Or. Admin. Code § 411-045-0010 - Definitions
Unless the context indicates otherwise, the following definitions apply to the rules in OAR chapter 411, division 045:
(1) Administrative Hearing - A hearing
related to a denial, reduction, or termination of benefits that is held when
requested by the PACE participant or his or her representative. A hearing may
also be held when requested by a PACE participant who believes a claim for
services was not acted upon with reasonable promptness or believes the payor
took an action erroneously.
(2)
Advance Directive - A process that allows a person to have another person make
health care decisions when he or she is unable to make the decision and tell a
doctor what life sustaining measures to take if he or she is near death.
(3) Aging and People with
Disabilities Division (APD) - A division within the Department that is the
designated State Unit on Aging (SUA) that also administers Medicaid's long-term
care program. APD is responsible for nursing facility and Medicaid home and
community-based services for eligible older adults and individuals with
disabilities. APD includes local offices and the AAAs who have contracted to
perform specific functions of the licensing and enrollment processes.
(4) Alternate Service Settings -
Residential 24-hour care facilities that include, but are not limited to,
residential care facilities, assisted living facilities, adult foster homes,
and nursing facilities.
(5)
Americans with Disabilities Act (ADA) - Federal law defining the civil rights
of persons with disabilities. The ADA requires that reasonable accommodations
be made in employment, service delivery, and facility accessibility.
(6) Ancillary Services - Those medical
services that are medically appropriate to support a covered service under the
PACE benefit package. A list of ancillary services and limitations is specified
in DMAP's Ancillary Services Criteria Guide.
(7) Appeal - A PACE participant's action
taken with respect to any instance where the PACE program reduces, terminates,
or denies a covered service.
(8)
Area Agency on Aging (AAA) - An established public agency within a planning and
service area designated under Section 305 of the Older American's Act that has
responsibility for local administration of Department programs. AAAs contract
with the Department to perform specific activities in relation to PACE programs
including processing of applications for Medicaid and determining the level of
care required under Oregon's State Medicaid Plan for coverage of nursing
facility services.
(9) Assessment
- The determination of a participant's need for covered services. An assessment
involves the collection and evaluation of data by each of the members of the
Interdisciplinary Team pertinent to the participant's health history and
current problems obtained through interview, observation, and record review.
The Assessment concludes with one of the following:
(a) Documentation of a diagnosis providing
the clinical basis for a written care plan; or
(b) A written statement that the participant
is not in need of covered services for a particular condition.
(10) Automated Information System
(AIS) - A computer system that provides information on the current eligibility
status for participants under the Medical Assistance Program.
(11) Care Plan - Service plan as defined in
this rule.
(12) Centers for
Medicare and Medicaid Services (CMS) - Formerly known as the Health Care
Financing Administration (HCFA). The federal agency under the Department of
Health and Human Services that is responsible for approving the PACE program
and joining the state in signing an agreement with the PACE program once it has
been approved as a provider under 42 CFR Part 460 .
(13) Clinical Record - The clinical record
includes, but is not limited to, the medical, social services, dental, and
mental health records of a PACE participant. Clinical records include the
Interdisciplinary Team's records, hospital records, and grievance and
disenrollment records.
(14)
Comfort Care - The provision of medical services or items that give comfort or
pain relief to a participant who has a terminal illness. Comfort care includes
the combination of medical and related services designed to make it possible
for a participant with terminal illness to die with dignity, respect, and with
as much comfort as is possible given the nature of the illness. Comfort care
includes but is not limited to, pain medication, palliative services, and
hospice care including those services directed toward ameliorating symptoms of
pain or loss of bodily function or to prevent additional pain or disability.
These guarantees are provided pursuant to 45 CFR, Chapter XIII, 1340.15. Where
applicable comfort care is provided consistent with Section 4751 OBRA 1990 -
Patient Self-Determination Act and ORS
127.505-127.660 and
127.800-127.897relating to
health care decisions. Comfort care does not include diagnostic or curative
care for the primary illness or care focused on active treatment of the primary
illness and intended to prolong life.
(15) Community Standard- Typical expectations
for access to the health care delivery system in the PACE participant's
community of residence. The Department requires that the health care delivery
system available to PACE participants take into consideration the community
standard and be adequate to meet the needs of PACE participants except where
the community standard is less than sufficient to ensure quality of care.
(16) Covered Services - Those
diagnoses, treatments, and services listed in OAR
410-141-0520. In addition, all
services that are to be covered by Medicare are covered services even if the
services fall below the currently funded line for the Oregon Health Plan.
Covered services also include those services listed in
42 CFR Sections
460.92 and
460.94.
