealth Program regulations, Specialty Inpatient Psychiatric Services for Eating Disorders must be supported by specially-trained staff. Additionally, specialized components of services include specialized treatment milieu, clinical expertise, clinical interventions, and evidence-based practices and procedures for supporting the unique needs of individuals with severe eating disorders.

Statewide Event Notification Service (ENS) Framework – an interoperable ENS network consisting of Certified ENS Vendors who have interconnected their ENS systems to serve all care providers in Massachusetts.

Upper Payment Limit – the term referring to the calculation by which it is determined whether the Contract payment methodology 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.

CONTRACTOR RESPONSIBILITIES

The Contractor shall:

A. Furnish Inpatient Services to MassHealth Members that conform to the requirements for such Inpatient Services as set forth in the MassHealth Program regulations; furnish only those Inpatient Services that qualify as medically necessary under the MassHealth Program regulations; furnish Inpatient 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.

B. If furnishing Outpatient Services to MassHealth Members, furnish Outpatient Services that conform to the requirements for such Outpatient Services as set forth in the MassHealth Program regulations; furnish only those Outpatient Services that qualify as medically necessary under the MassHealth Program regulations; furnish 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.

C. Comply with, and is subject to, all federal and state statutes, rules and regulations governing the MassHealth Program, including, but not limited to, Psychiatric Inpatient Hospital regulations at 130 CMR 425.000 et seq.; Psychiatric Hospital Outpatient Services regulations at 130 CMR 434.000 et seq., as applicable; and Administrative and Billing regulations at 130 CMR 450.000 et seq.; provided, however, that in the event of any conflict between the documents which are part of the Hospital’s Contract with EOHHS and any regulation now existing or hereinafter adopted, the terms of the Contract shall prevail. All references to statutes and regulations refer to such statutes and regulations as they may be amended from time to time. In addition, the Contractor must comply with all billing instructions and provider bulletins applicable to the Contractor’s participation in the MassHealth Program, now existing or adopted during the term of this Contract.

D. 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, the federal Centers for Medicare & Medicaid Services, and other government agencies as provided in applicable law.

E. Furnish services to Members without regard to race, color, religion, national origin, disability, age, sex, gender identity, sexual orientation, or status as a recipient of public assistance, and must comply with all applicable law concerning the same.

F. Accept, as payment in full for all Covered Services, the rates of payment and payment provisions set forth in the Section 4, and Appendix A to Attachment A, which is attached hereto and incorporated herein by reference.

G. Comply with all requirements of the Administrative and Billing regulations at 130 CMR 450.000 et seq. and shall promptly repay in accordance with such regulations any amounts owed to the MassHealth Program as a result of an overpayment, penalty, fine or other sanction. Notwithstanding any other provision of this Contract to the contrary, the MassHealth Program may recoup from future payments to the Contractor for Inpatient Services and Outpatient Services any amounts that are owed by the Contractor as a result of an overpayment, penalty, fine or other sanction.

H. Comply with all requirements of EOHHS’s Clinical Quality Incentive Program, as detailed in Section 6 and in Appendix C to Attachment A.

I. Comply with all Adverse Incident reporting requirements, as detailed in Appendix D to Attachment A and submit to MassHealth a written report of each Reportable Adverse Incident using the form found at https://www.mass.gov/how-to/behavioral-health-reporting-adverse-incidents.

J. Comply with Department of Mental Health Inpatient Licensing Division Clinical Competencies and Operational Standards, as detailed in Appendix E to Attachment A.

K. Comply with Discharge Planning Procedures for Members Experiencing or at Risk of Homelessness, as detailed in Appendix F to Attachment A.

L. Comply with Health Information Technology Requirements, as detailed in Appendix B to Attachment A M. Accept all referrals of MassHealth Members that meet the established admission criteria of the inpatient unit. This may include direct admissions. Prior to direct admission to the inpatient unit, the Contractor shall, to the extent possible permitted by law: Conduct a behavioral health clinical assessment, including a full biopsychosocial, medical necessity assessment and diversionary considerations. This assessment must be completed by a qualified behavioral health provider. For youth, under the age of 21 years old, the Contractor must conduct a screening as specified in 130 CMR 425.406. The Contractor shall document the assessment in the Member’s medical record and use the assessment to determine medical necessity of the direct admission.

N. Accept Members for admission via emergency and non-emergency transportation modalities.

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

EOHHS RESPONSIBILITIES

EOHHS shall:

A. Make Contract payments to the Contractor in accordance with the rates of payment and payment provisions set forth in this Contract and in the RY2026 Psychiatric Hospital RFA, which is attached hereto and incorporated herein by reference, 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.

B. Maintain, in accordance with applicable MassHealth Program regulations concerning privacy of Member records, all records furnished to EOHHS pursuant to the requirements of Section 8.16 herein.

PAYMENT SYSTEM

Section 4.1: General Provisions The Contractor shall accept payment at the rates established in this Contract as payment in full for all covered Inpatient Services, Outpatient Services and Administratively Necessary Days rendered on and after October 1, 2025, throughout the term of the Contract.

Section 4.2: Payment for Inpatient Services A Contractor will be paid for Inpatient Services using a combination of an Inpatient Per Diem Rate and a per inpatient admission rate, as described below.

Inpatient Per Diem Payments The Inpatient Per Diem Rate is a daily rate paid for any and all routine and ancillary Inpatient Services provided by a Contractor to a MassHealth Member, with the exception of any and all Administratively Necessary Days that shall be paid in accordance with Section 4.4 of Attachment A below. The Inpatient Per Diem Rates is listed in each Contractor’s Appendix A to Attachment A.