101 CMR, § 206.10

Current through Register 1533, October 25, 2024

Section 206.10 - Other Payment Provisions

(1)Temporary Resident Add-on.

(a) For dates of service beginning October 1, 2022, a nursing facility will be eligible for a member-specific temporary resident add-on if the resident meets all of the following criteria:

1. MassHealth is the resident's primary payer for nursing facility services at the time of admission;

2. the resident is medically eligible for nursing facility services under 130 CMR 456.409: Services Requirement for Medical Eligibility;

3. the resident was transferred to the nursing facility for temporary residence purposes directly from their home; and

4. the resident was discharged from the nursing facility to their home within 30 calendar days of the admission date.

(b)Payment Amount. For individuals younger than 22 years old, the add-on is $250 per member per day. For individuals 22 years of age or older, the add-on is $130 per member per day.

(2)Ventilator Add-on. For dates of service beginning October 1, 2024, a nursing facility that provides ventilator services to ventilator-dependent MassHealth members will receive a member-specific ventilator add-on of $343 per member per day, provided all of the following criteria are met:

(a) MassHealth is the resident's primary payer for nursing facility services at the time of admission;

(b) The resident requires ventilator services at least daily;

(c) The facility is approved by EOHHS to provide specialized ventilator-dependent services, in accordance with processes established through administrative bulletin or other written issuance;

(d) The facility maintains a program for specialized ventilator services, in accordance with MassHealth requirements established through administrative bulletin or other written issuance; and

(e) The facility is not receiving the communication-limited resident ventilator add-on described in 101 CMR 206.10(3) or the tracheostomy add-on described in 101 CMR 206.10(6) for the resident.

(3)Communication-limited Resident Ventilator Add-on. For dates of service beginning October 1, 2024, a nursing facility that provides services to ventilator-dependent MassHealth members will receive a member-specific add-on of $457 per member per day, provided all of the following criteria are met:

(a) MassHealth is the resident's primary payer for nursing facility services at the time of admission;

(b) The resident requires ventilator services at least daily and is unable to communicate without the assistance of specialized communication technology that relies on eye movements, such as certain individuals with advanced amyotrophic lateral sclerosis (ALS);

(c) The facility is approved by EOHHS to provide specialized ventilator-dependent services, in accordance with processes established through administrative bulletin or other written issuance;

(d) The facility maintains a program for specialized ventilator services, in accordance with MassHealth requirements established through administrative bulletin or other written issuance; and

(e) The facility is not receiving the ventilator add-on described in 101 CMR 206.10(2) or the tracheostomy add-on described in 101 CMR 206.10(6) for the resident.

(4)COVID-19 Testing Supplemental Payment.

(a)Supplemental Payment Methodology. For the period of July 1, 2022, through April 30, 2023, EOHHS will pay nursing facilities a monthly supplemental payment to offset the cost of COVID-19 tests needed for staff surveillance testing requirements established by DPH, resident testing, and visitor testing. Each monthly supplemental payment shall be calculated as follows for each facility.

1. Determine the total staff who were up to date with their COVID-19 vaccination status and multiply by 4.

2. Determine the total staff who are not up to date with their COVID-19 vaccination status and multiply by 8.

3. Determine the total resident census and multiply by 5 to account for resident and visitor testing.

4. Add together the three products calculated in 101 CMR 206.10(4)(a)1. through 3.

5. Multiply the sum calculated in 101 CMR 206.10(4)(a)4. by $12. This product will equal the facility's monthly COVID-19 testing supplemental payment.

(b)Definitions. For the purposes of 101 CMR 206.10(4), the following terms shall have the following meanings.

1.Calendar Quarter. Each of the four three-month periods in a given calendar year, running from January 1^st through March 31^st, April 1^st through June 30^th, July 1^st through September 30^th, and October 1^st through December 31^st.

2.Total Staff. The total quarterly average number of staff working at the facility as reported by the facility through the Centers for Disease Control and Prevention's National Healthcare Safety Network reporting tool (NHSN) for the most recent complete calendar quarter.

3.Total Resident Census. The total quarterly average number of residents in the facility as reported by the facility through NHSN for the most recent complete calendar quarter.

4.COVID-19 Vaccination Status. A determination of whether a person is up to date or not up to date in receiving their COVID-19 vaccines in accordance with DPH COVID-19 vaccination guidance for long term care facility staff, as reported by the facility through NHSN for the most recent complete calendar quarter.

(c)Disbursement of Supplemental Payments. The supplemental payments are paid on a monthly basis, and the payment amount shall be updated every three months, based on the previous, available calendar quarter data.

