101 CMR, § 359.03

Current through Register 1538, January 3, 2025

Section 359.03 - Rate Provisions

(1)Services Included in the Rate. The approved rate will include payment for all care and services that are part of the program of services of a Provider, as explicitly set forth in the terms of the purchase agreement between the Provider and the purchasing governmental unit(s).

(2)Reimbursement as Full Payment. Each Provider must, as a condition of acceptance of payment made by any purchasing governmental units for services rendered, accept the approved program rate as full payment and discharge of all obligations for the services rendered. Payment for services included in the scope of 101 CMR 359.00 from any other source must be used to offset the amount of the purchasing governmental unit's obligation for services rendered to the participant.

(3)Payment Limitations.

(a) No purchasing governmental unit may pay less than or more than the approved program rate, except that a participant contribution may be applied towards the Residential Habilitation room and board payment in accordance with policies and procedures established by the purchasing governmental unit.

(b) Where more than one payment rate is available for a covered service, the service is covered at the lowest available payment rate, unless a higher rate is approved by the purchasing governmental unit, except as provided in 101 CMR 359.03(3)(c).

(c) Notwithstanding the requirement of 101 CMR 359.03(3)(b), payment rates for certain HCBS waiver services will be determined as follows:

1.Residential Habilitation rates will be determined in the following manner:

a.Service Model Rate. The purchasing Governmental Unit will designate the applicable rate from among the basic lower intensity, basic, or Intermediate categories, or at medical/clinical level 1, medical/clinical level 2, or medical/clinical level 3 as outlined and defined in 101 CMR 420.00: Rates for Adult Long-term Residential Services.

b.Room and Board. The purchasing Governmental Unit will designate the applicable rate for room and board from among the site rates outlined in 101 CMR 420.00: Rates for Adult Long-term Residential Services.

2.Orientation and Mobility. Orientation and Mobility rates will be determined: based on one-way distance traveled to initiate the service in the following manner:

a. Level I: one to 30 miles;

b. Level II: 31 to 60 miles; and

c. Level III: over 60 miles.

3.Shared Home Supports. The purchasing Governmental Unit will designate the applicable stipend rate at level 1, 2 or 3, as outlined and defined in 101 CMR 411.00: Rates for Certain Placement, Support, and Shared Living Services.

4.Shared Living - 24 Hour Supports. Shared Living - 24-hour support rates will be determined in the following manner

a.Operational Rate: The purchasing Governmental Unit will designate the applicable rate from among the available operational rate levels as outlined and defined in 101 CMR 411.00: Rates for Certain Placement, Support, and Shared Living Services.

b.Stipend Rate: The purchasing Governmental Unit will designate the applicable rate from among the available Stipend Levels, corresponding to the designated operational rate Level as outlined and defined in 101 CMR 411.00: Rates for Certain Placement, Support, and Shared Living Services.

(4)Approved Rates. The approved rate will be the lowest of the provider's charge or amount accepted as payment from another payer or the rate listed in 101 CMR 359.03(4).

