The Massachusetts Medicaid fee schedule is published by the Executive Office of Health and Human Services (EOHHS) in Title 101 of the Code of Massachusetts Regulations, with separate sections setting the dollar amounts for each service category. Those rates govern what MassHealth pays providers in the fee-for-service program and, increasingly, serve as the benchmark behind managed care payments as well. Below is what the schedule covers in 2026, how the rates are set, and the billing and compliance rules that decide whether a provider actually gets paid.
Where the Rates Live and How They Are Set
EOHHS’s rate-setting authority comes from Massachusetts General Laws Chapter 118E. Section 13C lets the secretary establish rates of payment for health care services and delegate that function when appropriate.1General Court of Massachusetts. Massachusetts General Laws Part I, Title XVII, Chapter 118E, Section 13C Section 13D adds the constraints: rates must be based on reported provider costs from no more than four years prior, adjusted for reasonableness and audit findings, and must reimburse only what an efficiently run provider would spend.2General Court of Massachusetts. Massachusetts General Laws Part I, Title XVII, Chapter 118E, Section 13D
The dollar figures appear in 101 CMR, broken out by service type. The main sections are:
- 101 CMR 317.00 — medicine services3Mass.gov. 101 CMR 317.00: Rates for Medicine Services
- 101 CMR 316.00 — surgery and anesthesia
- 101 CMR 314.00 — dental
- 101 CMR 315.00 — vision care
- 101 CMR 318.00 — radiology
- 101 CMR 304.00 — community health centers
- 101 CMR 305.00 — behavioral health
- 101 CMR 322.00 — durable medical equipment
- 101 CMR 327.00 — ambulance services
For physician services, rates are built on the Resource-Based Relative Value Scale. Each service is assigned a relative value reflecting physician work, practice expense, and malpractice cost, then multiplied by a conversion factor to produce a dollar amount. Geography matters too. Metro Boston rates differ from the rest of the state, as the community health center schedule below makes clear.
Before rates take effect, EOHHS runs a public comment period, giving providers and other stakeholders a chance to raise problems.
Fee-for-Service Rates vs. Managed Care Payments
MassHealth pays through two channels, and the schedule works differently in each. Under fee-for-service, providers bill MassHealth directly at the rates in 101 CMR. Under managed care, EOHHS pays Accountable Care Organizations and managed care organizations a per-member capitation rate, and those plans negotiate their own payment arrangements with providers.
The capitation rates paid to ACOs and MCOs are built from a Total Cost of Care standard drawn from historical claims across both populations. EOHHS historically assumed managed care plans would pay hospitals up to 105% of the MassHealth fee schedule and professional services up to 110%. Under the current pricing approach, EOHHS assumes providers are paid at 100% of the fee-for-service schedule when setting capitation rates and benchmarks.4Mass.gov. Summary of Pricing Methodology for Accountable Care Organizations and Managed Care Organizations The practical effect: the published 101 CMR rates are now a more reliable baseline for what providers actually receive regardless of which track the patient sits in.
2026 Rate Updates
Community Health Centers and Hospitals
EOHHS updated Health Safety Net prospective payment rates for community health centers effective January 1, 2026. The Metro Boston rates are $231.61 for an established-patient visit and $310.73 for a new-patient visit. Outside Metro Boston, the corresponding rates are $214.78 and $288.15.5Mass.gov. January 2026 Rate Updates for CHC and Hospitals
FY2026 hospital payment rates took effect for dates of service beginning October 1, 2025. Hospitals had until January 21, 2026 to submit rate correction requests.5Mass.gov. January 2026 Rate Updates for CHC and Hospitals
Telehealth at Parity
Chapter 260 of the Acts of 2020 required that MassHealth reimburse telehealth services at no less than the rate for the same service delivered in person.6General Court of Massachusetts. Session Law – Acts of 2020 Chapter 260 MassHealth All Provider Bulletin 374, effective October 2023, made this permanent agency policy. Audio-video and audio-only visits are both covered, with audio-only limited to services listed in Appendix T of the CPT codebook. Providers must obtain the member’s consent for telehealth and offer the option to receive care in person.7Mass.gov. MassHealth All Provider Bulletin 374
Federal Rate Transparency Starting July 1, 2026
A 2024 CMS final rule will change how the fee schedule is reported publicly. Starting July 1, 2026, states must publish a comparative payment rate analysis showing how their Medicaid fee-for-service rates compare to Medicare for three service categories: primary care, obstetric and gynecological care, and outpatient mental health and substance use disorder treatment. The comparison is code-by-code against Medicare’s non-facility physician fee schedule, broken out by provider type, geography, and whether the patient is an adult or child.8Medicaid.gov. A Guide for States to the Fee-For-Service Provisions of the Ensuring Access to Medicaid Services Final Rule
On the managed care side, MCOs and prepaid health plans must submit annual payment analyses to the state comparing what they actually paid against Medicare rates for the same services. States must post the results publicly within 30 days of submitting them to CMS.9Federal Register. Medicaid Program; Medicaid and Children’s Health Insurance Program (CHIP) Managed Care Access, Finance, and Quality
Services the Schedule Will Not Pay For
Federal law prohibits Medicaid payment for provider-preventable conditions, and Massachusetts follows the rule. That covers hospital-acquired conditions identified by Medicare (certain infections, pressure injuries acquired during inpatient stays) and three specific serious errors: performing the wrong procedure on a patient, operating on the wrong body part, or performing a procedure on the wrong patient.10eCFR. 42 CFR 447.26 – Prohibition on Payment for Provider-Preventable Conditions The provider absorbs these costs in full.