(17) Dentally Appropriate - Services that are
required for prevention, diagnosis, or treatment of a dental condition and that
are:
(a) Consistent with the symptoms of a
dental condition or treatment of a dental condition;
(b) Appropriate with regard to standards of
good dental practice and generally recognized by the relevant scientific
community and professional standards of care as effective;
(c) Not solely for the convenience of the
PACE participant or a provider of the service; and
(d) The most cost effective of the
alternative levels of dental services that may be safely provided to a PACE
participant.
(18)
Dental Emergency Services - Dental services provided for severe pain, bleeding,
unusual swelling of the face or gums, or an avulsed tooth.
(19) Department - The Department of Human
Services.
(20) DHS - Department of
Human Services (DHS).
(21)
Disenrollment - The act of discharging a PACE participant from a PACE program.
After the effective date of disenrollment a PACE participant is no longer
authorized to obtain covered services from the PACE program.
(22) Emergency Services - The health care and
services provided for diagnosis and treatment of a medical condition
manifesting itself by acute symptoms of sufficient severity (including severe
pain) such that a prudent layperson, who possesses an average knowledge of
health and medicine, may reasonably expect the absence of immediate medical
attention to result in placing the health of the individual in serious
jeopardy, serious impairment to bodily functions, or serious dysfunction of any
bodily organ or part.
(23)
Enrollment - A process for the PACE program. A PACE participant's enrollment
with a PACE program indicates that the PACE participant obtains from, or is
referred by, the PACE program for all covered services.
(24) Grievance - A PACE participant's or the
participant's representative's clear expression of dissatisfaction with the
PACE program that addresses issues that are part of the PACE program's
contractual responsibility. The expression states the reason for the
dissatisfaction and may be in whatever form of communication or language that
is used by the participant or the participant's representative.
(25) Health Management Unit (HMU) - The DMAP
unit responsible for adjustments to enrollments and retroactive disenrollments.
(26) Interdisciplinary Team (IDT)
- PACE staff and PACE subcontractors with current and appropriate licensure,
certification, or accreditation who are responsible for assessment and
development of the PACE participant's care plan. An IDT may conduct assessments
of PACE participants and provide services to PACE participants within their
scope of practice, state licensure, or certification. An IDT includes at least
one representative from each of the following groups:
(a) Medical Doctor, Osteopathic Physician,
Nurse Practitioner, or Physician's Assistant;
(b) Registered Nurse or a Licensed Practical
Nurse supervised by a Registered Nurse;
(c) Social Worker with a Master's degree or a
Social Worker with a Bachelor degree who is supervised by a Master's level
Social Worker;
(d) Occupational
Therapist or a Certified Occupational Therapy Assistant supervised by an
Occupational Therapist;
(e)
Recreational Therapist or an Activity Coordinator with two years experience;
(f) Physical Therapist or a
Physical Therapy Assistant supervised by a Physical Therapist;
(g) Dietician and Pharmacist as indicated;
and
(h) In addition to the
positions listed above in subsections (a) to (g) of this section, the IDT
includes the PACE Center Manager, the Home Care Coordinator, Personal Care
Attendant, and the Driver or Transportation Coordinator.
(27) Medicaid - A federal and state funded
portion of the Medical Assistance Program established by Title XIX of the
Social Security Act, as amended and administered in Oregon by the Department of
Human Services.
(28) Medically
Appropriate - Services and medical supplies required for prevention, diagnosis,
or treatment of a health condition that encompasses physical or mental
conditions, or injuries, and that are:
(a)
Consistent with the symptoms of a health condition or treatment of a health
condition;
(b) Appropriate with
regard to standards of good health practice and generally recognized by the
relevant scientific community and professional standards of care as effective;
(c) Not solely for the convenience
of a PACE participant or a provider of the service or medical supplies; and
(d) The most cost effective of the
alternative levels of medical services or medical supplies that may be safely
provided to a PACE participant in the PACE program's judgment.
(29) Medicare - The federal health
insurance program for people who are 65 or older, certain younger people with
disabilities, and people with End-Stage Renal Disease (permanent kidney failure
requiring dialysis or a transplant, sometimes called ESRD).
(30) Non-Covered Services - Services or items
the PACE program is not responsible for providing or paying for.
(31) Non-Participating Provider - A provider
who does not have a contractual relationship with the PACE program, i.e., is
not on their panel of providers.
(32) Division of Medical Assistance Programs
(DMAP) - The division of the Oregon Health Authority responsible for
coordinating medical assistance programs. DMAP writes and administers the state
Medicaid rules for medical services, contracts with providers, maintains
records of participant eligibility and processes, and pays DMAP providers and
contractors such as PACE.
(33)
Oregon Health Plan (OHP) - The Medicaid demonstration project that expands
Medicaid eligibility. The Oregon Health Plan relies substantially upon a
prioritization of health services and managed care to achieve the policy
objectives of access, cost containment, efficacy, and cost effectiveness in the
allocation of health resources.