Service	HCBS Waiver	Units	Agency Rate	Non-agency Rate
Service	HCBS Waiver	Units	Agency Rate	Individual Provider (Self-employed Provider)	Self-directed Service
Adult Companion	ABI-N, MFP-CL	Per 15 Min.	$6.50	89.75% of Agency Rate	89.75% of Agency Rate
Assisted Living	ABI-RH, MFP-RS	Per Diem	$112.02	N/A	N/A
Assistive Technology - devices	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per Device	I.C.	N/A	N/A
Assistive Technology - evaluation and training	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per 15 Min.	See 101 CMR 423.00 Rates for Certain In-Home Basic Living Supports
Chore	ABI-N, MFP-CL	Per 15 Min.	$10.13	89.75% of Agency Rate	89.75% of Agency Rate
Community-based Day Supports	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per 15 Min.	See101 CMR 415.00: Rates for Community based Day Support Services; Levels A, B, C, & I	N/A	N/A
Community Support and Navigation	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per 15 Min.	See101 CMR 444.00: Rates for Certain Substance Use Disorder Services: Recovery Support Navigator Service	N/A	N/A
Community Family Training	ABI-N, MFP-CL	Per 15 Min.	See101 CMR 414.00: Rates for Family Stabilization Services (Family Training rate divided by 4 to determine rate per 15-minute increments)	89.75% of Agency Rate	N/A
Day Services	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per Diem,	Per Diem: $115.72	N/A	N/A
Day Services - partial per diem	ABI-N, ABI-RH, MFP-CL, MFP-RS	Partial Per Diem	Partial Per Diem: $57.86	N/A	N/A
Home Accessibility Adaptations	ABI-N, ABI-RH MFP-CL, MFP-RS	Item	I.C.	N/A	N/A
Home Delivered Meals	ABI-N, MFP-CL	Meal	$10	N/A	N/A
Home Health Aide	ABI-N, MFP-CL	Per 15 Min.	See101 CMR 350.00: Home Health Services	N/A	N/A
Homemaker	ABI-N, MFP-CL	Per 15 Min.	$8.22	89.75% of Agency Rate	89.75% of Agency Rate
Independent Living Supports	ABI-N, MFP-CL	Per Diem	$88.02	N/A	N/A
Individual Support and Community Habilitation	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per 15 Min.	See101 CMR 423.00: Rates for Certain Inhome Basic Living Sup-ports; Levels G-H & I	89.69% of Agency Rate	89.69% of Agency Rate
Laundry	ABI-N, MFP-CL	Per Order	$30.17	N/A	N/A
Occupational Therapy	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per Visit	See101 CMR 350.00: Home Health Services	See101 CMR 339.00: Restorative Services (out-of-office visit rate)	N/A
Orientation and Mobility Services	MFP-CL, MFP-RS	Per 15 Min	Level I: $33.58 Level II: $37.12 Level III: $40.66	Level I: $33.58 Level II: $37.12 Level III: $40.66	N/A
Peer Support	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per 15 Min.	See101 CMR 414.00: Rates for Family Stabilization Services (rate divided by 4 to determine rate per 15-minute increments)	89.75% of Agency Rate	89.75% of Agency Rate
Personal Care	ABI-N, MFP-CL	Per 15 Min.	$8.22	See101 CMR 309.00: Rates for Certain Services for the Personal Care Attendant Program	See101 CMR 309.00: Rates for Certain Services for the Personal Care Attendant Program
Physical Therapy	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per Visit	See101 CMR 350.00: Home Health Services	See101 CMR 339.00: Restorative Services (out-of-office visit rate)	N/A
Prevocational Services	ABI-N, ABI-RH, MFP-CL, MFP- RS	Per 15 Min.	See101 CMR 419.00: Rates for Supported Employment Services (rate for Individual Supported Employment)	N/A	N/A
Residential Family Training	ABI-RH, MFP-RS	Per 15 Min.	See101 CMR 414.00: Rates for Family Stabilization Services (Family Training rate divided by 4 to determine rate per 15-minute increments)	89.75% of Agency Rate	N/A
Residential Habilitation Room and Board	ABI-RH, MFP-RS	Per Diem	See101 CMR 420.00: Rates for Adult Long-term Residential Services (Site Rates)	N/A	N/A
Residential Habilitation Services	ABI-RH, MFP-RS	Per Diem	See101 CMR 420.00: Rates for Adult Long-term Residential Services (Basic Lower Intensity, Basic, or Intermediate categories, Medical/Clinical Level 1, Medical/Clinical Level 2, or Medical/Clinical Level 3	N/A	N/A
Respite	ABI-N, MFP-CL	Per Diem	I.C.	N/A	N/A
Shared Home Supports	ABI-N, MFP-CL	Per Diem	See101 CMR 411.00:Rates for Certain Placement, Support, and Shared Living Services (Operational Rate Level A, Stipend Levels 1, 2, or 3)	N/A	N/A
Shared Living - 24 Hour Supports	ABI-RH, MFP-RS	Per Diem	See101 CMR 411.00: Rates for Certain Placement, Support, and Shared Living Services	N/A	N/A
Skilled Nursing - LPN	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per Visit	See101 CMR 350.00: Home Health Services (Rates for Skilled Nursing Services)	N/A	N/A
Skilled Nursing - RN	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per Visit	See101 CMR 350.00: Home Health Services (Rates for Skilled Nursing Services)	N/A	N/A
Specialized Medical Equipment	ABI-N, ABI-RH, MFP-CL, MFP-RS	Item	See101 CMR 322.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment	See101 CMR 322.00: Durable Medical Equipment, Oxygen and Respiratory Therapy Equipment	N/A
Speech Therapy	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per Visit	See101 CMR 350.00: Home Health Services	See101 CMR 339.00: Restorative Services (out-of-office visit rate)	N/A
Supported Employment	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per 15 Min.	See101 CMR 419.00: Rates for Supported Employment Services (rate for Individual Supported Employment)	N/A	N/A
Supportive Home Care Aide	ABI-N, MFP-CL	Per 15 Min.	See101 CMR 350.00: Home Health Services (13.12% above the rate for Home Health Aide)	N/A	N/A
Transitional Assistance	ABI-N, ABI-RH, MFP-CL, MFP-RS	Per Episode	I.C.	N/A	N/A
Transportation	ABI-N, ABI-RH, MFP-CL, MFP-RS	One-way Trip	See101 CMR 327.00: Rates of Payment for Ambulance and Wheelchair Van Services	N/A	N/A
Vehicle Modification	ABI-N, MFP-CL	Item	I.C.	N/A	N/A

