Section 206.11 - Rates for Severe Mental and Neurological Disorder Services(1)Qualifying Nursing Facility. For dates of service beginning January 15, 2022, qualifying nursing facilities will be able to receive a member-based per diem rate for residents with severe mental or neurological disorders who are receiving specialized rehabilitation services for such disorders. In order to qualify for this member-based per diem rate, a nursing facility must (a) as of August 1, 2020, operate to provide nursing facility services, including the specialized rehabilitative services described in 101 CMR 206.11(1)(c), to residents with mental or neurological disorders, including residents with acquired brain injuries;(b) demonstrate, in the form and manner requested by EOHHS, that the percentage of the facility's annual resident days for residents with mental or neurological disorders, including residents with acquired or traumatic brain injuries, is at least 50% of its total annual resident days;(c) provide the following specialized rehabilitation services for its residents: 1. an individualized therapeutic skill development plan for each member;2. individual counseling;3. group counseling (therapeutic and life skills groups), with group sessions offered multiple times each week to ensure access based on member needs and preferences;4. sensory modulation and cognitive rehabilitation;5. neuropsychological testing, evaluation, and intervention;6. alcohol and substance use disorder counseling and prevention;7. all mental health services as indicated by each resident's Pre-admission Screening and Resident Review (PASRR) Level II evaluation, or coordinate with additional providers and practitioners, who may separately bill or be paid under the appropriate provider regulations, for services designated as specialized services under the PASRR program and therefore are services that are not included in standard nursing facility services;8. vocational programming; and9. community reintegration.(d) Maintain a program staff of specially trained professionals including, but not limited to, a neuropsychiatrist, a neuropsychologist, licensed mental health counselors, vocational specialists, life skills counselors, certified brain injury specialists, substance abuse counselors, and therapeutic technicians. All such staff must be trained in behavior modification and de-escalation techniques.(2)Per Diem Rate for Approved Admitted Members. For dates of service beginning October 1, 2023, qualifying nursing facilities may receive a flat member-based per diem rate of $486 for members with a mental or neurological disorder that severely affects the member's behavior who are admitted on or after August 1, 2020, provided that the qualifying nursing facility receives approval from MassHealth prior to the member's admission that the member requires specialized rehabilitative services described in 101 CMR 206.11(1) and is therefore eligible for this enhanced rate. The specialized rehabilitative services program is designed to transition the member back to community-based care or less-restrictive placement, and such rate applies only during the time that the member has been approved by MassHealth for the enhanced rate. Qualifying nursing facilities receiving this per diem rate are not eligible for any other per diem rates or payments established under 101 CMR 206.00 with respect to such approved members, except as provided in 101 CMR 206.11(3) or, if applicable, 101 CMR 206.10. Qualifying facilities may also admit members without seeking approval from the MassHealth agency. In such circumstances, qualifying nursing facilities will receive the standard nursing facility rate established under 101 CMR 206.00 with respect to those members.(3)High-cost Member Additional Rate. Qualifying nursing facilities may receive an additional member-based rate of $150 in addition to the per diem rate set by 101 CMR 206.11(2) for any member approved for admittance to the nursing facility for whom reasonable and allowable direct care costs associated with providing for such member's clinical care needs is more than 100% greater than the facility's average direct care costs per resident, provided that the facility (a) certifies that the direct care costs associated with providing services to such member meets the requirements of 101 CMR 206.11(3);(b) submits a summary of expected direct care costs associated with providing services to such member demonstrating that the requirements of 101 CMR 206.11(3) have been met; and(c) receives approval from the MassHealth agency for the additional rate, to be applied prospectively from the date of approval, with respect to such member. The MassHealth agency reserves the right to request additional documentation in support of the expected direct care costs prior to granting approval for this additional rate.
(4)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 Medicaid transitional add-on under 101 CMR 206.10(7), a homelessness rate add-on under 101 CMR 206.10(13), 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), or a complicated high-cost care need add-on under 101 CMR 206.15.Adopted by Mass Register Issue 1427, eff. 10/2/2020.Amended by Mass Register Issue 1429, eff. 10/5/2020.Amended by Mass Register Issue 1434, eff. 1/8/2021.Amended by Mass Register Issue 1437, eff. 2/2/2021.Amended by Mass Register Issue 1443, eff. 2/2/2021.Amended by Mass Register Issue 1454, eff. 10/1/2021.Amended by Mass Register Issue 1460, eff. 10/1/2021.Amended by Mass Register Issue 1465, eff. 3/18/2022.Amended by Mass Register Issue 1474, eff. 7/1/2022 (EMERGENCY).Amended by Mass Register Issue 1480, eff. 10/1/2022 (EMERGENCY).Amended by Mass Register Issue 1484, eff. 12/9/2022.Amended by Mass Register Issue 1498, eff. 5/31/2023 (EMERGENCY).Amended by Mass Register Issue 1503, eff. 5/31/2023 (EMERGENCY).Amended by Mass Register Issue 1505, eff. 9/29/2023.Amended by Mass Register Issue 1506, eff. 10/1/2023 (EMERGENCY).Amended by Mass Register Issue 1512, eff. 10/1/2023 (EMERGENCY).Amended by Mass Register Issue 1514, eff. 2/2/2024.Amended by Mass Register Issue 1532, eff. 10/1/2024 (EMERGENCY).