reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 452.00 › Section 452.04 - Filing and Reporting Requirements

Current through Register 1525, July 5, 2024
(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 the
			 purchasing governmental unit upon request all records relating to its reported
			 costs, including costs of any entity related by common ownership or
			 control.
(c)
Field
			 Audits
. EOHHS may conduct a field audit. EOHHS will make
			 reasonable attempts to schedule an audit at the mutual convenience of both
			 parties.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 452.00 › Section 452.05 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				101 CMR
				452.00 are severable. If any provision of
				101 CMR
				452.00 or application of such provision to any
				eligible provider or fiscal intermediary is held invalid or unconstitutional,
				such determination will not affect the validity or constitutionality of any
				remaining provisions of
				101 CMR
				452.00 or application of such provisions to eligible
				providers or fiscal intermediaries in circumstances other than those held
				invalid.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 512.00 - Nursing Facility User Fees › Section 512.03 - Facility Groups

Current through Register 1525, July 5, 2024
(1) Nursing
			 facility user fee payment liability will vary by facility group. The two groups
			 of facilities for purposes of
			 101 CMR
			 512.00 are defined in
			 101
			 CMR 512.03(1)(a) and (b):
(a)
Group I
: All
			 facilities that do not meet the criteria for group II, and;
(b)
Group II
: Any
			 nursing facility meeting one or more of the following criteria:
1. a non-profit continuing care retirement
			 community or non-profit residential care facility;
2. a non-profit facility that provides at
			 least 39,000 annual Medicaid bed days, as determined by EOHHS; or
3. a facility with a Medicaid utilization
			 rate of 87% or higher, as determined by EOHHS.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 512.00 - Nursing Facility User Fees › Section 512.04 - Calculation of User Fee

Current through Register 1525, July 5, 2024
(1) EOHHS or its
			 designee calculates the
per diem
user fee annually. The user
			 fee is calculated as follows.
(a) Determine
			 the amount of revenue to be collected in a fiscal year in accordance with
			 M.G.L. c. 118E, § 63.
(b)
			 Determine the expected number of non-Medicare patient days in Group I
			 facilities.
(c) Determine the
			 expected number of non-Medicare patient days in Group II facilities.
(d) Determine the standard rate such that the
			 product of estimated non-Medicare patient days in Group I facilities and the
			 Group I facility user fee rate and the product of estimated non-Medicare
			 patient days in Group II facilities and the Group II facility user fee rate
			 equal the amount of revenue to be collected in a fiscal year in accordance with
			 M.G.L. c. 118E, § 63.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 512.00 - Nursing Facility User Fees › Section 512.05 - Payment of User Fee

Current through Register 1525, July 5, 2024
(1)
Quarterly Assessment
. Each facility must pay a
			 quarterly assessment to EOHHS. Each facility must determine the amount of the
			 assessment owed for each quarter by multiplying (1) its total non-Medicare
			 patient days by (2) the
per diem
user fee established by
			 EOHHS.
(2)
User Fee
			 Form
. Each facility must submit its quarterly assessment on a form
			 prepared by EOHHS. Each facility must report its total patient days by payer
			 and its non-Medicare patient days on the user fee form. A facility is still
			 obligated to pay the user fee even if they have not received or accessed the
			 form.
(3)
Due
			 Date
.
(a) Assessment payments and
			 the user fee form are due according to the following schedule:
Assessment Period
Payment and Form Due Date
July 1st - September
							 30th
November 1st
October 1st - December
							 31st
February 1st
January 1st - March
							 31st
May 1st
April 1st - June
							 30th
August 1st
(b) If
			 a facility closes, it must pay any outstanding user fee obligations within 30
			 days of the date of closure.
(c)
Mergers, Acquisitions, and CHOW
. The assessment
			 obligation of any nursing facility is applied to an obligation of any successor
			 in interest or assignee of such nursing facility, as determined by EOHHS. A
			 successor in interest may include, but is not limited to, any purchaser of the
			 assets or stock, any new operator or licensee of an existing nursing facility,
			 any surviving entity resulting from merger or liquidation, or any receiver or
			 any trustee of the original nursing facility.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 512.00 - Nursing Facility User Fees › Section 512.06 - Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
General
. Each facility must file or make available
			 information that is required or that EOHHS deems reasonably necessary for
			 calculating and collecting the user fee.
(2)
Required
			 Reports
. Each facility must file required reports and forms with
			 EOHHS or its designee and must submit any additional documentation requested by
			 EOHHS or its designee to verify the accuracy of the data submitted.
(3)
Audit
. EOHHS or
			 its designee may inspect and copy the records of a facility for purposes of
			 auditing its calculation of the assessment.
(a) If EOHHS or its designee determines that
			 a facility has either overpaid or underpaid the assessment, it will notify the
			 facility of the amount due or refund the overpayment.
(b) EOHHS or its designee may offset
			 overpayments against amounts due EOHHS for the assessment.
(c) If a facility is aggrieved by a decision
			 of EOHHS or its designee as to the amount due, it may file an appeal to the
			 Division of Administrative Law Appeals within 60 days of the date of the notice
			 of underpayment or the date the notice is received, whichever is later. The
			 filing of an appeal will not toll the collection of interest and
			 penalties.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 512.00 - Nursing Facility User Fees › Section 512.07 - Other Provisions

