Common use of Final Reconciliation Clause in Contracts

Final Reconciliation. Each provider's uncompensated care costs must be recomputed based on the provider's audited CMS 2552 cost report for the actual service period. These recomputed costs must be carried over to the UCCR. The CMS 2552 cost report is audited and settled by the Medicare contractor to determine final allowable costs and reimbursement amounts as recognized by Medicare. For SNCP payments subject to the cost limit pursuant to STC 49(c), each provider’s allowable Medicaid, uncompensated care, and uninsured costs must be reconciled against associated applicable payments received for the year for which the payments were made. SNCP uncompensated care payments made to the provider for a cost limit reporting year cannot exceed the recomputed uncompensated care cost limit. If, at the end of the final reconciliation process, it is determined that expenditures claimed exceeded the individual provider's uncompensated care cost limit, thereby causing an overpayment, the Commonwealth must recoup the overpayment from the provider. Specifically, if an overpayment exists, the Commonwealth must determine if the overpayment occurred due to HSN Trust Fund payments or other SNCP payments, or from both payments. To the extent that the overpayment is a result of overpaid funds from the HSN Trust Fund, the Commonwealth must recover from the provider the amount overpaid to the provider from the HSN Trust Fund and credit that amount to the HSN Trust Fund. The HSN Trust Fund will redistribute such amounts to other providers as appropriate. To the extent that the overpayment is not the result of HSN Trust Fund payments, the Commonwealth must recover from the provider the overpayment, and the Commonwealth must properly credit the federal share to the federal government. For hospitals whose accounting fiscal year aligns with the cost limit reporting fiscal year (Federal fiscal year), the Medicaid and uninsured costs will be reflected in the CMS 2552 and UCCR that is submitted for the accounting fiscal year. For acute hospitals whose accounting fiscal years do not align with the reporting fiscal year, the reporting year cost limit will be calculated by applying the appropriate percentage of the two contiguous CMS 2552 and UCCR cost reports that span the reporting fiscal year so that the Federal fiscal year will be represented in the cost limit calculation. The Commonwealth must recover provider overpayments as it determines necessary based on its reconciliation calculations and availability of federal financial participation. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 The final reconciliation described above must be performed and completed within twelve months after all final, audited CMS 2552 cost reports become available online. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Institutions for Mental Diseases – Psychiatric Hospitals and Community Based Detoxification Centers (CBDCs) Protocol for Medicaid and Uncompensated Care Cost The Commonwealth will use the reports described below to collect data from these providers. Psychiatric hospitals will fill out the CMS 2552 and UCCR, as required of other hospitals in the cost limit protocol. CBDCs are non-hospital human and social services contractors that do not file a CMS 2552 cost report; therefore, for the purposes of the protocol, the Commonwealth will use only the Massachusetts Uniform Financial Statements and Independent Auditor’s Report (UFR) to determine costs and revenues. The UFR is the set of financial statements and schedules required of human and social service contracting with state departments. For the calculation of provider-specific cost limits, psychiatric hospitals and CBDCs will fill out the necessary reports with the information that is relevant to the services they provide to the Medicaid-eligible and HSN and uninsured populations. Determination of Allowable Medicaid and Uninsured Costs DSH Allowable Costs Per STC 50(f), the Commonwealth will use the Medicaid DSH statutory, regulatory, and policy definitions of allowable psychiatric hospital services and allowable Medicaid and uninsured costs in determining hospital-specific cost limits in its cost protocols. To the extent that the determination of uncompensated care costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Pharmacy service costs are separately identified on the CMS 2552 10 cost report and are not recognized as an inpatient or outpatient hospital service. Pharmacy service costs that are not part of an inpatient or outpatient rate and are billed as pharmacy service and reimbursed as such are not considered eligible for inclusion in the hospital-specific uncompensated cost limit allowable under DSH. To the extent that the determination of allowable pharmacy costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Costs included must be for services that meet the federal definition and the approved Massachusetts State plan definition of “hospital services” for medical assistance. “Medical assistance” is defined as the cost of care and services “for individuals, and, with respect to physicians’ or dentists’ services, at the option of the State, to individuals [who are eligible]…” Section 1905 of the Act. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Medicaid State Plan Allowable Costs Massachusetts must use the same definition for all inpatient hospital, outpatient hospital, and physician services, clinic services, non-hospital services, etc. as described in its approved Medicaid State plan, and in accordance with Section 1905 of the Social Security Act and the regulations promulgated thereunder, to define allowable service costs provided by institutions for mental disease. Massachusetts identifies other service costs, subject to CMS approval, that are not included in the Medicaid state plan definitions to be included as allowable uncompensated care costs in this document (see Cost Element table). Inpatient psychiatric hospital services: Psychiatric treatment provided under the direction of a psychiatrist in a psychiatric inpatient hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Outpatient psychiatric hospital services: Services provided to members on an outpatient basis in a psychiatric hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Community Based Detoxification Center (CBDC): CBDCs are eligible to receive Safety Net Care Pool payments as Institutions for Mental Diseases (IMDs) under the section 1115 demonstration. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Acute Inpatient Substance Abuse Treatment Services: Short-term medical treatment for substance withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post detoxification referrals provided by an inpatient unit, either freestanding or hospital-based, licensed as an acute inpatient substance abuse treatment service by the Massachusetts Department of Public Health under its regulations at 105 CMR 160.000 and 161.000. These services are delivered in a three-tiered system consisting of Levels III-A through III-C that must conform with the standards and patient placement criteria issued and enforced by the Massachusetts Department of Public Health's Bureau of Substance Abuse Services. Substance Abuse Outpatient Counseling Service: An outpatient counseling service that is a Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 rehabilitative treatment service for individuals and their families experiencing the dysfunctional effects of the use of substances. 1115 Demonstration Population Expenditures: Costs incurred by psychiatric hospitals and CBDCs for providing IMD services to members eligible for Medicaid through the State plan and section 1115 demonstration will be counted as allowable costs. Allowable costs for psychiatric hospital services and CBDC services provided under the 1115 demonstration include service-related expenditures (please note that all services authorized under the section 1115 demonstration are subject to the requirements and limitations specified in the STCs). The list of allowable services is contained in the Cost Element table. Medicaid Managed Care Costs: Costs incurred by IMDs for providing services to members enrolled in Medicaid managed care organizations including SCOs and ICOs, prepaid inpatient health plans, and any prepaid ambulatory health plans. Eligible costs are determined using the same methodology under this section.

