reglab/statecodes huggingface dataset:
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 327.00 - Rates of Payment for Ambulance and Wheelchair Van Services › Section 327.04 - Special Contracts

Current through Register 1525, July 5, 2024
(1) Notwithstanding
			 101
			 CMR 327.03, a governmental unit may enter
			 into a special contract with an eligible provider under which the governmental
			 unit will pay for services authorized but not listed in 101 CMR 327.00, or
			 authorized services performed in exceptional circumstances.
(2) Notwithstanding
			 101
			 CMR 327.03, a governmental unit may enter
			 into a selective contract with a transportation broker under which the
			 governmental unit will pay for authorized services arranged by the broker at
			 rates or through payment methodologies different than those set forth in
			 101
			 CMR 327.03.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 327.00 - Rates of Payment for Ambulance and Wheelchair Van Services › Section 327.05 - Nonpublic Ambulance Supplemental Payment Provisions

Current through Register 1525, July 5, 2024
(1)
Provider
			 Eligibility
. To be eligible to receive supplemental payments from
			 the Trust Fund, a nonpublic ambulance provider must be
(a) licensed under M.G.L. c. 111C, § 6,
			 as defined by the Department of Public Health (DPH);
(b) a MassHealth enrolled ambulance provider;
			 and
(c) in compliance with the
			 payment conditions set forth in
			 101
			 CMR 327.05(2).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 327.00 - Rates of Payment for Ambulance and Wheelchair Van Services › Section 327.06 - Reporting and Registration Requirements

Current through Register 1525, July 5, 2024
(1)
Required Reports
. Reporting requirements are governed
			 by 957 CMR 6.00:
Cost Reporting Requirements
and any reporting
			 or registration requirements set forth in 101 CMR 324.00:
Nonpublic
			 Ambulance Service Reimbursement Trust Fund Assessment and Funding
. In
			 addition, each eligible nonpublic ambulance provider that receives a
			 supplemental payment pursuant to
			 101
			 CMR 327.05 must file or make available all
			 records and information necessary to demonstrate compliance with conditions of
			 payment upon EOHHS request, including documentation of the uses of such
			 payments.
(2)
Penalty
			 for Noncompliance
. The purchasing governmental unit may impose a
			 penalty in the amount of up to 15% of its payments to any provider that fails
			 to submit required information. The purchasing governmental unit will notify
			 the provider in advance of its intention to impose a penalty under
			 101
			 CMR 327.06(2).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 327.00 - Rates of Payment for Ambulance and Wheelchair Van Services › Section 327.07 - Reductions in Payment

Current through Register 1525, July 5, 2024
EOHHS may deny, reduce, or withhold payment to an eligible
				nonpublic ambulance provider that fails to comply with any condition of payment
				set forth in
				101
				CMR 327.05. EOHHS will notify the nonpublic
				ambulance provider of its intention to deny, reduce, or withhold payment. EOHHS
				may apply reductions in payments to the successor in interest or any provider
				under common interest.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 327.00 - Rates of Payment for Ambulance and Wheelchair Van Services › Section 327.08 - Severability

Current through Register 1525, July 5, 2024
The provisions of 101 CMR 327.00 are severable, and if any
				provisions of 101 CMR 327.00 or the application of such provisions to any
				person or circumstances 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 327.00 or application of such provisions to
				eligible providers or circumstances other than those held
				invalid.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 329.00 - Rates for Psychological and Independent Clinical Social Work Services › Section 329.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
.
			 101 CMR
			 329.00 governs the rates of payment used by all
			 governmental units in making payments to eligible providers of psychological
			 and licensed independent clinical social work services to publicly aided
			 individuals in any suitable location, such as a private office, the client's
			 place of residence, using telehealth, or other appropriate facility. The rates
			 set forth in
			 101 CMR
			 329.00 do not apply to individuals covered by M.G.L.
			 c. 152, Workers' Compensation. Rates for services rendered to such individuals
			 are set forth in 114.3 CMR
			 40.03(2):
Services
			 and Rates Covered by other Regulations.
(2)
Applicable Dates of
			 Service
. Rates contained in
			 101 CMR
			 329.00 are effective for dates of service on or after
			 January 1, 2023
(3)
Coverage
.
			 101 CMR
			 329.00 and the rates of payment contained in
			 101 CMR
			 329.00 apply to psychological and licensed independent
			 clinical social work services rendered by eligible providers to publicly aided
			 individuals. As set forth in
			 101
			 CMR 329.03(2), the rates of
			 payment under
			 101 CMR
			 329.00 are full compensation for all services
			 rendered.
(4)
Disclaimer of Authorization of Services
.
			 101 CMR
			 329.00 is not authorization for or approval of the
			 services for which rates are determined pursuant to
			 101 CMR
			 329.00. Purchasing agencies and insurers are
			 responsible for the definition, authorization and approval of care and services
			 extended to publicly aided clients.
(5)
Coding Updates and
			 Corrections
. The Executive Office of Health and Human Services
			 (EOHHS) may publish procedure code updates and corrections in the form of an
			 administrative bulletin. The publication of such updates and corrections will
			 list:
(a) codes for which only the code
			 numbers change, with the corresponding cross references between existing and
			 new codes;
(b) codes for which the
			 code remains the same but the description has changed;
(c) deleted codes for which there are no
			 corresponding new codes; and
(d)
			 codes for entirely new services that require pricing. EOHHS will list these
			 codes and apply individual consideration (I.C.) reimbursement for these new
			 codes until appropriate rates can be developed.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 329.00 - Rates for Psychological and Independent Clinical Social Work Services › Section 329.03 - General Rate Provisions