Current through Register 1525, July 5, 2024
(1)
Severability
. The provisions of
			 101 CMR
			 512.00 are severable. If any provision or the
			 application of any provision is held to be invalid or unconstitutional, such
			 invalidity will not be construed to affect the validity or constitutionality of
			 any remaining provisions of
			 101 CMR
			 512.00 or the application of such
			 provisions.
(2)
Administrative Bulletins
. EOHHS may issue
			 administrative bulletins to clarify policies, update administrative
			 requirements, and specify information and documentation necessary to comply
			 with 101 CMR
			 512.00.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 514.00 - Rates For Family Stabilization Services › Section 514.01 - General Provisions

Current through Register 1525, July 5, 2024
101 CMR
				514.00 governs the collection of the hospital
				assessment established under M.G.L. c. 118E, § 67.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 514.00 - Rates For Family Stabilization Services › Section 514.03 - Hospital Groups

Current through Register 1525, July 5, 2024
(1)
Hospital Assessment Liability
. Hospital assessment
			 liability will vary by hospital group and by inpatient versus outpatient
			 revenues. The five groups of hospitals for purposes of
			 101 CMR
			 514.00 are defined as follows.
(a)
Group I
: Any
			 acute hospital identified as a safety net hospital in the MassHealth
			 demonstration waiver approved under subsection (a) of section 1115 of Title XI
			 of the federal Social Security Act and in effect as of October 1,
			 2022.
(b)
Group
			 II
: Any acute hospital that is an academic medical center,
			 teaching hospital, or specialty hospital, as determined by CHIA as of September
			 30, 2019, but excluding any hospital included in Group I.
(c)
Group III
: Any
			 private acute hospital operating as of September 30, 2019, but excluding any
			 hospital included in Group I or Group II.
(d)
Group IV
: The
			 Commonwealth's only non-state-owned public hospital, operating as of September
			 30, 2019.
(e)
Group
			 V
: Any nonpublic non-acute hospital operating as of September 30,
			 2019.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 514.00 - Rates For Family Stabilization Services › Section 514.04 - Calculation of Hospital Assessment

Current through Register 1525, July 5, 2024
(1) To
			 determine each hospital's annual assessment liability, the assessment rates
			 established in
			 101
			 CMR 514.04(3)  are applied
			 to a static fiscal year 2019 dataset of non-public gross patient service
			 revenues, except as described in
			 101
			 CMR 514.04(2).
(2) For new acute hospitals described in
			 101
			 CMR 514.03(2)(a)  and new
			 non-acute hospitals described in
			 101
			 CMR 514.03(2)(b), the
			 assessment rates established in
			 101
			 CMR 514.04(3)  are applied
			 to an annual projection of non-public gross patient service revenues, provided
			 by the hospital in accordance with
			 101
			 CMR 514.06(2), until such
			 time as CHIA includes the new hospital in their release of fiscal year cost
			 report data.
(a) For new acute hospitals,
			 beginning with the first complete calendar month following the date of the new
			 acute hospital's inclusion in CHIA's fiscal year cost report data, the
			 assessment rates established in
			 101
			 CMR 514.04(3)  are applied
			 to the static data included in such fiscal year cost report data.
(b) For new non-acute hospitals, beginning
			 with the first complete calendar quarter following the date of the new
			 non-acute hospital's inclusion in CHIA's fiscal year cost report data, the
			 assessment rates established in
			 101
			 CMR 514.04(3)  are applied
			 to the static data included in such fiscal year cost report data.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 514.00 - Rates For Family Stabilization Services › Section 514.05 - Payment of Hospital Assessment

