Charges for Services

(1) Scope. 104 CMR 30.04 applies to services for which the Department has an approved rate and that are provided by Department operated or contracted for facilities or programs. This includes the provision of room and board in a facility. Charges for room or board other than for that provided in a facility are governed by 104 CMR 30.06. (2) Purpose. To maximize revenue for costs of services provided by Department operated or contracted for facilities and programs from federal and state benefits and private health insurance reimbursements as required by M.G.L. c. 6A, § 16, the Department must charge patients, clients or fee payers for the services it provides, contracts for, or otherwise funds. The purpose of 104 CMR 30.04 is to establish how the Department will charge for the services for which it has approved rates and to allow for such charges to be adjusted on an individualized basis based on the ability to pay of the patient, client, or fee payer as determined in accordance with 104 CMR 30.04(6). (3) Definitions. In addition to the terms defined in 104 CMR 25.02: Definitions, the following terms shall have the meanings set forth in 104 CMR 30.04(4) throughout 104 CMR 30.04, unless the content clearly provides otherwise. Approved Rate. The charge for a service which is established by the Department in accordance with applicable law. Fee Payer. Any of the following persons, each of whom may be liable for charges for services: (a) the spouse of a patient or client, unless such spouse is separated, then only to the extent provided by a judicial order or a judicially approved separation agreement; (b) the parent(s) of a minor child who is not an emancipated minor or a mature minor; or (c) the legally authorized representative or other person who controls assets of a patient or client, or the patient's or client's spouse or parent(s); provided however, that the legally authorized representative or other person shall be responsible only to the extent he or she has control of a patient's or client's assets, or the assets of the patient's or client's spouse or parent(s), and only to the extent of such assets. Income. Any monies received by or on behalf of a client, including earned income, recurrent payments, payments in kind or lump sum payment. Income shall not include the following: (a) Financial aid provided to full or part time students. This includes scholarships and stipends for housing or earnings from work-study programs that are included in a student's financial aid package; (b) Payments made to and held by a client from the Supplemental Nutrition Assistance Program; or (c) Income that is directly deposited into a Plan to Achieve Self-support (PASS) approved by the Social Security Administration. Liquid Assets. Cash and all property capable of ready conversion into cash, such as stocks and bonds, regardless of whether such assets are held jointly or solely. Liquid assets do not include life insurance or its cash value, or assets subject to an irrevocable trust with the patient or client as named beneficiary, unless those assets are available to the patient or client or fee payer on demand. Patient or Client. A person who receives services from a Department operated or contracted for facility or program. Third-party Payer. An insurer, entitlement agency, or similar entity, which is obligated to pay for services provided to a patient or client. (4) Charges for Services. (a) The Department shall charge a patient, client or fee payer for the services provided to the patient or client by a facility or program operated or contracted for by the Department if the Department has an approved rate for the services. (b) The charge shall be at the approved rate. (c) A client is responsible for a charge unless the charge is covered by a third-party payer. (d) The Department shall adjust a charge based on a client's ability to pay in accordance with 104 CMR 30.04(6). (5) Notification of Charges for Services. The Department shall give patients, clients and their fee payers, if known, notice that they will be charged for any services provided by a Department operated or contracted for facility or program for which the Department has an approved rate. Notice shall also be given to the patients' or clients' legally authorized representative if applicable. (a) Such notice will be given: 1. at the time a patient or client, or his or her legally authorized representative, requests services; 2. upon admission to a facility operated or contracted for by the Department; 3. upon referral to any program operated or contracted for by the Department that provides a service for which the Department has an approved rate if not previously given; 4. at any time the approved rate for an applicable service changes; 5. annually thereafter as part of the patient's periodic review pursuant to 104 CMR 27.11: Periodic Review; or the review of the client's individual service plan pursuant to 104 CMR 29.09: Annual Review of the Individual Service Plan; or if the client does not have an individual service plan, upon the annual review of the client's Community Service Plan pursuant to 104 CMR 29.13: Review of the Community Service Plan; 6. upon request; and 7. at any other time deemed appropriate by the Department. (b) The notice shall be on a form approved by the Department and shall provide the following information, at a minimum: 1. the approved rate for all of the applicable services for which the Department has an approved rate; 2. the right of the patient, client, his or her legally authorized representative or fee payer to request a reduction to a charge billed by the Department based on the patient's or client's financial circumstances and the fee payer's financial circumstances if the fee payer is either the spouse or parent(s) of the patient or client; 3. the name and telephone number of the Department office or employee available for further information; and 4. the right of the patient, client, their legally authorized representative, or fee payer to appeal a charge as established in 104 CMR 30.04(8). (c) The Department shall offer to the patient, client, their legally authorized representative, or fee payer, the opportunity to have the notice explained to him or her by an appropriate representative. (6) Billing a Patient, Client or Fee Payer. (a) Determining Ability to Pay. In accordance with M.G.L. c. 123, § 32 and Department policies, the Department shall determine the ability of a patient, client or fee payer to pay the assessed charges. Based on the determination, the Department may reduce the amount to be collected for the assessed charges from the patient, client or fee payer. At a minimum, the Department policies must satisfy the following requirements: 1. In determining the ability to pay of a patient, client or fee payer, the Department will consider the patient's or client's income and liquid assets and those of a spouse or parent(s) if they are fee payers. If the spouse is separated from the patient or client, then the spouse's income and liquid assets will only be considered to the extent provided by a judicial order or a judicially approved separation agreement. 