101 CMR, § 358.03

Current through Register 1533, October 25, 2024

Section 358.03 - Rate Provisions

(1)Rates as Full Compensation. The rates under 101 CMR 358.03 constitute full compensation for applied behavior analysis services provided by eligible providers to publicly aided individuals, including full compensation for necessary administration and professional supervision associated with patient care.

(2)Rates of Payment. Payment rates under 101 CMR 358.03 are the lowest of

(a) the eligible provider's usual charge to the general public; or

(b) the schedule of allowable rates for services as set forth in 101 CMR 358.03(3).

(3)Fee Schedule.

Code	Payment Rate	Service Description
97151	$30.73	Behavior identification assessment, administered by a physician or other qualified health care professional, each 15 minutes of the physician's or other qualified health care professional's time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan. (Initial functional behavior assessment and reassessment.)
97153	$16.37	Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with one patient, each 15 minutes. (Adaptive behavior treatment.)
97154	$13.91	Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified health care professional, face-to-face with two or more patients, each 15 minutes. (Social skills group, up to eight participants.)
97155	$30.73	Adaptive behavior treatment with protocol modification, administered by physician or other qualified health care professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes. (Adaptive behavior treatment.)
97156	$30.73	Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes. (Parent training with or without child present.)
97157	$26.12	Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified health care professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes. (Multiple group parent training, up to eight participants.)
H0031-U2	$30.73	Mental health assessment by physician or other qualified health professional (Assessment and case planning for home services by a licensed professional. 15-minute rate.)

(4)Coding Updates and Corrections.

(a) EOHHS may publish procedure code updates and corrections in the form of an administrative bulletin. The publication of such updates and corrections will list

1. codes for which only the code numbers changed, with the corresponding crosswalk;

2. codes for which the code number remains the same but the description has changed; and

3. deleted codes for which there is no crosswalk.

(b) In addition, for entirely new codes that require new pricing, EOHHS will list these codes and apply individual consideration in reimbursing these new codes until rates are established.

(5)Billing. Each eligible provider must bill the governmental unit according to the appropriate fee schedule on a prescribed form. Each specific service must be separately enumerated on the bill.