reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.1 CMR 40.00 - NON-ACUTE HOSPITAL PUBLICLY ASSISTED RATES OF PAYMENT AND THE FEE FOR RESIDENTIAL ALCOHOLISM TREATMENT PROGRAMS › Section 40.15 - Administrative Review

Current through Register 1525, July 5, 2024
(1)
Purpose of Administrative Review
. To assure that a
			 hospital's rates are in continuing compliance with this part, the Division may
			 at any time and upon its own motion, review the rates upon notice to the
			 hospital.
(2)
Administrative Review of Transfers of Costs
. Where a
			 hospital has reduced or increased costs by the transfer of those costs to or
			 from other persons or entities which provide health care and services, the
			 Division may modify Reasonable Financial Requirements to reflect the change in
			 cost. In order to give effect to a transfer of cost each hospital must file
			 information concerning cost, volume and revenue 30 days prior to implementation
			 of a proposed transfer of cost, and must submit any additional information
			 regarding the transfer of cost which the Division may require.
(3)
Administrative Review and
			 Decision
. Upon notice of administrative review, a hospital shall
			 submit such books, records, documentation, and information as the Division may
			 require. After review, the Division will render a written decision and a
			 statement of reasons for its decision.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.1 CMR 40.00 - NON-ACUTE HOSPITAL PUBLICLY ASSISTED RATES OF PAYMENT AND THE FEE FOR RESIDENTIAL ALCOHOLISM TREATMENT PROGRAMS › Section 40.16 - Appeal

Current through Register 1525, July 5, 2024
A non-acute hospital which is aggrieved by an action or failure
				to act under 114.1 CMR 40.00 may file an appeal within 30 days to the Division
				of Administrative Law Appeals pursuant to the requirements of M.G.L. c. 118 G.
				The pendency of an appeal does not limit the Division's right to undertake
				administrative review under 114.1 CMR 40.00.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.1 CMR 40.00 - NON-ACUTE HOSPITAL PUBLICLY ASSISTED RATES OF PAYMENT AND THE FEE FOR RESIDENTIAL ALCOHOLISM TREATMENT PROGRAMS › Section 40.17 - Severability

Current through Register 1525, July 5, 2024
The provisions of 114.1 CMR 40.00 are hereby declared to be
				severable and if such provisions or the application of such provisions to any
				person or circumstances shall be held to be invalid or unconstitutional, such
				invalidity or unconstitutionality shall not be construed to affect the validity
				or constitutionality of any of the remaining provisions of 114.1 CMR 40.00 or
				the application of such provisions to hospitals or circumstances other than
				those held invalid.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.1 CMR 40.00 - NON-ACUTE HOSPITAL PUBLICLY ASSISTED RATES OF PAYMENT AND THE FEE FOR RESIDENTIAL ALCOHOLISM TREATMENT PROGRAMS › Section 40.18 - Administrative Information Bulletins

Current through Register 1525, July 5, 2024
The Division may, from time to time, issue administrative
				information bulletins to clarify its policy upon and understanding of
				substantive provisions of 114.1 CMR 40.00. In addition, the Division may issue
				administrative information bulletins which specify the information and
				documentation necessary to implement 114.1 CMR 40.00 if necessary for informed
				consideration of rate determination under 114.1 CMR 40.00.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.1 CMR 41.00 - RATES OF PAYMENT FOR SERVICES PROVIDED TO INDUSTRIAL ACCIDENT PATIENTS BY HOSPITALS › Section 41.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope, Purpose and Effective Date
. 114.1 CMR 41.00
			 establishes payment rates effective April 1, 2009, for services provided to
			 Industrial Accident Patients by Acute and Non-acute Hospitals under M.G.L. c.
			 152, the Workers' Compensation Act. Payment rates for services provided to
			 industrial accident patients by other providers are set forth in 114.3 CMR
			 40.00. Program policies relating to medical necessity and clinical
			 appropriateness are determined pursuant to M.G.L. c. 152 and
			 452 CMR 6.00. Hospitals must
			 comply with the Department of Industrial Accidents billing requirements under
			 452 CMR
			 7.02.
(2)
Coverage
. The
			 payment rates set forth in 114.3 CMR 41.00 are full payment for services
			 provided under M.G.L. c. 152, § 13, including any related administrative or
			 overhead costs. The insurer, employer and health care service provider may
			 agree upon a different payment rate than that established by 114.1 CMR 41.00.
			 No Industrial Accident Patient may be held liable for the payment for health
			 care services determined compensable under M.G.L. c. 152, § 13.
(3)
Authority
. 114.1
			 CMR 41.00 is adopted pursuant to M.G.L. c. 118G and M.G.L. c. 152.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.1 CMR 41.00 - RATES OF PAYMENT FOR SERVICES PROVIDED TO INDUSTRIAL ACCIDENT PATIENTS BY HOSPITALS › Section 41.03 - Hospital Inpatient Rates