Final Reconciliation. Each providerhospital's uncompensated care costs must be recomputed based on the providerhospital's audited CMS 2552 cost report for the actual service period. These recomputed costs must be carried over to the UCCR. The CMS 2552 cost report is audited and settled by the Medicare contractor to determine final allowable costs and reimbursement amounts as recognized by Medicare. For SNCP payments subject to the cost limit pursuant to STC 49(c), each provider’s allowable Medicaid, uncompensated care, and uninsured costs must be reconciled against associated applicable payments received for the year for which the payments were made. SNCP uncompensated care payments made to the provider hospital for a cost limit reporting year DY cannot exceed the recomputed uncompensated care cost limit. If, at the end of the final reconciliation process, it is determined that expenditures claimed exceeded the individual providerhospital's uncompensated care cost limit, thereby causing an overpayment, the Commonwealth must recoup the overpayment will be recouped from the provider. Specifically, if an overpayment exists, the Commonwealth must determine if the overpayment occurred due to HSN Trust Fund payments or other SNCP payments, or from both payments. To the extent that the overpayment is a result of overpaid funds from the HSN Trust Fund, the Commonwealth must recover from the provider the amount overpaid to the provider from the HSN Trust Fund and credit that amount to the HSN Trust Fund. The HSN Trust Fund will redistribute such amounts to other providers as appropriate. To the extent that the overpayment is not the result of HSN Trust Fund payments, the Commonwealth must recover from the provider the overpaymenthospital, and the Commonwealth must properly credit the federal share will be properly credited to the federal government. For hospitals whose accounting fiscal year aligns The final reconciliation follows the same computation as outlined above in the Interim Computation of Uncompensated Care Costs steps, except that the per diems and RCCs, Medicaid and uninsured days and charges, and payment offset amounts used will pertain to the actual service period (rather than the prior period). Per diems and RCCS will be derived from the audited cost report, and Medicaid and uninsured days, charges and payments will be updated with the latest available auditable data for the service period. No trending factor will be applied. The uncompensated care costs must again be adjusted to remove costs related to non-emergency services furnished to unqualified aliens. The state must ensure that there is no duplication of payments for the same hospital uncompensated care costs under the SNCP and under DSH; SNCP payments must be accounted for in the hospital's OBRA 93 hospital-specific limit. A hospital's uncompensated care cost limit is determined for the twelve month period in each DY, except for all other hospitals in DY 3 in which the uncompensated care cost limit is computed for the three month period ending December 31, 2013. Where a hospital's cost reporting fiscal year period does not coincide with the DY (Federal fiscal yearor partial DY in DY3), the Medicaid and uninsured uncompensated care costs will computed for a cost reporting period can be reflected in allocated to the CMS 2552 and UCCR DY (or partial DY) based on the number of cost reporting months that overlap with the DY (or partial DY). This is submitted consistent with the methodology for the accounting fiscal year. For acute hospitals whose accounting fiscal years do not align with the reporting fiscal year, the reporting year cost limit will be calculated by applying the appropriate percentage computation of the two contiguous CMS 2552 and UCCR cost reports that span the reporting fiscal year so that the Federal fiscal year will be represented in the cost OBRA 93 hospital-specific limit calculationfor a given DSH State Plan Rate Year. The Commonwealth must recover provider overpayments as it determines necessary based on its reconciliation calculations and availability of federal financial participation. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 The final reconciliation described above must will be performed and completed within twelve six months after all final, the audited CMS 2552 hospital Medicare cost reports become available onlinereport(s) are made available. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Institutions for Mental Diseases – Psychiatric Hospitals and Community Based Detoxification Centers (CBDCs) Protocol for Medicaid and Uncompensated Care Cost The Commonwealth will use the reports described below to collect data from these providers. Psychiatric hospitals will fill out the CMS 2552 and UCCR, as required final computation of other hospitals in the hospital uncompensated care cost limit protocol. CBDCs are non-hospital human as described above uses the same final cost report and social services contractors other relevant data as that do not file a CMS 2552 cost report; therefore, for used by the purposes of the protocol, the Commonwealth will use only the Massachusetts Uniform Financial Statements and Independent Auditor’s Report (UFR) to determine costs and revenues. The UFR is the set of financial statements and schedules required of human and social service contracting with state departments. For the calculation of provider-specific cost limits, psychiatric hospitals and CBDCs will fill out the necessary reports with the information that is relevant to the services they provide to the Medicaid-eligible and HSN and uninsured populations. Determination of Allowable Medicaid and Uninsured Costs DSH Allowable Costs Per STC 50(f), the Commonwealth will use the Medicaid DSH statutory, regulatory, and policy definitions of allowable psychiatric hospital services and allowable Medicaid and uninsured costs in determining its final OBRA 93 hospital-specific cost limits in its cost protocols. To limit computation for DSH payments for the extent that the determination of uncompensated care costs varies from the Medicaid given DSH requirements, the process must be accounted for in this document. Pharmacy service costs are separately identified on the CMS 2552 10 cost report and are not recognized as an inpatient or outpatient hospital service. Pharmacy service costs that are not part of an inpatient or outpatient rate and are billed as pharmacy service and reimbursed as such are not considered eligible for inclusion in the hospital-specific uncompensated cost limit allowable under DSH. To the extent that the determination of allowable pharmacy costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Costs included must be for services that meet the federal definition and the approved Massachusetts State plan definition of “hospital services” for medical assistance. “Medical assistance” is defined as the cost of care and services “for individuals, and, with respect to physicians’ or dentists’ services, at the option of the State, to individuals [who are eligible]…” Section 1905 of the Act. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Medicaid State Plan Allowable Costs Massachusetts must use the same definition for all inpatient hospital, outpatient hospital, and physician services, clinic services, non-hospital services, etc. as described in its approved Medicaid State plan, and in accordance with Section 1905 of the Social Security Act and the regulations promulgated thereunder, to define allowable service costs provided by institutions for mental disease. Massachusetts identifies other service costs, subject to CMS approval, that are not included in the Medicaid state plan definitions to be included as allowable uncompensated care costs in this document (see Cost Element table). Inpatient psychiatric hospital services: Psychiatric treatment provided under the direction of a psychiatrist in a psychiatric inpatient hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Outpatient psychiatric hospital services: Services provided to members on an outpatient basis in a psychiatric hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Community Based Detoxification Center (CBDC): CBDCs are eligible to receive Safety Net Care Pool payments as Institutions for Mental Diseases (IMDs) under the section 1115 demonstration. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Acute Inpatient Substance Abuse Treatment Services: Short-term medical treatment for substance withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post detoxification referrals provided by an inpatient unit, either freestanding or hospital-based, licensed as an acute inpatient substance abuse treatment service by the Massachusetts Department of Public Health under its regulations at 105 CMR 160.000 and 161.000. These services are delivered in a three-tiered system consisting of Levels III-A through III-C that must conform with the standards and patient placement criteria issued and enforced by the Massachusetts Department of Public Health's Bureau of Substance Abuse Services. Substance Abuse Outpatient Counseling Service: An outpatient counseling service that is a Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 rehabilitative treatment service for individuals and their families experiencing the dysfunctional effects of the use of substances. 1115 Demonstration Population Expenditures: Costs incurred by psychiatric hospitals and CBDCs for providing IMD services to members eligible for Medicaid through the State plan and section 1115 demonstration will be counted as allowable costs. Allowable costs for psychiatric hospital services and CBDC services provided under the 1115 demonstration include service-related expenditures (please note that all services authorized under the section 1115 demonstration are subject to the requirements and limitations specified in the STCs). The list of allowable services is contained in the Cost Element table. Medicaid Managed Care Costs: Costs incurred by IMDs for providing services to members enrolled in Medicaid managed care organizations including SCOs and ICOs, prepaid inpatient health plans, and any prepaid ambulatory health plans. Eligible costs are determined using the same methodology under this sectionRate Year.