Getting on the Fee Schedule: Enrollment and Screening
A provider cannot bill MassHealth until enrollment is approved. Applications go through the online MassHealth Provider Application Request Form or by mail to MassHealth Provider Enrollment in Quincy. Some provider types owe an application fee. Dental providers, long-term services and supports providers, and ordering/referring/prescribing providers follow separate enrollment tracks with their own portals.11Mass.gov. Apply to Become a MassHealth Provider
Federal rules add screening on top. Every Medicaid provider is assigned a categorical risk level of limited, moderate, or high, and intensity climbs at each tier. All providers face license verification and federal database checks. Moderate-risk providers also get pre-enrollment and post-enrollment site visits. High-risk providers submit to criminal background checks, including fingerprinting for anyone with a 5% or greater ownership interest.12eCFR. 42 CFR 455.450 – Screening Levels for Medicaid Providers Where more than one category could apply, the highest one governs.
Enrollment must be revalidated at least every five years. MassHealth can terminate any provider whose owners fail to cooperate with screening, and must deny enrollment to anyone with a 5% or greater ownership interest who has been convicted of a Medicare, Medicaid, or CHIP-related crime in the past ten years.13eCFR. 42 CFR Part 455 Subpart E – Provider Screening and Enrollment
Getting Paid: Clean Claims and Prompt Payment
Federal regulations set the payment clock. MassHealth must pay 90% of clean claims from individual and group-practice providers within 30 days of receipt, and 99% within 90 days. All other claims must be paid within 12 months, with narrow exceptions for claims involving fraud investigations, retroactive rate adjustments, or pending Medicare coordination.14eCFR. 42 CFR 447.45 – Timely Claims Payment The timer runs from the date MassHealth stamps the claim as received, so electronic submission usually starts it faster than paper.
A clean claim is one that can be processed without further information from the provider. Missing data, coding errors, or documentation gaps disqualify a claim from clean-claim status. Resubmission restarts the payment timeline, which is why billing accuracy matters as a cash-flow issue and not only a compliance one.
Appealing a Denied or Underpaid Claim
When MassHealth denies or underpays a claim because of agency error, providers can appeal under 130 CMR 450.323. Each appeal needs a standard appeal form or cover letter describing the specific MassHealth error, the provider’s name and ID, the member’s information, the date of service, and evidence that the claim was originally submitted on time. Providers also attach copies of the remittance advice showing how the claim was processed and a clean copy of the claim itself.15Cornell Law Institute. 130 CMR 450.323 – Appeals of Erroneously Denied or Underpaid Claims
Incomplete appeals are where most providers lose. Keep organized records of every claim submission, remittance advice, and resubmission.
Compliance Rules That Can Void Your Payment
The Massachusetts False Claims Act
Massachusetts General Laws Chapter 12, Sections 5A through 5O create civil liability for anyone who knowingly submits a false claim for government payment, makes a false record supporting such a claim, or conceals an obligation to return money to the state.16General Court of Massachusetts. Massachusetts General Laws Part I, Title II, Chapter 12, Section 5B Violations can bring treble damages and substantial per-claim civil penalties. The statute also reaches anyone who receives an overpayment and fails to disclose it within 60 days of identifying it, even if the original claim was submitted correctly.
The 60-Day Overpayment Rule
Federal regulations mirror this. A provider who identifies an overpayment has 60 days to report and return it, or until the date any corresponding cost report is due, whichever is later. If the provider needs time to investigate whether related overpayments exist, the deadline can be suspended for up to 180 days while a good-faith investigation is underway. Any overpayment retained past the deadline becomes an “obligation” under the federal False Claims Act.17eCFR. 42 CFR 401.305 – Requirements for Reporting and Returning of Overpayments
Exclusion List Screening
Federal law requires providers to screen employees and contractors against the HHS Office of Inspector General’s List of Excluded Individuals and Entities. Anyone on the LEIE is barred from federally funded health care programs, and employing an excluded individual exposes the provider to civil monetary penalties. OIG recommends checking the LEIE before hiring and on a routine basis for existing staff.18U.S. Department of Health and Human Services, Office of Inspector General. Background Information At enrollment and reenrollment, MassHealth providers must also pass federal database checks including the LEIE, the National Plan and Provider Enumeration System, and the Social Security Administration’s Death Master File, with LEIE checks occurring no less frequently than monthly.13eCFR. 42 CFR Part 455 Subpart E – Provider Screening and Enrollment