(d)Additional Guidance. EOHHS may, via administrative bulletin or other written issuance, establish a different data source for calculating the COVID-19 testing supplemental payments under 101 CMR 206.10(4), or establish additional rules governing such payments including, but not limited to, information on the relevant staff that must be tested, the frequency of testing, or additional reporting requirements.

(e)Correction of Material Error. EOHHS may adjust any testing supplemental payment upon EOHHS's determination that there was a material error in the calculation of the payment. EOHHS will not adjust any supplemental payment solely because a facility under-reported staff or resident numbers in its NHSN report.

(f)Audits and Enforcement. All information included in the NHSN reports is subject to verification and audit by EOHHS. Such verification or audit may include an in-person or desk audit, comparison of data to other data sources available to EOHHS, such as the federal Payroll Based Journal staffing level reporting tool, or other verification or audit mechanisms available to EOHHS. In the event that EOHHS determines a facility materially misstated or inaccurately reported information relevant to calculating the COVID-19 testing supplemental payment, EOHHS may pursue overpayment or sanction action under 130 CMR 450.000: Administrative and Billing Regulations.

(6)Tracheostomy Add-on. For dates of service beginning October 1, 2022, a nursing facility that provides tracheostomy services to tracheostomy-dependent MassHealth members will receive a member-specific tracheostomy add-on of $220 per member per day, provided all of the following criteria are met:

(a) MassHealth is the resident's primary payer for nursing facility services at the time of admission;

(b) the resident requires tracheostomy services; and

(c) the facility is not receiving the ventilator add-on described in 101 CMR 206.10(2) or the communication-limited resident ventilator add-on described in 101 CMR 206.10(3) for the resident.

(7)Medicaid Transitional Add-on. For dates of service beginning January 15, 2022, a nursing facility will be eligible for a transitional add-on of $200 per member per day for the first 60 days of the resident's nursing facility stay, not including any leaves of absence, if the resident meets all of the following criteria:

(a) MassHealth is the resident's primary payer for nursing facility services at the time of admission;

(b) The resident was transferred to the nursing facility directly from an acute or a non-acute inpatient hospital on or after January 15, 2022; and

(c) The resident is not returning to the nursing facility from a medical leave of absence.

(8)COVID-19 Monoclonal Antibody Treatment and COVID-19 Antiviral Treatment Claims.

(a) For dates of service beginning December 22, 2021, and notwithstanding any regulatory provision to the contrary, nursing facilities may submit separate claims to MassHealth on a fee-for-service basis for the administration of COVID-19 monoclonal antibody treatments and COVID-19 antiviral treatments to eligible MassHealth members and provided in a manner supported by medical evidence, provided in accordance with the emergency use authorization (EUA) issued by the federal Food and Drug Administration (FDA) or provided in accordance with full FDA approval, and provided in accordance with any guidance issued by DPH, the FDA, or CMS with respect to such treatments. Nursing facilities are required to ensure that any such monoclonal antibody treatments or antiviral treatments administered at the facility are administered by individuals whose education, credentials, and training qualify them to render such services.

(b) The costs of services described in 101 CMR 206.10(8)(a) are not included in the prospective payment system operating or nursing standard payment rates determined under 101 CMR 206.03 and 101 CMR 206.04. The costs of providing such services will be considered non-allowable costs under 101 CMR 206.08(3)(h)12.

(c) MassHealth payments for separate fee-for-service claims submitted by the nursing facility for the services described in 101 CMR 206.10(8)(a) must be paid at the rates established under 101 CMR 446.03(2) or 101 CMR 317.00, as applicable. Such fee-for-service claims payments must be considered payment in full for such services.

(d) EOHHS must establish, through administrative bulletin or other written issuance, the specific COVID-19 monoclonal antibody treatments or COVID-19 antiviral treatments that may be administered by the nursing facility, as well as the specific codes and billing instructions for such services.

(9)COVID-19 Vaccine Administration Claims.

(a) For dates of service beginning October 1, 2021, and notwithstanding any regulatory provision to the contrary, nursing facilities may submit separate claims to MassHealth on a fee-for-service basis for COVID-19 vaccine administration services, provided to eligible MassHealth members in accordance with an EUA issued by the FDA or full FDA approval, and in accordance with any guidance issued by the FDA or CMS with respect to such services. Nursing facilities are required to ensure that any such services administered by the facility are administered by individuals whose education, credentials, and training qualify them to render such services.

(b) The costs of services described in 101 CMR 206.10(9)(a) are not included in the prospective payment system operating or nursing standard payment rates determined under 101 CMR 206.03 and 101 CMR 206.04. The costs of providing such services will be considered non-allowable costs under 101 CMR 206.08(3)(h)12.