Current through Register 1525, July 5, 2024
(1)
Acute Hospitals.
(a)
Determination of Industrial Accident Inpatient Rates of Payment for
			 Massachusetts Acute Hospitals
. Payment for any eligible inpatient
			 service, and outpatient or observation stay as defined in 114. 1 CMR 4.04(2)
			 provided to an industrial accident patient by an acute hospital shall be equal
			 to the product of the industrial accident PAF and the published charge for the
			 service. The Division will determine the hospital-specific industrial accident
			 Rate Year Payment on Account Factor (PAF) calculated as follows:
1. The rate year PAF equals the lower of 1.0
			 or the hospital's base year Private Sector Gross Patient Service Revenue
			 (PSGPSR) minus its base year private sector contractual adjustments divided by
			 its base year Private Sector Gross Patient Service Revenue (PSGPSR). Private
			 sector revenues and contractual adjustments used in this calculation will be
			 those reported on the DHCFP-403 Schedule V-A cost report from Industrial
			 Accident, Managed Care and Non-Managed Care payer groups.
Rate Year PAF = the lower of 1.0 or
Base Year
				PSGPSR - Base Year Private Sector Contractual Adjustments
Base Year PSGPSR
2. The percentage equal to the lower of 1.00
			 or the total hospital's total base year Gross Patient Service Revenue (GPSR)
			 minus its base year total hospital contractual adjustments divided by its base
			 year total hospital GPSR
3. For any
			 hospital resulting from a merger, consolidation, or other such arrangement, a
			 single updated PAF will be calculated when merged data and charges become
			 available. Merged or consolidated hospitals shall utilize the PAF approved for
			 the specific site of service until a single updated PAF is calculated and
			 approved by the Division. In the event that there is no individual PAF approved
			 for the site of service, the median PAF multiplied by charges shall be payment
			 for all eligible inpatient and emergency department services
			 rendered.
4. For a new hospital or
			 hospital for which an approved PAF is not yet determined, the acute hospital
			 median PAF multiplied by charges shall be payment for any eligible inpatient
			 service, and outpatient or overnight observation stay rendered as defined in
			 114. 1 CMR 40.04(2).
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.1 CMR 41.00 - RATES OF PAYMENT FOR SERVICES PROVIDED TO INDUSTRIAL ACCIDENT PATIENTS BY HOSPITALS › Section 41.05 - Other Provisions

Current through Register 1525, July 5, 2024
(1)
Administrative Bulletins
. The Division may issue
			 Administrative Bulletins to clarify its policies on and understanding of
			 substantive provisions of 114.1 CMR 41.00, or to publish Hospital PAFs,
			 Hospital Uniform Assessment Percentages or procedure code updates and
			 corrections. For coding updates and corrections, the bulletin will list:
(a) new code numbers for existing codes, with
			 the corresponding cross references between existing and new code
			 numbers;
(b) deleted codes for
			 which there are no corresponding new codes; and
(c) codes for entirely new services that
			 require pricing. The Division will designate these codes to be paid by
			 individual consideration (I.C.) under 114.1 CMR 41.04(1)(c) until appropriate
			 rates are developed.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.1 CMR 41.00 - RATES OF PAYMENT FOR SERVICES PROVIDED TO INDUSTRIAL ACCIDENT PATIENTS BY HOSPITALS › Section 41.06 - Severability

Current through Register 1525, July 5, 2024
The provisions of 114. 1 CMR 41.00 are severable. If any
				provision of 114. 1 CMR 41.00 or the application of such provisions to any
				hospital, person, or circumstances should be held invalid or unconstitutional,
				such determination shall not be construed to affect the validity or
				constitutionality of any other provision of 114. 1 CMR 41.00 or the application
				of such provisions to other hospitals, persons or
				circumstances.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.3 CMR 13.00 - Rates for Freestanding Clinics Providing Abortion and Sterilization Services (Reserved)

Current through Register 1525, July 5, 2024
REGULATORY AUTHORITY
114. 3 CMR 13.00: M.G.L. c.118G.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.3 CMR 39.00 - Rehabilitation Center Services, Audiological Services, Restorative Services (Repealed)

Current through Register 1525, July 5, 2024
REGULATORY AUTHORITY
114. 3 CMR 39.00: M.G.L. c. 1l8G.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.3 CMR 40.00 - RATES FOR SERVICES UNDER M.G.L. c. 152, WORKERS' COMPENSATION ACT › Section 40.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope, Purpose and Effective Date
. 114.3 CMR 40.00
			 governs the payment rates effective April 1, 2009 for purchasers of health care
			 services under M.G.L. c. 152, the Workers' Compensation Act. Payment rates for
			 services provided by hospitals are set forth in 114.1 CMR 41.00. Program
			 policies relating to medical necessity and clinical appropriateness are
			 determined pursuant to M.G.L. c. 152 and
			 452 CMR 6.00.
(2)
Coverage
. The
			 payment rates set forth in 114.3 CMR 40.06 are full payment for services
			 provided under M.G.L. c. 152, § 13, including any related administrative or
			 overhead costs. The insurer, employer and health care service provider may
			 agree upon a different payment rate for any service set forth in the fee
			 schedule in 114.3 CMR 40.00. No employee may be held liable for the payment for
			 health care services determined compensable under M.G.L. c. 152, §
			 13.
(3)
Administrative
			 Bulletins
. The Division may issue administrative bulletins to
			 clarify substantive provisions of 114.3 CMR 40.00, or to publish procedure code
			 updates and corrections. For coding updates and correction, the bulletin will
			 list:
(a) new code numbers for existing codes,
			 with the corresponding cross references between existing and new codes
			 numbers;
(b) deleted codes for
			 which there are no corresponding new codes; and
(c) codes for entirely new services that
			 require pricing. The Division will designate these codes to be paid by
			 individual consideration under 114.3 CMR 40.04(3) until appropriate rates are
			 developed.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.3 CMR 40.00 - RATES FOR SERVICES UNDER M.G.L. c. 152, WORKERS' COMPENSATION ACT › Section 40.03 - Service and Rate Coverage Provisions