Current through Register 1525, July 5, 2024
(1)
General Rate Provisions
. The rates of payment for
			 psychological and licensed independent clinical social work services to which
			 101 CMR
			 329.00 applies are the lower of:
(a) The eligible provider's usual charge to
			 the general public for the same or similar services; or
(b) The schedule of allowable fees listed in
			 101
			 CMR 329.04 and
			 329.05.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 329.00 - Rates for Psychological and Independent Clinical Social Work Services › Section 329.04 - Allowable Fees for Psychological Assessments

Current through Register 1525, July 5, 2024
The payment rates for psychological assessments provided by a
				psychologist or technician for test administration and scoring are as
				follows:
Service
							 Code
Allowable
							 Fee
Description
96116
$88.82
Neurobehavioral status exam (clinical assessment of
							 thinking, reasoning and judgement,
e.g.,
acquired knowledge,
							 attention, language, memory, planning and problem solving, and visual spatial
							 abilities), by physician or other qualified health care professional, both
							 face-to-face time with the patient and time interpreting test results and
							 preparing the report; first hour.
96121
$75.98
Each additional hour (List separately in addition to
							 code for primary procedure.) (Add-on code to 96116.)
96130
$107.73
Psychological testing evaluation services by
							 physician or other qualified health care professional, including integration of
							 patient data, interpretation of standardized test results and clinical data,
							 clinical decision making, treatment planning and report and interactive
							 feedback to the patient, family member(s) or caregiver(s), when performed;
							 first hour.
96131
$81.91
Each additional hour (List separately in addition to
							 code for primary procedure.) (Add-on code to 96130.)
96132
$122.11
Neuropsychological testing evaluation services by
							 physician or other qualified health care professional, including integration of
							 patient data, interpretation of standardized test results and clinical data,
							 clinical decision making, treatment planning and report and interactive
							 feedback to the patient, family member(s) or caregiver(s), when performed;
							 first hour.
96133
$92.12
Each additional hour (List separately in addition to
							 code for primary procedures.) (Add-on code to 96132.)
96136
$44.89
Psychological or neuropsychological test
							 administration and scoring by physician or other qualified health care
							 professional, two or more tests, any method; first 30 minutes.
96137
$41.67
Each additional 30 minutes (List separately in
							 addition to code for primary procedure.) (Add-on code to 96136.)
96138
$37.83
Psychological or neuropsychological test
							 administration and scoring by technician, two or more tests, any method; first
							 30 minutes.
96139
$37.83
Psychological or neuropsychological test
							 administration and scoring by technician, two or more tests, any method; each
							 additional 30 minutes (List separately in addition to code for primary
							 procedure.) (Add-on code to 96138.)
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 329.00 - Rates for Psychological and Independent Clinical Social Work Services › Section 329.05 - Allowable Fees for Other Psychological and Independent Clinical Social Work Services

Current through Register 1525, July 5, 2024
(1) The payment
			 rates for psychological services provided by a psychologist are as follows.
Service Code
Allowable Fee
Description
90791-AH
$136.38
Psychiatric diagnostic evaluation. (Diagnostic
							 services.)
90791-HA-AH
$151.38
Psychiatric diagnostic evaluation performed with a
							 CANS (Children and Adolescent Needs and Strengths)
90832-AH
$59.16
Psychotherapy, 30 minutes with patient. (Individual
							 therapy.)
90834-AH
$95.46
Psychotherapy, 45 minutes with patient. (Individual
							 therapy.)
90837-AH
$125.69
Psychotherapy, 60 minutes with patient. (Individual
							 therapy.)
90847-AH
$101.43
Family psychotherapy (conjoint psychotherapy) (with
							 patient present), 50 minutes.
90853-AH
$30.31 per client, 1U hour session
Group psychotherapy (other than of a multiple-family
							 group). (Group therapy. Limited to 12 clients per group.)
90882-AH
$71.80
Environmental intervention for medical management
							 purposes on a psychiatric patient's behalf with agencies, employers, or
							 institutions
90887-AH
$67.31
Interpretation or explanation of results of
							 psychiatric, or other medical examinations and procedures, or other accumulated
							 data to family or other responsible persons, or advising them how to assist
							 patient (per U hour)
(2) The
			 payment rates for independent clinical social work services provided by a
			 licensed independent clinical social worker are as follows.
Service Code
Allowable Fee
Description
90791-AH
$130.48
Psychiatric diagnostic evaluation. (Diagnostic
							 services.)
90791-HA-HO
$145.48
Psychiatric diagnostic evaluation performed with a
							 CANS (Children and Adolescent Needs and Strengths)
90832-HO
$52.20
Psychotherapy, 30 minutes with patient. (Individual
							 therapy.)
90834-HO
$95.46
Psychotherapy, 45 minutes with patient. (Individual
							 therapy.)
90837-HO
$125.69
Psychotherapy, 60 minutes with patient. (Individual
							 therapy.)
90847-HO
$101.43
Family psychotherapy (conjoint psychotherapy) (with
							 patient present), 50 minutes.
90853-HO
$30.31 per client 1U hour session
Group psychotherapy (other than of a multiple-family
							 group). (Group therapy. Limited to 12 clients per group.)
90882 -HO
$71.80
Environmental intervention for medical management
							 purposes on a psychiatric patient's behalf with agencies, employers, or
							 institutions.
90887-HO
$59.40
Interpretation or explanation of results of
							 psychiatric, or other medical examinations and procedures, or other accumulated
							 data to family or other responsible persons, or advising them how to assist
							 patient (per U hour)
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 329.00 - Rates for Psychological and Independent Clinical Social Work Services › Section 329.06 - Special Provisions

