Current through Register 1531, September 27, 2024
(1)
Scope.
104
CMR 30.04 applies to services for which the
Department has an approved rate and that are provided by Department operated or
contracted for facilities or programs. This includes the provision of room and
board in a facility. Charges for room or board other than for that provided in
a facility are governed by
104
CMR 30.06.
(2)
Purpose. To
maximize revenue for costs of services provided by Department operated or
contracted for facilities and programs from federal and state benefits and
private health insurance reimbursements as required by M.G.L. c. 6A, § 16,
the Department must charge patients, clients or fee payers for the services it
provides, contracts for, or otherwise funds. The purpose of
104
CMR 30.04 is to establish how the Department
will charge for the services for which it has approved rates and to allow for
such charges to be adjusted on an individualized basis based on the ability to
pay of the patient, client, or fee payer as determined in accordance with
104
CMR 30.04(6).
(3)
Definitions. In
addition to the terms defined in
104
CMR 25.02: Definitions, the
following terms shall have the meanings set forth in
104
CMR 30.04(4) throughout
104
CMR 30.04, unless the content clearly
provides otherwise.
Approved Rate. The charge for a
service which is established by the Department in accordance with applicable
law.
Fee Payer. Any of the following
persons, each of whom may be liable for charges for services:
(a) the spouse of a patient or client, unless
such spouse is separated, then only to the extent provided by a judicial order
or a judicially approved separation agreement;
(b) the parent(s) of a minor child who is not
an emancipated minor or a mature minor; or
(c) the legally authorized representative or
other person who controls assets of a patient or client, or the patient's or
client's spouse or parent(s); provided however, that the legally authorized
representative or other person shall be responsible only to the extent he or
she has control of a patient's or client's assets, or the assets of the
patient's or client's spouse or parent(s), and only to the extent of such
assets.
Income. Any monies received by or on
behalf of a client, including earned income, recurrent payments, payments in
kind or lump sum payment. Income shall not include the following:
(a) Financial aid provided to full or part
time students. This includes scholarships and stipends for housing or earnings
from work-study programs that are included in a student's financial aid
package;
(b) Payments made to and
held by a client from the Supplemental Nutrition Assistance Program;
or
(c) Income that is directly
deposited into a Plan to Achieve Self-support (PASS) approved by the Social
Security Administration.
Liquid Assets. Cash and all property
capable of ready conversion into cash, such as stocks and bonds, regardless of
whether such assets are held jointly or solely. Liquid assets do not include
life insurance or its cash value, or assets subject to an irrevocable trust
with the patient or client as named beneficiary, unless those assets are
available to the patient or client or fee payer on demand.
Patient or Client. A person who
receives services from a Department operated or contracted for facility or
program.
Third-party Payer. An insurer,
entitlement agency, or similar entity, which is obligated to pay for services
provided to a patient or client.
(4)
Charges for
Services.
(a) The Department
shall charge a patient, client or fee payer for the services provided to the
patient or client by a facility or program operated or contracted for by the
Department if the Department has an approved rate for the services.
(b) The charge shall be at the approved
rate.
(c) A client is responsible
for a charge unless the charge is covered by a third-party payer.
(d) The Department shall adjust a charge
based on a client's ability to pay in accordance with
104
CMR
30.04(6).
(5)
Notification of Charges for
Services. The Department shall give patients, clients and their
fee payers, if known, notice that they will be charged for any services
provided by a Department operated or contracted for facility or program for
which the Department has an approved rate. Notice shall also be given to the
patients' or clients' legally authorized representative if applicable.
(a) Such notice will be given:
1. at the time a patient or client, or his or
her legally authorized representative, requests services;
2. upon admission to a facility operated or
contracted for by the Department;
3. upon referral to any program operated or
contracted for by the Department that provides a service for which the
Department has an approved rate if not previously given;
4. at any time the approved rate for an
applicable service changes;
5.
annually thereafter as part of the patient's periodic review pursuant to
104
CMR 27.11: Periodic Review;
or the review of the client's individual service plan pursuant to
104
CMR 29.09: Annual Review of the
Individual Service Plan; or if the client does not have an individual
service plan, upon the annual review of the client's Community Service Plan
pursuant to
104
CMR 29.13: Review of the Community
Service Plan;
6. upon
request; and
7. at any other time
deemed appropriate by the Department.
(b) The notice shall be on a form approved by
the Department and shall provide the following information, at a minimum:
1. the approved rate for all of the
applicable services for which the Department has an approved rate;
2. the right of the patient, client, his or
her legally authorized representative or fee payer to request a reduction to a
charge billed by the Department based on the patient's or client's financial
circumstances and the fee payer's financial circumstances if the fee payer is
either the spouse or parent(s) of the patient or client;
3. the name and telephone number of the
Department office or employee available for further information; and
4. the right of the patient, client, their
legally authorized representative, or fee payer to appeal a charge as
established in
104
CMR
30.04(8).
(c) The Department shall offer to the
patient, client, their legally authorized representative, or fee payer, the
opportunity to have the notice explained to him or her by an appropriate
representative.
(6)
Billing a Patient, Client or Fee Payer.
(a)
Determining Ability to
Pay. In accordance with M.G.L. c. 123, § 32 and Department
policies, the Department shall determine the ability of a patient, client or
fee payer to pay the assessed charges. Based on the determination, the
Department may reduce the amount to be collected for the assessed charges from
the patient, client or fee payer. At a minimum, the Department policies must
satisfy the following requirements:
1. In
determining the ability to pay of a patient, client or fee payer, the
Department will consider the patient's or client's income and liquid assets and
those of a spouse or parent(s) if they are fee payers. If the spouse is
separated from the patient or client, then the spouse's income and liquid
assets will only be considered to the extent provided by a judicial order or a
judicially approved separation agreement.
