130 Mass. Reg. 403.402
The following terms used in 130 CMR 403.000 have the meanings given in 130 CMR 403.402, unless the context clearly requires a different meaning. The reimbursed services defined in 130 CMR 403.402 are not determined by these definitions, but by the application of regulations elsewhere in 130 CMR 403.000 and 130 CMR 450.000: Administrative and Billing Regulations.
Accountable Care Organization (ACO) - an entity that enters into a population-based payment model contract with EOHHS as an accountable care organization, wherein the entity is held financially accountable for the cost and quality of care for an attributed or enrolled member population. ACOs include Accountable Care Partnership Plans, Primary Care ACOs, and MCO-administered ACOs.
Activities of Daily Living (ADL) - activities related to personal care, specifically bathing, grooming, dressing, toileting/continence, transferring/ambulation, and eating.
Branch Office - a location or site from which a home health agency provides services within a portion of the total geographic area served by the parent home health agency. The parent home health agency must provide supervision and administrative control of any branch office on a daily basis.
Calendar Week - seven consecutive days beginning Sunday at midnight and ending Saturday at 11:59 P.M.
Capitated Program - an ICO, SCO, ACO, or PACE organization, or any other entity that, according to a contract with EOHHS, covers home health and other medical services for members on a capitated basis.
Care Management - a function performed by the MassHealth agency or its designee that assesses and reassesses the medical needs of complex-care members and authorizes or coordinates long term services and supports (LTSS) that are medically necessary for such members to remain safely in the community.
Certification Period - a period of no more than 60 days in which the member's physician or ordering non-physician practitioner certified that the plan of care is medically appropriate and necessary.
Clinical Manager - a registered nurse employed by the MassHealth agency or its designee, who performs the in-person assessment of a member for MassHealth coverage of continuous skilled nursing (CSN) services and, if it is determined that CSN services are medically necessary, coordinates the authorization of medically necessary long term services and supports (LTSS) services for the member.
Complex-care Member - a MassHealth member whose medical needs, as determined by the MassHealth agency or its designee, are such that he or she requires a nurse visit of more than two continuous hours of nursing services to remain in the community.
Continuous Skilled Nursing (CSN) Services - skilled nursing care provided by a licensed nurse to complex-care members who require more than two continuous hours of nursing services per day.
Co-vending - an arrangement through which a member's CSN services are provided by one or more home health agencies or independent nurses, with each provider possessing its own MassHealth prior authorization to provide nursing services to the member.
Home Health Agency - a public or private organization that provides nursing and other therapeutic services to individuals whose place of residence conforms to the requirements of 42 CFR 440.70(c). Home health agency providers are governed by 130 CMR 403.000.
Home Health Aide - a person who is employed or contracted by a home health agency and meets the qualifications of a Home Health Aide to perform certain personal-care and other health-related services as described in 130 CMR 403.416(B) and according to 42 CFR 484.80.
Homemaker - a person who performs light housekeeping duties (for example, cooking, cleaning, laundry) for the purpose of maintaining a household.
Household - place of residence where two or more people are living that is in a group home, a residential care home, or other group living situation; at the same street address if it is a single family house that is not divided into apartments or units; or at the same apartment number or unit number if members live in a building that is divided into apartments or units.
Independent Nurse - a licensed nurse who independently enrolls as a provider in MassHealth to provide CSN services. Independent nurse providers are governed by MassHealth regulations at 130 CMR 414.000: Independent Nurse Services.
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 & 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.
Intermittent Skilled Nursing Visits - nursing services provided by a licensed nurse that are necessary to provide targeted skilled nursing assessment for a specific member medical need, and/or discrete procedures and/or treatments, typically for less than two consecutive hours, and limited to the time required to perform those duties.
Long-term Services and Supports (LTSS) - certain MassHealth-covered services intended to enable a member to remain safely in the community. Such services include, but are not limited to, home health, durable medical equipment, oxygen and respiratory equipment, personal-care attendant, and other health-related services as determined by the MassHealth agency or its designee.
Managed Care Organization (MCO) - any entity with which the MassHealth agency contracts under its MCO program to provide, arrange for, and coordinate care and certain other medical services to members on a capitated basis, and is approved by the Massachusetts Division of Insurance as a health maintenance organization (HMO), and is organized primarily for the purpose of providing health care services.
Maintenance Program - repetitive services, required to maintain or prevent the worsening of function, that do not require the judgment and skill of a licensed therapist for safety and effectiveness.
Marketing - any communication from a home health agency 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 home health agency provider, whether by inducing that member
Medical History - a component of the member's medical record that provides a summary of all health-related information about the member. A history includes, but is not limited to, medical and nursing care histories.
Medical Record - documentation, maintained by the home health agency, that includes medical history, diagnoses, physician or ordering non-physician practitioner orders, discipline-specific progress notes, member assessments, the member's plan(s) of care, and other information related to the member in accordance with 130 CMR 403.419(C).