(c) MassHealth payments for separate fee-for-service claims submitted by the nursing facility for the services described in 101 CMR 206.10(9)(a) must be paid at the rates established under 101 CMR 446.03(2): Medicine. Such fee-for-service claims must be considered payment in full for such services.

(d) EOHHS must establish, through administrative bulletin or other written issuance, the specific codes and billing instructions for such services.

(10)Time-limited COVID-19 Monthly Staffing Supplemental Payment.

(a)General. A nursing facility will be eligible for supplemental payments to offset increased costs of providing care not accounted for in the nursing facility's prospective payment system rates during the COVID-19 pandemic. The supplemental payments will be made over six months, in the months of January, February, March, April, May, and June 2022. Supplemental payments will be distributed to nursing facilities based on their proportion of the total Medicaid Days reported by all nursing facility providers. The period used to determine each nursing facility's proportion of the total Medicaid Days is April 1, 2021, through September 30, 2021, as reported on each nursing facility's User Fee Assessment Forms for that period. These payments are to be used to pay for increased direct-care staffing costs incurred for dates of service beginning January 1, 2022, through June 30, 2022.

(b)Calculation of a Monthly Supplemental Payment. EOHHS will use the following methodology to calculate the time-limited COVID-19 monthly supplemental payments for each MassHealth nursing facility provider:

1. Divide the number of Massachusetts Medicaid Days as reported by each nursing facility provider on their Quarterly User Fee Assessment Form for the period of April 1, 2021, through September 30, 2021, by the total number of Massachusetts Medicaid Days, including Fee-For-Service and Managed Care bed days, across all nursing facility providers, as reported by all nursing facility providers on the Quarterly User Fee Assessment Form for the same period.

2. Multiply the quotient calculated in 101 CMR 206.10(10)(b)1. by $58,600,000.

3. Divide the product calculated in 101 CMR 206.10(10)(b)2. by six.

4. Each COVID-19 monthly supplemental payment shall equal the amount calculated in 101 CMR 206.10(10)(b)3. for each nursing facility.

(c)Correction of Material Error. EOHHS may adjust any supplemental payment upon EOHHS's determination that there was a material error in the calculation of the payment. EOHHS will not adjust any supplemental payment solely because a facility under-reported Massachusetts Medicaid days in its Quarterly User Fee Assessment Form.

(d)Permissible Uses of COVID-19 Staffing Supplemental Payments.

1. Facilities may use the COVID-19 supplemental payment only for the following direct-care staff expenses: increases in base wages or retention bonuses for directly employed staff, signing bonuses for new employees, premium pay, shift differentials, and expenses related to temporary nursing agency staff. The permissible expenses to be funded through these supplemental payments must be incurred by June 30, 2022.

2. For the purposes of the COVID-19 supplemental payment, direct-care staff shall include the following staff categories: registered nurses; licensed practical nurses; certified nurse aides; non-certified or resident care aides; director of nurses; in-house clerical staff regularly interacting with residents and caregivers (e.g., receptionists, unit clerks, business office staff working on-site); security staff; staff development coordinators; dietary staff; housekeeping/laundry staff; quality assurance professional staff; MMQ evaluation nurse/MDS coordinators; social service workers; behavioral health staff; plant operations/maintenance staff; interpreter service staff; restorative therapy staff; recreational therapy staff; physician services staff; and pharmacy consultant staff. Direct-care staff shall not include nursing facility administrators.

(e)Reporting Requirements.

1. Each facility will be required to report to EOHHS on the ways in which it expects to use, and ultimately uses, its received supplemental payments. The required reporting will be incorporated in the interim and final DCC-Q reports that facilities are required to submit by March 1, 2022, and July 30, 2022, respectively, in accordance with 101 CMR 206.12(3). Failure to complete the required supplemental payment reporting on the interim and final DCC-Q reports, failure to timely submit the interim or final DCC-Q reports, use of funds on anything other than permissible uses described herein, failure to incur permissible expenses to be funded through these supplemental payments by June 30, 2022, or failure to actually pay the supplemental payments for such incurred permissible expenses may result in partial or full recoupment of received supplemental payments as an overpayment under 130 CMR 450.237: Overpayments: Determination.

2. All information included in the reports regarding supplemental payments is subject to verification and audit by EOHHS. Failure to submit the required reporting or comply with audits or document requests with respect to the requirements herein may result in partial or full recoupment of the supplemental payments as overpayments under 130 CMR 450.237: Overpayments: Determination, or sanctions under 130 CMR 450.238: Sanctions: General.

