Code of Massachusetts Regulations
101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES
Title 101 CMR 204.00 - Rates of Payment to Resident Care Facilities
Section 204.03 - General Rate Provisions
Universal Citation: 101 MA Code of Regs 101.204
Current through Register 1518, March 29, 2024
(1) General. EOHHS will determine a payment rate for dates of service on or after January 1, 2024, for each facility as follows.
(a)
Preliminary
Rate. The facility's preliminary rate is equal to the sum of
1. allowable variable costs determined under
101
CMR 204.04; and
2. allowable capital and other fixed costs as
determined under
101
CMR 204.05.
(b)
Rate
Adjustments. The preliminary rate as calculated in 101 CMR
204.03(1)(a) will be adjusted as follows.
1.
DTA Days Percentage Adjustment.
a. For each facility, calculate its DTA days
percentage by dividing its DTA days by the facility's total resident days, as
reported on Schedule 3 of the 2021 HCF-4.
b. Each facility will receive a DTA days
percentage adjustment equal to $30.31 multiplied by the percentage calculated
in 101 CMR 204.03(1)(b)1.a.
2.
GAFC Adjustment.
For each eligible facility, apply the GAFC adjustment in the same amount as
applied to the rate in effect on December 31, 2023.
(c)
Payment Rate.
Subject to the Payment Rate Maximum Increase as described in 101 CMR
204.03(1)(d) and the Resident Care Cost Quotient as described in 101 CMR
204.03(1)(e), the facility's January 1, 2024, payment rate is equal to the
greater of
1. the sum of the preliminary rate
as determined in 101 CMR 204.03(1)(a) and the payment rate adjustments as
determined in 101 CMR 204.03(1)(b), plus $8.00;
2. the facility's certified rate in effect on
December 31, 2023; or
3.
$105.
(d)
Payment Rate Maximum Increase. If the facility's
payment rate as calculated in 101 CMR 204.03(1)(c) is greater than the
facility's certified rate in effect on December 31, 2023, plus $70, the
facility will receive a downward adjustment such that the total payment rate
effective January 1, 2024, is equal to the facility's certified rate in effect
on December 31, 2023, plus $70.
(e)
Resident Care Cost Quotient (RCC-Q). If the facility's
RCC-Q score is less than the RCC-Q threshold established pursuant to
101
CMR 204.10(1), the facility
will receive a downward adjustment as described in
101
CMR 204.10.
(f)
Annualization
Adjustment. For the period from January 1, 2024, through January
31, 2024, EOHHS will apply an annualization adjustment of596.77% of the
difference between the facility's January 1, 2024, rate as determined in 101
CMR 204.03(1)(c), (d), and (e) and its certified rate in effect on December
31,2023, which accounts for the period July 1,2023, through December 31,
2023.
(2) Other Provisions.
(a)
Audits. EOHHS will establish rates after a
comprehensive desk audit of the base year cost report. The Center may also,
whenever possible, conduct on-site field audits to ensure the accuracy of the
claims for reimbursement and consistency in reporting. EOHHS will disallow any
cost for which the provider does not produce adequate documentation requested
by the Center during a desk or field audit.
(b)
General Cost
Principles. In order to be reimbursed, a cost must
1. be ordinary, necessary, and directly
related to the care of publicly aided residents;
2. be consistent with the prudent buyer
concept;
3. be for goods and
services actually provided in the resident care facility;
4. not have the transaction effect of
circumventing 101 CMR 204.00 under the principle that the substance of the
transaction must prevail over form;
5. actually be paid by the provider. Examples
of costs that are not considered paid for purposes of reimbursement include,
but are not limited to, costs that are discharged in bankruptcy; forgiven;
converted to a promissory note; and accruals of self-insured costs based on
actuarial estimates; and
6. not be
paid to a related party that has not been identified on the reports.
(c)
Non-allowable
Costs. Rates will not include those costs that are not
reimbursable, as defined below, are reimbursed through an allowance, or are for
services that are billed directly.