Current through Register 1525, July 5, 2024
(1)
Acute Hospital Monthly Assessment
. Beginning October
			 1, 2022, each acute hospital must pay a monthly assessment to EOHHS in a form
			 and manner specified by the Health Safety Net Office, equal to one twelfth of
			 its total annual assessment.
(2)
Non-acute Hospital Quarterly Assessment
. Beginning
			 October 1, 2022, each non-acute hospital must pay a quarterly assessment to
			 EOHHS in a form and manner specified by the Health Safety Net Office, equal to
			 one fourth of its total annual assessment.
(3)
Due Date
.
(a) Acute hospital assessment payments are
			 due on a monthly basis, with each assessment payment due on the last day of
			 each month.
(b) Non-acute hospital
			 assessment payments are due on a quarterly basis, with each quarterly
			 assessment payment due on the last day of each calendar quarter.
(c) If a hospital closes, it must pay any
			 outstanding hospital assessment obligations within 30 days of the date of
			 closure. If a hospital is acquired by or merges with another hospital, any
			 outstanding hospital assessments owed by the hospital being acquired or merging
			 must be paid within 30 days of the date of the acquisition or merger.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 514.00 - Rates For Family Stabilization Services › Section 514.06 - Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
General
. Each hospital must file or make available
			 information that EOHHS deems reasonably necessary for calculating and
			 collecting the hospital assessment.
(2)
Required Reporting for
			 Hospitals with Change of Status
. Any new hospital, merging
			 hospital, acquiring or acquired hospital, or closing hospital, as described in
			 101
			 CMR 514.03(2)(a) through
			 (c), must inform EOHHS of its change in
			 status at least 14 days prior to such change in status. Any new acute or
			 non-acute hospital, as described in
			 101
			 CMR 514.03(2)(a) and (b),
			 must provide projected annual revenue information, and any additional
			 supporting documentation as requested by EOHHS, in the form and format
			 requested by EOHHS within 30 days of beginning operations.
(3)
Additional
			 Documentation
. Each hospital must submit any additional
			 documentation requested by EOHHS or its designee to verify the accuracy of the
			 data submitted.
(4) Audit. EOHHS or
			 its designee may inspect and copy the records of a hospital for purposes of
			 auditing its calculation of the assessment. If EOHHS or its designee determines
			 that a hospital has either overpaid or underpaid the assessment, it will notify
			 the hospital of the amount due or refund the overpayment.
(5)
Penalties
. EOHHS
			 may impose a
per diem
penalty of $100 per day if a hospital
			 fails to furnish documentation required or requested under
			 101
			 CMR 514.06 within the timeframes specified in
			 101
			 CMR 514.05(3)  or as
			 specified by EOHHS upon request, or in administrative bulletins or other
			 written issuances.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 514.00 - Rates For Family Stabilization Services › Section 514.07 - Other Provisions

Current through Register 1525, July 5, 2024
(1)
Severability
. The provisions of
			 101 CMR
			 514.00 are severable. If any provision or the
			 application of any provision is held to be invalid or unconstitutional, such
			 invalidity will not be construed to affect the validity or constitutionality of
			 any remaining provisions of
			 101 CMR
			 514.00 or the application of such
			 provisions.
(2)
Administrative Bulletins
. EOHHS may issue
			 administrative bulletins to clarify policies, update administrative
			 requirements, and specify information and documentation necessary to comply
			 with 101 CMR
			 514.00.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 516.00 - Behavioral Health Access and Crisis Intervention Trust Fund Surcharge › Section 516.01 - Scope and Purpose

Current through Register 1525, July 5, 2024
101 CMR
				516.00 governs the procedures for collecting a
				surcharge to fund the Behavioral Health Access and Crisis Intervention Trust
				Fund. The Behavioral Health Access and Crisis Intervention Trust Fund surcharge
				is a surcharge on certain payments made to Massachusetts acute hospitals and
				ambulatory surgical centers.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 516.00 - Behavioral Health Access and Crisis Intervention Trust Fund Surcharge › Section 516.03 - Determination of Surcharge Liability and Payment.

Current through Register 1525, July 5, 2024
(1) EOHHS will collect a surcharge on certain
			 payments to hospitals and ambulatory surgical centers. The surcharge amount
			 equals the product of:
(a) payments subject
			 to the surcharge as defined in
			 101
			 CMR 516.03(3); and
(b) the assessment percentage as defined in
			 101
			 CMR 516.03(4).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 516.00 - Behavioral Health Access and Crisis Intervention Trust Fund Surcharge › Section 516.04 - Administrative Review

Current through Register 1525, July 5, 2024
(1)
Surcharge Liability
. EOHHS may conduct an
			 administrative review of surcharge liability payments at any time.
(2)
Reviews and
			 Audits
. In conducting such review, EOHHS will review data
			 submitted by hospitals, ambulatory surgical centers, and any other relevant
			 data, including surcharge data. All information provided by, or required from,
			 any payer, pursuant to
			 101 CMR
			 516.00 will be subject to audit by EOHHS. For
			 surcharge liability payments based upon a global fee or capitation payment
			 allocated according to an allocation method accepted by EOHHS pursuant to
			 101
			 CMR 516.03(4)(b), EOHHS'
			 review will be limited to determining whether this method was followed
			 accurately and whether the amounts reported were accurate.
(a) EOHHS may require the payer to submit
			 additional documentation reconciling the data it submitted with data received
			 from hospitals and ambulatory surgical centers.
(b) If EOHHS determines through its review
			 that a payer's surcharge liability payment was materially incorrect, EOHHS will
			 require a payment adjustment.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 516.00 - Behavioral Health Access and Crisis Intervention Trust Fund Surcharge › Section 516.05 - Other Provisions

Current through Register 1525, July 5, 2024
(1)
Reporting Requirements
. Each payer must file or make
			 available information that is required or that EOHHS deems reasonably necessary
			 for calculating and collecting the surcharge.
(2)
Administrative
			 Bulletins
. EOHHS may issue administrative bulletins to clarify
			 policies, update administrative requirements, and specify information and
			 documentation necessary to implement
			 101 CMR
			 516.00.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 516.00 - Behavioral Health Access and Crisis Intervention Trust Fund Surcharge › Section 516.06 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				101 CMR
				516.00 are severable. If any provision or the
				application of any provision is held to be invalid or unconstitutional, such
				invalidity shall not be construed to affect the validity or constitutionality
				of any remaining provisions of
				101 CMR
				516.00 or the application of such
				provisions.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 613.00 - Health Safety Net Eligible Services › Section 613.01 - General Provisions