Current through Register 1525, July 5, 2024
(1)
			 Services and Rates Covered by 114.3 CMR 40.00. Payment rates for the following
			 health care service are governed by the provisions of 114.3 CMR 40.00. These
			 services are:
(a) Acupuncture Services -
			 114.3 CMR 40.05(1)
(b) Anesthesia
			 Services - 114.3 CMR 40.05(2)
(c)
			 Chiropractic Services - 114.3 CMR 40.05(3)
(d) Clinical Laboratory Services - 114.3 CMR
			 40.05(4)
(e) Dental Services -
			 114.3 CMR 40.05(5)
(f) Durable
			 Medical Equipment - 114.3 CMR 40.05(6)
(g) Freestanding Diagnostic Facilities -
			 114.3 CMR 40.05(7)
(h) Freestanding
			 Ambulatory Surgical Centers - 114.3 CMR 40.05(8)
(i) Homemaker Services - 114.3 CMR
			 40.05(9)
(j) Medicine - 114.3 CMR
			 40.05(10)
(k) Psychology Services -
			 114.3 CMR 40.05(11)
(l) Radiology -
			 114.3 CMR 40.05(12)
(m) Restorative
			 Services - 114.3 CMR 40.05(13)
(n)
			 Surgery - 114.3 CMR 40.05(14)
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.3 CMR 40.00 - RATES FOR SERVICES UNDER M.G.L. c. 152, WORKERS' COMPENSATION ACT › Section 40.04 - Provisions Affecting Eligible Providers

Current through Register 1525, July 5, 2024
(1)
Facility Rate
. If a procedure other than those listed
			 in 114.3 CMR 40.06 with a PC and TC fee is performed at a site other than the
			 provider's office and is also properly billed by another health care provider,
			 each provider will be reimbursed at 50% of the listed fee.
(2)
Out-of-state
			 Providers
. An insurer may pay out-of-state provider for services
			 at the payment rates set forth in 114.3 CMR 40.00.
(3)
Individual Consideration
			 (I.C.)
. Services that are authorized but for which there are no
			 established rates are designated as I.C. items. The purchaser under M.G.L. c.
			 152 will determine an appropriate payment rate. Unless otherwise provided in
			 114.3 CMR 40.05, the payment will be determined in accordance with all of the
			 applicable following standards and criteria:
(a) The amount of time required to perform
			 the procedure,
(b) The degree of
			 skill required to perform the procedure,
(c) The severity or complexity of the
			 patient's disease, disorder or disability,
(d) The policies, procedures and practices of
			 other third party insurers,
(e) A
			 copy of the current invoice from the supplier for items if the provider cost
			 exceeds $500.00. The provider is responsible for maintaining invoices for any
			 items that cost less than $500.00 for a minimum of three years from the date of
			 the original bill to the carrier.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.3 CMR 40.00 - RATES FOR SERVICES UNDER M.G.L. c. 152, WORKERS' COMPENSATION ACT › Section 40.05 - Policies for Individual Service Types

Current through Register 1525, July 5, 2024
(1)
Acupuncture
.
(a)
Eligible Providers
. An Eligible Provider is any person
			 licensed by the Board of Registration in Acupuncture under M.G.L. c. 112, §§
			 148 through 162, to practice acupuncture.
(b)
Acupuncture
			 Services
. Acupuncture is the insertion of needles through the skin
			 at certain points on the body in an attempt to relieve pain or improve bodily
			 function. Services include examinations, Evaluation and Management services
			 (E/M), acupuncture treatments and supportive services. The acupuncture
			 treatment codes include a patient assessment. Additional E/M services may be
			 reported separately using the modifier '-25', if the patient's condition
			 requires a significant separately identifiable E/M service, above and beyond
			 the usual pre-service and post-service work associated with the
			 procedure.
(c)
Fees
. Payment rates for acupuncture services are set
			 forth in 114.3 CMR 40.06(1).
(d)
Modalities and Supportive Procedures
. A charge may be
			 assessed for modalities only in conjunction with an acupuncture treatment
			 performed during the course of the same visit.
(e)
Nutritional
			 Supplements
. The payment rate for nutritional supplements is the
			 invoice cost, plus a handling fee of $3.00.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.3 CMR 40.00 - RATES FOR SERVICES UNDER M.G.L. c. 152, WORKERS' COMPENSATION ACT › Section 40.08 - Severability