3. EOHHS may, via administrative bulletin or other written issuance, provide further detail, or establish additional reporting requirements with respect to this supplemental payment.

(11)Workforce Supplemental Payment.

(a)Calculation of Supplemental Payment. Effective January 15, 2022, a nursing facility will be eligible for a Workforce Supplemental Payment, to support workforce retention and recruitment efforts during the COVID-19 pandemic, calculated for each nursing facility as follows:

1. Determine the total number of Massachusetts Medicaid days, including fee-for-service (FFS) days and managed care days, as reported by all nursing facilities in their Quarterly User Fee Assessment Forms for the period of April 1,2021, through September 30, 2021.

2. Divide the total amount of available funds, $25,000,000, by the total number of Massachusetts Medicaid days as determined in 101 CMR 206.10(11)(a)1.

3. For each nursing facility, multiply the quotient calculated in 101 CMR 206.10(11)(a)2. by the nursing facility's Massachusetts Medicaid days, including FFS days and managed care days, as reported in the nursing facility's Quarterly User Fee Assessment Forms for the period of April 1, 2021, through September 30, 2021.

4. The total Workforce Supplemental Payment will equal the total calculated in 101 CMR 206.10(11)(a)3. for each nursing facility.

(b)Correction of Material Error. EOHHS may adjust any Workforce Supplemental Payment upon EOHHS's determination that there was a material error in the calculation of the payment. EOHHS will not adjust any Workforce Supplemental Payment solely because a facility under-reported Massachusetts Medicaid days in its Quarterly User Fee Assessment Form.

(c)Permissible Uses.

1. Facilities shall use these Workforce Supplemental Payments to support direct-care staff recruitment and retention initiatives that may include but are not limited to increases in base wages and/or retention bonuses for directly employed staff, signing bonuses for new employees, premium pay, and shift differentials. The permissible expenses to be funded through these Workforce Supplemental Payments must be incurred by June 30, 2022.

2. For the purposes of the Workforce Supplemental Payment, direct-care staff shall include the following staff categories: registered nurses; licensed practical nurses; certified nurse aides; non-certified or resident care aides; director of nurses; in-house clerical staff regularly interacting with residents and caregivers (e.g., receptionists, unit clerks, business office staff working on-site); security staff; staff development coordinators; dietary staff; housekeeping/laundry staff; quality assurance professional staff; MMQ evaluation nurse/MDS coordinators; social service workers; behavioral health staff; plant operations/maintenance staff; interpreter service staff; restorative therapy staff; recreational therapy staff; physician services staff; and pharmacy consultant staff. Direct-care staff shall not include nursing facility administrators or temporary nursing agency staff.

(d)Reporting Requirements.

1. Each facility will be required to report to EOHHS on the ways in which it expects to use, and ultimately uses, its received Workforce Supplemental Payments. The required reporting will be incorporated in the interim and final DCC-Q reports that facilities are required to submit by March 1,2022, and July 30, 2022, respectively, in accordance with 101 CMR 206.12(3). Failure to complete the required Workforce Supplemental Payment reporting on the interim and final DCC-Q reports, failure to timely submit the interim or final DCC-Q reports, use of funds on anything other than permissible uses described herein, failure to incur permissible workforce expenses by June 30, 2022, or failure to actually pay the Workforce Supplemental Payment for such incurred permissible workforce expenses may result in partial or full recoupment of received Workforce Supplemental Payments as overpayments under 130 CMR 450.237: Overpayments: Determination.

2. All information included in the reports regarding Workforce Supplemental Payments is subject to verification and audit by EOHHS. Failure to submit the required or comply with audits or document requests with respect to the requirements herein may result in partial or full recoupment of the Workforce Supplemental Payments as overpayments under 130 CMR 450.237: Overpayments: Determination, or sanctions under 130 CMR 450.238: Sanctions: General.

3. EOHHS may, via administrative bulletin or other written issuance, establish additional reporting requirements with respect to this supplemental payment.

(13)Homelessness Rate Add-on.

(a)Eligibility Criteria. For dates of service beginning January 15, 2022, a nursing facility will be eligible for a member-based homelessness rate add-on of $200 per member per day for up to the first 180 days of the member's nursing facility stay, not including any leaves of absence, if the member meets all of the following criteria.