Current through Register 1525, July 5, 2024
Scope and Purpose
. 101 CMR 613.00
				governs the criteria applicable April 1, 2024, for determining the services for
				which Acute Hospitals and Community Health Centers may be paid by the Health
				Safety Net, including the types of services that are paid by the Health Safety
				Net, and the criteria to determine Low Income Patient status, to determine
				Medical Hardship, and to submit claims for Bad Debt. Payment rates for Eligible
				Services, as defined in
				101
				CMR 613.03, are set forth in 101 CMR 614.00:
Health Safety Net Payments and Funding
.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 613.00 - Health Safety Net Eligible Services › Section 613.03 - Eligible Services Requirements

Current through Register 1525, July 5, 2024
(1)
General
. To qualify as a service eligible for payment,
			 the service must meet the following criteria.
(a)
Eligible Services
			 Categories
. There are three categories of services eligible for
			 payment from the Health Safety Net, as follows:
1. Reimbursable Health Services to Low Income
			 Patients as defined in
			 101 CMR
			 613.04;
2. Medical Hardship, pursuant to the
			 requirements in
			 101 CMR 613.05;
			 and
3. Bad Debt, pursuant to the
			 requirements in
			 101 CMR
			 613.06.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 613.00 - Health Safety Net Eligible Services › Section 613.04 - Eligible Services to Low Income Patients

Current through Register 1525, July 5, 2024
(1)
General
. Providers may submit claims for Reimbursable
			 Health Services to Low Income Patients determined in accordance with the
			 criteria in 101 CMR 613.04. Low Income Patients may be determined eligible for
			 Health Safety Net - Primary or Health Safety Net - Secondary, in accordance
			 with 101 CMR 613.04(6). The following individuals are not eligible for Low
			 Income Patient status:
(a) individuals who
			 have been determined eligible for any MassHealth program, including any premium
			 assistance program, but who have failed to enroll; and
(b) individuals whose enrollment in
			 MassHealth or the Premium Assistance Payment Program Operated by the Health
			 Connector has been terminated due to failure to pay
			 premiums.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 613.00 - Health Safety Net Eligible Services › Section 613.05 - Medical Hardship

Current through Register 1525, July 5, 2024
(1)
Eligibility
.
(a)
General
. A Massachusetts Resident at any Countable
			 Income level may qualify for Medical Hardship if allowable medical expenses
			 exceed a certain percentage of his or her Countable Income as specified in
			 101
			 CMR 613.05(1)(c). A
			 determination of Medical Hardship is a one-time determination and not an
			 ongoing eligibility category. An applicant may submit no more than two Medical
			 Hardship applications within a 12-month period.
(b)
Countable
			 Income
.
1.
Gross
			 Earned Income
.
a. Gross earned
			 income is the total amount of compensation received for work or services
			 performed without regard to any deductions.
b. Gross earned income for the self-employed
			 is the total amount of business income listed on the most recently filed
			 federal tax return or allowable on a federal tax return.
c. Seasonal income is income derived from an
			 income source that is associated with a particular time of the year. Annual
			 gross income is divided by 12 to obtain a monthly gross income with the
			 following exception: if the Patient has a disabling illness or accident during
			 or after the seasonal employment period that prevents the person's continued or
			 future employment, only current income will be considered in the eligibility
			 determination.
2.
Gross Unearned Income
.
a. Gross unearned income is the total amount
			 of income that does not directly result from the individual's own labor before
			 any income deductions are made.
b.
			 Unearned income includes, but is not limited to, social security benefits,
			 railroad retirement benefits, pensions, annuities, federal veterans' benefits,
			 interest and dividend income, unemployment benefits, child support, and
			 alimony.
3.
Rental Income
. Rental income is the total amount of
			 gross income less any deductions listed or allowable on the Patient's most
			 recently filed federal tax return or allowable on a federal tax
			 return.
(c)
Percentage of Countable Income
. To qualify for Medical
			 Hardship, the applicant's allowable medical expenses exceed a specified
			 percentage of the applicant's Countable Income as follows.
Income Level
Percentage of Countable
							 Income
0 - 205% FPL
10%
205.1 - 305% FPL
15%
305.1 - 405%
20%
405.1 - 605% FPL
30%
>605.1% FPL
40%
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 613.00 - Health Safety Net Eligible Services › Section 613.06 - Allowable Bad Debt

