101 CMR 310.00 — Rates for Adult Day Health Services

Final Adoption Date Published in Mass Register: June 20, 2025

101 CMR EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 310.00: RATES FOR ADULT DAY HEALTH SERVICES

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Section

310.01: General Provisions 310.02: General Definitions 310.03: Rate Provisions 310.04: Reporting Requirements 310.05: Severability

101 CMR 310.00 Rates for Adult Day Health Services

310.01 General Provisions

310.01: General Provisions

(1) Scope and Purpose. 101 CMR 310.00 governs the payment rates for adult day health services provided to publicly aided individuals. The payment rates in 101 CMR 310.00 also apply to individuals covered by the Workers’ Compensation Act, M.G.L. c. 152.

(2) Applicable Dates of Service. Rates contained in 101 CMR 310.00 apply for dates of service provided on or after July 1, 2025.

(3) Coverage. The payment rates in 101 CMR 310.00 are full compensation for adult day health services as well as for any related administrative or supervisory duties rendered in connection with the provision of adult day health services.

(4) Disclaimer of Authorization of Services. 101 CMR 310.00 is neither authorization for nor approval of the substantive services for which rates are determined pursuant to 101 CMR 310.00. Governmental units or workers’ compensation insurers that purchase care are responsible for the definition, authorization, and approval of care and services to covered individuals.

(5) Administrative Bulletins. EOHHS may issue administrative bulletins to clarify its policy on and understanding of substantive provisions of 101 CMR 310.00.

310.02 General Definitions

310.02: General Definitions

As used in 101 CMR 310.00, terms have the meanings set forth in 101 CMR 310.02.

Adult. Any person 18 years of age or older.

Adult Day Health Services. Programs approved by the MassHealth agency under 130 CMR 404.000: Adult Day Health Services and that provide for adult recipients an alternative to 24- hour long-term institutional care through an organized program of health care and supervision, restorative services, and socialization.

Basic Level of Care. The level of care for publicly aided clients receiving adult day health services as defined in 130 CMR 404.402: Basic Payment Level.

Center. The Center for Health Information and Analysis (CHIA) established under M.G.L. c. 12C.

Final Adoption Date Published in Mass Register: June 20, 2025

101 CMR EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 310.00: RATES FOR ADULT DAY HEALTH SERVICES

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Complex Level of Care. The level of care for publicly aided clients receiving adult day health services as defined in 130 CMR 404.402: Complex Payment Level.

Day Setting. Any single physical facility that is open at least Monday through Friday for eight hours per day that has been reviewed and approved by the MassHealth agency and other proper authorities for the operation of the adult day health services program.

Eligible Provider. Any person, partnership, corporation, or other entity that is authorized in the Commonwealth of Massachusetts to engage in the business of furnishing adult day health services to the public and who also meets such conditions of participation as may be adopted by a governmental unit.

EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A.

Governmental Unit. The Commonwealth; any department, agency, board, or commission of the Commonwealth; and any political subdivision of the Commonwealth.

Non-wheelchair Transportation. Transportation services provided by a motor vehicle for members who are ambulatory and can be transported in a van while seated on a bench or single- seat passenger chair.

Partial Per Diem. Adult day health services provided for a period equal to or less than three hours per day.

Per Diem. Adult day health services provided for a period greater than three hours per day. MassHealth will not pay for services that exceed six hours per day.

Publicly Aided Individual. A person whose medical and other services a governmental unit is in whole or part liable for under a statutory program.

Restorative Services. Indirect services, including, but not limited to, case conferences or those of an in-service educational therapist, speech pathologist, or other qualified restorative therapist.

Transportation. Method by which a member is brought from their home to the adult day health provider or from the adult day health provider to the member’s home. Transportation service includes assisting the member while they enter and exit the vehicle, as appropriate. A member’s home may include a temporary housing environment such as a shelter or transitional housing.

Wheelchair Transportation. Transportation service provided to a member who requires a wheelchair.

310.03 Rate Provisions

310.03: Rate Provisions

(1) Rate as Full Payment. Each eligible provider must, as a condition of receipt of payment from one or more purchasing governmental units for services rendered, accept the approved rates as full payment and discharge of all obligations for the services rendered, subject only to appellate

Final Adoption Date Published in Mass Register: June 20, 2025

101 CMR EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 310.00: RATES FOR ADULT DAY HEALTH SERVICES

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rights as set forth in M.G.L. 118E. There will be no duplication or supplementation of payment from sources other than those expressly recognized or anticipated in the computation of the rate. Any client resources or third-party payments received on behalf of a publicly assisted client must reduce, by that amount, the amount of the purchasing governmental unit’s obligation for services rendered to the publicly assisted client.

(2) Covered Services. The payment rates in 101 CMR 310.00 apply to adult day health services provided by eligible providers in a day setting, where (a) a patient's medical condition indicates a need for nursing care, supervision, or a need for therapeutic services that alone or in combination would require institutional placement; or (b) a patient's psycho-social condition is such that without program intervention the patient’s medical condition would continue to deteriorate or is such that institutional placement is imminent.

(3) Exclusions. The payment rates in 101 CMR 310.00 do not apply to the following circumstances and services: (a) specialized day programs primarily for the developmentally disabled, blind, deaf, or acutely mentally ill; (b) adult day health programs operating out of state; (c) physician services paid on a fee-for-service basis under 101 CMR 316.00: Rates for Surgery and Anesthesia Services and 101 CMR 317.00: Rates for Medicine Services; (d) restorative therapy services paid on a fee-for-service basis under 101 CMR 339.00: Rates for Restorative Services; and (e) services and costs paid under other regulations promulgated by EOHHS.

(4) Payment Rates. For dates of service on and after July 1, 2025, the base rate for adult day health services is the lower of the established charge or the rate listed below in 101 CMR 310.03(4).

Code Per Diem Base Rate Description S5102 $99.49 Basic Level of Care S5102 TG $136.72 Complex Level of Care Code Partial Per Diem Rate Description S5101 $49.75 Basic Level of Care S5101 TG $68.36 Complex Level of Care

Final Adoption Date Published in Mass Register: June 20, 2025

101 CMR EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

101 CMR 310.00: RATES FOR ADULT DAY HEALTH SERVICES

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310.04 Reporting Requirements

310.04: Reporting Requirements

(1) Required Reports. Reporting requirements are governed by 957 CMR 6.00: Cost Reporting Requirements.

(2) Penalty for Noncompliance. The purchasing governmental unit may impose a penalty in the amount of up to 15% of its payments to any provider that fails to submit required information. The purchasing governmental unit will notify the provider in advance of its intention to impose a penalty under 101 CMR 310.04.

310.05 Severability

310.05: Severability

The provisions of 101 CMR 310.00 are severable. If any provision of 101 CMR 310.00 or application of any provisions to an applicable person, entity, or circumstance is held invalid or unconstitutional, that holding will not be construed to affect the validity or constitutionality of any remaining provisions of 101 CMR 310.00 or application of those provisions to applicable individuals, entities, or circumstances.

REGULATORY AUTHORITY

101 CMR 310.00: M.G.L. c. 118E.

Code Rate Description T2003 $28.56 Non-wheelchair (ambulatory) transportation (one-way trip) T2003 U6 $34.98 Wheelchair transportation (one-way trip)