Final Reconciliation. 3 Community Based Detoxification Centers are the only provider type subject to the cost limit that does not submit the CMS 2552 cost report. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Each provider's uncompensated care costs must be recomputed based on the provider's audited CMS 2552 cost report for the actual service period. These recomputed costs must be carried over to the UCCR. The CMS 2552 cost report is audited and settled by the Medicare contractor to determine final allowable costs and reimbursement amounts as recognized by Medicare. For SNCP payments subject to the cost limit pursuant to STC 49(c), each provider’s allowable Medicaid, uncompensated care, and uninsured costs must be reconciled against associated applicable payments received for the year for which the payments were made. SNCP uncompensated care payments made to the provider for a cost limit reporting year cannot exceed the recomputed uncompensated care cost limit. If, at the end of the final reconciliation process, it is determined that expenditures claimed exceeded the individual provider's uncompensated care cost limit, thereby causing an overpayment, the Commonwealth must recoup the overpayment from the provider. Specifically, if an overpayment exists, the Commonwealth must determine if the overpayment occurred due to HSN Trust Fund payments or other SNCP payments, or from both payments. To the extent that the overpayment is a result of overpaid funds from the HSN Trust Fund, the Commonwealth must recover from the provider the amount overpaid to the provider from the HSN Trust Fund and credit that amount to the HSN Trust Fund. The HSN Trust Fund will redistribute such amounts to other providers as appropriate. To the extent that the overpayment is not the result of HSN Trust Fund payments, the Commonwealth must recover from the provider the overpayment, and the Commonwealth must properly credit the federal share to the federal government. For hospitals whose accounting fiscal year aligns with the cost limit reporting fiscal year (Federal fiscal year), the Medicaid and uninsured costs will be reflected in the CMS 2552 and UCCR that is submitted for the accounting fiscal year. For acute hospitals whose accounting fiscal years do not align with the reporting fiscal year, the reporting year cost limit will be calculated by applying the appropriate percentage of the two contiguous CMS 2552 and UCCR cost reports that span the reporting fiscal year so that the Federal fiscal year will be represented in the cost limit calculation. The Commonwealth must recover provider overpayments as it determines necessary based on its reconciliation calculations and availability of federal financial participation. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 The final reconciliation described above must be performed and completed within twelve months after all final, audited CMS 2552 cost reports become available online. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Institutions for Mental Diseases – Public Chronic Disease & Rehabilitation and Psychiatric Hospitals Inpatient and Community Based Detoxification Centers (CBDCs) Outpatient Hospital Protocol for Medicaid and Uncompensated Care Cost The Commonwealth will use the reports described below to collect data from these providers. Psychiatric hospitals will fill out the CMS 2552 and UCCR, as required of other hospitals in the cost limit protocol. CBDCs are non-hospital human and social services contractors that do not file a CMS 2552 cost report; therefore, for the purposes of the protocol, the Commonwealth will use only the Massachusetts Uniform Financial Statements and Independent Auditor’s Report (UFR) to determine costs and revenues. The UFR is the set of financial statements and schedules required of human and social service contracting with state departments. For the calculation of provider-specific cost limits, psychiatric hospitals and CBDCs will fill out the necessary reports with the information that is relevant to the services they provide to the Medicaid-eligible and HSN and uninsured populations. Determination of Allowable Medicaid and Uninsured Costs DSH Allowable Costs Per STC 50(f), the Commonwealth cost limit protocol will use the Medicaid DSH statutory, regulatory, and policy definitions of allowable psychiatric inpatient hospital and outpatient hospital services and allowable Medicaid and uninsured costs in determining hospital-specific cost limits in its cost protocolslimits. To the extent that the determination of uncompensated care costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Pharmacy service Allowable pharmacy costs are separately identified on include the CMS 2552 10 cost report of drugs and are not recognized as an inpatient or outpatient hospital servicepharmacy supplies requested by patient care departments and drugs charged to patients. Pharmacy service costs that are not part of an inpatient or outpatient rate and are billed service, such as retail pharmacy service and reimbursed as such costs, are not considered eligible for inclusion in the hospital-specific uncompensated cost limit allowable under DSH. To the extent that the determination of allowable pharmacy costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Costs included must be for services that meet the federal definition and the approved Massachusetts State plan definition of “hospital services” for medical assistance. “Medical assistance” is defined as the cost of care and services “for individuals, and, with respect to physicians’ or dentists’ services, at the option of the State, to individuals [who are eligible]…” Section 1905 of the Act. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Medicaid State Plan Allowable Costs Massachusetts must use the same definition for all inpatient hospital, outpatient hospital, and physician services, clinic services, non-hospital services, etc. as described in its approved Medicaid State state plan, and in accordance with Section 1905 of the Social Security Act and the regulations promulgated thereunder, to define allowable service costs provided by institutions for mental diseaseinpatient and outpatient hospitals. Massachusetts identifies other service costs, subject to CMS approval, that are not included in the Medicaid state plan definitions to be included as allowable uncompensated care costs in this document (see Cost Element table). Inpatient chronic disease and rehabilitation hospital services: Inpatient services are routine and ancillary services that are provided to recipients admitted as patients to a chronic disease or rehabilitation hospital. Such services Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Inpatient psychiatric hospital services: Psychiatric treatment provided under the direction of a psychiatrist in a psychiatric inpatient hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Outpatient chronic disease and rehabilitation hospital services: Rehabilitative and medical services provided to a member in a chronic disease or rehabilitation outpatient setting including but not limited to chronic disease or rehabilitation hospital outpatient departments, hospital- licensed health centers or other hospital satellite clinics, physicians’ offices, nurse practitioners’ offices, freestanding ambulatory surgery centers, day treatment centers, or the member’s home. Such services include, but are not limited to, radiology, laboratory, diagnostic testing, therapy services (i.e., physical, speech, occupational and respiratory) and Day surgery services. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Outpatient psychiatric hospital services: Services provided to members on an outpatient basis in a psychiatric hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Community Based Detoxification Center (CBDC): CBDCs are eligible to receive Safety Net Care Pool payments as Institutions for Mental Diseases (IMDs) under the section 1115 demonstration. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Acute Inpatient Substance Abuse Treatment Services: Short-term medical treatment for substance withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post detoxification referrals provided by an inpatient unit, either freestanding or hospital-based, licensed as an acute inpatient substance abuse treatment service by the Massachusetts Department of Public Health under its regulations at 105 CMR 160.000 and 161.000. These services are delivered in a three-tiered system consisting of Levels III-A through III-C that must conform with the standards and patient placement criteria issued and enforced by the Massachusetts Department of Public Health's Bureau of Substance Abuse Services. Substance Abuse Outpatient Counseling Service: An outpatient counseling service that is a Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 rehabilitative treatment service for individuals and their families experiencing the dysfunctional effects of the use of substances. Allowable Costs 1115 Demonstration Population Expenditures: Costs incurred by psychiatric and chronic disease and rehabilitation hospitals and CBDCs for providing IMD services to members eligible for Medicaid through the State plan and section 1115 demonstration (i.e., expansion populations) will be counted as allowable costs. Allowable In addition, allowable costs for psychiatric hospital of services and CBDC services provided that are not authorized under the 1115 demonstration include service-expenditures related expenditures (please note that all to services provided in the programs below and described in the Cost Element table. All services authorized under the section 1115 demonstration are subject to the requirements and limitations specified in the STCs). The list of allowable services is contained in the Cost Element tableDiversionary Behavioral Health Services. Medicaid Managed Care Costs: Costs incurred by IMDs psychiatric and chronic disease and rehabilitation hospitals for providing services to members enrolled in Medicaid managed care organizations including SCOs and ICOs, prepaid inpatient health plans, and any prepaid ambulatory health plans. Eligible costs are determined using the same methodology under this section. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Other Allowable Costs, Approved 1915(c) Waivers – Allowable costs are defined in the Cost Element table. Additional Allowable Costs – Allowable costs are defined in the Cost Element table. Certified Public Expenditures – Determination of Allowable Safety Net Care Pool Costs In accordance with the approved MassHealth Section 1115 demonstration, beginning July 1, 2014, the estimated fiscal year expenditures will be based on the actual fiscal year CMS 2552 and UCCR cost reports.