Current through Register 1525, July 5, 2024
(1)
General Requirements
. Acute Hospitals may submit
			 claims for Emergency Bad Debt as defined in 101 CMR 613.06(2). Acute Hospitals
			 and Community Health Centers may submit claims for Bad Debt for Urgent Care
			 Services as defined in 101 CMR 613.06(3) and (4). Providers may not submit a
			 claim for a deductible or coinsurance portion of a claim for which an insured
			 Patient or Low Income Patient is responsible. Providers may only submit claims
			 for the services described in
			 101 CMR 613.03(2)
			 through (4).
(a)
Required Collection
			 Action
. Providers may submit claims for Bad Debt only after
			 required collection action, including the following.
1.
Collecting Patient
			 Information
.
a.
Inpatient Services
. An Acute Hospital must identify
			 the department responsible for obtaining the information from the Patient, and
			 make reasonable efforts to obtain the financial information necessary to
			 determine responsibility for payment of the Acute Hospital bill from the
			 Patient or Guarantor. If the Patient or Guarantor is unable to provide the
			 information needed, and the Patient consents, an Acute Hospital must make
			 reasonable efforts to contact the relatives, friends, and Guarantor and the
			 Patient for additional information while the Patient is in the Acute Hospital.
			 If an Acute Hospital has not obtained sufficient Patient financial information
			 to assess the ability of the Patient or the Guarantor to pay for services prior
			 to the date of discharge, the Acute Hospital must make reasonable efforts to
			 obtain the necessary information at the time of the Patient's
			 discharge.
b.
Emergency
			 Room, Outpatient Services, and Community Health Center Services
. A
			 Provider must make reasonable efforts, as soon as reasonably possible, to
			 obtain the financial information necessary to determine responsibility for
			 payment of the bill from the Patient or Guarantor.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 613.00 - Health Safety Net Eligible Services › Section 613.07 - Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
General
. Each Provider must file or make available
			 information that the Health Safety Net Office deems necessary to verify that a
			 service for which a Provider submits a claim is an Eligible Service.
(a) The Health Safety Net Office may revise
			 the data specifications, the data collection scheduled, or other administrative
			 requirements by administrative bulletin.
(b) Providers must maintain records
			 sufficient to document compliance with all screening and documentation
			 requirements of
			 101 CMR 613.00. Providers
			 must maintain records documenting claims for Reimbursable Health Services to
			 Low Income Patients, Bad Debt for Emergency or Urgent Care services, and
			 Medical Hardship.
(c) The Health
			 Safety Net Office may deny payment for claims by any Provider that fails to
			 comply with the reporting requirements of
			 101 CMR 613.00 or
			 614.00:
Health
			 Safety Net Payments and Funding
until such Provider complies with the
			 requirements. The Health Safety Net Office will notify such Provider of its
			 intention to withhold payment.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 614.00 - Health Safety Net Payments and Funding › Section 614.01 - General Provisions

Current through Register 1525, July 5, 2024
Scope, Purpose, and Effective Date
.
				101 CMR
				614.00 governs Health Safety Net payments and funding
				effective for dates of service beginning October 1, 2022, including payments to
				Acute Hospitals and Community Health Centers and payments from Acute Hospitals
				and Surcharge Payers. The criteria for determining services for which Acute
				Hospitals and Community Health Centers may be paid by the Health Safety Net are
				set forth in
				101 CMR
				613.00:
Health Safety Net Eligible
				Services
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 614.00 - Health Safety Net Payments and Funding › Section 614.03 - Sources and Uses of Funds

Current through Register 1525, July 5, 2024
(1)
Available Revenue
.
(a) Except as provided in 101 CMR
			 614.03(1)(b), revenue available to fund Provider payments from the Health
			 Safety Net Trust Fund consists of
1. revenue
			 produced by Acute Hospital and Non-acute Hospital assessments and the surcharge
			 on Hospital Services and Ambulatory Surgical Center Services payments, less
a. 50% of the estimated cost, as determined
			 by the Secretary of Administration and Finance, of administering the Health
			 Safety Net and related assessments in accordance with M.G.L. c. 118E,
			 §§ 65 through 69;
b. any
			 amount designated to be transferred to the MassHealth Delivery System Reform
			 Trust Fund pursuant to M.G.L. c. 118E, § 66 or otherwise required by law;
			 and
c. any amount designated to be
			 transferred to the Non-acute Care Hospital Reimbursement Trust Fund established
			 in M.G.L. c. 29, § 2WWWW pursuant to M.G.L. c. 118E, § 66 or
			 otherwise required by law;
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 614.00 - Health Safety Net Payments and Funding › Section 614.04 - Acute Hospital and Non-acute Hospital Assessment Liability to the Health Safety Net Trust Fund

Current through Register 1525, July 5, 2024
(1)
Acute Hospital Assessment Calculation
. Each Acute
			 Hospital's gross liability to the Health Safety Net Trust Fund is equal to the
			 product of
(a) the ratio of its Assessed
			 Charges to all Acute Hospitals' Assessed Charges; and
(b) the Total Acute Hospital Assessment
			 Amount.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 614.00 - Health Safety Net Payments and Funding › Section 614.05 - Surcharge on Acute Hospital Payments

