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. 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 must reduce, by that amount, the amount of the purchasing governmental unit’s obligation for services rendered to the publicly assisted client. (2) Covered Services. The payment rates in 101 CMR 310.00 apply to adult day health services provided by eligible providers in a day setting, where (a) a patient's medical condition indicates a need for nursing care, supervision, or a need for therapeutic services that alone or in combination would require institutional placement; or (b) a patient's psycho-social condition is such that without program intervention the patient’s medical condition would continue to deteriorate or is such that institutional placement is imminent. (3) Exclusions. The payment rates in 101 CMR 310.00 do not apply to the following circumstances and services: (a) specialized day programs primarily for the developmentally disabled, blind, deaf, or acutely mentally ill; (b) adult day health programs operating out of state; (c) physician services paid on a fee-for-service basis under 101 CMR 316.00: Rates for Surgery and Anesthesia Services and 101 CMR 317.00: Rates for Medicine Services; (d) restorative therapy services paid on a fee-for-service basis under 101 CMR 339.00: Rates for Restorative Services; and (e) services and costs paid under other regulations promulgated by EOHHS. (4) Payment Rates. For dates of service on and after July 1, 2025, the base rate for adult day health services is the lower of the established charge or the rate listed below in 101 CMR 310.03(4). Code Per Diem Base Rate Description S5102 Basic Level of Care S5102 TG Complex Level of Care Code Partial Per Diem Rate Description S5101 Basic Level of Care S5101 TG Complex Level of Care