1. Costs
that are not reimbursable include
a. bad
debts, refunds, charity and courtesy allowances, and contractual adjustments to
the Commonwealth and other third parties;
b. recovery of expense items, that is,
expenses that are reduced or eliminated by applicable income including, but not
limited to, rental of quarters to employees and others, income from meals sold
to persons other than residents, telephone income, vending machine income, and
medical records income. Vending machine income will be recovered against the
variable cost, included in the variable cost allowance;
c. federal and state income taxes, except the
non-income related portion of the Massachusetts corporate excise tax;
d. expenses that are not directly related to
the provision of resident care including, but not limited to, expenses related
to other business activities and fundraising, gift shop expenses, research
expenses, rental expense for space not required by the Department and
expenditure of funds received under federal grants for compensation paid for
training personnel, and expenses related to grants or contracts for special
projects;
e. compensation and
fringe benefits for residents on a provider's payroll;
f. any amounts in excess of any schedule or
limitation contained in 101 CMR 204.00;
g. penalties and interest incurred because of
late payment of loans or other indebtedness, late filing of federal and state
tax returns, or from late payment of municipal taxes;
h. any increase in compensation or fringe
benefits granted as an unfair labor practice after a final adjudication by the
court of last resort;
i. accrued
expenses that remain unpaid more than 120 days after the close of the reporting
year, excluding vacation and sick time accruals, are not included in the
prospective rates. When the Center receives satisfactory evidence of payment,
EOHHS may reverse the adjustment and include that cost, if otherwise allowable,
in the applicable prospective rates. Except as provided above, a cost must
actually be paid by the provider in order to be reimbursable. Examples of costs
that are not considered paid for purposes of reimbursement include, but are not
limited to, costs that are discharged in bankruptcy; costs that are forgiven;
costs that are converted to a promissory note; and accruals of self-insured
costs that are based on actuarial estimates;
j. expenses for purchased service nursing
services purchased from temporary nursing agencies that are not registered with
the Department under 105 CMR 157.000: The Registration and Operation of
Temporary Nursing Service Agencies;
k. any expense or amortization of a
capitalized cost relating to costs incurred prior to the opening of the
facility;
l. expenses relating to
the financing of or otherwise supporting political or lobbying activities
regarding legislation to affect reimbursement methods; campaign contributions;
and advertising to create goodwill or otherwise affect payments made by
governmental units;
m. all legal
expenses; and those accounting expenses and filing fees associated with any
appeal process;
n. additional
rental payments or charges based upon receipts or income will not be considered
as additional rental expense;
o.
interest payments and charges based upon the provider's receipts or income will
not be considered as allowable interest expense;
p. any costs that were incurred in periods
other than the base year;
q. an
adjustment to base year costs to reflect the difference between the rates
charged to private residents in the base year if those rates are less than the
public rates certified in the base year. EOHHS will multiply the difference
between the base year rate for publicly aided residents and the average rate
charged private residents corresponding to the base year above. The adjustment
is calculated as follows: [(private income/resident private patient days) -
public base year rate per diem] x (base year resident private
patient days/base year patient days) = the per diem amount by
which the publicly aided rate will be reduced. In no instances will the
certified rate be lower than the lowest private rate assigned to an individual
for that period;
r. any costs,
including rental and leasehold expenses, for buildings and equipment that are
not located at the site of the resident care facility will not be allowable as
fixed costs; and
s. costs of
ancillary services that are required to be billed on a direct basis to the
purchasing government agency.
2.
Other Recoverable
Income. Costs reimbursed through an allowance or other specified
methodology include other recoverable income. Other recoverable income will be
recovered against an account in the appropriate cost group category, such as
variable cost allowance and fixed costs.
3.
Costs for Services Billed
Directly. The following supplies or services must be billed
directly to the purchaser in accordance with the purchaser's regulations or
policies.
a.
Physician. Direct physician services to individual
residents, including emergency physician services required by 105 CMR 150.000:
Standards for Long-term Care Facilities.
b.
Medical Supplies.
Direct medical services or supplies in accordance with the regulations or
written policy of the governmental unit responsible for paying for such
services or supplies in the per diem rates.
c.
Prescriptions.
Pharmacy costs related to legend drug prescriptions and prescribed legend drugs
for individual residents.
d.
Therapy. Direct restorative services provided upon
written order of a physician.
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