Current through Register 1525, July 5, 2024
(1)
General
. There is a surcharge on certain payments to
			 Acute Hospitals and Ambulatory Surgical Centers. The surcharge amount equals
			 the product of payments subject to surcharge as defined in
			 101
			 CMR 614.05(1)(b)  and the
			 Surcharge Percentage as defined in
			 101
			 CMR 614.05(2).
(a)
Surcharge Payer
.
1. A Surcharge Payer is an individual or
			 entity that makes payments for the purchase of health care Hospital Services
			 and Ambulatory Surgical Center Services, including a Managed Care Organization;
			 provided, however, that the term "surcharge payer" does not include Title XVIII
			 and Title XIX of the Social Security Act programs and their beneficiaries or
			 recipients, except Managed Care Organizations; other governmental programs of
			 public assistance and their beneficiaries or recipients; and the workers'
			 compensation program established pursuant to M.G.L. c. 152.
2. The same entity that pays that Acute
			 Hospital or Ambulatory Surgical Center for services must pay the surcharge. If
			 an entity such as a Third Party Administrator acts on behalf of a client plan
			 and uses the client plan's funds to pay for the services, or advances funds to
			 pay for the services for which it is reimbursed by the client plan, it must
			 also act on behalf of the client plan and use the client plan's funds to pay
			 the surcharge or advance funds to pay the surcharge for which it will be
			 reimbursed by the client plan.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 614.00 - Health Safety Net Payments and Funding › Section 614.07 - Payments to Community Health Centers

Current through Register 1525, July 5, 2024
(1)
General Provisions
.
(a) The Health Safety Net pays Community
			 Health Centers based on claims submitted to the Health Safety Net Office, less
			 applicable cost sharing amount, in accordance with the requirements of
			 101 CMR
			 613.00:
Health Safety Net Eligible
			 Services
and claims specifications determined by the Health Safety Net
			 Office. The Health Safety Net Office monitors the volume of claims submitted
			 and may adjust or withhold payments if it appears that there has been a
			 substantial change in the Provider's service delivery patterns including, but
			 not limited to, unbundling of services, upcoding, or other billing maximization
			 activities.
(b) The Health Safety
			 Net will pay a Community Health Center for prescribed drugs only if the
			 Community Health Center is providing prescribed drugs in accordance with
			 101
			 CMR 613.03(2).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 614.00 - Health Safety Net Payments and Funding › Section 614.08 - Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
General
. Each Provider, Surcharge Payer, and
			 Ambulatory Surgical Center must file with or make available to the Health
			 Safety Net Office or to an entity designated by the Health Safety Net Office to
			 collect data, as applicable, information that is required or that the Health
			 Safety Net Office deems reasonably necessary for implementation of
			 101 CMR
			 614.00.
(a) The
			 Health Safety Net Office may revise the data specifications, the data
			 collection scheduled, or other administrative requirements by administrative
			 bulletin.
(b) The Health Safety Net
			 Office or its designee may audit data submitted under
			 101 CMR
			 614.00 to ensure accuracy. The Health Safety Net
			 Office may adjust payments to reflect audit findings. Providers must maintain
			 records sufficient to document compliance with all documentation requirements
			 of 101 CMR
			 613.00:
Health Safety Net Eligible
			 Services
and 614.00.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 614.00 - Health Safety Net Payments and Funding › Section 614.09 - Special Provisions

Current through Register 1525, July 5, 2024
(1)
Financial Hardship
. An Acute Hospital or Surcharge
			 Payer may request a deferment or partial payment schedule due to financial
			 hardship.
(a) In order to qualify for such
			 relief, the Acute Hospital or Surcharge Payer must demonstrate that its ability
			 to continue as a financially viable going concern will be seriously impaired if
			 payments pursuant to
			 101
			 CMR 614.05 were made.
(b) If the Health Safety Net Office finds
			 that payments would be a financial hardship, the Health Safety Net Office may,
			 at its discretion, establish the terms of any deferment or partial payment plan
			 deferment. The deferment or payment schedule may include an interest charge.
1. The interest rate used for the payment
			 schedule does not exceed the prime rate plus 2%. The prime rate used is the
			 rate reported in the
Wall Slreel Journal
dated the last
			 business day of the month preceding the establishment of the payment
			 schedule.
2. A Surcharge Payer may
			 make a full or partial payment of its outstanding liability at any time without
			 penalty.
3. If a Surcharge Payer
			 fails to meet the obligations of the payment schedule, the Health Safety Net
			 Office may assess penalties pursuant to
			 101
			 CMR 614.05.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 701.00 - COMMUNITY HOSPITAL REINVESTMENT TRUST FUND PAYMENTS AND FUNDING › Section 701.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
. 101 CMR 701.00 governs the
			 Community Hospital Reinvestment Trust Fund payments and funding, including
			 payments to eligible acute care hospitals and payments from the Center. 101 CMR
			 701.00 does not govern other payments to acute care hospitals, including
			 payments pursuant to contracts under the Acute Care Hospital Request for
			 Applications.
(2)
Administrative Bulletins
. EOHHS may issue
			 administrative bulletins to clarify its policy on and understanding of
			 substantive provisions of 101 CMR 701.00.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 701.00 - COMMUNITY HOSPITAL REINVESTMENT TRUST FUND PAYMENTS AND FUNDING › Section 701.02 - General Definitions