Current through Register 1525, July 5, 2024
Preferred Provider Agreements
:
(1) A purchaser may apply for approval of a
			 Preferred Provider Agreement under which the governmental unit will purchase
			 specialized services at a reimbursement rate that reflects the particular
			 requirements of the services to be provided.
(2) In order for EOHHS to approve the
			 Agreement, the Agreement must
(a) Identify the
			 clinical needs of the purchaser's clients;
(b) Establish specific criteria for
			 evaluating provider qualifications to meet the clinical needs of the
			 purchaser's clients;
(c) Specify
			 the purchaser's role in managing the services provided to its clients,
			 including but not limited to prior authorizations;
(d) Specify the provider's duties in
			 complying with the administrative requirements established by the purchasing
			 agency;
(e) Demonstrate that the
			 rates to be paid are reasonable and reflect the additional services to be
			 provided; and
(f) If the
			 governmental unit is a state agency, the agency must demonstrate that the
			 provisions of
			 808 CMR
			 1.00:
Compliance, Reporting and Auditing for
			 Human and Social Services
relative to the procurement and form of the
			 Agreement have been satisfied.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 329.00 - Rates for Psychological and Independent Clinical Social Work Services › Section 329.07 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				101 CMR
				329.00 are severable. If any provision or the
				application of such provision to any eligible provider of services authorized
				in 101 CMR
				329.00 or any circumstance is held to be invalid or
				unconstitutional, such determination will not affect the validity or
				constitutionality of any remaining provisions of
				101 CMR
				329.00 to eligible providers or circumstances other
				than those held invalid.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 330.00 - Rates for Team Evaluation Services › Section 330.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope
. 101 CMR 330.00 governs the rates of payment for
			 team evaluation services purchased by a governmental unit.
(2)
Applicable Dates of
			 Service
. Rates contained in 101 CMR 330.00 apply for dates of
			 service provided on or after September 1, 2023.
(3)
Disclaimer of Authorization
			 of Services
. 101 CMR 330.00 is neither authorization for nor
			 approval of the services for which rates are determined pursuant to 101 CMR
			 330.00. Governmental units that purchase the services described in 101 CMR
			 330.00 are responsible for the definition, authorization, and approval of
			 services provided to clients.
(4)
Exclusion
. 101 CMR 330.00 does not govern rates of
			 payment to hospitals, community health centers, and mental health centers for
			 team evaluation services. Community health center rates are governed by 101 CMR
			 304.00:
Rates for Community Health Centers
. Mental health
			 center rates are governed by 101 CMR 306.00:
Rates of Payment for
			 Mental Health Services Provided in Community Health Centers and Mental Health
			 Centers
. Pursuant to M.G.L. c. 118E, § 13F, no acute hospital may
			 charge governmental units at a rate higher than the rate payable by the
			 MassHealth agency for these services.
(5)
Administrative
			 Bulletins
. EOHHS may issue administrative bulletins to clarify its
			 policy on substantive provisions of 101 CMR 330.00
(6)
Services and Rates Covered by
			 Other Regulations
. Rates of payment for the following services are
			 not included within the scope of 101 CMR 330.00 and instead are governed by
			 other regulations promulgated by EOHHS as described in
			 101
			 CMR 330.01(6).
Service(s)
Regulation
Medical evaluations
101 CMR 317.00:
Rates for Medicine
							 Services
Physical therapy evaluations, and those for
							 occupational therapy and speech pathology
101 CMR 339.00:
Rates for Restorative
							 Services
Audiological evaluations
101 CMR 323.00:
Rates for Hearing
							 Services
Radiological evaluations
101 CMR 318.00:
Rates for Radiology
							 Services
Visual evaluations
101 CMR 315.00:
Rates for Vision Care
							 Services and Ophthalmic Materials
Clinical laboratory testing
101 CMR 320.00:
Rates for Clinical Laboratory
							 Services
Psychological assessments/evaluations
Comprehensive neuropsychological assessments are an
							 exception. For this specific service, see the definition in
							 101
							 CMR 330.02 and the rate in
							 330.04(2).
101 CMR 329.00: Rates for Psychological and
							 Independent Clinical Social Work Services
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 330.00 - Rates for Team Evaluation Services › Section 330.02 - Definitions

