Code of Massachusetts Regulations
101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES
Title 101 CMR 423.00 - Rates For Certain In-Home Basic Living Supports
Section 423.03 - Rate Provisions

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

(2) Reimbursement as Full Payment. Each eligible 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 from any other source will be used to offset the amount of the purchasing governmental unit's obligation for services rendered to the publicly assisted client.

(3) Payment Limitations. Except as provided in 101 CMR 423.03(2) and (4), each purchasing governmental unit pays for services at the rates established in 101 CMR 423.03(5).

(4) Administrative Adjustment for Extraordinary Circumstances. A provider may petition the purchasing governmental unit for an administrative adjustment to reflect increases in operating costs due to unusual and unforeseen circumstances or extraordinary client service requirements not considered in the development of the current rates. Unusual and unforeseen circumstances are events of catastrophic nature (e.g., fire, flood, or earthquake) that are not covered by insurance that the prudent provider would carry. The provider must demonstrate that such cost increases gravely threaten the stability of service provision such that client or consumer access to necessary services is at risk. The purchasing governmental unit will evaluate the need for the administrative adjustment, determine whether funding is available, and convey that information to EOHHS for review to determine the amount of any adjustment.

(5) Approved Rates. The rate for a particular service is based on the level (A - K) assigned by the purchasing agency, and is based on the intensity of identified needs and characteristics of the client receiving the service. The approved rate is the lower of the provider's charge or amount accepted as payment from another payer or the rate listed in 101 CMR 423.03(5).