Rates for Home Health Services (101 CMR 350.00)

Effective Date: This proposed regulation would take effect August 1, 2026

Definitions:

The proposed regulation establishes definitions for Home Health Agency Value Based Payment (VBP) Services.

Medical Social Worker – Defines a MSW as a person who has a master’s or doctoral degree from a school of social work accredited by the Council on Social Work Education and has one year of social work experience in a health care setting. The definition requires that the social worker meet criteria defined in 42 CFR 484.115.

VBP Per Member Per Month Payment (PMPM) – refers to the monthly payment EOHHS will pay for VBP home health services.

Rates of Payment:

All codes for Home Health Services in the Home have been unchanged.

MassHealth is establishing two new payment rates for Value Based Payment:

• 99600 VBP Rate 1: $2957.60 PMPM
• 99600 VBP Rate-2: $3286.22 PMPM

Home Health Agency Manual (101 CMR 403.00)

Effective Date: This proposed regulation would take effect August 1, 2026.

Introduction of Home Health Value-Based Payment (VBP) Services

The proposed regulations formally establish a Home Health Agency Value-Based Payment (VBP) service model within 130 CMR 403.000. This includes:

• Definitions for VBP services, providers, and members
• A requirement that agencies be enrolled and contracted with EOHHS to participate
• A per-member-per-month (PMPM) payment structure for VBP services
• Inclusion of VBP services within the scope of covered home health services

VBP services must be prior authorized and include all medically necessary home health services provided to the member.

Clinical Eligibility Criteria for VBP Services

The regulations introduce specific clinical eligibility criteria for members to receive VBP services. For members who are new to VBP services or returning after a break in service, eligibility includes:

• At least two hospitalizations in the past 12 months, or
• One hospitalization and at least two emergency department visits in the past 12 months

In addition, members must require at least four visits per week of skilled nursing and/or medication administration services.

Members continuing in the VBP program must continue to meet the minimum visit frequency requirement.

Addition of Medical Social Worker (MSW) Services

The proposed regulations incorporate medical social worker services into the VBP service model.

Medical social workers must meet federal qualification requirements under 42 CFR 484.115 and may be included as part of the interdisciplinary services provided to VBP members.

Telehealth Provisions within VBP

The proposed regulations allow for telehealth visits as part of VBP services when:

• Clinically appropriate and medically necessary
• Used to support ongoing care

Telehealth may not be used for services that require hands-on care.

Alignment with EVV Requirements

The proposed language reinforces that home health services must be billed in accordance with Electronic Visit Verification (EVV) requirements, as defined by EOHHS.

Removal of Fiscal Soundness Requirement

The proposed regulations remove the requirement for home health agencies to submit a statement of fiscal soundness as part of provider participation.

Medication Administration Visit Definition Updated

The definition of a medication administration visit has been revised. The language has been updated from visits provided for the “sole purpose” of medication administration to visits provided for the “primary purpose” of medication administration.

Face-to-face Changes

MassHealth is proposing regulatory changes to align with CMS F2F regulatory changes. However, HCA is concerned the proposed changes do not properly align.

Rates for Hospice Services (101 CMR 343.00)

MassHealth released the proposed update to Hospice Regulation (101 CMR 343.00)

MassHealth has released a proposed update to 101 CMR 343.00: Rates for Hospice Services, effective October 1, 2025. The rate tables in the proposal fully align with Administrative Bulletin (AB) 26-01, which MassHealth issued in the fall to establish the FFY2026 hospice rates.

A review of the proposed regulation shows no substantive policy or operational changes. All edits are minor wording and formatting updates and do not affect billing requirements, eligibility, or program rules. The proposal simply reiterates the rates already published in AB 26-01.

Administrative Bulletin 26-01

MassHealth will hold a public hearing as part of the formal regulatory process, but the proposal does not introduce any changes beyond those in the previously released bulletin.