Definitions

As used in 101 CMR 415.00, unless the context requires otherwise, terms have the meanings in 101 CMR 415.02. Active Treatment. Care and services to improve and/or maintain the client’s quality of life in a nursing facility by promoting the optimal level of functioning that allows as much self-determination as possible and strives to prevent a regression of current optimal status. Client. An individual who receives services purchased by a governmental unit. Community-based Day Support Services (Services). Community-based day support services assist clients to build and maintain their ability to participate in community activities by focusing on skill areas that include communication, self-care, relationship-building, and community involvement. EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A. Governmental Unit. The Commonwealth, any board, commission, department, division, or agency of the Commonwealth and any political subdivision of the Commonwealth. Nursing Facility. An inpatient health-care facility with the staff and equipment to provide skilled care, rehabilitation, and other related health services to patients who need nursing care, but do not require hospitalization. Provider. Any individual, group, partnership, trust, corporation, or other legal entity that contracts with a purchasing agency to provide community-based day support services. Purchasing Agency. A governmental unit that purchases community-based day support services. (1) Services Included in the Rate. The payment rates in 101 CMR 415.00 are payment for all services provided to a client by a provider, subject to the terms of the contract between the provider and the purchasing agency. (2) Reimbursement as Full Payment. Each provider must, as a condition of acceptance of payment by a purchasing agency for services provided to a client, accept the payment rates established by 101 CMR 415.00 as full payment and discharge of all obligations for the services provided. The provider may not seek additional or supplemental payment from clients or other third parties for services for which rates are established by 101 CMR 415.00. If a provider receives any client funds or third party payments for services provided to a client, the purchasing agency’s obligation for services to the client will be offset by the amount received. (3) Payment Limitations. Except as provided in 101 CMR 415.03(2), each purchasing agency pays for services at the rates established in 101 CMR 415.03(5). (4) Administrative Adjustment for Extraordinary Circumstances. A method whereby, subject to availability of funds, a purchasing governmental unit may provide additional resource allocations to a qualified provider in response to unusual and unforeseen circumstances that substantially increase the cost of service delivery in ways not contemplated in the development of current rates. It must be demonstrated that such cost increases gravely threaten the stability of service provision such that client or consumer access to necessary services is at risk. The purchasing governmental unit will evaluate the need for the administrative adjustment, determine whether funding is available, and convey that information to EOHHS for review to determine the amount of any adjustment. (5) Approved Rates. The payment rate for services is based on the intensity level assigned to each client by the purchasing agency. Level A B C D I W Active Treatment Adult Nursing Facility Active Treatment Pediatric Nursing Facility Active Treatment (1) General Provisions. (a) Accurate Data. All reports, schedules, additional information, books, and records that are filed or made available to EOHHS must be certified under pains and penalties of perjury as true, correct, and accurate by the executive director or chief financial officer of the provider. (b) Examination of Records. Each provider must make available to EOHHS or purchasing agency upon request all records relating to its reported costs, including costs of any entity related by common ownership or control. (2) Required Reports. Each provider must file (a) an annual Uniform Financial Statements and Independent Auditor's Report completed in accordance with the filing requirements of 808 CMR 1.00: Compliance, Reporting and Auditing for Human and Social Services; (b) any cost report supplemental schedule as issued by EOHHS; and (c) any additional information requested by EOHHS within 21 days of a written request. (3) Penalty for Noncompliance. The purchasing governmental unit may impose a penalty in the amount of up to 15% of its payments to any provider that fails to submit required information. The purchasing governmental unit will notify the provider in advance of its intention to impose a penalty under 101 CMR 415.04(3). The provisions of 101 CMR 415.00 are severable. If any provision of 101 CMR 415.00 or application of any provision to an applicable individual, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of 101 CMR 415.00 or application of those provisions to applicable individuals, entities, or circumstances.