114 CMR 10.02 - Definitions

Meaning of Terms: As used in 114.6 CMR 10.00, unless the context otherwise requires, terms shall have the meanings ascribed in 114.6 CMR 10.00.

Acute Hospital. Any hospital licensed under M.G.L. c. 111, § 51 and the teaching hospital of the University of Massachusetts Medical School, which contains a majority of medical-surgical, pediatric, obstetric, and maternity beds as defined by the Department of Public Health.

Acute Hospital Services. Services listed on an acute hospital's license by the Department of Public Health.

Allowable Medical Expenses. Family medical bills from any provider that, if paid, would qualify as deductible medical expenses for federal income tax purposes. Unpaid bills for which the patient is still responsible, incurred prior to or after the date of a free care application, may be used. Paid bills, incurred after the date of the free care application, may also be included in the allowable medical expenses.

Bad Debt. An account receivable based on services furnished to any patient which:

(a) is regarded as uncollectible, following reasonable collection efforts, pursuant to 114.6 CMR 10.05, and pursuant to the hospital's or community health center's established Credit and Collection policy, that conforms with 114.6 CMR 10.09;

(b) is charged as a credit loss;

(c) is not the obligation of any federal or state governmental unit; and

(d) is not free care.

Center Care Program. Anambulatory managed care program that offers primary and preventive health care services to low-income, uninsured adult patients of independently licensed community health centers, administered by the Department of Public Health, pursuant to M.G.L., c.111, § 24H.

Charge. The uniform price for a specific service charged by a hospital or community health center.

Children's Medical Security Plan. A program of primary and preventive pediatric health care services for eligible children, from birth to age 18, administered by the Department of Public Health pursuant to M.G.L. c. 111, § 24G.

Collection Action. Any activity by which a hospital, community health center or a designated agent requests payment for services from a patient, a patient's guarantor, or a third party responsible for payment. Collection actions include activities such as pre-admission or pretreatment deposits, billing statements, collection follow-up letters, telephone contacts, personal contacts and activities of collection agencies and attorneys.

Commissioner. The Commissioner of the Division of Health Care Finance & Policy or designee.

CommonHealth. A Medicaid program for disabled adults and disabled children administered by the Division of Medical Assistance pursuant to M.G.L. c. 118E.

Community Health Center. A clinic which provides comprehensive ambulatory services and which:

(a) is licensed as a freestanding clinic by the Massachusetts Department of Public Health pursuant to M.G.L. c.111, § 51;

(b) meets the qualifications for certification (or provisional certification) by the Division of Medical Assistance and enters into a provider agreement pursuant to 130 CMR 405.000;

(c) operates in conformance with the requirements of 42 U.S.C. § 254c; and

(d) files cost reports as requested by the Division.

Credit and Collection Policy. A statement, in compliance with 114.6 CMR 10.09, of a hospital's or community health center's general policy and the principles that guide its billing and collection practices and procedures, as approved by its governing board.

Deductible. The patient's liability to the provider for partial free care purposes.

Division. The Division of Health Care Finance and Policy established under M.G.L. c. 118G.

Emergency Aid to the Elderly, Disabled and Children (EAEDC). A program of governmental benefits under M.G.L. c. 117A.

EmergencyCare. Medically necessary services provided after the sudden onset of a medical condition, whether physical or mental, manifesting itself by acute symptoms of sufficient severity, including severe pain, which a prudent lay person would reasonably believe is an immediate threat to life or has a high risk of serious damage to the individual's health. Conditions include, but are not limited to those which may result in jeopardizing the patient's health, serious impairment to bodily functions, serious dysfunction of any bodily organ or part, or active labor in women. Examination or treatment for emergency medical conditions or any such other service rendered to the extent required pursuant to 42 USC 1395(dd) qualifies as emergency care for Pool purposes.

EMTALA. The federal Emergency Medical Treatment and Active Labor Act under 42 USC 1395(dd).

Family. The patient, spouse and any minor dependents living in the household, and unborn children.

