Commonwealth of Massachusetts 
Executive Office of Health and Human Services 
Division of Medical Assistance 
600 Washington Street
Boston, MA 02111


MassHealth 
Day Habilitation Program Bulletin 3 
March 2000 

TO: Day Habilitation Providers Participating in MassHealth 

FROM: Mark E. Reynolds, Acting Commissioner 

RE: Rate Increase and Staffing Criteria for Day Habilitation Services Provided 
to Nursing Facility Residents 

Background

In November 1999 the Division of Health Care Finance and Policy 
(DHCFP) approved two new hourly rates for day habilitation services 
provided in a nursing facility to MassHealth members. 

Rates for Staffing Ratios

The new rates for providing services in nursing facilities are $28.90/hour for 
one-to-one ratio staffing and $16.02 per person for one-to-two and one-to-three 
ratio staffing. These new rates are retroactive to November 1, 1999. If a 
provider has already been paid for a date of service on and after November 1, 
1999, the provider may submit an adjusted claim to be paid the difference 
between the old rate paid and the new rates noted above. 

Policy Changes to One-to-One Staffing Ratios

Previously, a provider could bill for one-to-one staffing only when one 
individual was being served in the nursing facility. Effective April 1, 2000 
a provider may bill for one-to-one staffing when two or more individuals 
are served at the same nursing facility, if the individual’s medical or 
behavioral conditions relate directly to his or her ability to participate in 
groups with other residents as noted below. 

Criteria for One-to-One Staffing

The day habilitation program may bill for one-to-one staffing when two or  
more individuals are being served only if the individual meets the following 
criteria: 

A. One of the individuals is the only participant in the program with 
either a developmental disability or mental retardation; or 



MassHealth 
Day Habilitation Program Bulletin 3 
March 2000 
Page 2 

Criteria for One-to-One Staffing (cont.)

B. The individual requires: 

1. continuous, direct, physical assistance from a staff person without which, 
because of the individual’s medical condition or conditions, the individual 
could not participate in the program; or 
2. full-time staff intervention to monitor or manage one or more 
of the following types of behavior: 
a. Injurious to self — behavior that could or does cause 
injury to the individual; 
b. Injurious to others — behavior that could or does result 
in safety issues or harm to other members attending the 
day program; 
c. Destruction of property — behavior that could result in 
the damage of property; 
d. Risk of elopement — attempted or successful episodes of 
leaving the nursing facility; and 
e. Socially inappropriate — sexual behavior or disrobing 
in public. 

Providers must record in each individual’s record the clinical justification 
to support billing for one-to-one staffing. 

When there are two or more individuals in the facility with mental 
retardation or two or more with developmental disability, providers must 
not bill for a one-to-one staffing ratio unless at least one of the above 
criteria is met. Providers must not bill at a higher ratio when one or more 
individuals are absent from the program because of illness, 
appointments, other activities, scheduling conflicts, or any other reason. 

Questions If you have any billing questions, please contact the Unisys Provider 
Services Department at (617) 628-4141 or 1-800-325-5231. If you have 
any program questions, please contact Edward Bondi at (617) 210-5629.