Individual Consideration

When the rate of payment for the purchase or repair of certain prosthetic equipment has not been established by the Executive Office of Health and Human Services, the MassHealth agency pays for the service based on individual consideration, subject to all other conditions of payment. Such items are identified in Subchapter 6 of the Prosthetics Manual by the designation (I.C.) next to the description of the item or service. The MassHealth agency determines the rate of payment for an individual-consideration item or service based on the provider’s report of services and a current invoice that indicates the provider’s adjusted acquisition cost as defined in 130 CMR 428.421 and 428.422. Payment for the fitting of a prosthesis is included in the adjusted acquisition cost. Providers must maintain adequate records to document the individual consideration claim and must provide these documents to the MassHealth agency and the Attorney General’s Medicaid Fraud Control Unit upon demand (see 130 CMR 450.205: Recordkeeping and Disclosure). Payment to a provider for an individual consideration claim is the lower of: (A) the provider’s usual and customary charge to the general public; or (B) the adjusted acquisition cost of the item plus a markup not to exceed: (1) 70% for any item whose adjusted acquisition cost is less than $100; (2) 50% for any item whose adjusted acquisition cost is $100 or greater and less than $200; (3) 45% for any item whose adjusted acquisition cost is $200 or greater and less than $300; or (4) 40% for any item whose adjusted acquisition cost is $300 or greater. 4. Program Regulations