408.402 - Definitions

408.402. Definitions

The following terms used in 130 CMR 408.000 have the meanings given in 130 CMR 408.402, unless the context clearly requires a different meaning. Payment for services defined in 130 CMR 408.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 408.000 and 450.000: Administrative and Billing Regulations.

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

Adult Foster Care (AFC). A service ordered by a primary care provider delivered to a member in a qualified setting as described in 130 CMR 408.435 by a multidisciplinary team (MDT) and qualified AFC caregiver, that includes assistance with ADLs, IADLs, other personal care as needed, nursing oversight, and AFC care management, as described in 130 CMR 408.415(C).

AFC Caregiver. An independent contractor who is selected, supervised, and paid by the AFC provider for the provision of direct care in accordance with 130 CMR 408.415(A).

AFC Plan of Care. A person-centered, written plan based on clinical and psychosocial evaluations, describing activities to meet a member's medical, physical, emotional, and social needs and goals for AFC.

AFC Provider. An organization that meets the requirements of 130 CMR 408.404 and contracts with MassHealth as the provider for AFC.

AFC Qualified Setting. A location for the provision of AFC that meets all of the standards described in 130 CMR 408.435.

Alternative Caregiver. A person who meets all of the qualifications of an AFC caregiver and provides AFC to the member in a qualified setting in the absence of the AFC caregiver.

Alternative Caregiver Days. A short-term period during which a member receives AFC in a qualified setting from an alternative caregiver when the AFC caregiver is temporarily unavailable or unable to provide care.

Assisted Living Residence (ALR). Any entity that meets the requirements for certification pursuant to M.G.L. c. 19D and 651 CMR 12.00: Certification Procedures and Standards for Assisted Living Residences.

Clinical Assessment. The screening process of cataloging a member's need for AFC using a tool designated by the MassHealth agency and that forms the basis for prior authorization.

Clinical Evaluations. Nursing, fall risk, nutritional, skin, and other clinical or psychosocial evaluations conducted by the MDT that serve as the basis for the development of the AFC plan of care.

Community Health Worker. A public health worker qualified in accordance with 130 CMR 408.433(D)(1) who applies their unique understanding of the experience, language, or culture of the populations they serve in order to carry out their responsibilities in AFC-qualified settings.

Executive Office of Health and Human Services (EOHHS). The Executive Office of Health and Human Services established under M.G.L. c. 6A.

Family Member. A spouse, parent of a minor member, including adoptive parent, or any legally responsible relative of the member.

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

Instrumental Activities of Daily Living (IADLs). Activities related to independent living that are incidental to the care of the member and that include, but are not limited to, household-management tasks, laundry, shopping, housekeeping, meal preparation and cleanup, transportation (accompanying the member to medical providers and other appointments), care and maintenance of wheelchairs and adaptive devices, medication management and any paperwork required for receiving prescribed medications within the AFC setting, or any other medical need determined by the AFC provider as being instrumental to the health care and general well-being of the member.

Intake and Assessment Services. Preadmission services provided to a member seeking admission to an AFC program for AFC as described in 130 CMR 408.431(A)(2).

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 ยง 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, 24-hour supervision, coordination, and integration for health or rehabilitative services to help individuals function at their greatest ability.

Level I Service Payment. A rate established by MassHealth for members who meet the requirements of 130 CMR 408.419(D)(1).

Level II Service Payment. A rate established by MassHealth for members who meet the requirements of 130 CMR 408.419(D)(2).

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.

Medical Leave of Absence (MLOA). A short-term absence from an AFC-qualified setting, during which a member does not receive AFC from the AFC caregiver because the member is temporarily admitted to a hospital, nursing facility, or other medical setting.

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

Multidisciplinary Professional Team (MDT). A team employed or contracted by the AFC provider, including but not limited to, a program director, a registered nurse, and an AFC care manager, and which may also include a community health worker, that works in conjunction with the AFC caregiver.

Nonmedical Leave of Absence (NMLOA). A short-term absence from an AFC-qualified setting, during which a member does not receive AFC for nonmedical reasons.

Nursing Facility. An institution (or a distinct part of an institution) that 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 meet the requirements of Sections 1919(a) through (d) of the Social Security Act, and is licensed under and certified by the Massachusetts Department of Public Health.

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

Primary Care Provider (PCP) Summary Form. The form that a PCP uses to order AFC.

Program for All-inclusive Care for the Elderly Organization (PACE). An organization that participates in MassHealth under a contract with EOHHS and the Centers for Medicare & Medicaid Services (CMS) to provide a comprehensive package of medical, health care, and social services to eligible frail elders, as described under Section 1934 (42 U.S.C. 1396u-4) of the Social Security Act and federal PACE regulations at 42 CFR 460.

Rest Home. A facility or distinct units licensed as a level IV by the DPH under 105 CMR 150.000: Licensing of Long-term Care Facilities that are not certified to participate in Medicare or Medicaid and that provides a protective living environment and minimum basic care.

Significant Change. A major change in the member's status that

(1) is permanent;

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

(3) requires a multidisciplinary review or revision of the care plan. A significant change is presumed when a member authorized to receive AFC does not receive AFC for 90 days or more, or when the provider is seeking a change in service payment level.

(Amended by Mass Register Issue 1338, eff. 5/5/2017.)

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