Rate Provisions

(1) Services Included in the Rate. The approved rate will include payment for all care and services that are part of the program of services of a provider, as explicitly set forth in the terms of the purchase agreement between the provider and the purchasing governmental unit(s). (2) Reimbursement as Full Payment. Each provider must, as a condition of acceptance of payment made by any purchasing governmental units for services rendered, accept the approved program rate as full payment and discharge of all obligations for the services rendered. Payment for services included in the scope of 101 CMR 359.00 from any other source must be used to offset the amount of the purchasing governmental unit's obligation for services rendered to the participant. (3) Payment Limitations. (a) No purchasing governmental unit may pay less than or more than the approved program rate, except that a participant contribution may be applied toward the residential habilitation room and board payment in accordance with policies and procedures established by the purchasing governmental unit. (b) Where more than one payment rate is available for a covered service, the service is covered at the lowest available payment rate unless a higher rate is approved by the purchasing governmental unit, except as provided in 101 CMR 359.03(3)(c). (c) Notwithstanding the requirement of 101 CMR 359.03(3)(b), payment rates for certain HCBS waiver services will be determined as follows. 1. Residential Habilitation Rates. Residential habilitation rates will be determined in the following manner: a. Service Model Rate. The purchasing governmental unit will designate the applicable rate from among the basic lower intensity, basic, or intermediate categories, or at medical/clinical level 1, medical/clinical level 2, or medical/clinical level 3, as outlined and defined in 101 CMR 420.00: Rates for Adult Long-term Residential Services. b. Room and Board. The purchasing governmental unit will designate the applicable rate for room and board from among the site rates outlined in 101 CMR 420.00: Rates for Adult Long-term Residential Services. 2. Orientation and Mobility. Orientation and mobility rates will be determined based on one-way distance traveled to initiate the service in the following manner: a. Level I: one to 30 miles; b. Level II: 31 to 60 miles; and c. Level III: over 60 miles. 3. Shared Home Supports. The purchasing governmental unit will designate the applicable stipend rate at level 1, 2, or 3, as outlined and defined in 101 CMR 411.00: Rates for Certain Placement, Support, and Shared Living Services. 4. Shared Living - 24 Hour Supports. Shared living – 24-hour support rates will be determined in the following manner. a. Operational Rate. The purchasing governmental unit will designate the applicable rate from among the available operational rate levels as outlined and defined in 101 CMR 411.00: Rates for Certain Placement, Support, and Shared Living Services. b. Stipend Rate. The purchasing governmental unit will designate the applicable rate from among the available stipend levels, corresponding to the designated operational rate level as outlined and defined in 101 CMR 411.00: Rates for Certain Placement, Support, and Shared Living Services. (4) Approved Rates. The approved rate will be the lowest of the provider’s charge or amount accepted as payment from another payer or the rate listed in 101 CMR 359.03(4). Service HCBS Waiver Units Agency Rate Non-agency Rate Individual Provider (Self- employed Provider ) Self-directed Service Adult Companion ABI-N, MFP-CL Per 15 Min. 80.00% of Agency Rate 80.00% of Agency Rate Assisted Living ABI-RH, MFP-RS Per Diem N/A N/A Assistive Technology - devices ABI-N, ABI-RH, MFP-CL, MFP-RS Per Device IC N/A N/A Assistive Technology - evaluation and training ABI-N, ABI-RH, MFP-CL, MFP-RS Per 15 Min. See 101 CMR Certain In-Home Basic Living Supports 89.75% of Agency Rate N/A Chore ABI-N, MFP-CL Per 15 Min. 80.00% of Agency Rate 80.00% of Agency Rate Community-based Day Supports ABI-N, ABI-RH, MFP-CL, MFP-RS Per 15 Min. See 101 CMR Community- based Day