Appendix J, Sub Sample Clauses

Appendix J, Sub. Capitation Program Rate for Primary Care Entities, is hereby deleted and replaced with the attached Appendix J.  Denotes a service included in TCOC Calculations Each of the Services listed below will be included in Total Cost of Care (TCOC) calculations, except for those listed as Services Not Included in TCOC Calculations or listed as Excluded Services. MassHealth reserves the right to amend or modify this list, including but not limited to further defining the services listed below as well as adding or removing services. Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Acupuncture Treatment    Acute Inpatient Hospital    Ambulatory Surgery/Outpatient Hospital Care    Audiologist    Behavioral Health Services (see below)    Breast Pumps and Breast Milk Storage Bags    Certain COVID-19 Specimen Collection and Testing (until May 11, 2023)    Chiropractic Services    Chronic, Rehabilitation Hospital or Nursing Facility Services, up to 100 days per Contract Year, except stays in Commonwealth designated COVID-19 nursing facility, see non-TCOC Included Services in Exhibit 2.    Emergency Related Dental Services    Diabetes Self-Management Training    Dialysis    Durable Medical Equipment and Medical/Surgical Supplies 1) Durable Medical Equipment 2) Medical/Surgical Supplies    Early and Periodic Screening, Diagnosis and Treatment (EPSDT) Services  Early Intervention   Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Emergency Services    Family Planning    Fluoride Varnish   Hearing Aids    Home Health Services    Hospice    Infertility, related to an underlying medical condition    Laboratory    MassHealth Coordinating Aligned, Relationship-centered Enhanced Support (CARES) for Kids  Medical Nutritional Therapy    Orthotics    Oxygen and Respiratory Therapy Equipment    Pharmacy (Please see Exhibit 2 for categories of Pharmacy that are not included in TCOC calculations.)    Physician (primary and specialty)    Podiatry    Preventive Pediatric Health Screening and Diagnostic Services  Prosthetic Services and Devices    Radiology and Diagnostic Tests    Remote Patient Monitoring (RPM) 1) RPM 2) COVID-19 RPM    School Based Health Center Services   Therapy 1) Physical 2) Occupational    Coverage Types Service MassHealth Standard & Co...

Appendix J, Sub. Capitation Program Rate for Primary Care Entities, is hereby deleted and replaced with the attached Appendix J. Each of the Services listed below will be included in Total Cost of Care (TCOC) calculations, except for those listed as Services Not Included in TCOC Calculations or listed as Excluded Services. MassHealth reserves the right to amend or modify this list, including but not limited to further defining the services listed below as well as adding or removing services. Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus Chronic, Rehabilitation Hospital or Nursing Facility Services, up to 100 days per Contract Year, except stays in Commonwealth designated COVID-19 nursing facility, see non-TCOC Included Services in Exhibit 2. Infertility, related to an underlying medical condition MassHealth Coordinating Aligned, Relationship-centered Enhanced Support (CARES) for Kids These services coordinated by the Contractor are not factored into TCOC calculations. Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus 1. Adult Residential Rehabilitation Services for Substance Use Disorders (Level 3.1) 2. Family Residential Rehabilitation Services for Substance Use Disorders (Level 3.1) Coverage Types Service MassHealth Standard & CommonHealth Enrollees MassHealth Family Assistance Enrollees CarePlus 3. Transitional Age Youth and Young Adult Residential Rehabilitation Services for Substance Use Disorders (Level 3.1) 4. Youth Residential Rehabilitation Services for Substance Use Disorders (Level 3.1) 5. Pregnancy Enhanced Residential Rehabilitation Services for Substance Use Disorders (Level 3.1) 6. Co-Occurring Enhanced Residential Rehabilitation Services (Level 3.1) Recovery Coaching Recovery Support Navigators Tablets (for use as augmentative and alternative communication (AAC) devices) Transitional Support Services (TSS) for Substance Use Disorders (Level 3) Transportation (non-emergent, to in-state location or location within 50 miles of the Massachusetts border) Vision Care (non-medical component) Inpatient Services 1. Inpatient Mental Health Services 2. Inpatient Substance Use Disorder Services (Level 4) 3. Observation/Holding Beds 4. Administratively Necessary Day (AND) Services Diversionary Services

Appendix J, Sub. Capitation Program Rates for Primary Care Entities, is hereby deleted and replaced with the attached Appendix J. Amendment #1 to the First Amended and Restated PCACO Contract Listed below are the Per Member Per Month (PMPM) TCOC Benchmarks and Administrative Payments and Primary Care Sub-Capitation Payments (together “PCACO Payments”) for Contract Year 2 (January 1, 2024, through December 31, 2024), subject to state appropriation and all necessary federal approvals. TCOC Benchmarks do not include EOHHS adjustments described in Sections 4.5.D of the Contract. Exhibit 1.1: ACO TCOC Benchmarks (per member per month) effective January 1, 2024 – December 31, 2024 Northern $611.76 Greater Boston $664.41 Southern $677.05 Central $639.97 Western $589.55 Northern $272.34 Greater Boston $282.10 Southern $287.40 Central $279.63 Western $297.59 Northern $2,013.54 Greater Boston $2,191.96 Southern $2,136.55 Central $1,999.99 Western $1,743.34 Northern $1,161.85 Greater Boston $1,236.40 Southern $1,063.51 Central $1,121.55 Western $947.19 Northern $646.36 Greater Boston $629.47 Southern $732.15 Central $689.15 Western $630.05 Northern $2,120.78 Greater Boston $2,318.36 Southern $2,154.82 Central $1,990.09 Western $1,621.51 Exhibit 1.2: PCACO Payments (per member per month) effective January 1, 2024 – December 31, 2024 Northern $77.82 $69.00 $126.99 $69.86 $77.82 $126.99 Greater Boston $63.70 $62.15 $98.37 $63.76 $63.70 $98.37 Southern $67.49 $69.89 $97.21 $71.13 $67.49 $97.21 Central $59.79 $59.23 $102.64 $65.52 $59.79 $102.64 Western $49.06 $61.73 $91.50 $72.39 $49.06 $91.50 Northern $31.15 $27.04 $60.79 $58.57 $31.85 $64.88 Greater Boston $32.08 $27.73 $66.04 $68.39 $31.75 $71.14 Southern $32.13 $27.20 $63.55 $55.23 $33.56 $65.46 Central $31.50 $26.90 $60.67 $58.39 $32.69 $62.32 Western $30.38 $27.25 $53.97 $49.01 $31.32 $51.75 Northern $30.50 $26.75 $58.68 $57.34 $31.15 $62.67 Greater Boston $31.37 $27.42 $63.74 $67.07 $31.07 $68.71 Southern $31.41 $26.89 $61.31 $54.10 $32.77 $63.20 Central $30.82 $26.60 $58.58 $57.20 $31.95 $60.24 Western $29.75 $26.93 $52.14 $48.01 $30.63 $50.05 Northern $29.84 $26.45 $56.58 $56.11 $30.46 $60.46 Greater Boston $30.67 $27.12 $61.45 $65.75 $30.39 $66.29 Southern $30.70 $26.58 $59.07 $52.98 $31.99 $60.95 Central $30.14 $26.30 $56.49 $56.01 $31.21 $58.17 Western $29.11 $26.61 $50.32 $47.01 $29.95 $48.36