Family Income. The sum of annual earnings and cash benefits from all sources before taxes, less payments made for alimony and child support.

Federal Poverty Income Guidelines. The Federal Poverty Income Guidelines published annually by the federal Department of Health and Human Services.

Fiscal Year. The time period of 12 months beginning on October 1 of any calendar year and ending on September 30 of the immediately following calendar year.

Free Care. Unpaid hospital or community health center charges formedically necessary services which are eligible for reimbursement from the Pool pursuant to the criteria set forth in 114.6 CMR 10.03. Types of free care include: full free care, partial free care, medical hardship, and emergency bad debt.

Governmental Unit. The Commonwealth, and any department, agency, board, or commission of the Commonwealth, and any political subdivision of the Commonwealth.

Guarantor. A person or group of persons who assumes the responsibility of payment for all or part of a hospital or community health center's charge for services.

Health Insurance Plan. The Medicare program, the Medicaid program, or an individual or group contract or other plan providing coverage of health care services which is issued by a health insurance company, as defined in M.G.L. c. 175, c. 176A, c. 176B, c. 176G, or c. 176I.

Healthy Start. A health care program for pregnant women and infants administered by the Department of Public Health pursuant to M.G.L. c. 111, § 24D.

Hospital. An acute hospital.

MassHealth. A Medicaid program administered by the Division of Medical Assistance pursuant to M.G.L. c. 118E and in accordance with Title XIX of the Federal Social Security Act, and a § 1115 Demonstration Waiver.

Medicaid Program. The medical assistance program administered by the Division of Medical Assistance pursuant to M.G.L. c. 118E and in accordance with Title XIX of the Federal Social Security Act.

Medical Assistance Program. The Medicaid program, the Veterans Administration health, hospital, and community health programs and any other medical assistance program operated by a Governmental Unit for persons categorically eligible for such program.

Medically Necessary Service. A service that is reasonably expected to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a handicap, or result in illness or infirmity. Medically necessary services shall include inpatient and outpatient services as mandated under Title XIX of the Federal Social Security Act. Medically necessary services shall not include:

(a) non-medical services, such as social, educational, and vocational services,

(b) cosmetic surgery,

(c) canceled or missed appointments,

(d) telephone conversations and consultations,

(e) court testimony,

(f) research or the provision of experimental or unproven procedures including, but not limited to, treatment related to sex-reassignment surgery, and pre-surgery hormone therapy, and

(g) the provision of whole blood; provided, however, that administrative and processing costs associated with the provision of blood and its derivatives shall be payable.

Medicare Program. The medical insurance program established by Title XVIII of the Federal Social Security Act.

Pool. The Uncompensated Care Pool established pursuant to M.G.L. c. 118G, §18.

Provider. Any person, corporation, partnership, governmental unit, state institution and other entity qualified under the laws of the commonwealth to perform or provide health care services.

Publicly Aided Patient. A person who receives hospital or community health center care and services for which a Governmental Unit is liable in whole or in part under a statutory program.

Resident. A person living in Massachusetts with the intention of remaining in the state indefinitely. A resident is not required to maintain a fixed address. The following conditions do not meet the requirements for residency:

(a) confinement in a nursing home, hospital or other medical institution, and

(b) relocation to Massachusetts for the sole purpose of receiving health care benefits.

Uninsured Patient. A patient who does not have a policy of health insurance or is not a member of a health insurance or benefit program. A patient who has a policy of health insurance or is a member of a health insurance or benefit program which requires such patient to make payment of deductibles, or co-payments, or fails to cover certain medical services or procedures is not uninsured.

Urgent Care. Medically necessary services provided in a hospital or community health center after the sudden onset of a medical condition, whether physical or mental, manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent lay person would believe that the absence of medical attention within 24 hours could reasonably expect to result in:

(a) placing a patient's health in jeopardy;

(b) impairment to bodily function; or

(c) dysfunction of any bodily organ or part.

Urgent care services are provided for conditions that are not life-threatening and do not pose a high risk of serious damage to an individual's health.

Notes

114 CMR 10.02

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