1. MassHealth is the member's primary payer for nursing facility services at the time of admission;

2. The member is clinically eligible for nursing facility services under 130 CMR 456.409: Services Requirement for Medical Eligibility; and

3. The member has been approved for the member-based homelessness rate add-on by EOHHS because EOHHS has determined the member meets one or more of the following criteria:

a. The member has experienced homelessness for at least six months directly prior to admission as documented by a homeless provider agency and confirmed by EOHHS;

b. The member has been homeless directly prior to admission, as documented by a homeless provider agency and confirmed by EOHHS, and has a behavioral health condition;

c. The member is at risk of homelessness and has a behavioral health condition;

d. The member experienced a sudden or unexpected loss of primary residence (for example, due to fire, flooding, eviction, etc.) necessitating an emergency nursing facility admission; or

e. The member's living situation directly prior to admission required the involvement of Elder Protective Services.

(b)Non-applicability with Other Payments. A nursing facility may not receive this add-on for a member for whom the facility is receiving on the same dates of service a Medicaid transitional add-on under 101 CMR 206.10(7), a substance use disorder add-on or a substance use disorder induction period add-on under 101 CMR 206.10(14), a behavioral indicator add-on under 101 CMR 206.10(16), a bariatric add-on under 101 CMR 206.10(21), a per diem rate for severe mental or neurological disorders under 101 CMR 206.11, or a complicated high-cost care need add-on under 101 CMR 206.15.

(c)Relevant Definitions.

1. For the purposes of the homelessness rate add-on, a member experiencing homelessness is any member who lacks a fixed, regular, and adequate nighttime residence and who has a primary nighttime residence that is a public or private place not designed for or ordinarily used as a regular sleeping accommodation for human beings including a car, park, abandoned building, bus or train station, airport, or camping group; or who is living in a supervised publicly- or privately-operated emergency shelter designated to provide temporary living arrangements, including congregate shelters, transitional housing, and hotels and motels paid for by charitable organizations or by federal, state, or local government programs for low-income individuals.

2. For the purposes of the homelessness rate add-on, a member at risk of homelessness is any member who does not have sufficient resources or support networks (e.g., family, friends, faith-based or other social networks) immediately available to prevent them from moving to an emergency shelter or another place not meant for human habitation.

(14)Substance Use Disorder (SUD) Add-on and SUD Induction Period Add-on.

(a)Eligibility Criteria.

1. For dates of service beginning October 1, 2024, a nursing facility that meets the criteria set forth in 101 CMR 206.10(14)(a)3. or 4., as applicable, will be eligible for a member specific Substance Use Disorder (SUD) add-on of $50 per member per day for each member residing in the facility, for whom MassHealth is the primary payer, who has a documented SUD diagnosis listed in 101 CMR 206.10(14)(b) and who receives at least one SUD service or treatment listed in 101 CMR 206.10(14)(c).

2. For dates of services beginning October 1, 2024, a nursing facility that meets the criteria set forth in 101 CMR 206.10(14)(a)(3) or (4), as applicable, will be eligible for a member specific SUD induction period add-on of $200 per member per day of induction period for each member residing in the facility, for whom MassHealth is the primary payer, who has a documented SUD diagnosis listed in 101 CMR 206.10(14)(b), and who requires transportation with direct care staff to an Opioid Treatment Program (OTP) clinic for the member's induction period.

3. The facility will be eligible to receive the add-ons under 101 CMR 206.10(14)(a)(1) and (2) only if it submits to EOHHS an attestation in a form and manner specified by EOHHS by the deadline specified by EOHHS confirming that the facility has processes in place to provide services to residents with SUD. This provision applies to all facilities unless they are a High-SUD nursing facility as described in 101 CMR 206.10(14)(a)(4).

4. A facility that meets the criteria for a High-SUD nursing facility, as determined by EOHHS, will be eligible to receive the add-ons under 101 CMR 206.10(14)(a)(1) and (2) only if:

i. The facility submits to EOHHS an attestation in a form and manner specified by EOHHS by the deadline specified by EOHHS confirming that the facility has processes in place to provide services to residents with SUD; and

ii. The facility submits to EOHHS:

(1) an attestation in a form and manner specified by EOHHS by the deadline specified by EOHHS, certifying that the facility has executed an appropriate agreement to share data and collaborate with at least one OTP. Such agreement must include agreed-upon policies and procedures as specified by EOHHS in administrative bulletin or other written issuance; and

(2) a copy of the executed agreement.

(b)ICD-10 Groups. For the purposes of the SUD add-on and the SUD induction period add-on, eligible ICD-10 diagnosis groups include F10 through F16 (mental and behavioral disorders due to psychoactive substance), F19 (other psychoactive substance related disorders), and T40 (poisoning by, adverse effect of and underdosing of narcotics and psychodysleptics (hallucinogens)).

