Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid 600 Washington Street Boston, MA 02111 www.mass.gov/masshealth MASSHEALTH TRANSMITTAL LETTER ADH-19 September 2004 TO: Adult Day Health Providers Participating in MassHealth FROM: Beth Waldman, Medicaid Director RE: Adult Day Health Manual (Continuation of Transitional Payment Rate) This letter transmits revisions to the adult day health regulations to continue the transitional payment rate to certain dementia day service providers. This per diem rate was scheduled to expire on June 30, 2004, but line item 4000-0600 of Section 2 of Chapter 149 of the Acts of 2004 contained funding to continue this payment. The per diem rate is paid to dementia day service providers under contract with Aging Service Access Points under the Executive Office of Elder Affairs Home and Community Based Waiver Program in lieu of the adult day health (ADH) rates of payment established by the Division of Health Care Finance and Policy (DHCFP) for providing complex care to a member. These regulations were filed as an emergency, effective July 1, 2004. The effect of this amendment is that dementia day services provided after June 30, 2004, will continue to be paid at the transitional payment rate. Transitional Payment Rate The code assigned to this service is outlined in Subchapter 6 of the Adult Day Health Manual. Providers must bill for ADH services provided at the transitional payment rate by using two units per attendance day to remain in compliance with 130 CMR 404.415(C), which states, “Members must attend at least six hours each day, excluding transportation time to and from the program. Any alteration of this requirement is at the discretion of MassHealth and must be approved.” All regulatory and payment rate information about the transitional payment rate can be found in the Adult Day Health Manual at 130 CMR 404.414(D). Web Site Access and Questions This transmittal letter and the adult day health regulations are available on the MassHealth Web site at www.mass.gov/masshealth. If you have any questions, please call MassHealth Provider Services at 617-628-4141 or 1-800-325-5231. MASSHEALTH TRANSMITTAL LETTER ADH-19 September 2004 Page 2 NEW MATERIAL (The pages listed here contain new or revised language.) Adult Day Health Manual Pages 4-21 and 4-22 OBSOLETE MATERIAL (The pages listed here are no longer in effect.) Adult Day Health Manual Pages 4-21 and 4-22 — transmitted by Transmittal Letter ADH-18 • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 404.000) PAGE 4-21 ADULT DAY HEALTH MANUAL TRANSMITTAL LETTER ADH-19 DATE 07/01/04 (D) Rates of Payment. (1) Rates for Basic Level of Care and Complex Level of Care. MassHealth pays for basic level of care and complex level of care adult day health services at rates established by the Division of Health Care Finance and Policy. (2) Transitional Payment Rate. ADH providers who were, as of August 1, 2002, Dementia Day Service Providers under contract with Aging Service Access Points under the Executive Office of Elder Affairs Home and Community Based Waiver Program, will be paid, in lieu of the ADH rates of payment established by the Division of Health Care Finance and Policy, a per diem rate of $55.00 for providing complex level of care to a member. This rate will only apply to dates of service from August 1, 2002, through June 30, 2005. The transitional payment rate is limited to the number of members served in each provider’s Dementia Day Waiver Program as of August 1, 2002, as verified by payment information on file for dates of service August 1, 2002, through June 30, 2005. For dates of service on or after July 1, 2005, providers will be paid at the same level of care as other providers, as established by the Division of Health Care Finance and Policy. (3) Health Promotion and Prevention Rate (HPPR). MassHealth pays providers at the HPPR for adult day health services to a member who meets the clinical eligibility requirements at the time the member is admitted to the program but who, due to improved health, no longer meets these clinical requirements. 404.415: Conditions of Payment (A) MassHealth pays for adult day health services beginning with the effective date of the authorization. (B) MassHealth pays an adult day health provider for only those attendance days attended by an eligible MassHealth member. (C) MassHealth pays for adult day health services only when the member attends for at least two six-hour days. Members must attend the program at least six hours each day, excluding transportation time to and from the program. Any alteration from this requirement is at the discretion of MassHealth and must be approved. 404.416: Noncovered Services MassHealth does not pay for adult day health services for: (A) individuals who reside in an institutional setting; (B) any canceled program days or any attendance days missed by a member for any reason; and (C) any portion of a day during which the member is absent from the site, unless the program documents that the member was receiving services from the program staff outside of the adult day health site in a community setting. REGULATORY AUTHORITY 130 CMR 404.000: M.G.L. c. 118E, §§ 7 and 12. • Commonwealth of Massachusetts Division of Medical Assistance Provider Manual Series SUBCHAPTER NUMBER AND TITLE 4 PROGRAM REGULATIONS (130 CMR 404.000) PAGE 4-22 ADULT DAY HEALTH MANUAL TRANSMITTAL LETTER ADH-19 DATE 07/01/04 This page is reserved.