Code of Massachusetts Regulations
115 CMR - DEPARTMENT OF DEVELOPMENTAL SERVICES
Title 115 CMR 3.00 - Administration
Section 3.06 - Charges for Care - Department Facilities

Universal Citation: 115 MA Code of Regs 115.3

Current through Register 1537, December 20, 2024

(1) Authority. Under M.G.L. c. 123B, § 16, the Department is authorized to make charges for care of any person in its facilities.

(2) Purpose and Scope. 115 CMR 3.06 sets forth the rules governing charges for residential services and supports at any of the facilities listed in 115 CMR 3.03.

(3) Definitions. See 115 CMR 3.05(3).

(4) Notice.

(a) The Department shall give written notice of the charge to each fee-payor:
1. prior to the provision of residential services and supports in the facility, where applicable;

2. prior to a change in the charge;

3. at any other time deemed appropriate by the Department.

(b) The notice shall be sent at least 30 days prior to the date payment is due and shall show how the charges were determined and explain the appeal process.

(5) Determination of Charges.

(a) The residential charge for an individual is the residential rate for the residential services and supports provided at the facility.

(b) The residential charge shall be calculated in monthly amounts. Charges for individuals who received residential services and supports for less than a month shall be adjusted pro rata.

(c) For any individual whose cost for residential services and supportsis covered by the Medicaid program or by other third party contract, insurances, reimbursement, or entitlement programs, the Department shall charge the Medicaid Program and any other third party payor the residential charge due that month. If these sources provide for payment of less than the residential charge, then the Department shall charge the fee-payor in the accordance with 115 CMR 3.06(5)(e).

(d) For any individual who is not eligible to participate in the Medicaid program or whose cost for residential services and supports is not covered by other third party contract, insurances, reimbursement, or entitlement programs, the Department shall charge the fee-payor in accordance with 115 CMR 3.06(5)(e).

(e) The monthly fee-payor charge for an individual in a facility shall be an amount equal to the sum of the individual's recurrent payments received during the month and, for any individual who has liquid assets which are deemed countable assets by the Medicaid Assistance Program for the purpose of establishing or maintaining Medicaid eligibility, 1/12 of the liquid assets held by that individual at the end of that same month for which the charge for residential services and supports accrued; provided however, such charge is subject to the following:
1. Reduction by the amount the monthly fee-payor charge exceeds the remaining balance due from the fee-payor under 115 CMR 3.06(5)(c);

2. Reduction by the amount of the personal needs allowance established under state and federal laws governing the Medicaid program;

3. Reduction by the amount of adjustment, if any, permitted under 115 CMR 3.06(6);

4. Dependent funds held by a director of a facility shall be included as liquid assets for purposes of calculating the monthly fee-payor charge until the sum total of accumulated unpaid charges equals the amount of the individual's dependent funds, at which time the Department shall exclude the total of dependent funds in any subsequent calculation of the monthly fee-payor charge.

5. In any month where the fee-payor charge would cause liquid assets to fall below $1,000, that month's charge will be adjusted to allow the individual to retain $1,000 in liquid assets, and the provisions of 115 CMR 3.06(7) shall apply to the adjustment.

(f) The Department shall determine fee-payor charges at least annually and upon notification from a fee-payor of any change in circumstance as required by 115 CMR 3.05(9).

(6) Adjustment to Charges. If an individual who has necessary expenses but does not have sufficient funds to pay for these expenses in a particular month, the monthly fee-payor charge may be reduced by an amount that will enable the individual to pay such expenses. Expenses deemed necessary may include, but are not limited to, the following:

(a) Reasonable transitional expenses, including appropriate deposits to savings or checking accounts, necessary to enable the individual to move to a less restrictive living environment within the next 12 months;

(b) The cost of premiums required to enroll and maintain the individual in a health insurance program;

(c) Medical and dental expenses of the individual, including medication costs not covered by the residential rate, insurance or other third party reimbursement;

(d) Transportation expenses of the individual for services not provided under M.G.L. c. 19B, § 17;

(e) Alimony payments owed by the individual;

(f) Loan payments, but only if the loan was incurred by the individual to pay for expenses enumerated in 115 CMR 3.06(6);

(g) Funeral related payments and expenses of the individual;

(h) Educational costs, e.g., tuitin , of the in dividual;

(i) Uniforms or tools if required by the job and required to be purchased by the individual as the employee;

(j) Child support and day care expenses of the individual's minor child;

(k) Maintenance needs of the individual's spouse, minor children, and dependents at home;

(7) Accumulated Unpaid Charges.

(a) Every adjustment to charges made pursuant to 115 CMR 3.06(6) and resulting in a reduction in the monthly fee-payor charge shall accumulate as an unpaid charge and shall be subject to future billing as the individual's circumstances permit.

(b) The Department may bill a fee-payor for accumulated unpaid charges when the individual's income increases or circumstances change, subject to adjustments for necessary expenses as provided for under 115 CMR 3.06(6).

(8) Collection of Charges.

(a) The Department shall collect charges for residential services and supports from the fee-payor(s), the Medicaid Program, a third party payor or any combination thereof.

(b) Any amount received as income to the individual shall be treated as income for a period of 60 days from the date of receipt by the fee-payor for purposes of calculating the monthly fee-payor charges.

(c) The amount of the resident's charge which would be recoverable from dependent funds held by the facility director shall not be collected by the Department until such funds are transferred to the individual, his or her fiduciary other than the facility director, or upon the individual's death. At that time all accumulated unpaid charges shall be payable to the Department by the individual, the new fiduciary or the estate of the individual.

(d) As otherwise permitted by law, the Department may assert a lien against an individual's assets.

(9) Responsibility of Fee-payors.

(a) Fee-payors shall provide information on income, assets and expenses of the individual to the Department upon request, and shall report any known change in circumstance which could result in a change in the charge, or a change in the party to be billed, or a change in the funds subject to charge. Fee-payors must report each change in circumstance within ten days from the date they first learn of the change.

(b) In cases where information is not reported as required in 115 CMR 3.06(9)(a), the Department may determine the charge and adjustments based upon the best available information, and proceed to assess and collect charges for residential services and supports. The limitation set out in 115 CMR 3.06(5)(a) shall not apply to unreported changes in funds subject to charge.

(c) Fee-payors shall pay charges in a timely manner after billing.

(10) Appeal. Within 30 days of being notified of the amount of the individual's charge, a fee-payor may appeal the charge by notifying in writing the Commissioner.

(a) Grounds for appealing a charge for residential services and supports shall be as follows:
1. Miscalculation of the charge;

2. Misidentification of the fee-payor;

3. Failure to adjust the charge to account for necessary expenses in accordance with 115 CMR 3.05(6).

(b) During pendency of the appeal, the Department shall continue to bill the fee-payor the monthly charge for residential services and supports.

(c) The Commissioner or designee shall hear the appeal within 30 days of receipt of the notice. The fee-payor 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 Commissioner shall make a decision within 30 days of hearing the case, and shall notify in writing the fee-payor stating the reasons for such decision. The decision of the Commissioner is final.

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