Current through Register 1525, July 5, 2024
Assessment
. A professionally sound,
				complete, and suitably individualized examination and assessment of a child's
				need for special education and treatment services described in 603 CMR 28.00:
Special Education
, in the context of the child's physical,
				developmental, social, and educational history and current circumstances. This
				assessment is rendered by an authorized professional as defined in
				101
				CMR 330.02 who is trained in the area of
				suspected need and generally includes a written assessment report as defined in
				101
				CMR 330.02. Types of assessments may include,
				but are not limited to, the following.
(a)
Medical
			 Assessment
. A comprehensive health assessment by an authorized
			 physician that identifies medical problems that may affect the child's
			 education, such as physical constraints, chronic illness, neurological and
			 sensory deficits, and developmental dysfunction. The medical assessment
			 generally includes at least the following:
1.
			 a medical history to include health of family, prenatal and birth history,
			 developmental history, and history of significant medical conditions, including
			 hospitalization, injuries, and accidents;
2. a complete physical examination to include
			 blood pressure and nutritional assessment;
3. neurological and developmental assessments
			 to include gross motor functioning, fine motor functioning, language, and
			 visual and auditory functioning;
4.
			 tests for visual acuity and hearing by audiometry;
5. the ordering and interpretation of
			 diagnostic tests to include, if indicated, hematocrit or hemoglobin, sickle
			 cell test (if appropriate), blood lead test, urinalysis (with culture for
			 females), tuberculosis skin test, and other tests as indicated; and
6. a dental assessment and referral for a
			 complete dental examination, if one has not been done within six
			 months.
7. a written assessment
			 report.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 330.00 - Rates for Team Evaluation Services › Section 330.03 - General Rate Provisions

Current through Register 1525, July 5, 2024
(1)
Approved Rates
. The rates of payment for team
			 evaluation services described in 101 CMR 330.00 are the lower of
(a) the eligible provider's usual charge to
			 the general public for the same or similar services; or
(b) the rates of payment listed in
			 101
			 CMR 330.04.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 330.00 - Rates for Team Evaluation Services › Section 330.04 - Rates of Payment

Current through Register 1525, July 5, 2024
(1) The team
			 evaluation services listed in
			 101
			 CMR 330.01(6)  are
			 reimbursed on a fee-for-service basis. The rates of payment for those services
			 are found in the corresponding regulations listed in
			 101
			 CMR 330.01(6).
(2) For the team evaluation services listed
			 in 101 CMR
			 330.04(2), no other EOHHS
			 regulation contains rates of payment for that service. The rates of payment for
			 these services are as stated below in
			 101
			 CMR 330.04(2).
Service/Description
Rate of
							 Payment
Home assessment, including a written assessment, not
							 to exceed 2.5 hours
$127.76
Participation in team meeting by psychologist (if
							 requested by an administrator of special education, or the
							 parent)
$98.03/hour
Participation in team meeting by authorized social
							 worker, nurse, or counselor
$51.10/hour
Educational assessment by certified educational
							 personnel, or a licensed psychologist, including a written assessment report,
							 not to exceed 7.5 hours
$106.76/hour
Diagnostic observation: Observation by an authorized
							 psychologist or school psychologist of a child in a familiar setting such as
							 the home, workplace, the classroom or proposed classroom, or other community
							 settings to examine and determine the child's physical, psychological, social,
							 economic, educational, and vocational assets and disabilities for purposes of
							 developing a diagnostic formulation and designing a treatment
							 plan
$98.03/hour
Comprehensive neuropsychological assessment. The
							 allowed range of hours is nine through 24 hours.
$115.67/hour
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 330.00 - Rates for Team Evaluation Services › Section 330.05 - 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 provider.
(b)
Examination of
			 Records
. Each provider must make available to EOHHS or purchasing
			 governmental unit upon request all records relating to its reported costs,
			 including costs of any entity related by common ownership or control.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 330.00 - Rates for Team Evaluation Services › Section 330.06 - Severability