Final Reconciliation. Each providerFQHC-LA's uncompensated care costs must be recomputed based on the provider's actual audited CMS 2552 cost report for the actual service period. These recomputed costs must be carried over to the UCCR. The CMS 2552 cost report is audited to ensure costs are allowable consistent with Medicare and settled by Medicaid cost principles and applicable OMB Circulars; and that FQHC services and visits are recognized consistent with the Medicare contractor to determine final allowable costs and reimbursement amounts as recognized by Medicare. For SNCP payments subject to the cost limit pursuant to STC 49(c), each provider’s allowable Medicaid, uncompensated care, and uninsured costs must be reconciled against associated applicable payments received for the year for which the payments were madeMedicaid State plan. SNCP uncompensated care payments made to the provider FQHC-LA for a cost limit reporting year DY cannot exceed the recomputed uncompensated care cost limit. If, at the end of the final reconciliation process, it is determined that expenditures claimed exceeded the individual providerclinic's uncompensated care cost limit, thereby causing an overpayment, the Commonwealth must recoup the overpayment will be recouped from the provider. Specifically, if an overpayment exists, the Commonwealth must determine if the overpayment occurred due to HSN Trust Fund payments or other SNCP payments, or from both payments. To the extent that the overpayment is a result of overpaid funds from the HSN Trust Fund, the Commonwealth must recover from the provider the amount overpaid to the provider from the HSN Trust Fund and credit that amount to the HSN Trust Fund. The HSN Trust Fund will redistribute such amounts to other providers as appropriate. To the extent that the overpayment is not the result of HSN Trust Fund payments, the Commonwealth must recover from the provider the overpaymentclinic, and the Commonwealth must properly credit the federal share will be properly credited to the federal government. For hospitals whose The final reconciliation follows the same computation as outlined above in the Interim Computation of Uncompensated Care Costs steps, except that: - The cost per visit is computed based on audited allowable FQHC-LA cost and total visits pertaining to the actual service period cost report. - Both Medicaid visits and uninsured visits furnished during the service period are applied to the audited cost per visit to determine the clinic's Medicaid and uninsured costs. Medicaid and uninsured visits must be derived from the latest available auditable sources, including the State's PMMIS, managed care encounter data, and provider patient accounting fiscal year aligns with records. - Both Medicaid and uninsured revenues, applicable to actual service period and derived from the cost limit reporting fiscal year (Federal fiscal year)latest available auditable sources, the are offset against Medicaid and uninsured costs to arrive at the clinic's uncompensated care costs. - No trending factor will be reflected in the CMS 2552 and UCCR that applied. The uncompensated care costs must again be adjusted to remove costs related to non-emergency services furnished to unqualified aliens. An FQHC-LA's uncompensated care cost limit is submitted determined for the accounting fiscal yeartwelve month period in each DY, except for DY 3 in which the uncompensated care cost limit is computed for the three month period ending December 31, 2013. For acute hospitals whose accounting fiscal years do Where a clinic's cost reporting period does not align coincide with the reporting fiscal yearDY (or partial DY in DY3), the uncompensated care costs computed for a cost reporting year cost limit will period can be calculated by applying allocated to the appropriate percentage of the two contiguous CMS 2552 and UCCR cost reports that span the reporting fiscal year so that the Federal fiscal year will be represented in the cost limit calculation. The Commonwealth must recover provider overpayments as it determines necessary DY (or partial DY) based on its reconciliation calculations and availability the number of federal financial participationcost reporting months that overlap with the DY (or partial DY). Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 The final reconciliation described above must will be performed and completed within twelve eighteen months after all final, audited CMS 2552 the filing of FQHC-LA cost reports become available online. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Institutions for Mental Diseases – Psychiatric Hospitals and Community Based Detoxification Centers (CBDCs) Protocol for Medicaid and Uncompensated Care Cost The Commonwealth will use the reports described below to collect data from these providers. Psychiatric hospitals will fill out the CMS 2552 and UCCR, as required of other hospitals in the cost limit protocol. CBDCs are non-hospital human and social services contractors that do not file a CMS 2552 cost report; therefore, for the purposes of the protocol, the Commonwealth will use only the Massachusetts Uniform Financial Statements and Independent Auditor’s Report (UFR) to determine costs and revenues. The UFR is the set of financial statements and schedules required of human and social service contracting with state departments. For the calculation of provider-specific cost limits, psychiatric hospitals and CBDCs will fill out the necessary reports with the information that is relevant to the services they provide to the Medicaid-eligible and HSN and uninsured populations. Determination of Allowable Medicaid and Uninsured Costs DSH Allowable Costs Per STC 50(freport(s), the Commonwealth will use the Medicaid DSH statutory, regulatory, and policy definitions of allowable psychiatric hospital services and allowable Medicaid and uninsured costs in determining hospital-specific cost limits in its cost protocols. To the extent that the determination of uncompensated care costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Pharmacy service costs are separately identified on the CMS 2552 10 cost report and are not recognized as an inpatient or outpatient hospital service. Pharmacy service costs that are not part of an inpatient or outpatient rate and are billed as pharmacy service and reimbursed as such are not considered eligible for inclusion in the hospital-specific uncompensated cost limit allowable under DSH. To the extent that the determination of allowable pharmacy costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Costs included must be for services that meet the federal definition and the approved Massachusetts State plan definition of “hospital services” for medical assistance. “Medical assistance” is defined as the cost of care and services “for individuals, and, with respect to physicians’ or dentists’ services, at the option of the State, to individuals [who are eligible]…” Section 1905 of the Act. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Medicaid State Plan Allowable Costs Massachusetts must use the same definition for all inpatient hospital, outpatient hospital, and physician services, clinic services, non-hospital services, etc. as described in its approved Medicaid State plan, and in accordance with Section 1905 of the Social Security Act and the regulations promulgated thereunder, to define allowable service costs provided by institutions for mental disease. Massachusetts identifies other service costs, subject to CMS approval, that are not included in the Medicaid state plan definitions to be included as allowable uncompensated care costs in this document (see Cost Element table). Inpatient psychiatric hospital services: Psychiatric treatment provided under the direction of a psychiatrist in a psychiatric inpatient hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Outpatient psychiatric hospital services: Services provided to members on an outpatient basis in a psychiatric hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Community Based Detoxification Center (CBDC): CBDCs are eligible to receive Safety Net Care Pool payments as Institutions for Mental Diseases (IMDs) under the section 1115 demonstration. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Acute Inpatient Substance Abuse Treatment Services: Short-term medical treatment for substance withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post detoxification referrals provided by an inpatient unit, either freestanding or hospital-based, licensed as an acute inpatient substance abuse treatment service by the Massachusetts Department of Public Health under its regulations at 105 CMR 160.000 and 161.000. These services are delivered in a three-tiered system consisting of Levels III-A through III-C that must conform with the standards and patient placement criteria issued and enforced by the Massachusetts Department of Public Health's Bureau of Substance Abuse Services. Substance Abuse Outpatient Counseling Service: An outpatient counseling service that is a Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 rehabilitative treatment service for individuals and their families experiencing the dysfunctional effects of the use of substances. 1115 Demonstration Population Expenditures: Costs incurred by psychiatric hospitals and CBDCs for providing IMD services to members eligible for Medicaid through the State plan and section 1115 demonstration will be counted as allowable costs. Allowable costs for psychiatric hospital services and CBDC services provided under the 1115 demonstration include service-related expenditures (please note that all services authorized under the section 1115 demonstration are subject to the requirements and limitations specified in the STCs). The list of allowable services is contained in the Cost Element table. Medicaid Managed Care Costs: Costs incurred by IMDs for providing services to members enrolled in Medicaid managed care organizations including SCOs and ICOs, prepaid inpatient health plans, and any prepaid ambulatory health plans. Eligible costs are determined using the same methodology under this section.