Current through Register 1525, July 5, 2024
As used in 101 CMR 701.00, terms will have the meanings set
				forth in 101 CMR 701.02, except where the context clearly indicates
				otherwise.
Acute Care Hospital
. A hospital
				licensed under M.G.L. c. 111, § 51 that contains a majority of
				medical-surgical, pediatric, obstetric, and maternity beds, as defined by the
				Department of Public Health.
Center
. The Center for Health
				Information and Analysis established under M.G.L. c. 12C.
EOHHS
. The Executive Office of Health
				and Human Services established under M.G.L. c. 6A.
Gross Patient Service Revenue (GPSR)
.
				The total dollar amount of a hospital's charges for the provision of patient
				care rendered in a hospital rate year.
Hospital Cost Report
. The Hospital
				Statement of Costs, Revenues, and Statistics reported to the Center pursuant to
				957 CMR 9.00:
Hospital
				Financial Data Reporting Requirements
.
Hospital Rate Year
. The time period of
				12 months beginning on October 1st of any calendar
				year and ending on September 30th of the following
				calendar year.
State Fiscal Year
. The time period of
				12 months beginning on July 1st of any calendar year
				and ending on June 30th of the following calendar
				year.
Statewide Relative Price (SRP)
. A
				metric calculated by the Center pursuant to M.G.L. c. 29, § 2TTTT and c.
				12C, § 10. The SRP measures the total payments, including non-claims, made
				to acute care hospitals by health plans, expressed in the aggregate relative to
				a statewide average within a given insurance category.
Trust Fund
. The Community Hospital
				Reinvestment Trust Fund established under M.G.L. c. 29, § 2TTTT, effective
				October 1, 2016, to provide annual financial support to eligible acute care
				hospitals, as specified in 101 CMR 701.00. The Secretary of EOHHS, as trustee,
				will administer the fund and will make expenditures from the fund consistent
				with M.G.L. c. 29, § 2TTTT.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 701.00 - COMMUNITY HOSPITAL REINVESTMENT TRUST FUND PAYMENTS AND FUNDING › Section 701.03 - Sources and Uses of Fund

Current through Register 1525, July 5, 2024
(1)
General
. The Trust Fund may include money from public
			 and private sources, including gifts, grants and donations, interest earned on
			 such money, any other money authorized by the general court and specifically
			 designated to be credited to the fund (including, but not limited to, transfers
			 from the Center), and any funds provided from other sources.
(2)
Transfers from the
			 Center
.
(a)
State
			 Fiscal Year 2017
. Subject to appropriation, and not later than
			 June 30, 2017, the Center will transfer $5,000,000 to the Trust Fund.
(b)
State Fiscal Years 2018
			 Through 2021
. Subject to appropriation, and not later than June
			 30th of each year, beginning with State Fiscal Year
			 2018 through State Fiscal Year 2021, the Center will annually transfer
			 $10,000,000 to the Trust Fund.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 701.00 - COMMUNITY HOSPITAL REINVESTMENT TRUST FUND PAYMENTS AND FUNDING › Section 701.04 - General Payment Provisions

Current through Register 1525, July 5, 2024
(1)
Payment Eligibility
. To be eligible to receive payment
			 from the Trust Fund, an acute care hospital must be:
(a) licensed under M.G.L. c. 111, § 51,
			 as defined by the Department of Public Health; and
(b) a hospital with SRP below 120% of the
			 median SRP, as determined by the Center.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 701.00 - COMMUNITY HOSPITAL REINVESTMENT TRUST FUND PAYMENTS AND FUNDING › Section 701.05 - Filing and Reporting Requirements

Current through Register 1525, July 5, 2024
(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 eligible acute care hospital.
(b)
Examination of
			 Records
. Each eligible acute care hospital must make available all
			 records relating to its operation and all records relating to a realty service
			 or holding company or any entity in which there may be a common ownership or
			 interrelated directorate upon request of EOHHS for examination.
(c)
Field Audits
.
			 EOHHS or its designee may conduct field audits of eligible acute care hospitals
			 to verify compliance with any aspect of 101 CMR 701.00.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 701.00 - COMMUNITY HOSPITAL REINVESTMENT TRUST FUND PAYMENTS AND FUNDING › Section 701.06 - Noncompliance

Current through Register 1525, July 5, 2024
EOHHS may deny, reduce, or withhold payment to an eligible
				acute care hospital that fails to comply with any condition of payment or
				reporting requirement set forth in 101 CMR 701.00. EOHHS will notify the acute
				care hospital of its intention to deny, reduce, or withhold
				payment.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 701.00 - COMMUNITY HOSPITAL REINVESTMENT TRUST FUND PAYMENTS AND FUNDING › Section 701.07 - Severability