(c)SUD Services or Treatment. For the purposes of the SUD add-on and the SUD induction period add-on, eligible SUD services or treatment include opioid treatment services, medication for addiction treatment, and SUD-related counseling. EOHHS may establish further guidance regarding eligible SUD services and treatments through administrative bulletin or other written issuance.

(d)Denial of Payment and Overpayments. Facilities that fail to meet the requirements under 101 CMR 206.10(14)(a), (b), or (c) may be denied further SUD add-on payments and may be subject to overpayment action under 130 CMR 450.237: Overpayments: Determination. In addition, facilities that refuse to admit a resident with SUD solely because of their SUD diagnosis may be denied the SUD add-on for the rest of the rate year and may be subject to sanctions under 130 CMR 450.238: Sanctions: General.

(e)Additional Guidance. EOHHS may issue, via administrative bulletin or other written issuance, additional guidance regarding these add-ons, including but not limited to guidance on billing procedures and verification of medical records required to support the SUD diagnoses.

(15)Add-on for Home Dialysis in a Nursing Facility Setting.

(a)Dialysis Treatment for Members. Nursing facilities may have home dialysis services available on-site at the facility, after receiving approval from the Department of Public Health to operate an on-site home dialysis services program, in coordination with a licensed dialysis services provider.

(b)Add-on Rate of $85 per Member per Dialysis Treatment. Nursing facilities with an approved on-site home dialysis services program in accordance with 101 CMR 206.10(15)(a) may receive a rate add-on of $85 per member residing in the facility and receiving home dialysis services in the facility, for each instance of home dialysis services received in the nursing facility for which the following two conditions are concurrently met:

1. MassHealth is not the primary payer for the member's home dialysis services received in the nursing facility; and

2. MassHealth is the primary payer for the member's nursing facility services at the time of home dialysis services received in the nursing facility.

(c)Add-on Rate of $379 per Member per Dialysis Treatment. Nursing facilities with an approved on-site home dialysis services program in accordance with 101 CMR 206.10(15)(a) may receive a rate add-on of $379 per member residing in the facility and receiving home dialysis services in the facility, for each instance of home dialysis services received in the nursing facility for which the following two conditions are concurrently met:

1. MassHealth would be the primary payer for the dialysis services if they were received outside of the nursing facility; and

2. MassHealth is the primary payer for the member's nursing facility services at the time of home dialysis services received in the nursing facility.

(16)Behavioral Indicator Add-on.

(a)Eligibility Criteria. For dates of service beginning October 1, 2022, a nursing facility will be eligible for a member-specific behavioral indicator add-on of $50 per member per day for each member residing in the facility for whom MassHealth is the primary payer and who was coded as 2 or 3 on one or more of the following Minimum Data Set 3.0 (MDS 3.0) indicators: Behavioral Health (E0200A, E0200B, or E0200C), Rejection of Care (E0800), or Wandering (E0900). The add-on is meant to offset additional costs associated with certain members with behavioral conditions (for example, members with severe dementia).

(b)Additional Guidance. EOHHS may issue, via administrative bulletin or other written issuance, additional guidance regarding this add-on, including but not limited to billing procedures for the behavioral indicator add-on and verification of medical records required to support the MDS coding for the add-on.

(17)Add-on for Dialysis Services Provided at an Affiliated Inpatient Chronic Disease and Rehabilitation Hospital.

(a)Dialysis Treatment for Members. Nursing facility residents may receive dialysis services at an affiliated inpatient chronic disease and rehabilitation hospital that is licensed by DPH and located in the same building, in coordination with a licensed dialysis services provider, as long as the dialysis services are not licensed as outpatient services. If the dialysis services are licensed by DPH as services provided by an outpatient clinic in accordance with 105 CMR 145.000, the nursing facility may not receive the rate add-on under 101 CMR 206.10(17).

(b)Add-on Rate of $85 per Member per Dialysis Treatment. Nursing facilities may receive a rate add-on of $85 per member residing in the nursing facility and receiving dialysis services in a setting that meets the criteria specified in 101 CMR 206.10(17)(a) for each instance of dialysis services received in the affiliated facility for which the following two conditions are concurrently met:

1. MassHealth is not the primary payer for the member's dialysis services received in the affiliated facility; and

2. MassHealth is the primary payer for the member's nursing facility services at the time of dialysis services received in the affiliated facility.

(c)Add-on Rate of $379 per Member per Dialysis Treatment. Nursing facilities may receive a rate add-on of $379 per member residing in the nursing facility and receiving dialysis services in a setting that meets the criteria specified in 101 CMR 206.10(17)(a), for each instance of dialysis services received in the affiliated facility for which the following two conditions are concurrently met:

1. MassHealth would be the primary payer for the dialysis services if they were received outside of the nursing facility; and

2. MassHealth is the primary payer for the member's nursing facility services at the time of dialysis services received in the affiliated facility.