Final Reconciliation. Each providerhospital's or physician practice group's uncompensated care costs must be recomputed based on the provider's audited CMS 2552 cost report for the actual service period. These recomputed costs must be carried over to the UCCR. The CMS 2552 hospital cost report is audited and settled by the Medicare contractor to determine final allowable costs and reimbursement amounts as recognized by Medicare. For SNCP payments subject The physician practice group's cost report is also audited to the ensure costs are allowable consistent with Medicare and Medicaid cost limit pursuant to STC 49(c), each provider’s allowable Medicaid, uncompensated care, principles and uninsured costs must be reconciled against associated applicable payments received for the year for which the payments were madeOMB Circulars. SNCP uncompensated care payments made to the provider hospital or physician practice group for a cost limit reporting year DY cannot exceed the recomputed uncompensated care cost limit. If, at the end of the final reconciliation process, it is determined that expenditures claimed exceeded the individual providerhospital's or physician practice group's uncompensated care cost limit, thereby causing an overpayment, the Commonwealth must recoup the overpayment from the provider. Specifically, if an overpayment exists, the Commonwealth must determine if the overpayment occurred due to HSN Trust Fund payments or other SNCP payments, or from both payments. To the extent that the overpayment is a result of overpaid funds from the HSN Trust Fund, the Commonwealth must recover from the provider the amount overpaid to the provider from the HSN Trust Fund and credit that amount to the HSN Trust Fund. The HSN Trust Fund will redistribute such amounts to other providers as appropriate. To the extent that the overpayment is not the result of HSN Trust Fund payments, the Commonwealth must recover from the provider the overpaymentbe recouped, and the Commonwealth must properly credit the federal share will be properly credited to the federal government. For hospitals whose accounting fiscal year aligns The final reconciliation follows the same computation as outlined above in the Interim Computation of Uncompensated Care Costs steps, except that the RCCs, Medicaid and uninsured charges, payment offset amounts, and other relevant statistics such as time study or time study proxy data used will pertain to the actual service period (rather than the prior period). RCCs will be derived from the audited cost report, and Medicaid and uninsured charges and payments will be updated with the latest available auditable data for the service period. No trending factor will be applied. The uncompensated care costs must again be adjusted to remove costs related to non-emergency services furnished to unqualified aliens. Even for those particular hospitals who were previously allowed to use hospital departmental charges for interim payment purposes, physician professional charges must be used in the computation of uncompensated cost limit in the Interim Reconciliation above and the Final Reconciliation here. A hospital's or physician practice group's uncompensated care cost limit is determined for the twelve month period in each DY, except for all other providers in DY 3 in which the uncompensated care cost limit is computed for the three month period ending December 31, 2013. Where a hospital's or physician practice group's cost reporting fiscal year period does not coincide with the DY (Federal fiscal yearor partial DY in DY3), the Medicaid and uninsured uncompensated care costs will computed for a cost reporting period can be reflected in allocated to the CMS 2552 and UCCR DY (or partial DY) based on the number of cost reporting months that is submitted for overlap with the accounting fiscal yearDY (or partial DY). For acute hospitals whose accounting fiscal years do not align with the reporting fiscal yearhospital-incurred professional service uncompensated care costs, the reporting year cost limit will be calculated by applying the appropriate percentage of the two contiguous CMS 2552 and UCCR cost reports that span the reporting fiscal year so that the Federal fiscal year will be represented in the cost limit calculation. The Commonwealth must recover provider overpayments as it determines necessary based on its reconciliation calculations and availability of federal financial participation. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 The final reconciliation described above must will be performed and completed within twelve six months after all final, the audited CMS 2552 hospital Medicare cost reports become available online. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Institutions for Mental Diseases – Psychiatric Hospitals and Community Based Detoxification Centers (CBDCsreport(s) Protocol for Medicaid and Uncompensated Care Cost The Commonwealth will use the reports described below to collect data from these providers. Psychiatric hospitals will fill out the CMS 2552 and UCCR, as required of other hospitals in the cost limit protocol. CBDCs are non-hospital human and social services contractors that do not file a CMS 2552 cost report; therefore, for the purposes of the protocol, the Commonwealth will use only the Massachusetts Uniform Financial Statements and Independent Auditor’s Report (UFR) to determine costs and revenues. The UFR is the set of financial statements and schedules required of human and social service contracting with state departmentsmade available. For the calculation of providerphysician practice group-specific cost limits, psychiatric hospitals and CBDCs will fill out the necessary reports with the information that is relevant to the services they provide to the Medicaid-eligible and HSN and uninsured populations. Determination of Allowable Medicaid and Uninsured Costs DSH Allowable Costs Per STC 50(f)incurred professional service uncompensated care costs, the Commonwealth final reconciliation described above will use be performed and completed within eighteen months after the Medicaid DSH statutory, regulatory, and policy definitions filing of allowable psychiatric hospital services and allowable Medicaid and uninsured costs in determining hospital-specific physician practice group cost limits in its cost protocolsreport(s). To the extent that the determination of uncompensated care costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Pharmacy service costs are separately identified on the CMS 2552 10 cost report and are not recognized as an inpatient or outpatient hospital service. Pharmacy service costs that are not part of an inpatient or outpatient rate and are billed as pharmacy service and reimbursed as such are not considered eligible for inclusion Exhibit 1 to Attachment E Participating Providers in the hospital-specific uncompensated cost limit allowable under DSH. To the extent that the determination of allowable pharmacy costs varies from the Medicaid DSH requirementsSNCP (Previously approved through December 31, the process must be accounted for in this document. Costs included must be for services that meet the federal definition and the approved Massachusetts State plan definition of “hospital services” for medical assistance. “Medical assistance” is defined as the cost of care and services “for individuals, and, with respect to physicians’ or dentists’ services, at the option of the State, to individuals [who are eligible]…” Section 1905 of the Act. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Medicaid State Plan Allowable Costs Massachusetts must use the same definition for all inpatient hospital, outpatient hospital, and physician services, clinic services, non-hospital services, etc. as described in its approved Medicaid State plan, and in accordance with Section 1905 of the Social Security Act and the regulations promulgated thereunder, to define allowable service costs provided by institutions for mental disease. Massachusetts identifies other service costs, subject to CMS approval, that are not included in the Medicaid state plan definitions to be included as allowable uncompensated care costs in this document (see Cost Element table2013). Inpatient psychiatric hospital services: Psychiatric treatment provided under the direction of a psychiatrist in a psychiatric inpatient hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Outpatient psychiatric hospital services: Services provided to members on an outpatient basis in a psychiatric hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Community Based Detoxification Center (CBDC): CBDCs are eligible to receive Safety Net Care Pool payments as Institutions for Mental Diseases (IMDs) under the section 1115 demonstration. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Acute Inpatient Substance Abuse Treatment Services: Short-term medical treatment for substance withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post detoxification referrals provided by an inpatient unit, either freestanding or hospital-based, licensed as an acute inpatient substance abuse treatment service by the Massachusetts Department of Public Health under its regulations at 105 CMR 160.000 and 161.000. These services are delivered in a three-tiered system consisting of Levels III-A through III-C that must conform with the standards and patient placement criteria issued and enforced by the Massachusetts Department of Public Health's Bureau of Substance Abuse Services. Substance Abuse Outpatient Counseling Service: An outpatient counseling service that is a Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 rehabilitative treatment service for individuals and their families experiencing the dysfunctional effects of the use of substances. 1115 Demonstration Population Expenditures: Costs incurred by psychiatric hospitals and CBDCs for providing IMD services to members eligible for Medicaid through the State plan and section 1115 demonstration will be counted as allowable costs. Allowable costs for psychiatric hospital services and CBDC services provided under the 1115 demonstration include service-related expenditures (please note that all services authorized under the section 1115 demonstration are subject to the requirements and limitations specified in the STCs). The list of allowable services is contained in the Cost Element table. Medicaid Managed Care Costs: Costs incurred by IMDs for providing services to members enrolled in Medicaid managed care organizations including SCOs and ICOs, prepaid inpatient health plans, and any prepaid ambulatory health plans. Eligible costs are determined using the same methodology under this section.