Current through Register 1525, July 5, 2024
The provisions of 114.3 CMR 40.00 are severable. If any
				provision of 114.3 CMR 40.00 or the application of such provision to Eligible
				Providers of services or any circumstances should be held invalid or
				unconstitutional, such determination shall not be construed to affect the
				validity or constitutionality of any other provision of 114.3 CMR 40.00 or the
				application of any other provision.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 4.00 - Rates For Certain Social, Rehabilitation And Health Care Consultant Services › Section 4.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose and Effective Date
. 114. 5 CMR 4.00
			 governs rates of payment by governmental units to providers of health care
			 services which are not governed by any other Division regulation. 114. 5 CMR
			 4.00 is effective January 1, 1999.
(2)
Disclaimer of Authorization
			 of Services
. 114. 5 CMR 4.00 is not an authorization for or
			 approval of the substantive services and accommodations included within 114. 5
			 CMR 4.00. Governmental units which purchase health care services from providers
			 are responsible for definition, authorization and approval of care and services
			 extended publicly aided individuals. Information concerning substantive program
			 requirements must be obtained from the appropriate government unit.
(3)
Authority
. 114.
			 5 CMR 4.00 is adopted pursuant to M.G.Lc.118G
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 4.00 - Rates For Certain Social, Rehabilitation And Health Care Consultant Services › Section 4.03 - Filing and Reporting Requirements

Current through Register 1525, July 5, 2024
(1) Any
			 governmental unit purchasing health care services under 114. 5 CMR 4.00 shall
			 file, or cause to be filed, a properly completed budget indicating the total
			 proposed program or service operating costs to which the provider and
			 purchasing governmental unit(s) have agreed.
(2) Each provider and each purchasing
			 governmental unit shall file such information as the Division shall reasonably
			 request.
(3) Each provider shall
			 make available all books and records relating to the program(s) and service(s)
			 purchased by any governmental unit.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 4.00 - Rates For Certain Social, Rehabilitation And Health Care Consultant Services › Section 4.04 - Reasonable Cost Principles

Current through Register 1525, July 5, 2024
(1)
Allowable Costs
. Except as provided elsewhere in 114.
			 5 CMR 4.04, all expenses determined in accordance with the Principles of
			 Reimbursement for Provider Costs under 42 U.S.C. §§ 1395
et
			 seq
. as set forth in 42 CFR 413
et.seq.
and the
			 Provider Reimbursement Manual, are allowable costs.
(2)
Allocation of Costs and
			 Income
. If a provider conducts more than one program, it must
			 allocate costs to each program using a basis which the Division deems
			 reasonable. When a provider initiates a new program it may not allocate costs
			 from any established program to the new program during the first year of
			 operations.
(3)
Inputed
			 Values
. The fair market value of donated goods and services is
			 allowable to the extent that:
(a) this value
			 can be objectively and reliably determined; and
(b) the provider would have to expend agency
			 funds if the donated goods and services were not available and
(c) the provider controls the donated goods
			 in the same manner as goods owned by the agency and controls the donated
			 services in the same manner as it controls its employees, including control
			 over time, location, nature, and performance of the service.
The amount of allowable program cost shall be reduced by the
				inputed value of donated goods and services which are reported as income during
				the same period.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 4.00 - Rates For Certain Social, Rehabilitation And Health Care Consultant Services › Section 4.05 - Rate Determination

Current through Register 1525, July 5, 2024
(1)
Rate Calculation
. The Division will calculate the rate
			 by determining total reimbursable rate year costs, subtracting client resources
			 and, if necessary, dividing by projected service units.
(a) For programs having at least one year of
			 historical cost, the Division will determine total reimbursable rate year costs
			 by:
1. Adjusting the most recent available
			 annual cost data using the principles set forth in 114. 5 CMR 4.04
2. Increasing adjusted historical costs,
			 exclusive of fixed costs as defined in 114. 5 CMR 4.02, by a cost adjustment
			 factor to project them to the rate year. The cost adjustment factor shall
			 reflect appropriate projections of inflation indices and shall to the extent
			 practicable be consistent with cost adjustment factors used in other Division
			 regulations for similar providers. In appropriate circumstances the cost
			 adjustment factor may be zero.
3.
			 Adjusting for the reasonable costs negotiated by the provider and purchasing
			 governmental unit which relate to the following:
a. Increases in operating costs due to
			 compliance with changes in the laws or regulations concerning licensing or
			 safety;
b. Changes in operating
			 costs due to negotiated changes in the program; or
c. Unforeseen or unusual increases in
			 operating costs which are beyond the control of the provider and which are not
			 contemplated in the cost adjustment factor.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 4.00 - Rates For Certain Social, Rehabilitation And Health Care Consultant Services › Section 4.06 - Administrative Review

Current through Register 1525, July 5, 2024
To assure that an approved program rate is adequate and
				appropriate, the Division may, at any time, review such rate upon notice to the
				provider and all purchasing governmental units.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 4.00 - Rates For Certain Social, Rehabilitation And Health Care Consultant Services › Section 4.07 - Administrative Information Bulletins