(34) PACE - The Program of all Inclusive Care
for the Elderly (PACE) is a managed care entity that provides medical, dental,
mental health, social services, transportation, and long-term care services to
persons age 55 and older on a prepaid capitated basis in accordance with a
signed agreement with the Department and CMS.
(35) PACE Participant - An individual who
meets the Department criteria for nursing facility care and is enrolled in the
PACE program. These individuals are eligible under the following categories:
(a) AB/AD (Assistance to Blind and Disabled)
with Medicare - Individuals with concurrent Medicare eligibility with income
under Medicaid eligibility;
(b)
AB/AD without Medicare - Individuals without Medicare with income under
Medicaid eligibility;
(c) OAA (Old
Age Assistance) with Medicare - Individuals with concurrent Medicare Part A or
Medicare Parts A and B eligibility with income under Medicaid eligibility;
(d) OAA without Medicare -
Individuals without Medicare with income under Medicaid eligibility; or
(e) Private - Individuals with or
without Medicare with incomes over Medicaid eligibility.
(36) Participating Provider - An individual,
facility, corporate entity, or other organization that supplies medical,
dental, or mental health services or items who have agreed to provide those
services or items and to bill in accordance with a signed agreement with a PACE
program.
(37) Preventive Services
- Those services as defined under Expanded Definition of Preventive Services in
OAR 410-141-0480 and
410-141-0520.
(38) Primary Care Provider (PCP) - A medical
practitioner who has responsibility for supervising and coordinating initial
and primary care within his or her scope of practice for PACE participants.
Primary Care Providers initiate referrals for care outside their scope of
practice that may include consultations and specialist care, and assure the
continuity of medically or dentally appropriate care.
(39) Quality Improvement - Quality
improvement is the effort to improve the level of performance of a key process
or processes in health and long term care. A quality improvement program
measures the level of current performance of the processes, finds ways to
improve the performance, and implements new and better methods for the
processes. Quality Improvement includes the goals of quality assurance, quality
control, quality planning, and quality management in health care. Quality of
care reflects the degree to which health services for individuals and
populations increases the likelihood of desired health outcomes and is
consistent with current professional knowledge.
(40) Representative - A person who can assist
the PACE participant in making administrative related decisions such as, but
not limited to, completing an enrollment application, filing grievances, and
requesting disenrollment. A representative may be, in the following order of
priority, a person who is designated as the PACE participant's health care
representative, a court-appointed guardian, a spouse, other family member as
designated by the PACE participant, the Individual Service Plan Team (for
individuals with intellectual or developmental disabilities), or a
Department/AAA case manager or other Department designee. This definition does
not apply to health care decisions unless the representative has legal
authority to make such decisions.
(41) Seniors and People with Disabilities -
Aging and People with Disabilities as defined in this rule.
(42) Service Area - The geographic area
defined by Federal Information Processing Standards (FIPS) codes, or other
criteria determined by the Department, in which the PACE program has agreed to
provide services under the Oregon PACE program regulations and the Federal PACE
regulations 42 CFR Part 460. The service area is defined in the PACE contract
with the Department.
(43) Service
Plan - An individualized, written plan that addresses all relevant aspects of a
participant's health and socialization needs that is developed by the
Interdisciplinary Team with the involvement of the participant and the
participant's representative. A service plan is based on the findings of the
participant's assessments and defines specific service and treatment goals and
objectives, proposed interventions, and the measurable outcomes to be achieved.
A service plan is reviewed at least every four months or as indicated by a
change in the participant's condition.
(44) Triage - Evaluations conducted to
determine whether or not an emergency condition exists, and to direct the DMAP
member to the most appropriate setting for medically appropriate care.
(45) Urgent Care Services -
Covered services required to prevent a serious deterioration of a PACE
participant's health that results from an unforeseen illness or an injury and
for dental services necessary to treat such conditions as lost fillings or
crowns. Services that may be foreseen by the individual are not considered
urgent services.
(46) Valid Claim:
(a) An invoice received by the PACE program
for payment of covered health care services rendered to an eligible PACE
participant that:
(A) May be processed
without obtaining additional information from the provider of the service or
from a third party; and
(B) Has
been received within the time limitations prescribed in these rules.
(b) A "valid claim" is synonymous
with the federal definition of a "clean claim" as defined in
42 CFR
447.45(b).
(47) Valid Pre-Authorization - A
request, received by the PACE program for approval of covered health care
services provided by a non-participating provider to an eligible individual,
that may be processed without obtaining additional information from the
provider of the service or from a third party.
Notes
Stat. Auth.: ORS 410.090
Stats. Implemented: ORS 410.070
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