(5)Self-directed Service Rates.

(a)Employer Expense Component. The rates for Self-directed Services consists of two components: the Self-directed Worker rate and the Employer Expense Component (EEC).

Service	Unit	Self-directed Worker Rate	Employer Expense Component	Self-directed Service Rate
Adult Companion	Per 15 Min.	$5.23	$0.60	$5.83
Chore	Per 15 Min.	$8.16	$0.93	$9.09
Homemaker	Per 15 Min.	$6.63	$0.75	$7.38
Individual Supports and Community Habilitation: Level G	Per 15 Min.	$9.32	$1.06	$10.38
Individual Supports and Community Habilitation: Level H	Per 15 Min.	$10.04	$1.14	$11.18
Individual Supports and Community Habilitation: Level I	Per 15 Min.	$12.27	$1.40	$13.67
Peer Support	Per 15 Min.	$6.32	$0.72	$7.04
Personal Care	Per 15 Min.	See101 CMR 309.00: Rates for Certain Services for the Personal Care Attendant Program (rate divided by four to determine rate per 15-minute increments)

(b)Overtime Calculation. Overtime payments for self-directed services will be made in accordance with the federal Fair Labor Standards Act. Such payments will be made to self-directed workers at rate of one and a half times that of the rate for the service or services provided. For self-directed workers that provide services paid at different rates, such overtime rate will consist of the blended weighted rate based on the number of hours for which each service was provided during a single work week. For the purposes of 101 CMR 359.03(5)(b), the term overtime will mean self-directed services provided to one or more participants in excess of 40 hours per work week, where work week consists of a seven-day period beginning Sunday at 12:00 A.M. and ending the consecutive Saturday at 11:59 P.M.

(6)Approved Modifiers. Below are the approved modifiers for all four HCBS Waiver programs:

(a)Modifier Classification. Below are the classification descriptions for modifiers associated with both the ABI and MFP Waivers.

Modifier	Description
U1	Agency Provider
U2	Individual/Self-employed Provider
U4	ABI Nonresidential Habitation (ABI-N) Waiver
U5	ABI Residential Habitation (ABI-RH) Waiver
U8	MFP Community Living (MFP-CL) Waiver
U9	MFP Residential Supports (MFP-RS) Waiver
UB	Self-directed Service

(b)Service Codes and Modifiers by Service. The list of approved service codes and modifiers for all four ABI and MFP Waivers are as follows.