Medical Records Release Form - a signed authorization from the member or the member's parent or legal guardian, if the member is a minor, that allows the designated releasee to access the member's confidential health information from other health-care providers.
Medication Administration Visit - a nursing visit for the sole purpose of administration of medications where the targeted nursing assessment is medication administration and patient response only, and when the member is unable to perform the task due to impaired physical, cognitive, behavioral, and/or emotional issues, no able caregiver is present, the member has a history of failed medication compliance resulting in a documented exacerbation of the member's condition, and/or the task including the route of administration of medication requires a licensed nurse to provide the service. A medication administration visit may include administration of oral, intramuscular, and/or subcutaneous medication or administration of medications other than oral, intramuscular and/or subcutaneous medication, but does not include intravenous administration.
Nurse - a person licensed as a registered nurse or a licensed practical nurse by a state's board of registration in nursing of the state in which they practice.
Nursing Services - the assessment, planning, intervention, and evaluation of goal-oriented nursing care that requires specialized knowledge and skills acquired under the established curriculum of a school of nursing approved by a board of registration in nursing. Such services include only those services that require the skills of a nurse.
Occupational Therapist - a person who is currently licensed by and in good standing with the Massachusetts Division of Professional Licensure, Board of Allied Health Professionals, and is qualified in accordance with 42 CFR 484.4.
Occupational Therapy - therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct, rehabilitate, or prevent, maintain, or slow the worsening of functions that affect the activities of daily living that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Occupational therapy programs are designed to improve quality of life by recovering competence, preventing further injury or disability, and to improve the individual's ability to perform tasks required for independent functioning, so that the individual can engage in activities of daily living.
Occupational Therapy Assistant - a person who is currently licensed and in good standing with the Massachusetts Division of Professional Licensure, Board of Allied Health Professionals, must work under the supervision of a licensed occupational therapist as described in 130 CMR 432.404(B), and is qualified in accordance with 42 CFR 484.4.
Ordering Non-physician Practitioner - a nurse practitioner, physician's assistant, or clinical nurse specialist who is licensed in the state of Massachusetts to perform medical services according to their scope of practice. Ordering non-physician practitioners are also allowed to conduct face-to-face encounters. Nurse midwives are not allowed to order home health services.
Physical Therapist - a person who is currently licensed by and in good standing with the Massachusetts Division of Professional Licensure, Board of Allied Health Professionals, and is qualified in accordance with 42 CFR 484.4.
Physical Therapy - therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct, rehabilitate, or prevent, maintain, or slow the worsening of physical functions that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Physical therapy emphasizes a form of rehabilitation focused on treatment of dysfunctions involving neuromuscular, musculoskeletal, cardiovascular/pulmonary, or integumentary systems through the use of therapeutic interventions to optimize functioning levels.
Physical Therapy Assistant - a person who is currently licensed by and in good standing with the Massachusetts Division of Professional Licensure, Board of Allied Health Professionals, and must work under the supervision of a licensed physical therapist as described in 130 CMR 432.404(A), and is qualified in accordance with 42 CFR 484.4.
Primary Caregiver - the individual, other than the nurse or home health aide, who is primarily responsible for providing ongoing care to the member.
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).
Provider Portal - the online site by which LTSS providers, as applicable, submit all MassHealth LTSS prior authorization requests to a MassHealth designated vendor.
Request and Justification for Nursing and Home Health Aide Services Form - the form describing the nursing and home health aide needs of a member that a home health agency is required to submit to the MassHealth agency or its designee, when requesting prior authorization (PA) for intermittent nursing service through a paper PA.
Request and Justification for Therapy Services and Home Health Aide Services Form - the form describing the therapy and home health aide needs of a member that a home health agency may submit to the MassHealth agency or its designee, when requesting prior authorization for therapy services.
Respite Services - a range of services provided on a short-term or intermittent basis in response to the need for relief of those persons who normally provide this care.
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.
Skilled Nursing Visit - a nursing visit that is necessary to provide targeted skilled nursing assessment for a specific member medical need, and/or discrete procedures and/or treatments, typically for less than two consecutive hours, and limited to the time required to perform those duties.
Speech/Language Therapist (Speech/Language Pathologist) - a person who is currently licensed by and in good standing with the Massachusetts Board of Registration in Speech-language Pathology and Audiology and is qualified in accordance with 42 CRF 484.4.
Speech/Language Therapy - therapy services, including diagnostic evaluation and therapeutic intervention, that are designed to improve, develop, correct, rehabilitate, or prevent, maintain, or slow the worsening of speech/language communication and swallowing disorders that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Speech and language disorders are those that affect articulation of speech, sounds, fluency, voice, swallowing, and those that impair comprehension, spoken, written, or other symbol systems used for communication.
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.
Visit - a personal contact in the member's home or other non-institutional setting, for the purpose of providing a covered service by a registered or licensed nurse, home health aide, or physical, occupational, or speech/language therapist employed by, or contracting with, the home health agency.
130 CMR 403.402