Current through Register 1525, July 5, 2024
The Division may, from time to time, issue administrative
				information bulletins to clarify its policy upon and understanding of
				substantive provisions of 114. 5 CMR 4.00. In addition, the Division may issue
				administrative information bulletins which specify the information and
				documentation necessary to implement 114. 5 CMR 4.00 or necessary for informed
				consideration of program and rate requests.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 4.00 - Rates For Certain Social, Rehabilitation And Health Care Consultant Services › Section 4.08 - Severability

Current through Register 1525, July 5, 2024
The provisions of 114. 5 CMR 4.00 are severable, and, if any
				provision of 114. 5 CMR 4.00 or application of such provision to any operating
				agency or fiscal intermediary in any circumstances shall be held to be invalid
				or unconstitutional, such invalidity shall not be construed to affect the
				validity or constitutionality of any remaining provisions of 114. 5 CMR 4.00 or
				application of such provisions to operating agencies or fiscal intermediaries
				in circumstances other than those held invalid.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 10.00 - Criteria and procedures for awarding one-time grants to non-profit providers of elder care services › Section 10.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope, Purpose, and Effective Date
. 114. 5 CMR 10.00
			 governs the procedures and criteria used to award one-time grants to providers
			 of elder care totaling $8.0 million, authorized by St. 2000, c. 236, § 2A. 114.
			 5 CMR 10.00 specifies the grant disbursement procedures the Division will use
			 to comply with the Office of the Comptrollers regulation
			 815 CMR 2.00. 114. 5 CMR 10.00
			 is effective May 25, 2001.
(2)
Authority
. 114. 5 CMR 10.00 is adopted pursuant to St.
			 2000, c. 236, § 2A.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 10.00 - Criteria and procedures for awarding one-time grants to non-profit providers of elder care services › Section 10.03 - Grant Application Requirements

Current through Register 1525, July 5, 2024
(1)
			 Eligible grant applicants are defined as the following:
(a) Non-profit organization located in
			 Massachusetts and serving Massachusetts residents; and,
(b) One or more of the following providers of
			 care to the elderly:
1. Aging services access
			 points;
2. Nursing
			 facilities;
3. Home care providers;
4. Councils on aging;
5. Home health providers;
6. Adult day care providers (providing adult
			 and social services);
7.
			 Dementia-specific adult day care providers;
8. Assisted living facilities;
9. Other charitable organizations for the
			 elderly approved by the Division.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 10.00 - Criteria and procedures for awarding one-time grants to non-profit providers of elder care services › Section 10.04 - Application Procedure

Current through Register 1525, July 5, 2024
(1) The Division is
			 requiring Applicants to submit a letter of intent by April 27, 2001 (facsimiles
			 sent to (617) 727-7662 will be accepted). The letter must include the name,
			 address, and FEIN number (if available) of organization, and name, occupational
			 title, telephone number, fax number and e-mail address of grant application
			 contact. The letter must also state the type of grant for which the Applicant
			 intends to apply (
i.e
., equipment purchase/upgrade,
			 conversion/renovation of existing space, or acquisition/construction costs of
			 new physical space), and include an estimate of the amount of funding to be
			 requested. A letter of intent is required in order to receive a
			 grant.
(2)
Application
			 Deadline
. The Division must receive ten paper copies, plus one
			 copy on diskette in Microsoft Word (any version other than Word 2000) or Corel
			 WordPerfect, of the table of contents and narrative described in 114. 5 CMR
			 10.05(1)(a) and (b) and the required financial information described 114. 5 CMR
			 10.05(2)(a), (b) and (c), by 4:00 p.m. on April 30, 2001. The review Committee
			 will not consider Applications received after that date and time. Applications
			 must be submitted to the Division's offices at 2 Boylston Street,
			 5th floor, Boston, MA 02116, Attn: Elder Care Grant
			 Review Team.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 10.00 - Criteria and procedures for awarding one-time grants to non-profit providers of elder care services › Section 10.05 - Materials to be Submitted by Applicants

Current through Register 1525, July 5, 2024
(1) All
			 applicants must submit the following required programmatic material.
(a) Table of Contents listing at least all of
			 the items required in 114. 5 CMR 10.05.
(b)
Narrative
. The
			 narrative may not exceed six typewritten double-spaced pages, and must include
			 the following items:
1. Cover page with name,
			 address, and FEIN number (if available) of organization; name, occupational
			 title, telephone number, fax number and e-mail address of grant application
			 contact; and name, occupational title and signature of the organization's
			 representative that is authorized to execute a contract with the Division. The
			 cover page must clearly state the total amount of grant funding requested and
			 the type of grant for which the Applicant intends to apply
			 (
i.e
., equipment purchase/upgrade, conversion/ renovation of
			 existing space, or acquisition/construction costs of new physical
			 space).
2. Narrative description of
			 organization. This must include information on the number of clients and the
			 geographic region it serves, as well as the types of services
			 provided.
3. Narrative summary of
			 request for grant funding, justification for the amount of funds needed, and a
			 timetable for the expenditure of grant funds, if approved. The summary must
			 describe how the request will fulfill all the grant requirements listed in 114.
			 5 CMR 10.03.
4. Documentation of
			 any efforts the applicant has made to secure grant funds for this project from
			 other sources, if applicable.
5.
			 Listing of the source and amount of other funds that will be leveraged by the
			 award of these grant funds, if applicable.
6. Discussion of the future financial sustain
			 ability of this project if the funds are awarded.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 10.00 - Criteria and procedures for awarding one-time grants to non-profit providers of elder care services › Section 10.06 - Criteria for Awarding Grants