Current through Register 1525, July 5, 2024
The provisions of 101 CMR 330.00 are severable. If any
				provision of 101 CMR 330.00 or application of any provision to an applicable
				individual, entity, or circumstances is held invalid or unconstitutional, that
				holding will not be construed to affect the validity or constitutionality of
				any remaining provisions of 101 CMR 330.00 or application of those provisions
				to applicable individuals, entities, or circumstances.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 331.00 - Prescribed Drugs › Section 331.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope, Purpose and Effective Date
.
			 101 CMR
			 331.00 governs the payment rates effective April 1,
			 2017 for drugs dispensed by providers to publicly-aided individuals and
			 industrial accident patients.
(2)
Coverage
. The rates of payment under
			 101 CMR
			 331.00 are full compensation for professional services
			 rendered, as well as for any related administrative or supervisory
			 duties.
(3)
Administrative Bulletins
. EOHHS may issue
			 administrative bulletins to clarify its policy on and meaning of substantive
			 provisions of
			 101 CMR
			 331.00, to publish procedure code updates and
			 corrections and as otherwise specified in
			 101 CMR
			 331.00.
(4)
Disclaimer for Authorization
			 of Services
.
			 101 CMR
			 331.00 is not authorization for, or approval of, the
			 services for which rates are established by
			 101 CMR
			 331.00. Purchasers are responsible for the definition,
			 authorization, and approval of care and services provided to publicly-aided
			 individuals and industrial accident patients.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 331.00 - Prescribed Drugs › Section 331.03 - Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
Required Reports
. Required reports include, but are
			 not limited to, reports required by the Center's regulation
			 957
			 CMR 6.00:
Cost Reporting
			 Requirements
, and any additional reports requested by EOHHS to
			 facilitate compliance with the requirements of 42 CFR Part 447.
(2)
Penalty for
			 Noncompliance
. A purchasing governmental unit may reduce the
			 payment rates of any provider that fails to timely file required information
			 with the Center or EOHHS, as applicable, by 5% during the first month of
			 noncompliance, and by an additional 5% during each month of noncompliance
			 thereafter (
i.e
., 5% reduction during the first month of
			 noncompliance, 10% reduction during the second month of noncompliance, and so
			 on). The purchasing governmental unit must notify the provider in advance of
			 its intention to impose a penalty for noncompliance.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 331.00 - Prescribed Drugs › Section 331.04 - Payment for Prescription Drugs

Current through Register 1525, July 5, 2024
(1)
Payment for Multiple Source Drugs
. Payment for
			 multiple source drugs not designated as Brand Name Preferred and not certified
			 as medically necessary (
i.e
., drugs for which the prescriber
			 has not designated "no substitution" and "brand name medically necessary" on
			 the prescription form), other than blood clotting factor and drugs obtained
			 through the 340B Drug Pricing Program, must not exceed the lowest of
(a) the Federal Upper Limit of the drug, if
			 any, plus the appropriate dispensing fee as listed in
			 101 CMR 331.06;
			 or
(b) the Massachusetts Maximum
			 Allowable Cost of the drug, if any, plus the appropriate dispensing fee as
			 listed in
			 101 CMR 331.06;
			 or
(c) the AAC of the drug, plus
			 the appropriate dispensing fee as listed in
			 101 CMR 331.06;
			 or
(d) the usual and customary
			 charge.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 331.00 - Prescribed Drugs › Section 331.05 - Payment for Over-the-counter Drugs

Current through Register 1525, July 5, 2024
Payment to providers for an over-the-counter drug dispensed is
				the lowest of
(1) the Massachusetts
			 Maximum Allowable Cost of the drug, if any, plus the appropriate dispensing fee
			 as listed in
			 101 CMR 331.06;
			 or
(2) the AAC of the drug, plus
			 the appropriate dispensing fee as listed in
			 101 CMR 331.06;
			 or
(3) the usual and customary
			 charge.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 331.00 - Prescribed Drugs › Section 331.06 - Dispensing Fees

Current through Register 1525, July 5, 2024
(1)
Drugs
. Except for compounded drugs and blood clotting
			 factor obtained through the 340B Drug Pricing Program, the dispensing fee is
			 $10.02 per prescription.
(2)
Compounded Drugs
. For compounded drugs, the dispensing
			 fee is $10.02 plus
(a) an additional $7.50
			 for compounded drugs whose dispensing involves the mixing two or more
			 commercially prepared products, compounding requiring the mixing two or more
			 commercially prepared products; or
(b) an additional $10.00 for compounded drugs
			 whose dispensing involves compounding lotions, shampoos, suspensions, or the
			 mixing of powders or liquids into cream, ointment, or gel base; or
(c) an additional $15.00 for compounded drugs
			 whose dispensing involves compounding capsules, troches, suppositories, or
			 pre-filled syringes; or
(d) an
			 additional $30.00 for compounded drugs needing a sterile environment when
			 mixing.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 331.00 - Prescribed Drugs › Section 331.07 - Special Provisions