(18)Payments for Quality Improvements through COVID-19 Preparedness.

(a)General. A nursing facility will be eligible for a COVID-19 preparedness payment, as calculated in 101 CMR 206.10(18)(c), to be made upon verification of eligibility criteria described in 101 CMR 206.10(18)(b).

(b)Eligibility Criteria. A nursing facility will be eligible for a COVID-19 preparedness payment if the facility meets all of the criteria in 101 CMR 206.10(18)(b)1. through 5. MassHealth may provide further detail on such criteria, including on the specific infection control requirements, attestation forms and deadlines, any necessary reporting deadlines, specific requirements for COVID-19 therapeutic plans, and other information as MassHealth determines necessary pursuant to 101 CMR 206.10(18)(f).

1. The nursing facility

a. had an HPPD, as defined in 101 CMR 206.13(3), of 3.58 or higher for at least one calendar quarter from October 1, 2022, through December 31, 2024; or

b. achieved a minimum of 10% improvement in HPPD in at least one calendar quarter from January 1, 2023, through December 31, 2024, as compared to the calendar quarter ending December 31, 2022.

2. The nursing facility meets a minimum threshold of staff and residents who are up-to-date with COVID-19 vaccinations, with thresholds and deadlines established by MassHealth through administrative bulletin or other written issuance.

3. The nursing facility must attest to implementing core components of infection control requirements and outline a plan for ensuring compliance with these requirements and be in continuous substantial compliance with such requirements during the rate year.

4. A nursing facility must attest to having a plan in place to administer COVID-19 therapeutics, including monoclonal antibodies and antiviral therapies, to its residents as clinically appropriate.

5. The nursing facility must meet the 75% DCC-Q threshold established under 101 CMR 206.12(1).

(c)Payment Methodology. EOHHS will use the following methodology to calculate COVID-19 preparedness payments for each eligible nursing facility.

1. Determine the total number of Massachusetts Medicaid days, including fee-for-service (FFS) days and managed care days, as reported by eligible nursing facilities in their Quarterly User Fee Assessment Forms for the period of July 1, 2021, through June 30, 2022.

2. Determine which of the two thresholds of staff and residents who are up-to-date with COVID-19 vaccinations a nursing facility meets.

3. If the facility meets the higher of the two thresholds in 101 CMR 206.10(18)(c)2., multiply by 3 the number of Massachusetts Medicaid days, including fee-for-service (FFS) days and managed care days, as reported by an eligible nursing facility in its Quarterly User Fee Assessment Forms for the period of July 1, 2021, through June 30, 2022.

4. If the facility meets the lower of the two thresholds in 101 CMR 206.10(18)(c)2., keep the same the number of Massachusetts Medicaid days, including fee-for-service (FFS) days and managed care days, as reported by an eligible nursing facility in its Quarterly User Fee Assessment Forms for the period of July 1, 2021, through June 30, 2022.

5. Sum up Massachusetts Medicaid days in 101 CMR 206.10(18)(c)3. and 101 CMR 206.10(18)(c)4.

6. Divide the total amount of available funds, $16,550,000, by the total number of Massachusetts Medicaid days as determined in 101 CMR 206.10(18)(c)5.

7. For each eligible nursing facility meeting the higher of the two thresholds in 101 CMR 206.10(18)(c)2., multiply the quotient calculated in 101 CMR 206.10(18)(c)6. by the eligible nursing facility's Massachusetts Medicaid days, as calculated in 101 CMR 206.10(18)(c)3.

8. For each eligible nursing facility meeting the lower of the two thresholds in 101 CMR 206.10(18)(c)2., multiply the quotient calculated in 101 CMR 206.10(18)(c)6. by the eligible nursing facility's Massachusetts Medicaid days, as they appear in 101 CMR 206.10(18)(c)4.

9. If the product in 101 CMR 206.10(18)(c)7. is greater than $700,000, cap the total calculated for each eligible nursing facility at $700,000; otherwise keep the total as is.

10. If the product in 101 CMR 206.10(18)(c)8. is greater than $300,000, cap the total calculated for each eligible nursing facility at $300,000; otherwise keep the total as is.

11. Sum up the amounts calculated in 101 CMR 206.10(18)(c)9. and 101 CMR 206.10(18)(c)10.

12. Subtract the sum calculated in 101 CMR 206.10(18)(c)11. from $16,550,000.

13. Sum up Massachusetts Medicaid days for eligible nursing facilities in 101 CMR 206.10(18)(c)4. whose amounts calculated in 101 CMR 206.10(18)(c)10. are less than $300,000.

