The Commonwealth of Massachusetts



Administrative Bulletin 14-04

Payments under Section 1202 of the Federal Affordable Care Act

for Certain Primary Care Services Covered by MassHealth

Regulation: 101 CMR 317.00: Medicine

Effective January 1, 2014

In accordance with 101 CMR 317.03(11), the following rates are effective January 1, 2014, for eligible providers. See MassHealth All Provider Bulletin 230 and All Provider Bulletin 235 for information about eligibility for Section 1202 rates. Section 1202 rates are developed by the Centers for Medicare & Medicaid Services (CMS). MassHealth will update Section 1202 rates as necessary. The Section 1202 rates, as well as any updated rates, will be communicated via Administrative Bulletin.

Fee Schedule

|Code |Nonfacility |Facility |Global |

|90460 | | |$23.29 |

|90460-SL | | |$23.29 |

|90461 | | |$0.00 |

|90461-SL | | |$0.00 |

|90471 | | |$26.80 |

|90471-SL | | |$23.29 |

|(vaccines for children, age 18 and | | | |

|under) | | | |

|90471-SL | | |$26.80 |

|(ages 19 and up) | | | |

|90472 | | |$13.17 |

|90472-SL | | |$23.29 |

|(vaccines for children, age 18 and | | | |

|under) | | | |

|90472-SL | | |$13.17 |

|(ages 19 and up) | | | |

|90473 | | |$26.80 |

|90473-SL | | |$23.29 |

|(vaccines for children, age 18 and | | | |

|under) | | | |

|90473-SL | | |$26.80 |

|(ages 19 and up) | | | |

|90474 | | |$13.17 |

|90474-SL | | |$23.29 |

|(vaccines for children, age 18 and | | | |

|under) | | | |

|90474-SL | | |$13.17 |

|(ages 19 and up) | | | |

|99201 |$45.56 |$27.19 | |

|99202 |$78.04 |$51.85 | |

|99203 |$112.75 |$78.75 | |

|99204 |$172.34 |$134.82 | |

|99205 |$214.52 |$174.27 | |

|99211 |$21.31 |$9.58 | |

|99212 |$45.95 |$26.02 | |

|99213 |$76.38 |$52.93 | |

|99214 |$112.57 |$81.30 | |

|99215 |$150.52 |$114.56 | |

|99217 | | |$75.09 |

|99218 | | |$102.41 |

|99219 | | |$139.91 |

|99220 | | |$191.30 |

|99221 | | |$104.32 |

|99222 | | |$141.94 |

|99223 | | |$209.42 |

|99224 | | |$41.08 |

|99225 | | |$74.95 |

|99226 | | |$108.07 |

|99231 | | |$40.43 |

|99232 | | |$74.42 |

|99233 | | |$107.29 |

|99234 | | |$138.93 |

|99235 | | |$174.39 |

|99236 | | |$224.99 |

|99238 | | |$75.22 |

|99239 | | |$111.06 |

|99281 | | |$21.54 |

|99282 | | |$42.21 |

|99283 | | |$62.94 |

|99284 | | |$119.78 |

|99285 | | |$176.21 |

|99291 |$284.15 |$229.43 | |

|99292 |$126.57 |$114.84 | |

|99304 | | |$96.18 |

|99305 | | |$136.99 |

|99306 | | |$173.52 |

|99307 | | |$46.43 |

|99308 | | |$71.61 |

|99309 | | |$94.35 |

|99310 | | |$140.16 |

|99318 | | |$99.55 |

|99324 | | |$57.52 |

|99325 | | |$83.60 |

|99326 | | |$144.27 |

|99327 | | |$192.60 |

|99328 | | |$223.22 |

|99334 | | |$62.84 |

|99335 | | |$98.35 |

|99336 | | |$138.71 |

|99337 | | |$199.60 |

|99341 | | |$57.13 |

|99342 | | |$82.29 |

|99343 | | |$134.48 |

|99344 | | |$188.50 |

|99345 | | |$227.24 |

|99347 | | |$57.54 |

|99348 | | |$87.02 |

|99349 | | |$132.00 |

|99350 | | |$183.67 |

|99381 |$116.09 |$80.13 | |

|99382 |$121.06 |$85.10 | |

|99383 |$126.15 |$90.19 | |

|99384 |$142.33 |$106.37 | |

|99385 |$138.23 |$102.27 | |

|99386 |$159.22 |$124.05 | |

|99387 |$172.99 |$133.12 | |

|99391 |$104.43 |$73.16 | |

|99392 |$111.40 |$80.13 | |

|99393 |$111.01 |$80.13 | |

|99394 |$121.46 |$90.19 | |

|99395 |$124.07 |$92.80 | |

|99396 |$132.16 |$100.89 | |

|99397 |$142.33 |$106.37 | |

|99407 |$53.74 |$52.81 | |

|99460 | | |$97.74 |

|99461 |$103.28 |$66.93 | |

|99462 | | |$43.36 |

|99463 | | |$118.70 |

|99464 | | |$73.12 |

|99465 | | |$158.05 |

|99466 | | |$263.20 |

|99467 | | |$127.14 |

|99468 | | |$957.02 |

|99469 | | |$408.24 |

|99471 | | |$884.87 |

|99472 | | |$414.46 |

|99475 | | |$592.60 |

|99476 | | |$358.35 |

|99477 | | |$358.08 |

|99478 | | |$141.75 |

|99479 | | |$128.57 |

|99480 | | |$123.74 |

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DEVAL L. PATRICK

Governor

JOHN W. POLANOWICZ

Secretary

KRISTIN L. THORN

Medicaid Director

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