101 CMR 361.00 — Rates for Continuous Skilled Nursing Agency and Independent Nursing Services

Final Adoption Date Published in Mass. Register: August 2, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 361.00: RATES FOR CONTINUOUS SKILLED NURSING AGENCY AND INDEPENDENT NURSING SERVICES

1 Section

361.01: General Provisions 361.02: General Definitions 361.03: General Rate Provisions 361.04: Rates of Payment 361.05: Administrative Adjustment 361.06: Filing and Reporting Requirements 361.07: Severability

101 CMR 361.00 Rates for Continuous Skilled Nursing Agency and Independent Nursing Services

361.01 General Provisions

361.01: General Provisions

(1) Scope. 101 CMR 361.00 establishes rates of payment for continuous skilled nursing agency services and independent nursing services rendered by eligible providers to publicly aided individuals. The rates set forth in 101 CMR 361.00 also apply to individuals covered by M.G.L. c. 152 (the Workers’ Compensation Act).

(2) Applicable Dates of Service. Rates contained in 101 CMR 361.00 apply for dates of service on or after August 1, 2024, unless otherwise specifically noted.

(3) Coverage. (a) Separate rates are specified for the following situations.

1. The eligible provider bills as an individual practitioner for professional services rendered, and the services are not covered by a facility rate.
2. The eligible provider bills as a provider agency and employs, either through contractual agreement or salary, qualified professionals who do not bill independently for professional services rendered and whose services are not covered by a facility rate. (b) The allowable fees established pursuant to 101 CMR 361.00 for services provided to publicly aided individuals apply to all continuous skilled nursing services, registered nurse (RN) supervisory visits, and complex care assistant services, as defined in 101 CMR 361.02, regardless of the type of program under which MassHealth is purchasing the services. The allowable fees are full compensation for the continuous skilled nursing services, RN supervisory visits, and complex care assistant services rendered including, but not limited to, administrative or supervisory duties and costs in connection with service provision.

(4) Administrative Bulletins. EOHHS may issue administrative bulletins to clarify its policy on substantive provisions of 101 CMR 361.00 and to specify the information and documentation necessary to implement 101 CMR 361.00.

(5) Coding Updates and Corrections. EOHHS may publish procedure code updates and corrections in the form of an administrative bulletin. Updates may reference coding systems including, but not limited to, the American Medical Association’s Current Procedural Terminology (CPT) and/or the Healthcare Common Procedure Coding System (HCPCS). The publication of such updates and corrections will list:

Final Adoption Date Published in Mass. Register: August 2, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 361.00: RATES FOR CONTINUOUS SKILLED NURSING AGENCY AND INDEPENDENT NURSING SERVICES

2 (a) codes for which the code numbers change, with the corresponding cross-references between new codes and the codes being replaced. Rates for such new codes are set at the rate of the code that is being replaced; (b) codes for which the code number remains the same, but the description has changed; and (c) deleted codes for which there are no corresponding new codes.

(6 ) Disclaimer of Authorization of Services. 101 CMR 361.00 is not authorization for or approval of the substantive services, or lengths of time, for which rates are paid pursuant to 101 CMR 361.00. Governmental units or workers’ compensation insurers that purchase services from eligible providers are responsible to define, authorize, and approve the services extended to covered individuals and the length of time for which the approval is applicable.

361.02 General Definitions

361.02: General Definitions

As used in 101 CMR 361.00, terms have the meanings set forth in 101 CMR 361.02, unless the context requires otherwise.

Center. The Center for Health Information and Analysis established under M.G.L. c. 12C.

Complex Care Assistant. A person who is employed or contracted by a CSN agency and meets the qualifications of a complex care assistant to perform certain health-related services as described in 130 CMR 438.415(C): Recordkeeping.

Continuous Skilled Nursing (CSN) Agency. A public or private organization that meets the requirements of 130 CMR 438.000: Continuous Skilled Nursing Agency and provides CSN agency services to complex care members within the member’s home.

Continuous Skilled Nursing (CSN) Agency Services. CSN services and complex care assistant services as described in 130 CMR 438.402: Definitions and delivered to MassHealth-eligible members. For details on requirements, see 130 CMR 438.000: Continuous Skilled Nursing Agency.