Current through Register 1525, July 5, 2024
(1)
Payment for Drugs Obtained Through the 340b Drug Pricing
			 Program
.
(a) The payment for
			 drugs other than blood clotting factor obtained through the 340B Drug Pricing
			 Program and dispensed by 340B covered entities is the 340B AAC of the drug plus
			 the appropriate dispensing fee as listed in
			 101 CMR
			 331.06.
(b) The payment for blood clotting factor
			 obtained through the 340B Drug Pricing Program and dispensed by 340B covered
			 entities is the 340B ceiling price of the drug, plus 2.75¢ per unit
			 (IU/RCo/Fu/mcg) or such other amount as EOHHS may specify
via
administrative bulletin upon guidance or approval by CMS.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 331.00 - Prescribed Drugs › Section 331.08 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				101 CMR
				331.00 are severable, and if any provision of
				101 CMR
				331.00 or application of such provisions to any
				provider or 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
				101 CMR
				331.00 or application of such provisions to any
				providers or circumstances other than those held invalid.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 334.00 - Rates for Prostheses, Prosthetic Devices, and Orthotic Devices › Section 334.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
. 101 CMR 334.00 governs the payment
			 rates to be used by all governmental units for prostheses, prosthetic devices,
			 and orthotic devices provided to publicly aided individuals. The rates set
			 forth in 101 CMR 334.00 do not apply to individuals covered by M.G.L. c. 152
			 (the Workers' Compensation Act). Rates for services provided to these
			 individuals are set forth in 114.3 CMR
			 40.03(2):
Services
			 and Rates Covered by Other Regulations
.
(2)
Applicable Dates of
			 Service
. Rates contained in 101 CMR 334.00 apply for dates of
			 service provided on or after April 1, 2024, unless otherwise
			 specified.
(3)
Coverage
. 101 CMR 334.00 and the payment rates
			 established under 101 CMR 334.00 apply to the direct purchase and repair of
			 prescribed custom-made prostheses and prosthetic devices manufactured and
			 supplied by providers, including the cost of customized fitting and client
			 service. 101 CMR 334.00 also applies to the purchase and repair of orthotic
			 devices. These rates are full payment for prostheses, prosthetic devices, and
			 orthotic devices provided by sale, as well as full payment for any related
			 supervisory or administrative duties, fittings and adjustments rendered in
			 connection with the provision of prostheses, prosthetic devices, and orthotic
			 devices.
(4)
Disclaimer
			 of Authorization of Services
. 101 CMR 334.00 is not authorization
			 for or approval of the procedures for which rates are determined pursuant to
			 101 CMR 334.00. Governmental units that purchase care are responsible for the
			 definition, authorization, and approval of care to publicly aided
			 individuals.
(5)
Coding
			 Updates and Corrections
. The Executive Office of Health and Human
			 Services (EOHHS) may publish procedure code updates and corrections in the form
			 of an Administrative Bulletin. The publication of such updates and corrections
			 will list:
(a) codes for which the code
			 numbers only changed, with the corresponding crosswalk;
(b) codes for which the codes remain the
			 same, but the descriptions have changed;
(c) deleted codes for which there are no
			 crosswalks; and
(d) entirely new
			 codes.
For new codes without Medicare fees as of the date of the
				Administrative Bulletin EOHHS will apply individual consideration in
				establishing payment for such codes. Rates established by administrative
				bulletin will remain in effect until such time EOHHS adopts a revised
				regulation or superseding administrative bulletin.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 334.00 - Rates for Prostheses, Prosthetic Devices, and Orthotic Devices › Section 334.03 - General Rate Provisions

Current through Register 1525, July 5, 2024
(1)
General Rate Provisions for the Purchase of Prostheses, Prosthetic
			 Devices, and Orthotic Devices
. Payment to provider of prosthetic
			 or orthotic devices or services are the lower of:
(a) the provider's usual and customary
			 charge; or
(b) the rates set forth
			 in 101 CMR 334.03(10) or any applicable administrative bulletin.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 334.00 - Rates for Prostheses, Prosthetic Devices, and Orthotic Devices › Section 334.04 - Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
Required Reports
. All providers must comply with the
			 requirements of 957 CMR 6.00:
Cost Reporting
			 Requirements
.
(2)
Penalty for Noncompliance
. The purchasing governmental
			 unit may impose a penalty in the amount of up to 15% of its payments to any
			 provider that fails to submit required information. The purchasing governmental
			 unit will notify the provider in advance of its intention to impose a penalty
			 under 101 CMR 334.04(2).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 334.00 - Rates for Prostheses, Prosthetic Devices, and Orthotic Devices › Section 334.05 - Severability