Service	Agency			Individual Provider (Self-employed Provider)			Self-directed Service
Code	1^st Position Modifier	2^nd Position Modifier	Code	1^st Position Modifier	2^nd Position Modifier	Code	1^st Position Modifier	2^nd Position Modifier
Adult Companion	-	-	-	S5125	U4	-	S5125	U4	UB
	-	-	-	S5125	U8	-	S5125	U8	UB
	S5135	U4	-	-	-	-	-	-	-
	S5135	U8	-	-	-	-	-	-	-
Assisted Living	T2031	U5	-	-	-	-	-	-	-
Assisted Living	T2031	U9	-	-	-	-	-	-	-
Assistive Technology -devices	T2029	U4	-	-	-	-	-	-
	T2029	U5	-	-	-	-	-	-
	T2029	U8	-	-	-	-	-	-
	T2029	U9	-	-	-	-	-	-
Assistive Technology -evaluation and training	97755	U4
	97755	U5
	97755	U8
	97755	U9
Chore Services	S5120	U4	U1	S5120	U4	U2	S5120	U4	UB
Chore Services	S5120	U8	U1	S5120	U8	U2	S5120	U8	UB
Community-based Day Supports	S5100	U4	-	-	-	-	-	-
	S5100	U4	U1	-	-	-	-	-
	S5100	U4	U2
	S5100	U4	U3
	S5100	U5	-	-	-	-	-	-	-
	S5100	U5	U1	-	-	-	-	-	-
	S5100	U5	U2	-	-	-	-	-	-
	S5100	U5	U3	-	-	-	-	-	-
	S5100	U8	-	-	-	-	-	-	-
	S5100	U8	U1	-	-	-	-	-	-
	S5100	U8	U2	-	-	-	-	-	-
	S5100	U8	U3	-	-	-	-	-	-
	S5100	U9	-	-	-	-	-	-	-
	S5100	U9	U1	-	-	-	-	-	-
	S5100	U9	U2	-	-	-	-	-	-
	S5100	U9	U3	-	-	-	-	-	-
Community Support and Navigation	H2015	U4	-	-	-	-	-	-	-
	H2015	U5	-	-	-	-	-	-	-
	H2015	U8	-	-	-	-	-	-	-
	H2015	U9	-	-	-	-	-	-	-
Community Family Training	S5110	U4	U1	S5110	U4	U2
Community Family Training	S5110	U8	U1	S5110	U8	U2	-	-	-
Day Services	S5102	U4	-	-	-	-	-	-
	S5102	U5	-	-	-	-	-	-	-
	S5102	U8	-	-	-	-	-	-	-
	S5102	U9	-	-	-	-	-	-	-
Day Services -partial per diem	S5102	U4
	S5102	U5
	S5102	U8	-
	S5102	U9	-
Home Accessibility Adaptations	S5165	U4	-	-	-	-	-
	S5165	U5	-	-	-	-	-
	S5165	U8	-	S5165	U8
	S5165	U9	-	S5165	U9	-	-	-	-
Home Delivered Meals	S5170	U4	-	-	-	-	-	-	-
Home Delivered Meals	S5170	U8
Homemaker	S5130	U4	U1	S5130	U4	U2	S5130	U4	UB
Homemaker	S5130	U8	U1	S5130	U8	U2	S5130	U8	UB
Home Health Aide	G0156	U4
Home Health Aide	G0156	U8	-	-	-	-	-	-	-
Independent Living Supports	H0043	U4
Independent Living Supports	H0043	U8	-	-	-	-	-	-	-
Individual Support and Community Habilitation (Individual Provider/Self-directed Worker)	-	-	-	H2014	U4	U1, U2, U3	H2014	U4	U1, UB U2, UB U3, UB
	-	-	-	H2014	U8	U1, U2, U3	H2014	U8	U1, UB U2, UB U3, UB
	H2014	U9	U1, U2, U3	H2014	U9	-
Individual Support and Community Habilitation (Agency)	S5108	U4	U1, U2, U3	-	-	-	-	-	-
	S5108	U8	U1, U2, U3	-	-	-	-	-	-
	S5108	U9	U1, U2, U3	-	-	-	-	-	-