Continuous Skilled Nursing (CSN) Services. Skilled nursing care provided by a licensed nurse to complex care members who require more than two continuous hours of nursing services per day and as defined in 130 CMR 438.000: Continuous Skilled Nursing Agency.

Eligible Provider. An individual practitioner or an organization that meets such conditions of participation as have been or may be adopted by a governmental unit purchasing CSN or CSN agency services.

EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A.

Governmental Unit. The Commonwealth of Massachusetts and any department, agency, board, commission, division, or political subdivision of the Commonwealth.

Final Adoption Date Published in Mass. Register: August 2, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 361.00: RATES FOR CONTINUOUS SKILLED NURSING AGENCY AND INDEPENDENT NURSING SERVICES

3 Home Health Agency. An organization that meets the requirements of 130 CMR 403.000: Home Health Agency to provide home health services, including continuous skilled nursing.

Individual Practitioner. An RN or licensed practical nurse (LPN), who directly provides authorized continuous skilled nursing services and who bills independently for professional services rendered as defined in 130 CMR 414.402: Independent Nurse.

Provider Agency. A partnership, corporation, or other entity, other than an individual, that provides authorized CSN agency services, as defined in 101 CMR 361.02: Continuous Skilled Nursing (CSN) Agency Services, by an RN, LPN, or complex care assistant (as applicable) who is its employee.

Publicly Aided Individual. A person who receives health care and services for which a governmental unit is in whole or part liable under a statutory program.

Reasonable Costs. Those reasonable and necessary costs incurred by an eligible provider of CSN, subject to the requirements and limitations of 101 CMR 361.00. In determining the reasonableness of costs, EOHHS may consider the particular services offered, the introduction of efficiency measures, the requirements for staffing, and the costs of providing comparable service.

Security/Escorts. The provision of security services to direct care personnel in the performance of a reimbursable home health visit.

Sixty-day Supervisory Visit (60-day Supervisory Visit). The 60-day supervisory visit conducted by an RN and described in 130 CMR 438.415(C)(5)(c), made to the member’s home in order to observe and assess the complex care assistant while they are performing care. A reassessment of the member’s needs may be done at this time.

Weekday. The hours from 7:00 A.M. to 3:00 P.M., Monday through Friday.

Weekend and Nights. (a) Weekend. The hours from 3:00 P.M., Friday, to 7:00 A.M., Monday. (b) Nights. The hours from 3:00 P.M. to 7:00 A.M., Monday through Friday. (c) Holidays. All official Commonwealth of Massachusetts holidays. For purposes of 101 CMR 361.00, holidays that occur on a weekend are observed on that day and not the preceding Friday or following Monday. New Year's Day Martin Luther King Jr. Day Presidents’ Day Patriots’ Day Memorial Day Juneteenth Independence Day Independence Day Labor Day Indigenous Peoples’ Day Veterans Day

Final Adoption Date Published in Mass. Register: August 2, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 361.00: RATES FOR CONTINUOUS SKILLED NURSING AGENCY AND INDEPENDENT NURSING SERVICES

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361.03 General Rate Provisions

361.03: General Rate Provisions

Rates of payment for authorized continuous skilled nursing services to which 101 CMR 361.00 applies will be the lower of (a) the eligible provider's usual fee to patients other than publicly aided patients; or (b) the schedule of rates set forth in 101 CMR 361.04.

361.04 Rates of Payment

361.04: Rates of Payment

(1) Continuous Skilled Nursing Services. (a ) Single Patient, per Straight-time Hour. Weekend rates are the same as night rates.

Rates per 15 Minutes: Single Patient, per Straight-time Hour Code Modifier Agency Individual Practitioner Description T1002 $23.61 $19.46 RN Services, Weekday T1002 UJ $25.14 $20.88 RN Services, Nights T1002 $33.12 $28.22 RN Services, Holidays T1003 $16.35 $13.47 LPN Services, Weekday T1003 UJ $17.41 $14.46 LPN Services, Nights T1003 $23.01 $19.60 LPN Services, Holidays

(b ) Multiple-patient Nursing.