Support Services; Levels A, B, C, & I N/A N/A Community Support and Navigation ABI-N, ABI-RH, MFP-CL, MFP-RS Per 15 Min. See 101 CMR Certain Substance Use Disorder Services: Recovery Support Navigator Service N/A N/A Service HCBS Waiver Units Agency Rate Non-agency Rate Individual Provider (Self- employed Provider ) Self-directed Service Community Family Training ABI-N, MFP-CL Per 15 Min. See 101 CMR Family Stabilization Services (Family Training rate divided by 4 to determine rate per 15-minute increments) 89.75% of Agency Rate N/A Day Services ABI-N, ABI-RH, MFP-CL, MFP-RS Per Diem See 101 CMR Day Habilitation Services: Skills Training and Development Per Diem, Level N/A N/A Day Services – half per diem ABI-N, ABI-RH, MFP-CL, MFP-RS Half Per Diem See 101 CMR Day Habilitation Services: Skills Training and Development Half Per Diem, Level 2 N/A N/A Home Accessibility Adaptations ABI-N, ABI-RH MFP-CL, MFP-RS Item IC IC N/A Home Delivered Meals ABI-N, MFP-CL Meal N/A N/A Home Health Aide ABI-N, MFP-CL Per 15 Min. See 101 CMR Home Health Services N/A N/A Homemaker ABI-N, MFP-CL Per 15 Min. 80.00% of Agency Rate 80.00% of Agency Rate Service HCBS Waiver Units Agency Rate Non-agency Rate Individual Provider (Self- employed Provider ) Self-directed Service Independent Living Supports ABI-N, MFP-CL Per Diem N/A N/A Individual Support and Community Habilitation ABI-N, ABI-RH, MFP-CL, MFP-RS Per 15 Min. See 101 CMR Certain In-home Basic Living Supports; Levels G-H & I 89.69% of Agency Rate 89.69% of Agency Rate Laundry ABI-N, MFP-CL Per Order N/A N/A Occupational Therapy ABI-N, ABI-RH, MFP-CL, MFP-RS Per Visit See 101 CMR Home Health Services See 101 CMR 339.00: Restorative Services (out- of-office visit rate) N/A Orientation and Mobility Services MFP-CL, MFP-RS Per 15 Min Level I: $33.58 Level II: $37.12 Level III: $40.66 Level I: Level II: Level III: N/A Peer Support ABI-N, ABI-RH, MFP-CL, MFP-RS Per 15 Min. See 101 CMR Family Stabilization Services (rate divided by 4 to determine rate per 15-minute increments) 89.75% of Agency Rate 89.75% of Agency Rate Personal Care ABI-N, MFP-CL Per 15 Min. See 101 CMR 309.00: Rates for Certain Services for the Personal Care See 101 CMR 309.00: Rates for Certain Services for the Personal Care Attendant Program Service HCBS Waiver Units Agency Rate Non-agency Rate Individual Provider (Self- employed Provider ) Self-directed Service Attendant Program Physical Therapy ABI-N, ABI-RH, MFP-CL, MFP-RS Per Visit See 101 CMR Home Health Services See 101 CMR 339.00: Restorative Services (out- of-office visit rate) N/A Prevocational Services ABI-N, ABI-RH, MFP-CL, MFP- RS Per 15 Min. See 101 CMR Supported Employment Services (rate for Individual Supported Employment) N/A N/A Residential Family Training ABI-RH, MFP-RS Per 15 Min. See 101 CMR Family Stabilization Services (Family Training rate divided by 4 to determine rate per 15-minute increments) 89.75% of Agency Rate N/A Residential Habilitation Room and Board ABI-RH, MFP-RS Per Diem See 101 CMR Adult Long-term Residential Services (Site Rates) N/A N/A Residential Habilitation Services ABI-RH, MFP-RS Per Diem See 101 CMR Adult Long-term Residential Services (Basic Lower Intensity, Service HCBS Waiver Units Agency Rate Non-agency Rate Individual Provider (Self- employed Provider ) Self-directed Service Basic, or Intermediate categories, Medical/Clinical Level 1, Medical/Clinical Level 2, or Medical/Clinical Level 3 N/A N/A Respite ABI-N, MFP-CL Per Diem IC N/A N/A Shared Home Supports ABI-N, MFP-CL Per Diem See 101 CMR 411.00: Rates for Certain Placement, Support, and Shared Living Services (Operational Rate Level A, Stipend Levels 1, 2, or 3) N/A N/A Shared Living – 24 Hour Supports ABI-RH, MFP-RS Per Diem See 101 CMR Certain Placement, Support, and Shared Living Services N/A N/A Skilled Nursing – LPN ABI-N, ABI-RH, MFP-CL, MFP-RS Per Visit See 101 CMR Home Health Services (Rates for Skilled Nursing Services) N/A N/A Skilled Nursing – RN ABI-N, ABI-RH, Per Visit See 101 CMR N/A N/A Service HCBS Waiver Units Agency Rate Non-agency Rate Individual Provider (Self- employed Provider ) Self-directed Service MFP-CL, MFP-RS Home Health Services (Rates for Skilled Nursing Services) Specialized Medical Equipment ABI-N, ABI-RH, MFP-CL, MFP-RS Item See 101 CMR Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment See 101 CMR 322.