Rate Provisions

(1) Services Included in the Rate. The approved rate includes payment for all care and services that are part of the program of services of an eligible provider, as explicitly set forth in the terms of the purchase agreement between the eligible provider and the purchasing governmental unit(s). (2) Reimbursement as Full Payment. Each eligible 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 from any other source will be used to offset the amount of the purchasing governmental unit's obligation for services rendered to the publicly assisted client. (3) Payment Limitations. No purchasing governmental unit may pay less than or more than the approved program rate, except as cited in 101 CMR 420.03. (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. Providers must demonstrate that these 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) Blended Contract Rate Calculation. Purchasing governmental units may pay a blended contract rate for the purchase of two or more ALTR programs. The blended rate will be calculated according to the following formula: Sum of {[(Per Diem rate for Program Model 1)*(Units purchased of Program Model 1)*(Number of clients purchased in Program 1) / (Total number of clients in Program 1)], [(Per Diem rate for Program Model 2)*(Units purchased of Program Model 2)*(Number of clients purchased in Program 2) / (Total number of clients in Program 2)], [(Per Diem rate for Program Model 3)*(Units purchased of Program Model 3)* (Number of clients purchased in Program 3) / (Total number of clients in Program 3)],…,[Total funding for Add-ons]} Divided by the [(Sum of the Units purchased)*(Count of clients)] for all programs in the contract. (6) Service Model Naming Convention. 101 CMR 420.03(6)(a) and (b) describe the naming convention for the service models as listed in the rate tables. (a) Basic and Intermediate. The name of each service model rate consists of six characters. The first character represents the category of the service tier, “B” for basic, and “I” for intermediate. The second through fifth characters describe the number of direct care FTEs associated with the model. The sixth character represents the capacity range for the model. Capacity 1 models are represented with “A,” capacity 2-3 models are represented with “B,” and capacity 4+ models are represented with “C.” Example: I06.5B describes an intermediate, 6.5 FTE program with capacity of 2 or 3. (b) Medical/Clinical. The name of each medical/clinical service model rate consists of seven characters. The first character, “M,” represents the medical/clinical service tier. The second through fifth characters describe the number of direct care FTEs associated with the model. The sixth character represents the capacity range for the model. Capacity 1 models are represented with “A,” capacity 2-3 models are represented with “B,” and capacity 4+ models are represented with “C.” The seventh character represents the level of incremental resources contained in the medical/clinical service model. Example: M10.5C2 represents a medical level 2 program with 10.5 FTEs and a capacity of four or more. (7) Programs Located outside the Commonwealth of Massachusetts. (a) If an ALTR is located outside of the Commonwealth of Massachusetts in a state that has an established state rate or price setting mechanism, the purchasing governmental unit will pay for the service using the rate established, authorized, or approved by the state in which the program is located, if the rate is the lowest charged by a provider for the program. If the requested rate is not the lowest charged by the provider for the program, the provider must identify and document the amount of the lowest rate charged, which will then be used by the purchasing governmental unit to pay for services. For the purchasing governmental unit to pay this rate, the following must be submitted to the purchasing governmental unit by the provider: 1. a certification from the provider that the rate requested to be authorized is the lowest charged by the provider for the program; and 2. a copy of the rate authorization or approval by the state in which the program is located, including the effective dates of the rate. (b) If an ALTR service is located outside the Commonwealth of Massachusetts in a state where there is no established state rate or price setting mechanism, the purchasing governmental unit will pay for the service using the rates set forth in 101 CMR 420.03(8). (8) Approved Rates. The rates in 101 CMR 420.03(8) are the payment rates for services purchased by a governmental unit. The approved rate will be the lower of the provider’s charge or amount accepted as payment from another payer or the rate listed. (a) Per Diem Service Model Program Rates. 