Current through Register 1525, July 5, 2024
The grant review Committee will evaluate all applications that
				meet all of the minimum requirements listed in 114. 5 CMR 10.03 using the
				following criteria.
Points
(1) Grant proposals that will benefit low-income
							 populations, as defined in 114. 5 CMR 10.02 and identified through the use of
							 governmental data and/or individual program data.
0 - 25
(2) Grant proposals that will benefit under served
							 populations, as defined in 114. 5 CMR 10.02.0 - 25
(3) Grant proposals that have future financial
							 sustain ability.
0 - 20
(4) For equipment purchases, requests for purchasing
							 medical equipment as defined in 114. 5 CMR 10.02. For conversion or renovation
							 of existing space and for acquisition and construction costs of new physical
							 plant space, requests for grant funding that will leverage other funds.
0 - 15
(5) Applicants that demonstrate that requested funds
							 are not readily available from another funding source and that the applicant
							 has some level of financial need.
0 - 10
(6) Applicants that will help to balance the
							 geographic distribution of awards throughout the entire State.
0 - 5
Total 0 - 100
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 10.00 - Criteria and procedures for awarding one-time grants to non-profit providers of elder care services › Section 10.07 - Review and Selection Procedure

Current through Register 1525, July 5, 2024
(1) The
			 Division will establish a grant review Committee, comprised of State agency
			 staff. The grant review Committee will be composed of two separate
			 Subcommittees. One Subcommittee will evaluate the programmatic material
			 required in 114. 5 CMR 10.05(1); the other Subcommittee will evaluate the
			 financial material required in 114. 5 CMR 10.05(2).
(2) The Committee will review all
			 applications to determine if they have fulfilled all the application
			 requirements in 114. 5 CMR 10.03 and have submitted all required materials in
			 114. 5 CMR 10.05. Applications that do not meet all the requirements in 114. 5
			 CMR 10.03, and/or have not submitted all required materials in 114. 5 CMR
			 10.05, will not be further reviewed and will not be approved for
			 funding.
(3) The Committee will
			 further review applications that meet all required application requirements in
			 114. 5 CMR 10.03, and have submitted all required materials in 114. 5 CMR
			 10.05, in accordance with the award criteria in 114. 5 CMR 10.06. The Committee
			 may request an Applicant to submit any additional information it deems
			 necessary to complete its review, including an oral presentation. The Division
			 must receive all requested additional materials within five business days of
			 the Committee's request in order for the Committee to consider the additional
			 materials.
(4) The Committee will
			 recommend to the Commissioner Applicants to receive grants, and the amounts to
			 be awarded. The Committee may award an amount higher or lower than that
			 requested by the Applicant. Awards will be made based on the availability of
			 funds, the degree to which an applicant meets the criteria in 114. 5 CMR 10.06,
			 and the degree to which the grant meets the Applicant's need for such funding.
			 The total amount of the grants awarded will be $ 8 .0 million. The maximum any
			 individual grant applicant can be awarded will be $1.0 million.
(5) The Commissioner will make the final
			 award decisions based on the recommendations of the Committee and the criteria
			 in 114. 5 CMR 10.06. The Commissioner's decisions are final and not subject to
			 appeal.
(6) The Division will
			 notify all Applicants of their selection or non-selection for a
			 grant.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 10.00 - Criteria and procedures for awarding one-time grants to non-profit providers of elder care services › Section 10.08 - Grant Contract

Current through Register 1525, July 5, 2024
(1) All Applicants
			 selected to receive a grant must execute contracts with the Division, as
			 required by
			 815 CMR 2.05,
			 in order to receive payment.
(2)
			 The grant contract will specify, as applicable:
(a) any financial, programmatic, technical or
			 other reporting the Division deems appropriate to monitor and evaluate the
			 funded activities;
(b) any
			 conditions or restrictions on the funding, including any monitoring of the
			 grantee's operations;
(c) any
			 additional means the Division will use to hold the grantee accountable for
			 proper performance under the grant;
(d) with respect to grants under 114. 5 CMR
			 10.03(3)(b) or (c), any deadlines for completing components of the
			 project.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 10.00 - Criteria and procedures for awarding one-time grants to non-profit providers of elder care services › Section 10.09 - Severability