Laundry	S5175	U4	-	-	-	-	-	-	-
Laundry	S5175	U8	-
Occupational Therapy	S9129	U4	U1	S9129	U4	U2	-	-	-
	S9129	U5	U1	S9129	U5	U2	-	-	-
	S9129	U8	U1	S9129	U8	U2	-	-	-
	S9129	U9	U1	S9129	U9	U2	-	-	-
Orientation and Mobility Services	H2021	U4	U1, U2, U3	H2021	U4	U1, U2, U3
	H2021	U5	U1, U2, U3	H2021	U5	U1, U2, U3
	H2021	U8	U1, U2, U3	H2021	U8	U1, U2, U3	-	-	-
	H2021	U9	U1, U2, U3	H2021	U9	U1, U2, U3	-	-	-
Peer Support	H0038	U4	U1	H0038	U4	U2	H0038	U4	UB
	H0038	U5	U1	H0038	U5	U2	H0038	U5	UB
	H0038	U8	U1	H0038	U8	U2	H0038	U8	UB
	H0038	U9	U1	H0038	U9	U2	H0038	U9	UB
Personal Care	T1019	U4	-	-	-	-	-	-	-
Personal Care	T1019	U8	U1	T1019	U8	U2	T1019	U8	UB
Physical Therapy	S9131	U4	U1	S9131	U4	U2	-	-	-
	S9131	U5	U1	S9131	U5	U2	-	-	-
	S9131	U8	U1	S9131	U8	U2	-	-	-
	S9131	U9	U1	S9131	U9	U2	-	-	-
Prevocational Services	T2019	U4
	T2019	U5	-	-	-	-	-	-	-
	T2019	U8	-	-	-	-	-	-	-
	T2019	U9	-	-	-	-	-	-	-
Residential Family Training	S5110	U5	U1	S5110	U5	U2
Residential Family Training	S5110	U9	U1	S5110	U9	U2	-	-	-
Residential Habilitation	T2016	U5	-	-	-	-	-	-	-
Residential Habilitation	T2016	U9	-	-	-	-	-	-	-
Respite	H0045	U4	-	-	-	-	-	-	-
Respite	H0045	U8	-	-	-	-	-	-	-
Shared Home Supports	H2016	U4	U1
	H2016	U4	U2
	H2016	U4	U3
	H2016	U8	U1-	-	-	-	-	-	-
	H2016	U8	U2	-	-	-	-	-	-
	H2016	U8	U3	-	-	-	-	-	-
Shared Living -24-hour Supports	T2033	U5	-	-	-	-	-	-	-
Shared Living -24-hour Supports	T2033	U9	-	-	-	-	-	-	-
Skilled Nursing - RN	G0299	U4
	G0299	U5
	G0299	U8	-	-	-	-	-	-	-
	G0299	U9	-	-	-	-	-	-	-
Skilled Nursing - LPN	G0300	U4
	G0300	U5
	G0300	U8	-	-	-	-	-	-	-
	G0300	U9	-	-	-	-	-	-	-
Specialized Medical Equipment	T2029	U4	-	T2029	U4	-	-	-	-
	T2029	U5	-	T2029	U4	-	-	-	-
	T2029	U8	-	-	-	-	-	-	-
	T2029	U9	-	-	-	-	-	-	-
Speech Therapy	S9128	U4	U1	S9128	U4	U2	-	-	-
	S9128	U5	U1	S9128	U5	U2	-	-	-
	S9128	U8	U1	S9128	U8	U2	-	-	-
	S9128	U9	U1	S9128	U9	U2	-	-	-
Supported Employment	H2023	U4	-	-	-	-	-	-	-
	H2023	U5	-	-	-	-	-	-	-
	H2023	U8	-	-	-	-	-	-	-
	H2023	U9	-	-	-	-	-	-	-
Supportive Home Care Aide	T1004	U4
Supportive Home Care Aide	T1004	U8	-	-	-	-	-	-	-
Transportation	T2003	U4	-	-	-	-	-	-	-
	T2003	U5	-	-	-	-	-	-	-
	T2003	U8	-	-	-	-	-	-	-
	T2003	U9	-	-	-	-	-	-	-
Transitional Assistance	T2038	U4	-	-	-	-	-	-	-
	T2038	U5	-	-	-	-	-	-	-
	T2038	U8	-	-	-	-	-	-	-
	T2038	U9	-	-	-	-	-	-	-
Vehicle Modification	T2039	U4
Vehicle Modification	T2039	U8	-	-	-	-	-	-	-