Final Reconciliation. Each provider(1) Within sixty (60) days after final completion of Landlord 's uncompensated care costs must be recomputed based on TI Work, Landlord shall cause Landlord's Representative to provide Tenant with the provider's audited CMS 2552 cost report for Final Reconciliation and arrange to meet with Tenant to discuss the actual service period. These recomputed costs must be carried over to the UCCR. The CMS 2552 cost report is audited and settled by the Medicare contractor to determine final allowable costs and reimbursement amounts as recognized by Medicare. For SNCP payments subject to the cost limit pursuant to STC 49(c), each provider’s allowable Medicaid, uncompensated care, and uninsured costs must be reconciled against associated applicable payments received for the year for which the payments were made. SNCP uncompensated care payments made to the provider for a cost limit reporting year cannot exceed the recomputed uncompensated care cost limit. If, at the end of the final reconciliation process, it is determined that expenditures claimed exceeded the individual provider's uncompensated care cost limit, thereby causing an overpayment, the Commonwealth must recoup the overpayment from the provider. Specifically, if an overpayment exists, the Commonwealth must determine if the overpayment occurred due to HSN Trust Fund payments or other SNCP payments, or from both paymentscontents thereof. To the extent Landlord requires information in Tenant's possession in order for Landlord to prepare the Final Reconciliation, Landlord will promptly notify Tenant of the needed information, and Tenant agrees to provide such information to Landlord promptly after Landlord's written request specifying the information required to the extent in Tenant's possession, custody or control. Landlord's delivery of the Final Reconciliation shall be excused for so long as Tenant delays in providing information needed to complete same which is in Tenant's possession, custody or control to Landlord. If the Final Reconciliation indicates that the overpayment is a result total cost to complete Landlord's TI Work exceeds the TI Allowance, then such excess shall constitute an Excess TI Cost for purposes of overpaid funds this Exhibit C and shall be payable by Tenant to Landlord within ten (10) business days after Landlord's written demand (to the extent not theretofore funded by Tenant). (2) If the Final TI Bid (or any combination of Tl Costs for which Tenant will be responsible hereunder) exceeds the TI Allowance, Landlord shall have the right to require payment from the HSN Trust Fund, the Commonwealth must recover from the provider Tenant of the amount overpaid by which aggregate Excess TI Costs exceeds the T! Allowance prior to being obligated to proceed with the TI Work from which such Excess TI Costs are derived, which payment shall be made by Tenant to Landlord within ten (10) business days after Landlord's written demand accompanied by reasonable substantiating documentation, and which (ifbeingpaid to defray Excess Costs which are not yet due and payable to the provider from contractor under the HSN Trust Fund and credit that amount to terms of the HSN Trust Fund. The HSN Trust Fund will redistribute such amounts to other providers as appropriate. To the extent that the overpayment is not the result of HSN Trust Fund payments, the Commonwealth must recover from the provider the overpayment, and the Commonwealth must properly credit the federal share to the federal government. For hospitals whose accounting fiscal year aligns with the cost limit reporting fiscal year (Federal fiscal year), the Medicaid and uninsured costs applicable construction contract) will be reflected held by Landlord, in the CMS 2552 and UCCR that is submitted for the accounting fiscal year. For acute hospitals whose accounting fiscal years do not align with the reporting fiscal year, the reporting year cost limit will be calculated by applying the appropriate percentage of the two contiguous CMS 2552 and UCCR cost reports that span the reporting fiscal year so that the Federal fiscal year will be represented in the cost limit calculation. The Commonwealth must recover provider overpayments as it determines necessary based on its reconciliation calculations and availability of federal financial participation. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 The final reconciliation described above must be performed and completed within twelve months after all final, audited CMS 2552 cost reports become available online. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Institutions for Mental Diseases – Psychiatric Hospitals and Community Based Detoxification Centers (CBDCs) Protocol for Medicaid and Uncompensated Care Cost The Commonwealth will use the reports described below to collect data from these providers. Psychiatric hospitals will fill out the CMS 2552 and UCCR, as required of other hospitals in the cost limit protocol. CBDCs are non-hospital human and social services contractors that do not file a CMS 2552 cost report; therefore, for the purposes of the protocol, the Commonwealth will use only the Massachusetts Uniform Financial Statements and Independent Auditor’s Report (UFR) to determine costs and revenues. The UFR is the set of financial statements and schedules required of human and social service contracting with state departments. For the calculation of provider-specific cost limits, psychiatric hospitals and CBDCs will fill out the necessary reports with the information that is relevant to the services they provide to the Medicaid-eligible and HSN and uninsured populations. Determination of Allowable Medicaid and Uninsured Costs DSH Allowable Costs Per STC 50(f), the Commonwealth will use the Medicaid DSH statutory, regulatory, and policy definitions of allowable psychiatric hospital services and allowable Medicaid and uninsured costs in determining hospital-specific cost limits in its cost protocols. To the extent that the determination of uncompensated care costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Pharmacy service costs are separately identified on the CMS 2552 10 cost report and are not recognized as an inpatient or outpatient hospital service. Pharmacy service costs that are not part of an inpatient or outpatient rate and are billed as pharmacy service and reimbursed as such are not considered eligible for inclusion in the hospital-specific uncompensated cost limit allowable under DSH. To the extent that the determination of allowable pharmacy costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Costs included must be for services that meet the federal definition and the approved Massachusetts State plan definition of “hospital services” for medical assistance. “Medical assistance” is defined as the cost of care and services “for individuals, and, with respect to physicians’ or dentists’ services, at the option of the Statetrust, to individuals [who are eligible]…” Section 1905 be disbursed pari passu with any amounts utilized by Landlord to make payments in respect of the ActTI Costs. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Medicaid State Plan Allowable Costs Massachusetts must use the same definition for all inpatient hospital, outpatient hospital, and physician services, clinic services, non-hospital services, etc. as described in its approved Medicaid State plan, and in accordance with Section 1905 of the Social Security Act and the regulations promulgated thereunder, Any amounts paid by Tenant to define allowable service costs provided by institutions for mental disease. Massachusetts identifies other service costs, subject to CMS approval, that are not included in the Medicaid state plan definitions to be included as allowable uncompensated care costs in this document (see Cost Element table). Inpatient psychiatric hospital services: Psychiatric treatment provided under the direction of a psychiatrist in a psychiatric inpatient hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Outpatient psychiatric hospital services: Services provided to members on an outpatient basis in a psychiatric hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Community Based Detoxification Center (CBDC): CBDCs are eligible to receive Safety Net Care Pool payments as Institutions for Mental Diseases (IMDs) under the section 1115 demonstration. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Acute Inpatient Substance Abuse Treatment Services: Short-term medical treatment for substance withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post detoxification referrals provided by an inpatient unit, either freestanding or hospital-based, licensed as an acute inpatient substance abuse treatment service by the Massachusetts Department of Public Health under its regulations at 105 CMR 160.000 and 161.000. These services are delivered in a three-tiered system consisting of Levels III-A through III-C that must conform with the standards and patient placement criteria issued and enforced by the Massachusetts Department of Public Health's Bureau of Substance Abuse Services. Substance Abuse Outpatient Counseling Service: An outpatient counseling service that is a Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 rehabilitative treatment service for individuals and their families experiencing the dysfunctional effects of the use of substances. 1115 Demonstration Population Expenditures: Costs incurred by psychiatric hospitals and CBDCs for providing IMD services to members eligible for Medicaid through the State plan and section 1115 demonstration will be counted as allowable costs. Allowable costs for psychiatric hospital services and CBDC services provided under the 1115 demonstration include service-related expenditures (please note that all services authorized under the section 1115 demonstration are subject to the requirements and limitations specified in the STCs). The list of allowable services is contained in the Cost Element table. Medicaid Managed Care Costs: Costs incurred by IMDs for providing services to members enrolled in Medicaid managed care organizations including SCOs and ICOs, prepaid inpatient health plans, and any prepaid ambulatory health plans. Eligible costs are determined using the same methodology Landlord under this section.provision shall be credited against such Excess TI Costs. D. First-

