101 CMR, § 343.04

Current through Register 1536, December 6, 2024

Section 343.04 - General Rate Provisions

(1)Effect of 101 CMR 343.00. The rates of payment under 101 CMR 343.00 constitute full compensation for hospice services provided to publicly aided individuals, including necessary administration and professional supervision. These established rates of payment for authorized services, with the exception of payment for room and board, will be set in accordance with Centers for Medicare & Medicaid Services (CMS) regulation at 42 CFR 418.302.

(2)Rate Determination. Each payment rate is determined by CMS to reflect the cost incurred by a hospice in efficiently providing the core and supplemental services associated with that type of hospice care to Medicaid beneficiaries. The allowable Medicaid hospice rates are determined in accordance with 42 CFR 418.302. The Medicaid rates are determined by adding the unweighted amount to the wage component, as adjusted to reflect local differences in wages, in accordance with 42 CFR 418.306.

(3)Rates. Allowable rates for hospice services are outlined in 101 CMR 343.04(3)(a) and (b).

(a) Providers will be paid at the compliant or noncompliant rates established by CMS based on compliance with federal quality reporting requirements.

(b) If CMS amends the amounts listed in 42 CFR 418.306, the Medicaid rates will change accordingly. Said changes will be listed in an EOHHS administrative bulletin.

(c) For those hospice clients residing in nursing facilities, the per diem rate will equal 95% of the rate that would have been paid by the Commonwealth to a particular nursing facility for a non-hospice Medicaid beneficiary.

(d) Use modifier transmittal number TN for codes T2042 and T2043 when billing for members outside the county in which the provider is located.

(e) MassHealth-enrolled hospice providers located out of state must bill MassHealth using the TN modifier for all codes using the TN modifier. The rates of payment will be based on the rate applicable to the county in which the member resides. Absent use of the TN modifier, the rate of payment for hospice services provided by an out-of-state hospice provider is the lowest applicable rate listed in 101 CMR 343.04(3)(f).

(f) The rates of payment for authorized hospice services effective October 1, 2021, are the rates listed in 101 CMR 343.04(3)(f).

Barnstable			Compliant Rate	Noncompliant Rate
T2042	Routine Home Care (one-60 days)	Per Diem	$237.32	$228.12
T2042 UD	Routine Home Care (61+ days)	Per Diem	$187.34	$180.07
G0299 (RN services) G0155 (Social Worker services)	Service Intensity Add-on	Per Hour/Max four hours	$71.61	$68.84
T2043	Continuous Home Care	Per Hour	$71.62	$68.84
T2044	Inpatient Respite	Per Diem	$576.71	$554.33
T2045	General Inpatient	Per Diem	$1,239.64	$1,191.54

Berkshire			Compliant Rate	Noncompliant Rate
T2042	Routine Home Care (one-60 days)	Per Diem	$223.82	$215.14
T2042 UD	Routine Home Care (61+ days)	Per Diem	$176.68	$169.82
G0299 (RN services) G0155 (Social Worker services)	Service Intensity Add-on	Per Hour/Max four hours	$67.02	$64.42
T2043	Continuous Home Care	Per Hour	$67.02	$64.42
T2044	Inpatient Respite	Per Diem	$546.20	$525.00
T2045	General Inpatient	Per Diem	$1,171.56	$1,126.11

Bristol			Compliant Rate	Noncompliant Rate
T2042	Routine Home Care (one-60 days)	Per Diem	$218.78	$210.30
T2042 UD	Routine Home Care (61+ days)	Per Diem	$172.71	$166.00
G0299 (RN services) G0155 (Social Worker services)	Service Intensity Add-on	Per Hour/Max four hours	$65.31	$62.78
T2043	Continuous Home Care	Per Hour	$65.31	$62.78
T2044	Inpatient Respite	Per Diem	$534.82	$514.07
T2045	General Inpatient	Per Diem	$1,146.18	$1,101.71

Essex/Middlesex			Compliant Rate	Noncompliant Rate
T2042	Routine Home Care (one-60 days)	Per Diem	$225.56	$216.81
T2042 UD	Routine Home Care (61+ days)	Per Diem	$178.06	$171.15
G0299 (RN services) G0155 (Social Worker services)	Service Intensity Add-on	Per Hour/Max four hours	$67.62	$64.99
T2043	Continuous Home Care	Per Hour	$67.62	$64.99
T2044	Inpatient Respite	Per Diem	$550.14	$528.79
T2045	General Inpatient	Per Diem	$1,180.36	$1,134.56

Franklin/Hampden/Hampshire			Compliant Rate	Noncompliant Rate
T2042	Routine Home Care (one-60 days)	Per Diem	$218.61	$210.13
T2042 UD	Routine Home Care (61+ days)	Per Diem	$172.57	$165.87
G0299 (RN services) G0155 (Social Worker services)	Service Intensity Add-on	Per Hour/Max four hours	$65.25	$62.72
T2043	Continuous Home Care	Per Hour	$65.25	$62.72
T2044	Inpatient Respite	Per Diem	$534.43	$513.69
T2045	General Inpatient	Per Diem	$1,145.31	$1,100.87

Norfolk/Plymouth/Suffolk			Compliant Rate	Noncompliant Rate
T2042	Routine Home Care (one-60 days)	Per Diem	$241.23	$231.88
T2042 UD	Routine Home Care (61+ days)	Per Diem	$190.43	$180.04
G0299 (RN services) G0155 (Social Worker services)	Service Intensity Add-on	Per Hour/Max four hours	$72.94	$70.12
T2043	Continuous Home Care	Per Hour	$72.95	$70.12
T2044	Inpatient Respite	Per Diem	$585.55	$562.82
T2045	General Inpatient	Per Diem	$1,259.35	$1,210.48

Worcester			Compliant Rate	Noncompliant Rate
T2042	Routine Home Care (one-60 days)	Per Diem	$229.20	$220.31
T2042 UD	Routine Home Care (61+ days)	Per Diem	$180.93	$173.91
G0299 (RN services) G0155 (Social Worker services)	Service Intensity Add-on	Per Hour/Max four hours	$68.85	$66.18
T2043	Continuous Home Care	Per Hour	$68.85	$66.18
T2044	Inpatient Respite	Per Diem	$558.36	$536.69
T2045	General Inpatient	Per Diem	$1,198.69	$1,152.18

Rural: Dukes and Nantucket			Compliant Rate	Noncompliant Rate
T2042	Routine Home Care (one-60 days)	Per Diem	$256.14	$246.20
T2042 UD	Routine Home Care (61+ days)	Per Diem	$202.20	$194.34
G0299 (RN services) G0155 (Social Worker services)	Service Intensity Add-on	Per Hour/Max four hours	$78.01	$74.99
T2043	Continuous Home Care	Per Hour	$78.02	$74.99
T2044	Inpatient Respite	Per Diem	$619.22	$595.19
T2045	General Inpatient	Per Diem	$1,334.47	$1,282.69

Use modifier TN for T2042 and T2043 when billing for members outside the county in which the provider is located.