Current through Register 1525, July 5, 2024
The provisions of 101 CMR 334.00 are severable. If any
				provision of 101 CMR 334.00 or the application of any provision to an
				applicable individual, entity, or circumstance is held invalid or
				unconstitutional, that holding will not be construed to affect the validity or
				constitutionality of any remaining provisions of 101 CMR 334.00 or application
				of those provisions to applicable individuals, entities, or
				circumstances.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 337.00 - Rates for Dialysis Treatments and Home Dialysis Supplies › Section 337.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope and Purpose
. 101 CMR 337.00 governs the payment
			 rates to be used by all governmental units and purchasers under M.G.L. c. 152,
			 § 1 (the Workers' Compensation Act) for dialysis treatments, treatment for
			 acute kidney injuries (AKIs), and home dialysis supplies provided to publicly
			 aided and industrial accident patients.
(2)
Applicable Dates of
			 Service
. Rates contained in 101 CMR 337.00 apply for dates of
			 service provided on or after April 1, 2024.
(3)
Disclaimer of Authorization
			 of Services
. 101 CMR 337.00 is not authorization for or approval
			 of the services for which rates are determined pursuant to 101 CMR 337.00. The
			 governmental purchasers and purchasers under M.G.L. c. 152 of these services
			 are responsible for
(a) the definitions and
			 authorization of services for their beneficiaries; and
(b) providing information as to program
			 policies and benefit limitations.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 337.00 - Rates for Dialysis Treatments and Home Dialysis Supplies › Section 337.02 - Definitions

Current through Register 1525, July 5, 2024
Terms used in 101 CMR 337.00 have the meanings set forth in
				101
				CMR 337.02.
Acute Kidney Injury (AKI)
. A sudden
				and often reversible reduction in the kidney function, as measured by increased
				creatinine or decreased urine volume.
Calcimimetics
. A class of drugs used
				to treat hyperparathyroidism, a condition in which the parathyroid glands
				produce a high amount of parathyroid hormone in patients with chronic kidney
				disease.
Center
. The Center for Health
				Information and Analysis, established under M.G.L. c. 12C.
Centers for Medicare & Medicaid Services
				(CMS)
. The federal agency in the Department of Health and Human
				Services that is responsible for the determination of reimbursement for the
				provision of services to Medicare-covered patients.
Chronic Maintenance Dialysis
				Treatment
. Dialysis treatment provided on an outpatient basis for
				a stabilized patient. The treatment may take the form of hemodialysis,
				hemofiltration, intermittent peritoneal dialysis, continuous ambulatory
				peritoneal dialysis, or continuous cycling peritoneal dialysis and may occur in
				a facility or at home.
Dialysis Program Rate(s)
. A provider's
				rate(s) established by CMS for the end stage renal disease (ESRD) program of
				Medicare.
EOHHS
. The Executive Office of Health
				and Human Services, established under M.G.L. c. 6A.
Established Charge
. The lowest rate
				paid by any payer for treatment.
Governmental Purchaser
. The
				Commonwealth of Massachusetts and any of its departments, agencies, boards,
				commissions, and political subdivisions, which purchase dialysis
				services.
Home Dialysis Supplies
. Supplies used
				in conjunction with home dialysis treatment identified in 101 CMR 322.00:
Rates for Durable Medical Equipment, Oxygen and Respiratory Therapy
				Equipment
.
Industrial Accident Patient
. A person
				who receives medical services for which persons, corporations, or other
				entities are in whole or part liable under M.G.L. c. 152.
Provider
. Any independent outpatient
				dialysis facility licensed by the Department of Public Health and certified by
				the MassHealth agency.
Publicly Aided Individual
. A person
				who receives health care and other services for which a governmental unit is in
				whole or in part liable under a statutory program of public assistance.
Purchaser under M.G.L. c. 152
. An
				insurance company, self insurer, or worker's compensation agent of a department
				of the Commonwealth, county, city, or district that purchases medical services
				subject to M.G.L. c. 152, § 1.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 337.00 - Rates for Dialysis Treatments and Home Dialysis Supplies › Section 337.03 - Rate(s) Determination

Current through Register 1525, July 5, 2024
(1) Rates paid to
			 providers will be subject to the following adjustments and limitations.
(a) In a case where the established charge(s)
			 is lower than the dialysis rate(s) and is not based upon an established
			 income-related sliding fee scale for self-payers, the established charge(s) is
			 the rate(s) paid to the provider.
(b) If home training is included as part of a
			 provider's dialysis program, governmental purchasers and purchasers under
			 M.G.L. c. 152 who choose to purchase the service must pay the dialysis rate(s)
			 plus an add-on listed in
			 101
			 CMR 337.03(3)  under the
			 appropriate service code.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 337.00 - Rates for Dialysis Treatments and Home Dialysis Supplies › Section 337.04 - Rates for Home Dialysis Supplies

Current through Register 1525, July 5, 2024
Rates for home dialysis supplies that a governmental purchaser
				chooses to purchase separately from other services are contained in 101 CMR
				322.00:
Rates for Durable Medical Equipment, Oxygen and Respiratory
				Therapy Equipment
.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 337.00 - Rates for Dialysis Treatments and Home Dialysis Supplies › Section 337.05 - Rates for Laboratory Services

Current through Register 1525, July 5, 2024
Rates for laboratory services associated with dialysis that a
				governmental purchaser or purchaser under M.G.L. c. 152 chooses to purchase
				separately from other services are contained in 101 CMR 320.00:
Rates
				for Clinical Laboratory Services
.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 337.00 - Rates for Dialysis Treatments and Home Dialysis Supplies › Section 337.06 - Rates for Prescribed Drugs

