101 CMR 425.03 - Rate Provisions

(1) Services Included in the Rate. The approved rate includes payment for all care and services that are part of the program of services of an eligible provider, as explicitly set forth in the terms of the purchase agreement between the eligible provider and the purchasing governmental unit(s).
(2) Reimbursement as Full Payment. Each eligible provider must, as a condition of acceptance of payment made by any purchasing governmental units for services rendered, accept the approved program rate as full payment and discharge of all obligations for the services rendered. Payment from any other source will be used to offset the amount of the purchasing governmental unit's obligation for services rendered to the publicly assisted client.
(3) Payment Limitations. No purchasing governmental unit may pay less than or more than the approved program rate.
(4) Administrative Adjustment for Extraordinary Circumstances. A provider may petition the purchasing governmental unit for an administrative adjustment to reflect increases in operating costs due to unusual and unforeseen circumstances or extraordinary client service requirements not considered in the development of the current rates. Unusual and unforeseen circumstances are events of catastrophic nature (e.g., fire, flood, or earthquake) that are not covered by insurance that the prudent provider would carry. The provider must demonstrate that such cost increases gravely threaten the stability of service provision such that client or consumer access to necessary services is at risk. The purchasing governmental unit will evaluate the need for the administrative adjustment, determine whether funding is available, and convey that information to EOHHS for review to determine the amount of any adjustment.
(5) Approved Rates. The approved rate is the lower of the provider's charge or amount accepted as payment from another payer or the rate listed in 101 CMR 425.03(5).



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101 CMR 425.03
Adopted by Mass Register Issue 1317, eff. 7/15/2016. Amended by Mass Register Issue S1360, eff. 3/9/2018. Amended by Mass Register Issue 1419, eff. 6/12/2020. Amended by Mass Register Issue 1472, eff. 6/24/2022.

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