2. In calculating a patient's or client's income and liquid assets, or if applicable, the income and liquid assets of a spouse or parent(s), for the purpose of determining ability to pay, a certain amount of such income or liquid assets will be exempted to allow for the individual's support; the support of the individual's dependent(s) and, if applicable, spouse, and to permit the individual to maintain a residence in the community. 3. A reduction will not be permitted if the patient, client or fee payer requests that the Department not bill the charge to a third-party payer or otherwise precludes the third party payer from paying the Department. 4. A reduction will not be permitted if the patient, client or fee payer does not provide the Department with the information needed to determine his or her ability to pay as specified by the Department's written policies regarding ability to pay. (b) Review of Ability to Pay. The Department shall review the ability to pay of a patient or client, or if applicable, the patient's or client's spouse or parent(s), as follows: 1. when the patient or client first receives a service for which the Department has an approved rate; 2. annually; 3. on request of the patient or client, or his or her legally authorized representative; 4. on the request of the fee payer; and 5. whenever the Department has reason to believe that the ability to pay of the patient or client, or if applicable, the patient's or client's spouse or parent(s), has changed. (c) Information. The patient or client, or if applicable, the patient's or client's spouse or parent(s), is responsible for providing or assisting the Department in obtaining the information needed to review his or her ability to pay. If the Department fails to receive such information, the Department may determine ability to pay based upon its best available information and proceed to bill and collect charges. (d) Notice. Each patient and client and his or her legally authorized representative and applicable fee payer(s) shall receive notice of the determination of the ability to pay and whether a charge or charges will be adjusted, and of the right to appeal such determinations in accordance with 104 CMR 30.04(8). (e) Billing a Client, Patient or Fee Payer. A patient, client or fee payer will be billed any charge not reduced to zero in accordance with 104 CMR 30.04(6). The bill shall include a statement of the charge(s), the reduction amount, if any, and the right to appeal the charge(s) as set forth in 104 CMR 30.04(8). Any charge or charges shall be due and payable within the time specified in the bill. (7) Facility Director's Authority. If a patient who is billed for services has deposited funds with a facility director or designee of a Department facility such facility director or designee shall deduct the charges, or if appropriate, the reduced charges, from those funds; provided however, that: (a) The patient has capacity and the facility director or designee has requested in writing authority to deduct such charges and has received such authority from the patient; or (b) The patient has a legally authorized representative and the facility director or designee has requested in writing authority to deduct such charges and has received such authority from the legally authorized representative; or (c) The funds have been entrusted to the facility director or designee as the patient's representative payee; provided however, that the patient will receive notice of the charge and any decision to reduce the charge and will have the appeal rights described in 104 CMR 30.04(8); and (d) All notice provisions as specified above have been complied with; and (e) No appeal of the charge or the Department's decision regarding a reduction of charge has been filed by the patient or representative, or if an appeal has been filed, it has been heard and decided; and (f) The facility director or designee has first addressed the need for expenditure of such funds pursuant to the provisions of 104 CMR 30.01, and after he or she has first made all deductions and expenditures from such patient's funds pursuant to the policies promulgated under the provisions of 104 CMR 30.04(6). For the purposes of 104 CMR 30.04(7)(a) through (d), the facility director or designee shall be deemed to have such authority if, within 30 days of requesting such authority in writing, the patient or legally authorized representative has not responded to such request so long as the facility director or designee has documented that the patient or other person has received such request and so long as the facility has taken reasonable steps to assist the patient or other person to understand the nature of the request. (8) Appeal of Charges. Within 21 days after issuance of a bill, a patient, client, his or her legally authorized representative, or fee payer(s) may appeal the charge by notifying the Commissioner in writing. The notice must state what is being appealed and the basis for the appeal as provided in 104 CMR 30.04(8)(b). The Commissioner may accept an appeal after 21 days for good cause. (a) General Provisions. 1. To the extent possible, disagreements concerning a charge of a patient, client or fee payer should be resolved informally with the Area Director or designee prior to utilizing this appeal mechanism. 2. This appeal process has been established to comply with the State Comptroller's Office's requirements concerning debt collection, which are set out at 815 CMR 9.00: Debt Collection and Intercept. (b) Grounds for Appeal. Grounds for appealing a charge shall be limited to the following: 1. Whether the client or patient, in fact, received the service for which he or she or the fee payer is billed; 2. Misidentification of the fee payer; or 3. Whether the amount billed was calculated in accordance with the Department's policy for reducing charges. The rate that the Department charges for its services is not subject to appeal. (c) The Commissioner or designee shall hear the appeal within 30 days of receipt of the appeal. The appellant shall be given an opportunity to present oral or written statements relevant to the charge, to question a representative of the Department concerning the charge, and to have a representative, if any, present. Such a proceeding shall not be an adjudicatory proceeding within the meaning of M.G.L. c. 30A. The standard of proof on all issues shall be a preponderance of the evidence and the burden of proof shall be on the appellant. The Commissioner shall make a decision within 30 days of hearing the case and shall notify in writing the appellant stating the reason for such decision. The decision of the Commissioner is final.