1. Two Individuals, per Straight-time Hour. When only one of the individuals is publicly aided, the fee for services to the publicly aided individual will be ½ of the appropriate rate listed in the table “Two Individuals, per Straight-t ime Hour.” Weekend rates are the same as night rates.

Rates per 15 Minutes: Two Individuals, per Straight-time Hour Code Modifier Agency Individual Practitioner Description T1002 TT $33.21 $28.13 RN Services, Weekday T1002 U1 $35.36 $30.18 RN Services, Nights T1002 TT $46.59 $40.80 RN Services, Holidays T1003 TT $23.10 $19.56 LPN Services, Weekday T1003 U1 $24.61 $20.99 LPN Services, Nights T1003 TT $32.52 $28.46 LPN Services, Holidays

2. Three Individuals, per Straight-time Hour. When only one of the individuals is publicly aided, the fee for services to the publicly aided individual will be ⅓ of the appropriate rate listed. When two of the individuals are publicly aided, the fee for services to the publicly aided individuals will be ⅔ of the appropriate rate listed. Weekend rates are the same as night rates.

Final Adoption Date Published in Mass. Register: August 2, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 361.00: RATES FOR CONTINUOUS SKILLED NURSING AGENCY AND INDEPENDENT NURSING SERVICES

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Rates per 15 Minutes: Three Individuals, per Straight-time Hour Code Modifier Agency Individual Practitioner Description T1002 U2 $39.68 $32.62 RN Services, Weekday T1002 U3 $42.24 $35.00 RN Services, Nights T1002 U2 $55.66 $47.31 RN Services, Holidays T1003 U2 $28.04 $22.68 LPN Services, Weekday T1003 U3 $29.87 $24.34 LPN Services, Nights T1003 U2 $39.47 $33.00 LPN Services, Holidays

(c ) Overtime. Weekend rates are the same as night rates.

Rates per 15 Minutes: Overtime Code Modifier Agency Individual Practitioner Description T1002 TU $32.66 $27.88 RN Services, Weekday T1002 U4 $34.77 $29.91 RN Services, Nights T1002 TU $48.77 $40.43 RN Services, Holidays T1003 TU $22.74 $19.41 LPN Services, Weekday T1003 U4 $24.22 $20.83 LPN Services, Nights T1003 TU $32.01 $28.25 LPN Services, Holidays

(d ) Complex Care Assistant and RN Supervisory Visits.

Rate per 15 Minutes: Complex Care Assistant and RN Supervisory Visits Code Modifier Agency Description T1002 U5 $23.61 60-day Supervisory Visit (RN) T1004 $11.25 Complex Care Assistant Visit

361.05 Administrative Adjustment

361.05: Administrative Adjustment

(1) A certified home health agency or CSN agency may apply for a change in rate(s) of payment due to costs associated with providing interpreter and security/escort services as defined in 101 CMR 361.02.

(2) Administrative adjustment may be provided on a prospective basis only.

(3) Administrative relief will consist of an adjustment to the rate calculated by dividing the costs from the most recently filed and reviewed Cost Report filed pursuant to 101 CMR 361.06, by the number of service units reported for that corresponding period. The costs allowed will be limited to reasonable costs as defined in 101 CMR 361.02.

Final Adoption Date Published in Mass. Register: August 2, 2024

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 361.00: RATES FOR CONTINUOUS SKILLED NURSING AGENCY AND INDEPENDENT NURSING SERVICES

6 (4) An administrative adjustment that an agency was awarded in a prior period may be updated by EOHHS using data from the most recent Cost Report.

361.06 Filing and Reporting Requirements

361.06: Filing and Reporting Requirements

(1) Required Cost Reports. Cost reporting requirements are governed by 957 CMR 6.00: Cost Reporting Requirements.

(2) Penalty for Noncompliance. The purchasing governmental unit may impose a penalty in the amount of up to 15% of its payments to any provider that fails to submit required information. The purchasing governmental unit will notify the provider in advance of its intention to impose a penalty under 101 CMR 361.06(2).

361.07 Severability

361.07: Severability

The provisions of 101 CMR 361.00 are severable. If any provision of 101 CMR 361.00 or application of any provision to an applicable individual, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of 101 CMR 361.00 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

101 CMR 361.00: M.G.L. c. 118E.