Current through Register 1525, July 5, 2024
The provisions of 101 CMR 701.00 are severable. If any
				provision of 101 CMR 701.00 or the application of such provision of 101 CMR
				701.00 is held invalid or unconstitutional, such determination will not be
				construed to affect the validity or constitutionality of any other provision of
				101 CMR 701.00 or the application of any other provision.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 801.00 - Drug Manufacturer Negotiations and Accountability › Section 801.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
. 101 CMR 801.00 governs the process
			 for direct negotiations between the Executive Office of Health and Human
			 Services (EOHHS) and manufacturers for supplemental rebate agreements (SRAs),
			 the public process for determining a drug's target value, and referrals of
			 manufacturers to the Health Policy Commission (HPC).
(2)
Administrative
			 Bulletins
. EOHHS may issue administrative bulletins to clarify its
			 policy on and understanding of substantive provisions of 101 CMR
			 801.00.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 801.00 - Drug Manufacturer Negotiations and Accountability › Section 801.03 - Direct Negotiations

Current through Register 1525, July 5, 2024
(1)
General
.
(a) EOHHS
			 may enter into direct negotiations with any manufacturer for an SRA for any
			 covered drug(s) manufactured by the manufacturer. Such negotiations may be
			 initiated by EOHHS or by the manufacturer, provided that nothing obligates
			 EOHHS to engage in negotiations with any manufacturer.
(b) EOHHS will seek to prioritize direct
			 negotiations in a manner that maximizes value to the Commonwealth, and will
			 only enter into an SRA if EOHHS determines that doing so will maximize value to
			 the Commonwealth in a manner consistent with the concept of "best value" as
			 defined at
			 801 CMR 21.02:
Definitions
and consideration of the factors described in 101
			 CMR 801.03(3), as appropriate.
(c)
			 Nothing precludes EOHHS from utilizing the processes described at
			 801 CMR 21.00:
Procurement of Commodities or Services, including Human and Social
			 Services
, or any other process allowed under state law, to enter into
			 an SRA as an alternative to a direct negotiation.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 801.00 - Drug Manufacturer Negotiations and Accountability › Section 801.04 - Determination of Target Value

Current through Register 1525, July 5, 2024
(1)
General
. EOHHS may determine a target value for any
			 covered drug that meets the following requirements:
(a) The covered drug must be a high-cost
			 drug; and
(b) The covered drug must
			 have been the subject of a failed direct negotiation under 101 CMR
			 801.03(2)(b).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 801.00 - Drug Manufacturer Negotiations and Accountability › Section 801.05 - Referral to the Health Policy Commission

Current through Register 1525, July 5, 2024
(1)
General
.
(a) EOHHS
			 may refer a manufacturer to the HPC for review of a covered drug under M.G.L.
			 c. 6D, § 8A, provided that the following conditions are met:
1. The covered drug meets the requirements of
			 101 CMR 801.04(1), and EOHHS and the manufacturer have not subsequently
			 executed an SRA for the covered drug under 101 CMR 801.04(4) or
			 otherwise;
2. EOHHS has posted a
			 final target value for the covered drug under 101 CMR 801.04(2)(g) and not more
			 than 180 days have passed since EOHHS has posted said final target value;
			 and
3. The Secretary has provided
			 written notice of the referral to the HPC, with a copy to the
			 manufacturer.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 801.00 - Drug Manufacturer Negotiations and Accountability › Section 801.06 - Confidentiality

Current through Register 1525, July 5, 2024
Subject to 101 CMR 801.05(2), any non-public information shared
				with EOHHS by the manufacturer during the course of a direct negotiation under
				101 CMR 801.03 or during the process for determining a target value under 101
				CMR 801.04, or by the HPC under M.G.L. c. 6D, § 8A, will not be a public
				record under M.G.L. c. 4, § 7 or M.G.L. c. 66, and EOHHS will regard any
				records expressly designated as such by the manufacturer or HPC as confidential
				and proprietary.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 801.00 - Drug Manufacturer Negotiations and Accountability › Section 801.07 - Interaction with Other Regulations

Current through Register 1525, July 5, 2024
The application of any provision of 101 CMR 801.00, including
				the determination of a target value under 101 CMR 801.04, does not constitute a
				determination of medical necessity for a covered drug by the MassHealth agency
				for any individual MassHealth member, a determination that payment is available
				for a covered drug from the MassHealth agency to any MassHealth provider, or
				establish the rate of payment for any covered drug by EOHHS, and does not
				otherwise supersede any other applicable provision of another MassHealth or
				EOHHS regulation, including
				101 CMR
				331.00:
Prescribed Drugs
,
				130 CMR
				406.000:
Pharmacy Services
, or
				130 CMR 450.000:
Administrative and Billing Regulations
.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 801.00 - Drug Manufacturer Negotiations and Accountability › Section 801.08 - Severability

Current through Register 1525, July 5, 2024
The provisions of 101 CMR 801.00 are severable. If any
				provision or subprovision of 101 CMR 801.00 or the application of such
				provision or subprovision of 101 CMR 801.00 is held invalid or
				unconstitutional, such determination will not be construed to affect the
				validity or constitutionality of any other provision or subprovision of 101 CMR
				801.00 or the application thereof.