General Provisions

(1) Scope and Purpose. 101 CMR 322.00 governs the determination of rates of payment to be used by all governmental units in making payment to eligible providers of durable medical equipment and supplies provided to publicly aided individuals. The rates set forth in 101 CMR 322.00 do not apply to individuals covered by the Workers' Compensation Act, M.G.L. c. 152. Rates for services rendered to such individuals are set forth in 114.3 CMR 40.06: Fees. (2) Applicable Dates of Service. Rates contained in 101 CMR 322.00 apply for dates of service provided on or after March 1, 2026, unless otherwise specified. (3) Coverage. 101 CMR 322.00 and the rates of payment contained herein apply to the following categories: (a) the purchase or rental of durable medical equipment; (b) the purchase of medical and surgical supplies; (c) the purchase or rental of seating, positioning, mobility systems, and related accessories; (d) the purchase or rental of prescribed oxygen delivery systems and respiratory therapy devices and related supplies; (e) the purchase or rental of intravenous and enteral therapy, equipment, and related supplies and services; and (f) the repair or modification of the above listed types of equipment. (4) Exclusions. 101 CMR 322.00 and the rates of payment contained herein do not apply to the following services: (a) respiratory therapy services rendered by a qualified respiratory therapist; (b) all services included in the reimbursement to an institutional provider; and (c) all services for inpatients at a facility licensed as an acute or chronic disease and rehabilitation hospital. (5) Disclaimer of Authorization of Services. 101 CMR 322.00 is not authorization for nor approval of the procedures for which rates are determined pursuant to 101 CMR 322.00. Governmental units that purchase care are responsible for the definition, authorization, and approval of care to publicly aided individuals. (6) 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 the code numbers only changed, with the corresponding crosswalk; (b) codes for which the code numbers remain the same but the description has changed; (c) deleted codes for which there is no crosswalk; and (d) for entirely new codes that require new pricing, EOHHS may list these codes and price them at a percentage of the prevailing Medicare fees as described in 101 CMR 322.01(6)(d) and 101 CMR 322.03(16), when Medicare fees are available. When Medicare fees are not available or when otherwise designated by EOHHS as described in 101 CMR 322.03(16), EOHHS may apply individual consideration, adjusted acquisition cost plus a standard markup, or specify a fixed rate as described in 101 CMR 322.01(7)(e) in reimbursing for these new codes until appropriate rates can be developed. (7) Administrative Bulletins. EOHHS may issue administrative bulletins to (a) clarify its policy on substantive provisions of 101 CMR 322.00; (b) specify any durable medical equipment or medical supplies subject to a preferred supplier contract or contracts between a supplier and a governmental unit or units, the governmental unit(s) and eligible providers subject to the contract, the duration of the preferred supplier contract, the prices at which such durable medical equipment or medical supplies will be available to eligible providers (as defined by the preferred supplier contract), the rates which eligible providers (as defined by the preferred supplier contract) will be paid by the relevant governmental unit(s) for such durable medical equipment or medical supplies, and any other information deemed necessary by EOHHS; (c) specify any durable medical equipment or medical supplies subject to a rebate agreement or agreements between a manufacturer and a governmental unit or units, the governmental unit(s) and eligible providers subject to the agreement, the duration of the rebate agreement, the rates which will be paid to eligible providers (as defined by the applicable rebate agreement) by the relevant governmental unit(s) for the specified durable medical equipment or medical supplies, and any other information deemed necessary by EOHHS; (d) specify upward adjustments to the standard markup defined at 101 CMR 322.02 for codes when a governmental unit determines that the standard markup requires adjustment to account for increased provider costs and/or a shift in utilization patterns or to maintain access to care; (e) specify a fixed rate for codes which do not have a Medicare rate or would otherwise be priced at individual consideration based on an adjusted acquisition cost when a fixed rate can be determined by using a comparison of industry rates including Medicare crossover payments, other state Medicaid payment rates and Medicaid third-party liability/private insurance rates; (f) specify upward adjustments to historical fixed rates which do not have a Medicare rate for codes when a governmental unit determines that the historical fixed rate requires adjustment to account for increased provider costs and/or a shift in utilization patterns or to maintain access to care; (g) specify any durable medical equipment or medical supplies subject to the pricing methodology described at 101 CMR 322.03(20); (h) describe conditions of payment for an add-on payment for certain mobility system repairs for MassHealth members under 101 CMR 322.05(1); and (i) describe conditions of payment for supplemental payments for certain patient lift systems or other designated services under 101 CMR 322.05(2) for MassHealth members who are eligible for both Medicare and MassHealth services (dual eligible members).