2. In calculating a patient's or client's
income and liquid assets, or if applicable, the income and liquid assets of a
spouse or parent(s), for the purpose of determining ability to pay, a certain
amount of such income or liquid assets will be exempted to allow for the
individual's support; the support of the individual's dependent(s) and, if
applicable, spouse, and to permit the individual to maintain a residence in the
community.
3. A reduction will not
be permitted if the patient, client or fee payer requests that the Department
not bill the charge to a third-party payer or otherwise precludes the third
party payer from paying the Department.
4. A reduction will not be permitted if the
patient, client or fee payer does not provide the Department with the
information needed to determine his or her ability to pay as specified by the
Department's written policies regarding ability to pay.
(b)
Review of Ability to
Pay. The Department shall review the ability to pay of a patient
or client, or if applicable, the patient's or client's spouse or parent(s), as
follows:
1. when the patient or client first
receives a service for which the Department has an approved rate;
2. annually;
3. on request of the patient or client, or
his or her legally authorized representative;
4. on the request of the fee payer;
and
5. whenever the Department has
reason to believe that the ability to pay of the patient or client, or if
applicable, the patient's or client's spouse or parent(s), has
changed.
(c)
Information. The patient or client, or if applicable,
the patient's or client's spouse or parent(s), is responsible for providing or
assisting the Department in obtaining the information needed to review his or
her ability to pay. If the Department fails to receive such information, the
Department may determine ability to pay based upon its best available
information and proceed to bill and collect charges.
(d)
Notice. Each
patient and client and his or her legally authorized representative and
applicable fee payer(s) shall receive notice of the determination of the
ability to pay and whether a charge or charges will be adjusted, and of the
right to appeal such determinations in accordance with
104
CMR 30.04(8).
(e)
Billing a Client, Patient or
Fee Payer. A patient, client or fee payer will be billed any
charge not reduced to zero in accordance with
104
CMR 30.04(6). The bill shall
include a statement of the charge(s), the reduction amount, if any, and the
right to appeal the charge(s) as set forth in
104
CMR 30.04(8). Any charge or
charges shall be due and payable within the time specified in the
bill.
(7)
Facility Director's Authority. If a patient who is
billed for services has deposited funds with a facility director or designee of
a Department facility such facility director or designee shall deduct the
charges, or if appropriate, the reduced charges, from those funds; provided
however, that:
(a) The patient has capacity
and the facility director or designee has requested in writing authority to
deduct such charges and has received such authority from the patient;
or
(b) The patient has a legally
authorized representative and the facility director or designee has requested
in writing authority to deduct such charges and has received such authority
from the legally authorized representative; or
(c) The funds have been entrusted to the
facility director or designee as the patient's representative payee; provided
however, that the patient will receive notice of the charge and any decision to
reduce the charge and will have the appeal rights described in
104
CMR 30.04(8); and
(d) All notice provisions as specified above
have been complied with; and
(e) No
appeal of the charge or the Department's decision regarding a reduction of
charge has been filed by the patient or representative, or if an appeal has
been filed, it has been heard and decided; and
(f) The facility director or designee has
first addressed the need for expenditure of such funds pursuant to the
provisions of
104
CMR 30.01, and after he or she has first made
all deductions and expenditures from such patient's funds pursuant to the
policies promulgated under the provisions of
104
CMR 30.04(6).
For the purposes of
104
CMR 30.04(7)(a) through (d),
the facility director or designee shall be deemed to have such authority if,
within 30 days of requesting such authority in writing, the patient or legally
authorized representative has not responded to such request so long as the
facility director or designee has documented that the patient or other person
has received such request and so long as the facility has taken reasonable
steps to assist the patient or other person to understand the nature of the
request.
(8)
Appeal of Charges. Within 21 days after issuance of a
bill, a patient, client, his or her legally authorized representative, or fee
payer(s) may appeal the charge by notifying the Commissioner in writing. The
notice must state what is being appealed and the basis for the appeal as
provided in
104
CMR 30.04(8)(b). The
Commissioner may accept an appeal after 21 days for good cause.
(a)
General
Provisions.
1. To the extent
possible, disagreements concerning a charge of a patient, client or fee payer
should be resolved informally with the Area Director or designee prior to
utilizing this appeal mechanism.
2.
This appeal process has been established to comply with the State Comptroller's
Office's requirements concerning debt collection, which are set out at 815 CMR
9.00: Debt Collection and Intercept.
(b)
Grounds for
Appeal. Grounds for appealing a charge shall be limited to the
following:
1. Whether the client or patient,
in fact, received the service for which he or she or the fee payer is
billed;
2. Misidentification of the
fee payer; or
3. Whether the amount
billed was calculated in accordance with the Department's policy for reducing
charges.
The rate that the Department charges for its services is not
subject to appeal.
(c) The Commissioner or designee shall hear
the appeal within 30 days of receipt of the appeal. The appellant shall be
given an opportunity to present oral or written statements relevant to the
charge, to question a representative of the Department concerning the charge,
and to have a representative, if any, present. Such a proceeding shall not be
an adjudicatory proceeding within the meaning of M.G.L. c. 30A. The standard of
proof on all issues shall be a preponderance of the evidence and the burden of
proof shall be on the appellant. The Commissioner shall make a decision within
30 days of hearing the case and shall notify in writing the appellant stating
the reason for such decision. The decision of the Commissioner is
final.
