101 CMR 348.00 — Rates for Day Habilitation Services

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

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 348.00: RATES FOR DAY HABILITATION SERVICES

1 Section

348.01: General Provisions 348.02: Definitions 348.03: Rate Provisions 348.04: Filing and Reporting Requirements 348.05: Severability

101 CMR 348.00 Rates for Day Habilitation Services

348.01 General Provisions

348.01: General Provisions

(1) Scope, Purpose, and Effective Date. 101 CMR 348.00 governs the payment rates for day habilitation services rendered to publicly aided individuals. The rates set forth in 101 CMR 348.00 also apply to day habilitation services governed by 130 CMR 419.000: Day Habilitation Center Services and other comparable programs.

(2) Applicable Dates of Service. Rates contained in 101 CMR 348.00 apply for dates of service on and after August 1, 2024, unless otherwise indicated.

(3) Coverage. The payment rates in 101 CMR 348.00 are full compensation for day habilitation services provided to publicly aided individuals as well as for any related administrative or supervisory duties rendered in connection with the provision of day habilitation services.

(4) Coding Updates and Corrections. EOHHS may publish procedure code updates and corrections in the form of an Administrative Bulletin. The publication of such updates and corrections will list: (a) codes for which only the code numbers change, with the corresponding cross references between existing and new codes; (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.

(5) Administrative Bulletins. EOHHS may issue administrative bulletins to clarify its policy on and understanding of substantive provisions of 101 CMR 348.00.

(6) Disclaimer of Authorization of Services. 101 CMR 348.00 is neither authorization for nor approval of the substantive programs for which rates are determined pursuant to 101 CMR 348.00. Governmental units that purchase care are responsible for the definition, authorization, and approval of care and services extended to covered individuals.

348.02 Definitions

348.02: Definitions

Meaning of Terms. Terms used in 101 CMR 348.00, unless the context requires otherwise, have the meanings ascribed in 101 CMR 348.02.

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

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 348.00: RATES FOR DAY HABILITATION SERVICES

2 Admission Services. Services provided to ensure safe and appropriate care planning for day habilitation members enrolling in day habilitation services for the first time. This is a one-time only claim per MassHealth member ID.

Approved Rates. The rates of payment that have been certified by EOHHS and filed with the Secretary of the Commonwealth. These rates govern payment for services under 101 CMR 348.00.

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

Day Habilitation Program. A structured, goal-oriented active treatment program of medically oriented, therapeutic, and habilitation services to raise recipients' levels of functioning and facilitate independent living and self-management in their communities.

Eligible Provider. Any individual, partnership, corporation, or other entity that offers services for purchase by a governmental unit and that meets the conditions of purchase or licensure established under 130 CMR 419.000: Day Habilitation Center Services.

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

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

Half Per Diem. Day habilitation services provided for a period equal to or less than three hours per day.

Monitor Transportation. Transportation services provided when the member is accompanied by an escort to ensure safety due to signs and symptoms related to medical needs, including Alzheimer’s disease and related dementias, or due to other known and verified behaviors related to mental health or developmental disability diagnoses.

Per Diem. Day habilitation services provided for a period greater than three hours per day.

Publicly Aided Individual. A person whose medical and other services a governmental unit is in whole or in part liable for under a statutory program.

Quarter Per Diem. Day habilitation services provided for a period equal to or less than 1½ hours per day.

Re-engagement Services. Services provided to ensure successful re-engagement of members who have not received site-based services during the period of March 24, 2020, through June 30, 2023. This is a one-time only claim per MassHealth member ID on or after the 45 th day of service with sustainable re-engagement in site-based services.

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

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 348.00: RATES FOR DAY HABILITATION SERVICES

3 Transportation. Method by which a member is brought from their home to the day habilitation provider or from the day habilitation provider to the member’s home. Transportation service includes assisting the member while they enter and exit the vehicle, as appropriate. A member’s home may include a temporary housing environment such as a shelter or transitional housing.

Wheelchair Transportation. Transportation service provided to a member who requires a wheelchair.