Final Reconciliation. Each providerFQHC-LA's uncompensated care costs must be recomputed based on the provider's actual audited CMS 2552 cost report for the actual service period. These recomputed costs must be carried over to the UCCR. The CMS 2552 cost report is audited to ensure costs are allowable consistent with Medicare and settled by Medicaid cost principles and applicable OMB Circulars; and that FQHC services and visits are recognized consistent with the Medicare contractor to determine final allowable costs and reimbursement amounts as recognized by Medicare. For SNCP payments subject to the cost limit pursuant to STC 49(c), each provider’s allowable Medicaid, uncompensated care, and uninsured costs must be reconciled against associated applicable payments received for the year for which the payments were madeMedicaid State plan. SNCP uncompensated care payments made to the provider FQHC-LA for a cost limit reporting year DY cannot exceed the recomputed uncompensated care cost limit. If, at the end of the final reconciliation process, it is determined that expenditures claimed exceeded the individual providerclinic's uncompensated care cost limit, thereby causing an overpayment, the Commonwealth must recoup the overpayment will be recouped from the provider. Specifically, if an overpayment exists, the Commonwealth must determine if the overpayment occurred due to HSN Trust Fund payments or other SNCP payments, or from both payments. To the extent that the overpayment is a result of overpaid funds from the HSN Trust Fund, the Commonwealth must recover from the provider the amount overpaid to the provider from the HSN Trust Fund and credit that amount to the HSN Trust Fund. The HSN Trust Fund will redistribute such amounts to other providers as appropriate. To the extent that the overpayment is not the result of HSN Trust Fund payments, the Commonwealth must recover from the provider the overpaymentclinic, and the Commonwealth must properly credit the federal share will be properly credited to the federal government. For hospitals whose The final reconciliation follows the same computation as outlined above in the Interim Computation of Uncompensated Care Costs steps, except that: - The cost per visit is computed based on audited allowable FQHC-LA cost and total visits pertaining to the actual service period cost report. - Both Medicaid visits and uninsured visits furnished during the service period are applied to the audited cost per visit to determine the clinic's Medicaid and uninsured costs. Medicaid and uninsured visits must be derived from the latest available auditable sources, including the State's PMMIS, managed care encounter data, and provider patient accounting fiscal year aligns with records. - Both Medicaid and uninsured revenues, applicable to actual service period and derived from the cost limit reporting fiscal year (Federal fiscal year)latest available auditable sources, the are offset against Medicaid and uninsured costs to arrive at the clinic's uncompensated care costs. - No trending factor will be reflected in the CMS 2552 and UCCR that applied. The uncompensated care costs must again be adjusted to remove costs related to non-emergency services furnished to unqualified aliens. An FQHC-LA's uncompensated care cost limit is submitted determined for the accounting fiscal yeartwelve month period in each DY, except for DY 3 in which the uncompensated care cost limit is computed for the three month period ending December 31, 2013. For acute hospitals whose accounting fiscal years do Where a clinic's cost reporting period does not align coincide with the reporting fiscal year, the reporting year cost limit will be calculated by applying the appropriate percentage of the two contiguous CMS 2552 and UCCR cost reports that span the reporting fiscal year so that the Federal fiscal year will be represented DY (or partial DY in the cost limit calculation. The Commonwealth must recover provider overpayments as it determines necessary based on its reconciliation calculations and availability of federal financial participation. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 The final reconciliation described above must be performed and completed within twelve months after all final, audited CMS 2552 cost reports become available online. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Institutions for Mental Diseases – Psychiatric Hospitals and Community Based Detoxification Centers (CBDCs) Protocol for Medicaid and Uncompensated Care Cost The Commonwealth will use the reports described below to collect data from these providers. Psychiatric hospitals will fill out the CMS 2552 and UCCR, as required of other hospitals in the cost limit protocol. CBDCs are non-hospital human and social services contractors that do not file a CMS 2552 cost report; therefore, for the purposes of the protocol, the Commonwealth will use only the Massachusetts Uniform Financial Statements and Independent Auditor’s Report (UFR) to determine costs and revenues. The UFR is the set of financial statements and schedules required of human and social service contracting with state departments. For the calculation of provider-specific cost limits, psychiatric hospitals and CBDCs will fill out the necessary reports with the information that is relevant to the services they provide to the Medicaid-eligible and HSN and uninsured populations. Determination of Allowable Medicaid and Uninsured Costs DSH Allowable Costs Per STC 50(fDY3), the Commonwealth will use the Medicaid DSH statutory, regulatory, and policy definitions of allowable psychiatric hospital services and allowable Medicaid and uninsured costs in determining hospital-specific cost limits in its cost protocols. To the extent that the determination of uncompensated care costs varies from computed for a cost reporting period can be allocated to the Medicaid DSH requirements, the process must be accounted for in this document. Pharmacy service costs are separately identified DY (or partial DY) based on the CMS 2552 10 number of cost report and are not recognized as an inpatient or outpatient hospital service. Pharmacy service costs reporting months that are not part of an inpatient or outpatient rate and are billed as pharmacy service and reimbursed as such are not considered eligible for inclusion in the hospital-specific uncompensated cost limit allowable under DSH. To the extent that the determination of allowable pharmacy costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Costs included must be for services that meet the federal definition and the approved Massachusetts State plan definition of “hospital services” for medical assistance. “Medical assistance” is defined as the cost of care and services “for individuals, and, with respect to physicians’ or dentists’ services, at the option of the State, to individuals [who are eligible]…” Section 1905 of the Act. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Medicaid State Plan Allowable Costs Massachusetts must use the same definition for all inpatient hospital, outpatient hospital, and physician services, clinic services, non-hospital services, etc. as described in its approved Medicaid State plan, and in accordance with Section 1905 of the Social Security Act and the regulations promulgated thereunder, to define allowable service costs provided by institutions for mental disease. Massachusetts identifies other service costs, subject to CMS approval, that are not included in the Medicaid state plan definitions to be included as allowable uncompensated care costs in this document (see Cost Element table). Inpatient psychiatric hospital services: Psychiatric treatment provided under the direction of a psychiatrist in a psychiatric inpatient hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Outpatient psychiatric hospital services: Services provided to members on an outpatient basis in a psychiatric hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Community Based Detoxification Center (CBDC): CBDCs are eligible to receive Safety Net Care Pool payments as Institutions for Mental Diseases (IMDs) under the section 1115 demonstration. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Acute Inpatient Substance Abuse Treatment Services: Short-term medical treatment for substance withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post detoxification referrals provided by an inpatient unit, either freestanding or hospital-based, licensed as an acute inpatient substance abuse treatment service by the Massachusetts Department of Public Health under its regulations at 105 CMR 160.000 and 161.000. These services are delivered in a three-tiered system consisting of Levels III-A through III-C that must conform overlap with the standards and patient placement criteria issued and enforced by the Massachusetts Department of Public Health's Bureau of Substance Abuse Services. Substance Abuse Outpatient Counseling Service: An outpatient counseling service that is a Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 rehabilitative treatment service for individuals and their families experiencing the dysfunctional effects of the use of substances. 1115 Demonstration Population Expenditures: Costs incurred by psychiatric hospitals and CBDCs for providing IMD services to members eligible for Medicaid through the State plan and section 1115 demonstration will be counted as allowable costs. Allowable costs for psychiatric hospital services and CBDC services provided under the 1115 demonstration include service-related expenditures DY (please note that all services authorized under the section 1115 demonstration are subject to the requirements and limitations specified in the STCsor partial DY). The list of allowable services is contained in the Cost Element table. Medicaid Managed Care Costs: Costs incurred by IMDs for providing services to members enrolled in Medicaid managed care organizations including SCOs and ICOs, prepaid inpatient health plans, and any prepaid ambulatory health plans. Eligible costs are determined using the same methodology under this section.