2-3 Capacity Site FTE Basic Level Intermediate Level Medical 3 Specialized Behavioral -- -- -- -- -- -- 1 Capacity Site FTE Basic Level Intermediate Level $ $835.80 -- -- -- -- -- -- -- -- 2-3 Capacity Site FTE Basic Level Intermediate Level Medical 3 Specialized Behavioral -- -- -- -- 4+ Capacity Site FTE Basic Level Intermediate Level Specialized Behavioral -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- -- 4+ Capacity Site FTE Basic Level Intermediate Level Specialized Behavioral -- -- -- -- -- -- (b) Add-on Rates. Category Unit Rate Direct Care Hour Direct Care Day Direct Care (Intermediate/Medical) Hour Direct Care (Intermediate/Medical) Day Certified Nurse Assistant (CNA) Hour Licensed Practical Nurse (LPN) Hour Registered Nurse (RN) Hour Clinician (LICSW) Hour Clinical Psychologist Hour Psychologist/Psychiatrist (PhD Level) Hour Vehicle Add-on Per Day Per Month Sedan Minivan Van Wheelchair Van Vehicle Upgrade Per Day Per Month Sedan to Minivan Sedan to Van Sedan to Wheelchair Van Minivan to Van Minivan to Wheelchair Van Van to Wheelchair Van Remote Direct Supports Per Hour Remote Direct Supports (c) Site Rates. 1. Site Rates for Programs Operating Prior to July 1, 2014. The table in 101 CMR 420.03(8)(c) lists per diem site unit cost ranges and the corresponding per diem site rate. Occupancy Rate Index Site Unit Cost Range Per Diem Site Rate Occupancy Rate Index Site Unit Cost Range Per Diem Site Rate $143.22 + 2. New Program Site or Current Site Replacement Rate. a. A site rate for a new or replacement residence, based on the particular needs of the individuals proposed for placement at the site, will be established using the Application for New Site Occupancy, or other such process as determined by the purchasing governmental unit. The application must include the provider’s best estimates of site- specific costs and must be supported by available documentation. Costs may be subject to reasonable limits as determined by the purchasing governmental unit. A food allowance of $9.15 per resident per day will be included as an occupancy expense for each new or replacement residence. The application will be subject to audit and verification by the purchasing governmental unit to ensure the application data is accurate. The purchasing governmental unit may require the provider to return any excess funding received through this provision. New site occupancy rates established by the Executive Office of Health and Human Services and the purchasing governmental units during the period of July 1, 2014 through June 30, 2024, will continue at the rates established by the New Site Occupancy process effective during that period, but may be subject to adjustments for extenuating circumstances as determined by the purchasing governmental unit. b. The maximum per person per month rates for new program sites or replacement sites for each geographic occupancy rate zone as defined in 101 CMR 420.03(9) are as follows. Occupancy Rate Zone Maximum Allowable Rate Index Maximum Allowable Monthly Rate Unit Central/West $2,163 per person per month Southeast $2,350 per person per month Northeast $2,350 per person per month Cape and Islands $2,514 per person per month Metro Boston $2,514 per person per month c. The maximum per person per month rate for new program or replacement sites that serve individuals with acquired brain injury, or sites that are medically intensive, as determined by the purchasing governmental unit, is $2,995. d. The maximum per person per month rate for new program or replacement sites that serve individuals in sites designated as behaviorally intensive, as determined by the purchasing governmental unit, is $2,995, that is, rate index 20. e. Exceptions to the maximum allowable rate for new