Current through Register 1525, July 5, 2024
The provisions of 114. 5 CMR 10.00 are severable. If any
				provisions or the application of any provision to any provider of elder care
				services or circumstancesis held invalid or unconstitutional, such invalidity
				shall not be construed to affect the validity or constitutionality of any
				remaining provisions of 114. 5 CMR 10.00 or the application of such provisions
				to providers of elder care services other than those held
				invalid.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 10.00 - Criteria and procedures for awarding one-time grants to non-profit providers of elder care services › Section 10.10 - Documentation and Audit

Current through Register 1525, July 5, 2024
(1) Hospitals and
			 Community Health Centers must maintain auditable records of their activities
			 made in compliance with the criteria and requirements of regulation 114. 6 CMR
			 10.00, including documentation of Free Care accounts and Free Care
			 applications. Hospitals must also document their activities as required in 114.
			 6 CMR 7.00. Community Health Centers must also document their activities as
			 required in 114. 6 CMR 8.00.
(2)
			 The Division may, through various mechanisms, audit Free Care accounts of Acute
			 Hospitals and Community Health Centers to determine compliance with this
			 section and shall deny Pool payment for any audited account that fails to
			 comply. These audit mechanisms may include verification of Free Care
			 eligibility and ensuring that other coverage options are utilized fully before
			 Free Care is granted.
(3) The
			 Division may disallow payment for services covered by MassHealth, another
			 program of public assistance, or other health insurance plan in which the
			 patient is enrolled.
(4) The
			 Division will disallow payment from the Pool for non-Medically Necessary
			 Services.
(5) The Division will
			 determine the level of payment that will be disallowed from the Pool using a
			 methodology to appropriately extrapolate the amount of audited accounts that
			 fail to comply with 114. 6 CMR 10.00 as compared to all of the Hospital's or
			 Community Health Center's Free Care accounts.
(6) A Hospital aggrieved by any action or
			 failure to act by the Division may seek a review pursuant to the provisions of
			 114. 6 CMR 7.05.
(7) A Community
			 Health Center aggrieved by any action or failure to act by the Division may
			 seek a review pursuant to the provisions of 114. 6 CMR 8.00.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 10.00 - Criteria and procedures for awarding one-time grants to non-profit providers of elder care services › Section 10.11 - Special Provisions

Current through Register 1525, July 5, 2024
(1)
Penalties for Diversion of Free Care Patients
.
(a)
Diversion Subject to
			 Penalty
. A diversion is subject to a penalty if:
1. the Division finds that an eligible
			 patient was transferred from one Hospital to another Hospital without the
			 consent of the receiving Hospital; and
2. the transfer was in violation of
			 EMTALA.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 10.00 - Criteria and procedures for awarding one-time grants to non-profit providers of elder care services › Section 10.12 - Severability

Current through Register 1525, July 5, 2024
The provisions of 114. 6 CMR 10.00 are hereby declared to be
				severable. If any such provisions or the application of such provisions to any
				Hospital or Community Health Center or circumstances shall be held to be
				invalid or unconstitutional, such invalidity shall not be construed to affect
				the validity or constitutionality of any remaining provisions of 114. 6 CMR
				10.00 or the application of such provisions to Hospitals or Community Health
				Centers or circumstances other than those held invalid.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 23.00 - PAYER REPORTING OF TOTAL MEDICAL EXPENSES AND RELATIVE PRICES › Section 23.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
. 114. 5 CMR 23.00 governs the
			 methodology and filing requirements for health care payers to calculate and
			 report Health Status Adjusted Total Medical Expenses and Relative Prices to the
			 Division of Health Care Finance and Policy.
(2)
Authority
. 114.
			 5 CMR 23.00 is adopted pursuant to M.G.L. c. 118G, § 6.
(3)
Effective Date
.
			 114. 5 CMR 23.00 is effective on April 1, 2011.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 23.00 - PAYER REPORTING OF TOTAL MEDICAL EXPENSES AND RELATIVE PRICES › Section 23.03 - General Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
Annual Reports.
(a)
			 Each Payer shall file annually its TME by Physician Group, Physician Local
			 Practice Group, and Member Zip Code, and its Relative Prices for Hospitals,
			 Physicians, and Other Providers in accordance with the requirements of 114. 5
			 CMR 23.04 and 23.05.
(b) A Private
			 Health Care Payer is subject to the reporting requirements in 114. 5 CMR 23.00
			 if:
1. The Payer is a Surcharge Payer and the
			 Payer's Payments Subject to Surcharge placed the Payer at the company level
			 within the top 12 Surcharge Payers for the period October 1, 2009 through
			 September 30, 2010 as determined by the Division and posted on the Division's
			 website; or
2. The Payer contracts
			 with the office of Medicaid, the Commonwealth Health Insurance Connector, or
			 the Group Insurance Commission to pay for or arrange for the purchase of health
			 care services on behalf of individuals enrolled in health coverage programs
			 under Titles XVIII, XIX, or XXI, under the Commonwealth Care Health Insurance
			 program, Medicaid managed care organizations, or under the Group Insurance
			 Commission.
3. If a Private Health
			 Care Payer subject to the reporting requirements of 114. 5 CMR 23.00 makes
			 separate surcharge payments under 114. 6 CMR 14.00 for individual plans or
			 clients the Payer shall file the required data for all of its plans or
			 clients.
(c) Public
			 Health Care Payers may provide data to the Division pursuant to an interagency
			 service agreement.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 23.00 - PAYER REPORTING OF TOTAL MEDICAL EXPENSES AND RELATIVE PRICES › Section 23.04 - Health Status Adjusted Total Medical Expenses