14. Divide the amount calculated in 101 CMR 206.10(18)(c)12. by the number calculated in 101 CMR 206.10(18)(c)13.

15. For each eligible nursing facility in 101 CMR 206.10(18)(c)4. whose amounts calculated in 101 CMR 206.10(18)(c)10. are less than $300,000, multiply the quotient calculated in 101 CMR 206.10(18)(c)14. by the eligible nursing facility's Massachusetts Medicaid days, as calculated in 101 CMR 206.10(18)(c)4.

16. For each eligible nursing facility in 101 CMR 206.10(18)(c)4. whose amounts calculated in 101 CMR 206.10(18)(c)10. are less than $300,000, sum up the amount in 101 CMR 206.10(18)(c)10. and the product calculated in 101 CMR 206.10(18)(c)15.

17. If the amount calculated in 101 CMR 206.10(18)(c)16. is greater than $300,000, cap the total calculated for each eligible nursing facility at $300,000; otherwise keep the total as is.

18. Sum up the amounts calculated in 101 CMR 206.10(18)(c)9. and 101 CMR 206.10(18)(c)10. for eligible facilities that reached the $300,000 cap, and in 101 CMR 206.10(18)(c)17.

19. Subtract the sum calculated in 101 CMR 206.10(18)(c)18. from $16,550,000.

20. Repeat the above steps for eligible facilities in 101 CMR 206.10(18)(c)4. whose amounts are less than $300,000 until the remaining funds are fully distributed.

21. The COVID-19 preparedness payments, for each eligible nursing facility, will equal the total calculated in 101 CMR 206.10(18)(c)9., 101 CMR 206.10(18)(c)10., 101 CMR 206.10(18)(c)17., or 101 CMR 206.10(18)(c)20., depending on whether an eligible facility was above or below the allowable cap.

(d)Overpayments. A nursing facility that fails to meet the criteria under 101 CMR 206.10(18)(b)1. and/or remain in compliance with all infection control requirements during the period of December 1, 2022, through June 30, 2023, under 101 CMR 206.10(18)(b)4. may be subject to overpayment action under 130 CMR 450.237: Overpayments: Determination.

(e)Correction of Material Error. EOHHS may adjust any supplemental payment upon EOHHS's determination that there was a material error in the calculation of the payment. EOHHS will not adjust any supplemental payment solely because a facility under-reported Massachusetts Medicaid days in its Quarterly User Fee Assessment Form.

(f)Additional Guidance. EOHHS may issue, via administrative bulletin or other written issuance, additional guidance regarding this add-on.

(21)Bariatric Add-on.

(a) For dates of service beginning on February 2, 2024, nursing facilities may receive a member-based rate add-on of $300 per member per day for each member residing in a facility for whom MassHealth is the primary payer and all of the following conditions are met:

1. prior to the member's admission, the facility must receive approval from MassHealth to bill the add-on based on the clinical profile of the member;

2. the member has a Body Mass Index (BMI) greater than 40 that can be supported by an ICD-10 code after admission;

3. the member is dependent, as defined by MDS, for at least one activity of daily living that requires a service listed in 130 CMR 456.409(B); and

4. the member requires a minimum of two staff members to assist with transfers, personal care and/or bed mobility.

(b)Non-applicability with Other Payments. A nursing facility may not receive this payment for a member for whom the facility is receiving on the same dates of service a homelessness rate add-on under 101 CMR 206.10(13), a severe mental and neurological disorder add-on under 101 CMR 206.11, or a complicated high-cost care need add-on under 101 CMR 206.15.

(22)Supplemental Payment for Qualified Nursing Facilities Located near North Adams.

(a) Beginning October 1, 2024, a nursing facility located within 17 miles of 71 Hospital Avenue in North Adams, Massachusetts will qualify for a supplemental payment to support additional allowable costs. Each qualified nursing facility will receive a proportional payment of the total amount available of $2,973,456.

(b) Qualified nursing facilities will receive a supplemental payment, which will be calculated and determined as follows.

1. Calculate the total of all qualified nursing facilities' Massachusetts Medicaid days, as reported on quarterly User Fee Assessment Forms for the period April 1, 2023, through March 31, 2024.

2. Determine each qualified nursing facility's proportion of Massachusetts Medicaid days as a total of all qualified nursing facility Massachusetts Medicaid days.

3. Multiply the proportion of each facility's Medicaid User Fee days by the total amount available of $2,973,456.