Current through Register 1518, March 29, 2024
(1)
Scope and Purpose.
101 CMR
322.00 governs the determination of rates of payment
to be used by all governmental units in making payment to eligible providers of
durable medical equipment and supplies provided to publicly aided individuals.
The rates set forth in
101 CMR
322.00 do not apply to individuals covered by the
Workers' Compensation Act, M.G.L. c. 152. Rates for services rendered to such
individuals are set forth in 114.3 CMR 40.06:
Fees.
(2)
Applicable Dates of Service. Rates contained in
101 CMR
322.00 apply for dates of service provided on or after
July 7, 2023, unless otherwise specified.
(3)
Coverage.
101 CMR
322.00 and the rates of payment contained herein apply
to the following categories:
(a) the purchase
or rental of durable medical equipment;
(b) the purchase of medical and surgical
supplies;
(c) the purchase or
rental of seating, positioning, mobility systems, and related
accessories;
(d) the purchase or
rental of prescribed oxygen delivery systems and respiratory therapy devices
and related supplies;
(e) the
purchase or rental of intravenous and enteral therapy, equipment, and related
supplies and services;
(f) the
repair or modification of the above listed types of equipment.
(4)
Exclusions.
101 CMR
322.00 and the rates of payment contained herein do
not apply to the following services:
(a)
respiratory therapy services rendered by a qualified respiratory
therapist;
(b) all services
included in the reimbursement to an institutional provider;
(c) all services for inpatients at a facility
licensed as an acute or chronic disease and rehabilitation hospital.
(5)
Disclaimer of
Authorization of Services.
101 CMR
322.00 is not authorization for nor approval of the
procedures for which rates are determined pursuant to
101 CMR
322.00. Governmental units that purchase care are
responsible for the definition, authorization, and approval of care to publicly
aided individuals.
(6)
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 the code numbers only
changed, with the corresponding crosswalk;
(b) codes for which the code numbers remain
the same but the description has changed;
(c) deleted codes for which there is no
crosswalk; and
(d) for entirely new
codes that require new pricing, EOHHS may list these codes and price them at a
percentage of the prevailing Medicare fees as described in
101
CMR 322.01(7)(d) and
101
CMR 322.03(16), when
Medicare fees are available. When Medicare fees are not available or when
otherwise designated by EOHHS as described in
101
CMR 322.03(16), EOHHS may
apply individual consideration, adjusted acquisition cost plus a standard
markup, or specify a fixed rate as described in
101
CMR 322.01(7)(e) in
reimbursing for these new codes until appropriate rates can be
developed.
(7)
Administrative Bulletins. EOHHS may issue
administrative bulletins to:
(a) clarify its
policy on substantive provisions of
101 CMR
322.00;
(b) specify any durable medical equipment or
medical supplies subject to a preferred supplier contract or contracts between
a supplier and a governmental unit or units, the governmental unit(s) and
eligible providers subject to the contract; the duration of the preferred
supplier contract, the prices at which such durable medical equipment or
medical supplies will be available to eligible providers (as defined by the
preferred supplier contract), the rates which eligible providers (as defined by
the preferred supplier contract) will be paid by the relevant governmental
unit(s) for such durable medical equipment or medical supplies, and any other
information deemed necessary by EOHHS;
(c) specify any durable medical equipment or
medical supplies subject to a rebate agreement or agreements between a
manufacturer and a governmental unit or units, the governmental unit(s) and
eligible providers subject to the agreement, the duration of the rebate
agreement, the rates which will be paid to eligible providers (as defined by
the applicable rebate agreement) by the relevant governmental unit(s) for the
specified durable medical equipment or medical supplies, and any other
information deemed necessary by EOHHS;
(d) specify upward adjustments to the
standard markup defined at
101
CMR 322.02 for codes when a governmental unit
determines that the standard markup requires adjustment to account for
increased provider costs and/or a shift in utilization patterns or to maintain
access to care;
(e) specify a fixed
rate for codes which do not have a Medicare rate or would otherwise be priced
at Individual Consideration based on an adjusted acquisition cost when a fixed
rate can be determined by using a comparison of industry rates including
Medicare crossover payments, other state Medicaid payment rates and Medicaid
third-party liability/private insurance rates;
(f) specify upward adjustments to historical
fixed rates which do not have a Medicare rate for codes when a governmental
unit determines that the historical fixed rate requires adjustment to account
for increased provider costs and/or a shift in utilization patterns or to
maintain access to care; and
(g)
specify any durable medical equipment or medical supplies subject to the
pricing methodology described at
101
CMR 322.03(20).