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment N/A Speech Therapy ABI-N, ABI-RH, MFP-CL, MFP-RS Per Visit See 101 CMR Home Health Services See 101 CMR 339.00: Restorative Services (out- of-office visit rate) N/A Supported Employment ABI-N, ABI-RH, MFP-CL, MFP-RS Per 15 Min. See 101 CMR Supported Employment Services (rate for Individual Supported Employment) N/A N/A Supportive Home Care Aide ABI-N, MFP-CL Per 15 Min. See 101 CMR Home Health Services (13.12% above the rate for Home Health Aide) N/A N/A Transitional Assistance ABI-N, ABI-RH, MFP-CL, MFP-RS Per Episode IC N/A N/A (5) Self-directed Service Rates. (a) Employer Expense Component. The rates for self-directed services consist of two components: the self-directed worker rate and the employer expense component (EEC). The list in 101 CMR 359.03(5)(a) identifies the self-directed worker rates and EEC for self- directed service rates. Service Unit Self-directed Worker Rate Employer Expense Component Self-directed Service Rate Adult Companion Per 15 Min. Chore Per 15 Min. Homemaker Per 15 Min. Individual Supports and Community Habilitation: Level G Per 15 Min. Individual Supports and Community Habilitation: Level H Per 15 Min. Service HCBS Waiver Units Agency Rate Non-agency Rate Individual Provider (Self- employed Provider ) Self-directed Service Transportation ABI-N, ABI-RH, MFP-CL, MFP-RS One-way Trip See 101 CMR 327.00: Rates of Payment for Ambulance and Wheelchair Van Services N/A N/A Vehicle Modification ABI-N, MFP-CL Item IC N/A N/A Service Unit Self-directed Worker Rate Employer Expense Component Self-directed Service Rate Individual Supports and Community Habilitation: Level I Per 15 Min. Peer Support Per 15 Min. Personal Care Per 15 Min. See 101 CMR 309.00: Rates for Certain Services for the Personal Care Attendant Program (rate divided by four to determine rate per 15-minute increments) (b) Overtime Calculation. Overtime payments for self-directed services will be made in accordance with the federal Fair Labor Standards Act. Such payments will be made to self- directed workers at rate of one and a half times that of the rate for the service or services provided. For self-directed workers that provide services paid at different rates, such overtime rate will consist of the blended weighted rate based on the number of hours for which each service was provided during a single work week. For the purposes of 101 CMR 359.03(5)(b), the term overtime will mean self-directed services provided to one or more participants in excess of 40 hours per work week, where work week consists of a seven-day period beginning Sunday at 12:00 A.M. and ending the consecutive Saturday at 11:59 P.M. (6) Approved Modifiers. The approved modifiers for all four HCBS Waiver programs are as follows. (a) Modifier Classification. The classification descriptions for modifiers associated with both the ABI and MFP Waivers are as follows. Modifier Description TV Holiday Time (for use by FI only) Agency Provider or Level 1 or Level B or Level G Individual/Self-employed Provider or Level 2 or Level C or Level H Level 3 or Level I ABI Nonresidential Habitation (ABI-N) Waiver ABI Residential Habitation (ABI-RH) Waiver MFP Community Living (MFP-CL) Waiver MFP Residential Supports (MFP-RS) Waiver UB Self-directed Service UC Devices UD Paid Time Off (for use by FI only) (b) Service Codes and Modifiers by Service. The list of approved service codes and modifiers for all four ABI and MFP Waivers are as follows. The Agency and Individual Provider service codes and modifiers are located in the first table, while the Self-directed Service codes and modifiers are located in the second table below. Service Agency Individual Provider (Self-employed Provider) Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier Adult Companion - - - - - - - - Assisted Living T2031 - - - - - - T2031 - - - - - - Assistive Technology - devices T2029 UC - - - - - T2029 UC - - - - - T2029 UC - - - - - T2029 UC - - - - - Assistive Technology – evaluation and training - - - - - - - - Chore Services - - - - Community- based Day Supports - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Service Agency Individual Provider (Self-employed Provider) Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier - - - - - - - - - - - - - - - - - - - - - - - - - - Community Behavioral Health Support and Navigation H2015 - - - - - - H2015 - - - - - - H2015 - - - - - - H2015 - - - - - - Community Family Training - - - - Day Services - - - - - - - - - - - - - - - - - - - - - - - - Day Services – half per diem - - - - - - - - - - - - - - - - - - - - - - - - Home Accessibility Adaptations - - - - - - - - Home Delivered Meals - - - - - - - - - - - - Homemaker - - - - Home Health Aide G0156 - - - - - - G0156 - - - - - - Independent Living Supports H0043 - - - - - - H0043 - - - - - - Service Agency Individual Provider (Self-employed Provider) Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier Individual Support and Community Habilitation - - - - H2014 - - - - - H2014 - - - - - H2014 - - - - - H2014 - - - - - H2014 - - - - - H2014 - - - - - H2014 - - - - - H2014 - - - - - H2014 - - - - - H2014 - - - - - H2014 - - - - - H2014 - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Laundry - - - - - - - - - - - - Occupational Therapy - - - - - - - - Orientation and Mobility Services H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - Service Agency Individual Provider (Self-employed Provider) Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - H2021 - Peer Support H0038 - H0038 - H0038 - H0038 - H0038 - H0038 - H0038 - H0038 - Personal Care T1019 - T1019 - T1019 - T1019 - Physical Therapy - - - - - - - - Prevocational Services T2019 - - - - - - T2019 - - - - - - T2019 - - - - - - T2019 - - - - - - Residential Family Training - - - - Residential Habilitation T2016 - - - - - - T2016 - - - - - - Respite H0045 - - - - - - H0045 - - - - - - Shared Home Supports H2016 - - - - - H2016 - - - - - H2016 - - - - - Service Agency Individual Provider (Self-employed Provider) Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier H2016 - - - - - H2016 - - - - - H2016 - - - - - Shared Living-24- Hour Supports T2033 - - - - - - T2033 - - - - - - Skilled Nursing - RN G0299 - - - - - - G0299 - - - - - - G0299 - - - - - - G0299 - - - - - - Skilled Nursing - LPN G0300 - - - - - - G0300 - - - - - - G0300 - - - - - - G0300 - - - - - - Specialized Medical Equipment T2029 - - T2029 - T2029 - - T2029 - T2029 - - T2029 - T2029 - - T2029 - Speech Therapy - - - - - - - - Supported Employment H2023 - - - - - - H2023 - - - - - - H2023 - - - - - - H2023 - - - - - - Supportive Home Care Aide T1004 - - - - - - T1004 - - - - - - Transportation T2003 - - - - - - T2003 - - - - - - T2003 - - - - - - T2003 - - - - - - T2038 - - - - - - Service Agency Individual Provider (Self-employed Provider) Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier Code 1st Position Modifie r 2nd Position Modifier 3rd Position Modifier Transitional Assistance T2038 - - - - - - T2038 - - - - - - T2038 - - - - - - Vehicle Modification T2039 - - - - - - T2039 - - - - - - Service Self-directed Service Code 1st Position Modifier 2nd Position Modifier 3rd Position Modifier 4th Position Modifier Adult Companion UB - - UB - - UB UD - UB UD - Chore Services UB - - UB - - UB UD - UB UD - Homemaker UB - - UB - - UB UD - UB UD - Individual Support and Community Habilitation H2014 UB - H2014 UB - H2014 UB - H2014 UB - H2014 UB - H2014 UB - H2014 UB - H2014 UB - H2014 UB - H2014 UB - Service Self-directed Service Code 1st Position Modifier 2nd Position Modifier 3rd Position Modifier 4th Position Modifier H2014 UB - H2014 UB - H2014 UB UD H2014 UB UD H2014 UB UD H2014 UB UD H2014 UB UD H2014 UB UD H2014 UB UD H2014 UB UD H2014 UB UD H2014 UB UD H2014 UB UD H2014 UB UD Peer Support H0038 UB - - H0038 UB - - H0038 UB - - H0038 UB - - H0038 UB UD - H0038 UB UD - H0038 UB UD - H0038 UB UD - Personal Care T1019 UB - - T1019 UB - - T1019 UB UD - T1019 UB UD - T1019 UB TV - T1019 UB TV -