Code of Massachusetts Regulations
114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY
Title 114.1 CMR 39.00 - CHRONIC AND REHABILITATION PUBLICLY ASSISTED RATES OF PAYMENT AND THE FEE FOR RESIDENTIAL ALCOHOLISM TREATMENT PROGRAMS
Section 39.04 - Rates of Payment to Publicly Assisted Patients

Universal Citation: 114.1 CMR 39.00 MA Code of Regs 39.04

Current through Register 1531, September 27, 2024

(1) Payment Rates. Payment for Inpatient Services to Publicly Assisted Patients will be made at the Inpatient Rate determined pursuant to 114. 1 CMR 39.05. Payment for Outpatient Services to Publicly Assisted Patients will be made at the Outpatient Rate determined pursuant to 114. 1 CMR 39.06.

(2) Applicability. Rates of payment determined under the rules of 114. 1 CMR 39.04 include:

(a) Payment for all inpatient and outpatient hospital care and services which are provided by a chronic/rehabilitation hospital to publicly-assisted patients.

(b) Payment for Administrative Days which are provided by a hospital to publicly-assisted patients under Title XIX of the Social Security Act.

(3) General Payment Provisions.

(a) Reimbursement as Full Payment. Each chronic/rehabilitation hospital which provides services to publicly-aided patients shall, as a condition of receipt of payment, accept reimbursement at rates established by the Division, subject to appellate rights set forth in M.G.L. c. 118G, as full payment and discharge of all obligations of such individuals. There shall be no duplication or supplementation of payment for services provided to publicly-assisted patients.

(b) Reimbursement Limitation. Reimbursement determined under 114. 1 CMR 39.00 for publicly assisted patients shall not exceed that reimbursement which would result from application of the Principles of Reimbursement of Provider costs established under 42 U.S.C. §§ 1395 et seq., the Medicare Act.
1. For each fiscal year the Division shall calculate the percentage, if any, by which hospitals' Medicaid payment rates must be adjusted in order for the Division of Medical Assistance to comply with the upper limit requirements on Medicaid inpatient and outpatient hospital payments as specified in 42 CFR 447.272 and 42 CFR 447.321. The Division shall calculate the upper limit separately for inpatient services and outpatient services.

2. The Division shall determine whether reimbursement determined under 114. 1 CMR 39.00 exceeds the upper limit by comparing the aggregate amount that the Medicare program would pay for Medicaid patients using Medicare principles to the aggregate amount that would be paid using the Medicaid Inpatient Rates determined pursuant to 114. 1 CMR 39.05 and the Medicaid Outpatient Rates calculated pursuant to 114. 1 CMR 39.06 applied to projected rate year utilization. If the aggregate payment amount pursuant to 114. 1 CMR 39.00 is greater than the aggregate payment amount using Medicare principles, an upper limit adjustment is necessary.

3. If an upper limit adjustment is necessary, the Division shall issue an administrative bulletin setting forth the methodology for calculating such adjustment.

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