Final Reconciliation. Each providerhospital's uncompensated care costs must be recomputed based on the providerhospital's audited CMS 2552 cost report for the actual service period. These recomputed costs must be carried over to the UCCR. The CMS 2552 cost report is audited and settled by the Medicare contractor to determine final allowable costs and reimbursement amounts as recognized by Medicare. For SNCP payments subject to the cost limit pursuant to STC 49(c), each provider’s allowable Medicaid, uncompensated care, and uninsured costs must be reconciled against associated applicable payments received for the year for which the payments were made. SNCP uncompensated care payments made to the provider hospital for a cost limit reporting year DY cannot exceed the recomputed uncompensated care cost limit. If, at the end of the final reconciliation process, it is determined that expenditures claimed exceeded the individual providerhospital's uncompensated care cost limit, thereby causing an overpayment, the Commonwealth must recoup the overpayment will be recouped from the provider. Specifically, if an overpayment exists, the Commonwealth must determine if the overpayment occurred due to HSN Trust Fund payments or other SNCP payments, or from both payments. To the extent that the overpayment is a result of overpaid funds from the HSN Trust Fund, the Commonwealth must recover from the provider the amount overpaid to the provider from the HSN Trust Fund and credit that amount to the HSN Trust Fund. The HSN Trust Fund will redistribute such amounts to other providers as appropriate. To the extent that the overpayment is not the result of HSN Trust Fund payments, the Commonwealth must recover from the provider the overpaymenthospital, and the Commonwealth must properly credit the federal share will be properly credited to the federal government. For hospitals whose accounting fiscal year aligns The final reconciliation follows the same computation as outlined above in the Interim Computation of Uncompensated Care Costs steps, except that the per diems and RCCs, Medicaid and uninsured days and charges, and payment offset amounts used will pertain to the actual service period (rather than the prior period). Per diems and RCCS will be derived from the audited cost report, and Medicaid and uninsured days, charges and payments will be updated with the latest available auditable data for the service period. No trending factor will be applied. The uncompensated care costs must again be adjusted to remove costs related to non-emergency services furnished to unqualified aliens. The state must ensure that there is no duplication of payments for the same hospital uncompensated care costs under the SNCP and under DSH; SNCP payments must be accounted for in the hospital's OBRA 93 hospital-specific limit. A hospital's uncompensated care cost limit is determined for the twelve month period in each DY, except 1) for PCH in DY 5 in which the uncompensated care cost limit is computed for the three month period ending December 31, 2015, and 2) for all other hospitals in DY 3 in which the uncompensated care cost limit is computed for the three month period ending December 31, 2013. Where a hospital's cost reporting fiscal year period does not coincide with the DY (Federal fiscal yearor partial DY in DY3 or DY 5), the Medicaid and uninsured uncompensated care costs will computed for a cost reporting period can be reflected in allocated to the CMS 2552 and UCCR DY (or partial DY) based on the number of cost reporting months that overlap with the DY (or partial DY). This is submitted consistent with the methodology for the accounting fiscal year. For acute hospitals whose accounting fiscal years do not align with the reporting fiscal year, the reporting year cost limit will be calculated by applying the appropriate percentage computation of the two contiguous CMS 2552 and UCCR cost reports that span the reporting fiscal year so that the Federal fiscal year will be represented in the cost OBRA 93 hospital-specific limit calculationfor a given DSH State Plan Rate Year. The Commonwealth must recover provider overpayments as it determines necessary based on its reconciliation calculations and availability of federal financial participation. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 The final reconciliation described above must will be performed and completed within twelve six months after all final, the audited CMS 2552 hospital Medicare cost reports become available online. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Institutions for Mental Diseases – Psychiatric Hospitals and Community Based Detoxification Centers (CBDCsreport(s) Protocol for Medicaid and Uncompensated Care Cost The Commonwealth will use the reports described below to collect data from these providers. Psychiatric hospitals will fill out the CMS 2552 and UCCR, as required of other hospitals in the cost limit protocol. CBDCs are non-hospital human and social services contractors that do not file a CMS 2552 cost report; therefore, for the purposes of the protocol, the Commonwealth will use only the Massachusetts Uniform Financial Statements and Independent Auditor’s Report (UFR) to determine costs and revenues. The UFR is the set of financial statements and schedules required of human and social service contracting with state departments. For the calculation of provider-specific cost limits, psychiatric hospitals and CBDCs will fill out the necessary reports with the information that is relevant to the services they provide to the Medicaid-eligible and HSN and uninsured populations. Determination of Allowable Medicaid and Uninsured Costs DSH Allowable Costs Per STC 50(f), the Commonwealth will use the Medicaid DSH statutory, regulatory, and policy definitions of allowable psychiatric hospital services and allowable Medicaid and uninsured costs in determining hospital-specific cost limits in its cost protocols. To the extent that the determination of uncompensated care costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Pharmacy service costs are separately identified on the CMS 2552 10 cost report and are not recognized as an inpatient or outpatient hospital service. Pharmacy service costs that are not part of an inpatient or outpatient rate and are billed as pharmacy service and reimbursed as such are not considered eligible for inclusion in the hospital-specific uncompensated cost limit allowable under DSH. To the extent that the determination of allowable pharmacy costs varies from the Medicaid DSH requirements, the process must be accounted for in this document. Costs included must be for services that meet the federal definition and the approved Massachusetts State plan definition of “hospital services” for medical assistance. “Medical assistance” is defined as the cost of care and services “for individuals, and, with respect to physicians’ or dentists’ services, at the option of the State, to individuals [who are eligible]…” Section 1905 of the Act. Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 Medicaid State Plan Allowable Costs Massachusetts must use the same definition for all inpatient hospital, outpatient hospital, and physician services, clinic services, non-hospital services, etc. as described in its approved Medicaid State plan, and in accordance with Section 1905 of the Social Security Act and the regulations promulgated thereunder, to define allowable service costs provided by institutions for mental disease. Massachusetts identifies other service costs, subject to CMS approval, that are not included in the Medicaid state plan definitions to be included as allowable uncompensated care costs in this document (see Cost Element table). Inpatient psychiatric hospital services: Psychiatric treatment provided under the direction of a psychiatrist in a psychiatric inpatient hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Outpatient psychiatric hospital services: Services provided to members on an outpatient basis in a psychiatric hospital. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Community Based Detoxification Center (CBDC): CBDCs are eligible to receive Safety Net Care Pool payments as Institutions for Mental Diseases (IMDs) under the section 1115 demonstration. Such services are as described in Section 1905 of the Social Security Act and the regulations promulgated thereunder. Acute Inpatient Substance Abuse Treatment Services: Short-term medical treatment for substance withdrawal, individual medical assessment, evaluation, intervention, substance abuse counseling, and post detoxification referrals provided by an inpatient unit, either freestanding or hospital-based, licensed as an acute inpatient substance abuse treatment service by the Massachusetts Department of Public Health under its regulations at 105 CMR 160.000 and 161.000. These services are delivered in a three-tiered system consisting of Levels III-A through III-C that must conform with the standards and patient placement criteria issued and enforced by the Massachusetts Department of Public Health's Bureau of Substance Abuse Services. Substance Abuse Outpatient Counseling Service: An outpatient counseling service that is a Massachusetts MassHealth Section 1115 Demonstration Safety Net Care Pool Uncompensated Care Cost Limit Protocol December 11, 2013 rehabilitative treatment service for individuals and their families experiencing the dysfunctional effects of the use of substances. 1115 Demonstration Population Expenditures: Costs incurred by psychiatric hospitals and CBDCs for providing IMD services to members eligible for Medicaid through the State plan and section 1115 demonstration will be counted as allowable costs. Allowable costs for psychiatric hospital services and CBDC services provided under the 1115 demonstration include service-related expenditures (please note that all services authorized under the section 1115 demonstration are subject to the requirements and limitations specified in the STCs). The list of allowable services is contained in the Cost Element table. Medicaid Managed Care Costs: Costs incurred by IMDs for providing services to members enrolled in Medicaid managed care organizations including SCOs and ICOs, prepaid inpatient health plans, and any prepaid ambulatory health plans. Eligible costs are determined using the same methodology under this sectionmade available.