program sites or replacement sites established pursuant to 101 CMR 420.03(8)(c)2.b. may be granted by the purchasing governmental unit to new or replacement sites where the site developer has applied to receive Facility Consolidation Funding administered through the Community Economic Development Assistance Corporation. The purchasing governmental unit may issue guidance by bulletin or other written issuance to clarify its application of exceptions made in accordance with 101 CMR 420.03(8)(c)2.e. (9) Occupancy Rate Zones for New Program or Current Replacement Site Rates. (a) Metro Boston: Ashland, Belmont, Boston, Brookline, Cambridge, Canton, Chelsea, Dedham, Dover, Foxborough, Framingham, Holliston, Hopkinton, Hudson, Marlborough, Medfield, Millis, Milton, Natick, Needham, Newton, Norfolk, Northborough, Norwood, Plainville, Quincy, Revere, Sharon, Sherborn, Somerville, Southborough, Sudbury, Walpole, Waltham, Watertown, Wayland, Wellesley, Westborough, Weston, Westwood, Winthrop, Wrentham. (b) Southeast: Abington, Acushnet, Attleboro, Avon, Berkley, Braintree, Bridgewater, Brockton, Carver, Cohasset, Dartmouth, Dighton, Duxbury, East Bridgewater, Easton, Fairhaven, Fall River, Freetown, Halifax, Hanover, Hanson, Hingham, Holbrook, Hull, Kingston, Lakeville, Mansfield, Marion, Marshfield, Mattapoisett, Middleborough, New Bedford, North Attleborough, Norton, Norwell, Pembroke, Plymouth, Plympton, Randolph, Raynham, Rehoboth, Rochester, Rockland, Scituate, Seekonk, Somerset, Stoughton, Swansea, Taunton, Wareham, West Bridgewater, Westport, Weymouth, Whitman. (d) Cape and Islands: Aquinnah, Barnstable, Bourne, Brewster, Chatham, Chilmark, Dennis, Eastham, Edgartown, Falmouth, Gosnold, Harwich, Mashpee, Nantucket, Oak Bluffs, Orleans, Provincetown, Sandwich, Tisbury, Truro, Wellfleet, West Tisbury, Yarmouth. (d) Northeast: Acton, Amesbury, Andover, Arlington, Bedford, Beverly, Billerica, Boxborough, Boxford, Burlington, Carlisle, Chelmsford, Concord, Danvers, Dracut, Dunstable, Essex, Everett, Georgetown, Gloucester, Groveland, Hamilton, Haverhill, Ipswich, Lawrence, Lexington, Lincoln, Littleton, Lowell, Lynn, Lynnfield, Malden, Manchester by the Sea, Marblehead, Maynard, Medford, Melrose, Merrimac, Methuen, Middleton, Nahant, Newbury, Newburyport, North Andover, North Reading, Peabody, Reading, Rockport, Rowley, Salem, Salisbury, Saugus, Stoneham, Stow, Swampscott, Tewksbury, Topsfield, Tyngsborough, Wakefield, Wenham, West Newbury, Westford, Wilmington, Winchester, Woburn. (e) Central/West: Adams, Agawam, Alford, Amherst, Ashburnham, Ashby, Ashfield, Athol, Auburn, Ayer, Barre, Becket, Belchertown, Bellingham, Berlin, Bernardston, Blackstone, Blandford, Boylston, Brimfield, Brookfield, Buckland, Charlemont, Charlton, Cheshire, Chester, Chesterfield, Chicopee, Clarksburg, Clinton, Colrain, Conway, Cummington, Dalton, Bolton, Deerfield, Douglas, Dudley, East Brookfield, East Longmeadow, Easthampton, Egremont, Erving, Fitchburg, Florida, Franklin, Gardner, Gill, Goshen, Grafton, Granby, Granville, Great Barrington, Greenfield, Groton, Hadley, Hampden, Hancock, Hardwick, Harvard, Hatfield, Hawley, Heath, Hinsdale, Holden, Holland, Holyoke, Hopedale, Hubbardston, Huntington, Lancaster, Lanesborough, Lee, Leicester, Lenox, Leominster, Leverett, Leyden, Longmeadow, Ludlow, Lunenburg, Medway, Mendon, Middlefield, Milford, Millbury, Millville, Monroe, Monson, Montague, Monterey, Montgomery, Mount Washington, New Ashford, New Braintree, New Marlborough, New Salem, North Adams, North Brookfield, Northampton, Northbridge, Northfield, Oakham, Orange, Otis, Oxford, Palmer, Paxton, Pelham, Pepperell, Peru, Petersham, Phillipston, Pittsfield, Plainfield, Princeton, Richmond, Rowe, Royalston, Russell, Rutland, Sandisfield, Savoy, Sheffield, Shelburne, Shirley, Shrewsbury, Shutesbury, South Hadley, Southampton, Southbridge, Southwick, Spencer, Springfield, Sterling, Stockbridge, Sturbridge, Sunderland, Sutton, Templeton, Tolland, Townsend, Tyringham, Upton, Uxbridge, Wales, Ware, Warren, Warwick, Washington, Webster, Wendell, West Boylston, West Brookfield, West Springfield, West Stockbridge, Westfield, Westhampton, Westminster, Whately, Wilbraham, Williamsburg, Williamstown, Winchendon, Windsor, Worcester, Worthington.