404.402 - Definitions

404.402. Definitions

The following terms used in 130 CMR 404.000 have the meanings given in 130 CMR 404.402 unless the context clearly requires a different meaning.

Activities of Daily Living (ADL) - fundamental personal care tasks performed daily as part of an individual's routine self-care. ADLs include, but are not limited to, eating, toileting, dressing, bathing, transferring, and mobility/ambulation.

Adult Day Health (ADH) - a community-based and non-residential service that provides nursing care, supervision, and health related support services in a structured group setting to MassHealth members who have physical, cognitive, or behavioral health impairments. The ADH service has a general goal of meeting the ADL, and/or skilled nursing therapeutic needs of MassHealth members delivered by a MassHealth agency approved ADH provider that meets the conditions of 130 CMR 404.000.

Adult Day Health Program - a site-based program that is licensed by the Department of Public Health (DPH) under 105 CMR 158.00: Licensure of Adult Day Health Programs and that has been reviewed and approved by the MassHealth agency and by other appropriate authorities for the provision of ADH for a specific number of daily participants. If a provider offers ADH in more than one location, each location is a separate ADH program and must meet the provisions of 130 CMR 404.000.

Basic Payment Level - the payment rate established by MassHealth for a ADH provider's provision of ADH services to members who meet the criteria set forth in 130 CMR 404.414(D)(1).

Capitated Program - An ICO, SCO, or PACE organization, or any other entity that, pursuant to a contract with EOHHS, covers ADH and other medical services for members on a capitated basis.

Clinical Assessment - the screening process of documenting a member's need for ADH using a tool designated by the MassHealth agency and which assessment forms the basis for prior authorization of ADH.

Complex Payment Level - the payment rate established by the MassHealth agency for an ADH provider's provision of ADH services to members who meet the criteria set forth in 130 CMR 404.414(D)(2) .

Department of Public Health (DPH) - an agency of the Commonwealth of Massachusetts, established under M.G.L. c. 17, § 1.

EOHHS - the Executive Office of Health and Human Services established under M.G.L. c. 6A.

Hospital - a facility that is licensed or operated as a hospital by the Massachusetts Department of Public Health or the Massachusetts Department of Mental Health that provides diagnosis and treatment on an inpatient or outpatient basis for patients who have any of a variety of medical conditions.

Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID) - a facility, or distinct part of a facility, that provides intermediate care facility services as defined under 42 CFR § 440.150, and that meets federal conditions of participation, and is licensed by the State primarily for the diagnosis, treatment, or rehabilitation for individuals with intellectual disabilities; and provides, in a protected residential setting, ongoing evaluation, planning, 24hour supervision, coordination, and integration for health or rehabilitative services to help individuals function at their greatest ability.

Integrated Care Organization (ICO) - an organization with a comprehensive network of medical, behavioral health care, and long-term services and supports providers that integrates all components of care, either directly or through subcontracts, and has contracted with EOHHS and the Centers for Medicare and Medicaid Services (CMS) and been designated as an ICO to provide services to dual eligible individuals under M.G.L. c. 118E. ICOs are responsible for providing enrolled members with the full continuum of Medicare- and MassHealth-covered services.

Marketing - any communication from an ADH provider, or its agent, to a member, or his or her family or caregivers, that can reasonably be interpreted as intended to influence the member's choice of ADH provider, whether by inducing that member

(1) to retain that ADH provider to provide ADH services to the member,

(2) not to retain ADH services from another ADH provider, or

(3) to cease receiving ADH services from another ADH provider.

Marketing shall not include choice counseling or navigation services provided by community partners pursuant to their contracts with EOHHS.

MassHealth - the medical assistance and benefit programs administered by EOHHS pursuant to Title XIX of the Social Security Act (42 U.S.C. 1396), Title XXI of the Social Security Act (42 U.S.C. 1397), M.G.L. c. 118E, and other applicable laws and waivers to provide and pay for medical services to eligible members.

Member - a person determined by the MassHealth agency to be eligible for MassHealth.

Nursing Facility - an institution (or a distinct part of an institution) which is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, rehabilitation services for the rehabilitation of injured people, people with disabilities, or sick persons, or on a regular basis, health-related care and services to individuals who because of their mental or physical condition require care and services that the meets the requirements of Sections 1919(a), (b), (c) and (d) of the Social Security Act and is licensed under and certified by the Massachusetts Department of Public Health.

Programs of All-inclusive Care for the Elderly (PACE) - the Programs of All-inclusive Care for the Elderly (PACE), as described in 42 CFR 460 and 130 CMR 519.007(C): Program of All-inclusive Care for the Elderly (PACE).

Primary Care Provider (PCP) - a physician or a physician assistant or nurse practitioner who practices under the supervision of a physician.

Senior Care Organization (SCO) - a managed care organization that participates in MassHealth under a contract with the MassHealth agency to provide coordinated care and medical services through a comprehensive network to eligible members 65 years of age or older. SCOs are responsible for providing enrolled members with the full continuum of MassHealth-covered services, and for dual eligible members, the full continuum of MassHealth and Medicare covered services.

Significant Change - a major change in the member's status that

(1) is permanent or will not normally resolve itself without further interventions;

(2) impacts more than one area of the member's health status; and

(3) requires an interdisciplinary review or revision of the care plan.

A significant change is presumed when a member authorized to receive ADH does not receive ADH for 90 days or more, or when the provider is seeking a change in service payment level.

Unfair or Deceptive Acts or Practices - any unfair or deceptive acts or practices, as that term is defined in M.G.L. c. 93A, § 2, and the regulations promulgated thereunder by the Massachusetts Attorney General.

(Amended by Mass Register Issue 1370, eff. 7/27/2018. Amended by Mass Register Issue 1372, eff. 7/27/2018.)

The following state regulations pages link to this page.