101 CMR 206.15 - Add-on for Members with Complicated High-cost Care Needs
(1)
Members with Complicated
High-cost Care Needs. Nursing facilities may receive a
member-based rate add-on, in addition to the facility's standard per
diem rate established under
101 CMR
206.00, for any member (for example, a resident
requiring 1:1 staffing), for whom reasonable and allowable direct care costs
associated with providing for such member's clinical care needs are
significantly greater than the standard nursing facility rate (for example,
because the member's care needs necessitates the purchase or rental of
specialized equipment or hiring of additional staff). The facility may receive
an add-on for such member, as calculated according to
101
CMR 206.15(2), provided that
all of the following conditions are met:
(a)
Prior to admission, the facility certifies that the direct care costs
associated or expected to be associated with providing services to such member
are necessary to provide the services recommended by the member's physician and
care team, and documented in the member's care plan;
(b) The facility submitted a summary of
expected direct care costs associated with providing services to such member
demonstrating that the requirements of
101
CMR 206.15 have been met;
(c) The facility provides the MassHealth
agency with any additional or clarifying documentation in support of the actual
or expected direct care costs associated with the resident's care needs;
and
(d) The facility receives
approval from the MassHealth agency for the add-on.
(2)
Complicated and High-cost
Care Add-on Calculation. The add-on rate shall be a daily rate
equal to the total reasonable and allowable costs associated with the high-cost
member as determined by EOHHS, above the standard nursing, capital, and
operating costs considered and included in calculating the nursing facility's
standard per diem rates established under
101 CMR
206.00, up to a maximum add-on of $600 per day. EOHHS
shall have sole discretion over what may be considered a reasonable and
allowable cost for the purposes of calculating this add-on. The add-on for each
resident shall be effective on the later of the date the nursing facility
receives MassHealth approval for the add-on or the date of the member's
admission to the nursing facility. A nursing facility may not receive this
add-on for a member for whom the facility is receiving on the same dates of
service a Medicaid transitional add-on under
101
CMR 206.10(7), a
homelessness rate add-on under
101
CMR 206.10(13), a substance
use disorder add-on or a substance use disorder induction period add-on under
101
CMR 206.10(14), a behavioral
indicator add-on under
101
CMR 206.10(16), a bariatric
add-on under
101
CMR 206.10(21), or a
per diem rate for severe mental or neurological disorders
under
101
CMR 206.11.
(3)
Periodic
Recertification. A nursing facility that receives the add-on under
101
CMR 206.15 may be required periodically to
recertify to MassHealth that all conditions established under
101
CMR 206.15(1)(a) continue
to be met with respect to each member for whom it receives the add-on, and must
submit updated direct care cost information for each member. If the facility
fails to provide such certification and information, MassHealth may terminate
the add-on received by the nursing facility for the member.
Notes
State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.
(1) Members with Complicated High-cost Care Needs. Nursing facilities may receive a member-based rate add-on, in addition to the facility's standard per diem rate established under 101 CMR 206.00, for any member (for example, a resident requiring 1:1 staffing), for whom reasonable and allowable direct care costs associated with providing for such member's clinical care needs are significantly greater than the standard nursing facility rate (for example, because the member's care needs necessitates the purchase or rental of specialized equipment or hiring of additional staff). The facility may receive an add-on for such member, as calculated according to 101 CMR 206.15(2), provided that all of the following conditions are met:
(a) Prior to admission, the facility certifies that the direct care costs associated or expected to be associated with providing services to such member are necessary to provide the services recommended by the member's physician and care team, and documented in the member's care plan;
(b) The facility submitted a summary of expected direct care costs associated with providing services to such member demonstrating that the requirements of 101 CMR 206.15 have been met;
(c) The facility provides the MassHealth agency with any additional or clarifying documentation in support of the actual or expected direct care costs associated with the resident's care needs; and
(d) The facility receives approval from the MassHealth agency for the add-on.
(2) Complicated and High-cost Care Add-on Calculation. The add-on rate shall be a daily rate equal to the total reasonable and allowable costs associated with the high-cost member as determined by EOHHS, above the standard nursing, capital, and operating costs considered and included in calculating the nursing facility's standard per diem rates established under 101 CMR 206.00, up to a maximum add-on of $600 per day. EOHHS shall have sole discretion over what may be considered a reasonable and allowable cost for the purposes of calculating this add-on. The add-on for each resident shall be effective on the later of the date the nursing facility receives MassHealth approval for the add-on or the date of the member's admission to the nursing facility. A nursing facility may not receive this add-on for a member for whom the facility is receiving on the same dates of service a Medicaid transitional add-on under 101 CMR 206.10(7), a homelessness rate add-on under 101 CMR 206.10(13), a substance use disorder add-on or a substance use disorder induction period add-on under 101 CMR 206.10(14), a behavioral indicator add-on under 101 CMR 206.10(16), a bariatric add-on under 101 CMR 206.10(21), or a per diem rate for severe mental or neurological disorders under 101 CMR 206.11.
(3) Periodic Recertification. A nursing facility that receives the add-on under 101 CMR 206.15 may be required periodically to recertify to MassHealth that all conditions established under 101 CMR 206.15(1)(a) continue to be met with respect to each member for whom it receives the add-on, and must submit updated direct care cost information for each member. If the facility fails to provide such certification and information, MassHealth may terminate the add-on received by the nursing facility for the member.