Current through Register 1525, July 5, 2024
(1)
TME by Physician Group and
			 Physician Local Practice Group.
(a)
Reporting
			 Requirements
.
1. Payers shall
			 report TME by Physician Group and Physician Local Practice Group for
			 Massachusetts Members required to select a primary care physician.
2. Payers shall report TME for Physician
			 Groups and Physician Local Practice Groups Physician Local Practice Groups with
			 at least 36,000 Member Months for the calendar year.
3. Payers shall report TME separately for
			 Medicaid and Commonwealth Care (combined), Medicare, commercial full-claim, and
			 commercial partial-claim plans. Commercial (self and fully insured) data for
			 physicians' groups or zip codes for which the Payer is able to collect
			 information on all direct medical claims and subcarrier claims shall be
			 reported in the full-claim category. Commercial (self and fully insured) data
			 for physicians' groups or zip codes that do not include all medical and
			 subcarrier claims shall be reported in the partial-claim category. Payers must
			 include the full amount paid for medical claims, including amounts paid under
			 stop-loss or reinsurance agreements, even if the Payer was not directly
			 providing payment for those services. Payers shall not include data for which
			 they are the secondary or tertiary payer such as Medicare Supplement.
4. Payers shall report TME data in the
			 aggregate for all Physician Groups and Physician Local Practice Groups with
			 fewer than 36,000 Member Months for the calendar year.
5. Payers shall attribute Non-claims Payments
			 to a Provider at the Local Practice Group Level and thereafter at the Physician
			 Group Level. If direct attribution is not possible, Payers shall allocate
			 Non-claims Payments by Member Months.
6. Payers must report the risk adjustment
			 tool and version used to report the Health Status Adjustment Score. The
			 Division may specify additional requirements for reporting the Health Status
			 Adjustment Score by Administrative Bulletin or in the Data Specification
			 Manual.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.5 CMR 23.00 - PAYER REPORTING OF TOTAL MEDICAL EXPENSES AND RELATIVE PRICES › Section 23.06 - Other Provisions

Current through Register 1525, July 5, 2024
(1)
Administrative and Technical Information Bulletins
.
			 The Division may revise the specifications or other administrative requirements
			 from time to time by notice or administrative bulletin.
(2)
Severability
.
			 The provisions of 114. 5 CMR 23.00 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 114. 5 CMR 23.00 or the application of such
			 provisions.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.6 CMR 10.00 - CRITERIA FOR DETERMINING ELIGIBILITY FOR FREE CARE AT ACUTE CARE HOSPITALS AND FREESTANDING COMMUNITY HEALTH CENTERS › Section 10.06 - Patient Rights and Responsibilities

Current through Register 1525, July 5, 2024
(1)
Patient Rights
. Hospitals and Community Health Centers
			 must advise patients of the following rights to:
(a) apply for Free Care within one year of
			 determining the patient's financial liability at a Hospital, or within 90 days
			 of determining the patient's financial liability at a Community Health Center,
			 unless the Hospital or Community Health Center can document continuous
			 collection action or patient payments during the intervening time,
(b) a payment plan, as described in 114.6 CMR
			 10.05, if the patient is determined to be eligible for partial Free Care or
			 Medical Hardship,
(c) a written
			 notice of the eligibility decision within 30 days of completion of a written
			 Free Care application and submission of the required supporting
			 documentation,
(d) notice of the
			 right to file a grievance pursuant to 114.6 CMR 10.07, and
(e) file a grievance as outlined in 114.6 CMR
			 10.07 of an eligibility or scope of services determination.
Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.6 CMR 10.00 - CRITERIA FOR DETERMINING ELIGIBILITY FOR FREE CARE AT ACUTE CARE HOSPITALS AND FREESTANDING COMMUNITY HEALTH CENTERS › Section 10.07 - Patient Grievances

Current through Register 1525, July 5, 2024
There shall be an administrative review process for any person
				aggrieved by a Hospital's or Community Health Center's denial of Free Care. The
				Division will review cases involving eligibility and covered services. The
				grievance process must follow these steps:
(1) The person must send a written complaint
			 to the Division. The patient may include supporting documentation with the
			 complaint.
(2) The Division will
			 send a copy of the complaint to the Hospital or Community Health Center and may
			 ask the Hospital or Community Health Center for additional
			 information.
(3) The Hospital or
			 Community Health Center has 30 days to answer the complaint in
			 writing.
(4) When the Division has
			 received all necessary information, it will review the complaint and the
			 Hospital's or Community Health Center's answer. The Division will issue a
			 written decision to the person and to the Hospital or Community Health Center
			 within 30 days of the receipt of all necessary information. The decision will
			 contain a brief explanation of the reasons for the Division's
			 actions.