General Rate Provisions

(1) Effect of 101 CMR 343.00. The rates of payment under 101 CMR 343.00 constitute full compensation for hospice services provided to publicly aided individuals, including necessary administration and professional supervision. These established rates of payment for authorized services, with the exception of payment for room and board, will be set in accordance with Centers for Medicare & Medicaid Services (CMS) regulation 42 CFR 418.302. (2) Rate Determination. Each payment rate is determined by CMS to reflect the cost incurred by a hospice in efficiently providing the core and supplemental services associated with that type of hospice care to Medicaid beneficiaries. The allowable Medicaid hospice rates are determined in accordance with 42 CFR 418.302. The Medicaid rates are determined by adding the unweighted amount to the wage component, as adjusted to reflect local differences in wages, in accordance with 42 CFR 418.306. (3) Rates. Allowable rates for hospice services are outlined in 101 CMR 343.04(3)(a) and (b). (a) Providers will be paid at the compliant or noncompliant rates established by CMS based on compliance with federal quality reporting requirements. (b) If CMS amends the amounts listed in 42 CFR 418.306, the Medicaid rates will change accordingly. Said changes will be listed in an EOHHS administrative bulletin. (c) For those hospice clients residing in nursing facilities, the per diem rate will equal 95% of the rate that would have been paid by the Commonwealth to a particular nursing facility for a non-hospice Medicaid beneficiary. (d) Use modifier transmittal number TN for codes T2042 and T2043 when billing for members outside the county in which the provider is located. (e) MassHealth enrolled hospice providers located out-of-state must bill MassHealth using the TN modifier for all codes using the TN modifier. The rate of payment will be based on the rate applicable to the county in which the member resides. Absent use of the TN modifier, the rate of payment for hospice services provided by an out-of-state hospice provider is the lowest applicable rate listed in 101 CMR 343.04(3)(f). (f) The rates of payment for authorized hospice services effective October 1, 2025, are the rates listed in 101 CMR 343.04(3)(f). Barnstable Berkshire Code Description Frequency Compliant Rate Non-Compliant Rate Routine Home Care (1-60 days) Per Diem T2042 UD Routine Home Care (61+ days) Per Diem G0299 (RN services) G0155 (Social Worker services) Service Intensity Add- on Per Hour/Max four hours Continuous Home Care Per Hour Inpatient Respite Per Diem General Inpatient Per Diem Bristol Code Description Frequency Compliant Rate Non-Compliant Rate Routine Home Care (1-60 days) Per Diem T2042 UD Routine Home Care (61+ days) Per Diem Code Description Frequency Compliant Rate Non-Compliant Rate Routine Home Care (1-60 days) Per Diem T2042 UD Routine Home Care (61+ days) Per Diem G0299 (RN services) G0155 (Social Worker services) Service Intensity Add- on Per Hour/Max four hours Continuous Home Care Per Hour Inpatient Respite Per Diem General Inpatient Per Diem Code Description Frequency Compliant Rate Non-Compliant Rate G0299 (RN services) G0155 (Social Worker services) Service Intensity Add- on Per Hour/Max four hours Continuous Home Care Per Hour Inpatient Respite Per Diem General Inpatient Per Diem Essex/Middlesex Code Description Frequency Compliant Rate Non-Compliant Rate Routine Home Care (1-60 days) Per Diem T2042 UD Routine Home Care (61+ days) Per Diem G0299 (RN services) G0155 (Social Worker services) Service Intensity Add- on Per Hour/Max four hours Continuous Home Care Per Hour Inpatient Respite Per Diem General Inpatient Per Diem Franklin/Hampden/Hampshire Code Description Frequency Compliant Rate Non-Compliant Rate Routine Home Care (1-60 days) Per Diem T2042 UD Routine Home Care (61+ days) Per Diem G0299 (RN services) G0155 (Social Worker services) Service Intensity Add- on Per Hour/Max four hours Continuous Home Care Per Hour Inpatient Respite Per Diem General Inpatient Per Diem Norfolk/Plymouth/Suffolk Code Description Frequency Compliant Rate Non-Compliant Rate Routine Home Care (1-60 days) Per Diem T2042 UD Routine Home Care (61+ days) Per Diem G0299 (RN services) G0155 (Social Worker services) Service Intensity Add- on Per Hour/Max four hours Continuous Home Care Per Hour Inpatient Respite Per Diem General Inpatient Per Diem Worcester Code Description Frequency Compliant Rate Non-Compliant Rate Routine Home Care (1-60 days) Per Diem T2042 UD Routine Home Care (61+ days) Per Diem G0299 (RN services) G0155 (Social Worker services) Service Intensity Add- on Per Hour/Max four hours Continuous Home Care Per Hour Inpatient Respite Per Diem General Inpatient Per Diem Rural: Dukes and Nantucket Code Description Frequency Compliant Rate Non-Compliant Rate Routine Home Care (1-60 days) Per Diem T2042 UD Routine Home Care (61+ days) Per Diem Code Description Frequency Compliant Rate Non-Compliant Rate G0299 (RN services) G0155 (Social Worker services) Service Intensity Add- on Per Hour/Max four hours Continuous Home Care Per Hour Inpatient Respite Per Diem General Inpatient Per Diem