Current through Register 1525, July 5, 2024
Payment for allowed drugs is included in the all-inclusive
				bundled payment, except that calcimimetics are paid separately from the bundled
				payment, as described in
				101
				CMR
				337.03(3).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 337.00 - Rates for Dialysis Treatments and Home Dialysis Supplies › Section 337.07 - Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
Required Reports
. Reporting requirements are governed
			 by 957 CMR 6.00:
Cost Reporting Requirements
.
(2)
Penalty for
			 Noncompliance
. The purchasing governmental unit may impose a
			 penalty in the amount of up to 15% of its payments to any provider that fails
			 to submit required information. The purchasing governmental unit will notify
			 the provider in advance of its intention to impose a penalty under
			 101
			 CMR 337.07(2).
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 337.00 - Rates for Dialysis Treatments and Home Dialysis Supplies › Section 337.08 - Bad Debt Settlement

Current through Register 1525, July 5, 2024
Governmental purchasers and purchasers under M.G.L. c. 152
				cannot participate in the Medicare bad debt settlement negotiated between CMS
				and the provider at the end of the provider's fiscal year.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 337.00 - Rates for Dialysis Treatments and Home Dialysis Supplies › Section 337.09 - Severability

Current through Register 1525, July 5, 2024
The provisions of 101 CMR 337.00 are severable. If any
				provision of 101 CMR 337.00 or application of any provision to an applicable
				individual, entity, or circumstance is held invalid or unconstitutional, that
				holding will not be construed to affect the validity or constitutionality of
				any remaining provisions of 101 CMR 337.00 or application of those provisions
				to applicable individuals, entities, or circumstances.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 339.00 - Rates for Restorative Services › Section 339.01 - General Provisions

Current through Register 1525, July 5, 2024
(1)
Scope, Purpose, and Effective Date
.
			 101 CMR 339.00 governs the
			 rates of payment to be used by all governmental units for rehabilitation center
			 services and restorative services provided to publicly aided individuals by
			 eligible providers. Rates for services rendered to individuals covered by
			 M.G.L. c. 152 (the Workers' Compensation Act) are set forth at 114.3 CMR
			 40.06(12):
Restorative Services Description
.
(2)
Applicable Dates of
			 Service
. Rates contained in
			 101 CMR 339.00 apply for
			 dates of service provided on or after April 1, 2022.
(3)
Coverage
. Except
			 as provided otherwise,
			 101 CMR 339.00 and the rates
			 of payment contained in
			 101 CMR 339.00 apply to
			 services rendered by eligible providers of rehabilitation center services and
			 eligible providers of restorative services to publicly aided individuals. The
			 rates of payment specified in
			 101 CMR 339.00 are full
			 compensation for professional services rendered, as well as for any
			 administrative or supervisory duties.
(4)
Exceptions
.
			 Rates of payment contained in
			 101 CMR 339.00 do not apply
			 to indirect services, such as case conferences or in-service education programs
			 provided by eligible providers in long-term-care facilities.
(5)
Coding Updates and
			 Corrections
. EOHHS may publish procedure code updates and
			 corrections in the form of an Administrative Bulletin. The publication of such
			 updates and corrections will list
(a) codes
			 for which only the code number has changed, with the corresponding
			 crossreference between new and existing codes;
(b) codes for which the code remains the
			 same, but the description has changed;
(c) deleted codes for which there are no
			 corresponding new codes; and
(d)
			 entirely new codes that require new pricing. EOHHS may designate these codes as
			 individual consideration until appropriate rates can be developed.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 339.00 - Rates for Restorative Services › Section 339.03 - General Rate Provisions

Current through Register 1525, July 5, 2024
(1)
Rate Determination
. Rates of payment for authorized
			 services to which
			 101 CMR
			 339.00 applies are the lower of
(a) the usual fee of the eligible provider of
			 rehabilitation center services or the eligible provider of restorative services
			 to patients other than publicly aided individuals; or
(b) the schedule of allowable fees set forth
			 in
			 101 CMR
			 339.04.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 339.00 - Rates for Restorative Services › Section 339.05 - Filing and Reporting Requirements

Current through Register 1525, July 5, 2024
(1)
Required Reports
. Reporting requirements are governed
			 by
			 957
			 CMR 6.00:
Cost Reporting
			 Requirements.
(2)
Penalty for Noncompliance
. The purchasing governmental
			 unit may impose a penalty in the amount of up to 15% of its payments to any
			 provider that fails to submit required information. The purchasing governmental
			 unit will notify the provider in advance of its intention to impose a penalty
			 under
			 101 CMR
			 350.06(2):
Administrative Adjustment.
Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 339.00 - Rates for Restorative Services › Section 339.06 - Severability

Current through Register 1525, July 5, 2024
The provisions of
				101 CMR
				339.00 are severable and if any such provisions or the
				application of such provisions to any person or circumstances will be held to
				be invalid or unconstitutional, such invalidity will not be construed to affect
				the validity or constitutionality of any remaining provisions to eligible
				providers or circumstances other than those held invalid.