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. Code Per Diem Rate Description Skills training and development, per diem, Level 1(community program) Skills training and development per diem, Level 2 (community program) Skills training and development, per diem, Level 3 (community program) Skills training and development, per diem, Level 4 (community program & nursing facility residents) Code Half Per Diem Base Rate Description Skills training and development, half per diem , Level 1 (community program) (community program) (community program) (community program & nursing facility residents) Code Quarter Per Diem Description S5100-U5- Skills training and development, quarter per diem, Level 1(community program) S5100-U5- Skills training and development, quarter per diem, Level 2(community program) S5100-U5- Skills training and development, quarter per diem, Level 3 (community program) S5100-U5- Skills training and development, quarter per diem, Level 4 (community program & nursing facility residents) Code One-time Only Description S5105 Admission Services (one-time only on or after the 45th day of service) S5105-KZ $12,000.00 Re-engagement Services (one-time only on or after the 45th day of service) Code Per One-Way Trip Description T2003 Non-wheelchair (ambulatory) transportation T2003-U6 Wheelchair transportation (one-way trip) T2003-U7 Monitor transportation (one-way trip)