348.03 Rate Provisions

348.03: Rate Provisions

(1) Rate as Full Payment. Each eligible provider must, as a condition of receipt of payment from one or more purchasing governmental units for services rendered, accept the approved rates as full payment and discharge of all obligations for the services rendered, subject only to appellate rights as set forth in M.G.L. c. 118E. There will be no duplication or supplementation of payment from sources other than those expressly recognized or anticipated in the computation of the rate. Any client resources or third-party payments received on behalf of a publicly assisted client will reduce, by that amount, the amount of the purchasing governmental unit's obligation for services rendered to the publicly assisted client.

(2) Approved Day Habilitation Program Rates. For services provided in day habilitation programs in the community, the approved rates include payment for all care and services that are customarily part of the program of services of an eligible provider, subject only to the terms of the purchase agreement between the eligible provider and the purchasing governmental unit(s). The rate of payment for authorized services is the lower of the established charge or the rate listed in 101 CMR 348.03(5).

(3) Day Habilitation Services in Nursing Facilities. Certain residents of nursing facilities who qualify for day habilitation services may be unable to participate in these services in community settings. These individuals may qualify for day habilitation services to be provided at the nursing facility in which they reside. In order to be eligible for these nursing facility services, the individual must meet criteria established by the MassHealth agency. These members will be billed at the Level 4 rate. The approved rates cover all care and services associated with the provision of day habilitation services in a nursing facility.

(4) Payment Level for Nursing Facility Residents in Community Day Habilitation Programs. Certain qualifying individuals in nursing facilities may need supplemental services in the form of additional staff assistance to enable them to leave their nursing facility to participate in day habilitation services in the community. The MassHealth agency will pay the Level 4 rate for those individuals so they may participate in a community day habilitation program.

(5) Allowable Fees. The rates of payment for authorized day habilitation program services, unless otherwise noted in 101 CMR 348.03, must be the lower of the established charge or the rate listed in 101 CMR 348.03(5). Refer to purchasers' manuals for special coding instructions and limitations on number of units.

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

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 348.00: RATES FOR DAY HABILITATION SERVICES

4 Code Per Diem Rate Description S5102-U1 $125.91 Skills training and development, per diem, Level 1(community program) S5102-U2 $167.85 Skills training and development per diem, Level 2 (community program) S5102-U3 $290.97 Skills training and development, per diem, Level 3 (community program) S5102-U4 $414.09 Skills training and development, per diem, Level 4 (community program & nursing facility residents)

Code Half Per Diem Base Rate Description S5101-U1 $62.96 Skills training and development, half per diem , Level 1 (community program) S5101-U2 $83.93 Skills training and development, half per diem, Level 2 (community program) S5101-U3 $145.49 Skills training and development, half per diem, Level 3 (community program) S5101-U4 $207.05 Skills training and development, half per diem, Level 4 (community program & nursing facility residents)

Code Quarter Per Diem Description S5100-U5- U1 $31.48 Skills training and development, quarter per diem, Level 1(community program) S5100-U5- U2 $41.96 Skills training and development, quarter per diem, Level 2(community program) S5100-U5- U3 $72.74 Skills training and development, quarter per diem, Level 3 (community program) S5100-U5- U4 $103.52 Skills training and development, quarter per diem, Level 4 (community program & nursing facility residents)

Code One-time Only Description S5105 $2000.00 Admission Services (one-time only on or after the 45 th day of service) S5105-KZ $12,000.00 Re-engagement Services (one-time only on or after the 45 th day of service)

Code Per One-Way Trip Description T2003 $28.56 Non-wheelchair (ambulatory) transportation T2003-U6 $34.98 Wheelchair transportation (one-way trip) T2003-U7 $34.98 Monitor transportation (one-way trip)

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

101 CMR: EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 348.00: RATES FOR DAY HABILITATION SERVICES

5

348.04 Filing and Reporting Requirements

348.04: Filing and Reporting Requirements

(1) Required Reports. 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 348.04.

348.05 Severability

348.05: Severability

The provisions of 101 CMR 348.00 are severable. If any provision of 101 CMR 348.00 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 348.00 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

101 CMR 348.00: M.G.L. c. 118E