130 CMR, § 610.004
For purposes of 130 CMR 610.000, the following terms are defined as follows:
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.
Accountable Care Partnership Plan (ACPP) - a type of ACO with which the MassHealth agency contracts under its ACO 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.
Acting Entity - the MassHealth agency, a MassHealth managed care contractor, or a nursing facility responsible for making a determination that can be appealed. The acting entity also includes the Department of Mental Health and the Department of Developmental Services when making a PASRR determination. The acting entity includes the Department of Developmental Services for purposes of denial, suspension, reduction, modification, or termination of services or for failure to act on a waiver participant's request for services for the following HCBS Waiver Programs: Acquired Brain Injury - Residential Habilitation (ABI-RH) and Moving Forward Plan - Residential Supports (MFP-RS). The acting entity includes the Massachusetts Rehabilitation Commission for purposes of denial, suspension, reduction, modification, or termination of services or for failure to act on a waiver participant's request for services for the following HCBS Waiver Programs: Acquired Brain Injury - Nonresidential Habilitation (ABI-N), Moving Forward Plan - Community Living (MFP-CL), and Traumatic Brain Injury (TBI).
Adequate Notice - a notice concerning an intended appealable action that states the intended action by the MassHealth agency; the reason or reasons for the intended action; the MassHealth regulation supporting the action; an explanation of the right to request a fair hearing; and the circumstances under which assistance is continued as set out in 130 CMR 610.026.
Appealable Action - certain actions or inactions, as further described in 130 CMR 610.032, by the MassHealth agency, a MassHealth managed care contractor, a nursing facility, the Department of Mental Health, or the Department of Developmental Services.
Appeal Representative -
(1) a person or an organization who agrees to comply with applicable rules regarding confidentiality and conflicts of interest in the course of representing an applicant or member, provided such person or organization
(a) has provided the BOH with written authorization from the applicant or member to act responsibly on his or her behalf during the appeal process; or
(b) has, under applicable law, authority to act on behalf of an applicant or member at an appeal or otherwise in making decisions related to health care or payment for health care including, but not limited to, a guardian, conservator, personal representative of the estate of an applicant or member, holder of power of attorney, or an invoked health care proxy; or
(2) a person or organization who has been designated an authorized representative, as defined in 130 CMR 610.004: Authorized Representative, pursuant to a valid Authorized Representative Designation Form.
Appellant - an applicant, member, or nursing facility resident requesting a fair hearing, including individuals who are appealing a PASRR determination. An appellant may also include a community spouse of an institutionalized applicant when the community spouse is exercising a fair hearing appeal right that he or she has under 130 CMR 520.016: Long-term-care: Treatment of Assets or 130 CMR 520.017: Right to Appeal the Asset Allowance or Minimum-monthly-maintenance-needs Allowance.
Applicant - a person, including a waiver applicant, who has applied or attempted to apply for an assistance program administered by the MassHealth agency.
Application - an application as defined in 130 CMR 501.001: Definition of Terms and 130 CMR 515.001: Definition of Terms.
Assistance - any medical assistance or benefits provided to a member by the MassHealth agency.
Authorized Representative - an authorized representative as defined in 130 CMR 501.001: Definition of Terms and 130 CMR 515.001: Definition of Terms.
Behavioral Health Contractor - the entity contracted with EOHHS to provide, arrange for, and coordinate behavioral health care and other services to members on a capitated basis.
Board of Hearings (BOH) - the designated hearing unit within the Executive Office of Health and Human Services (EOHHS) Office of Medicaid.
Department of Mental Health (DMH) - the state agency organized under M.G.L. c. 19, or its agent.
Department of Developmental Services (DDS) - the state agency organized under M.G.L. c. 19B, or its agent.
Director - the Director of BOH (also known as BOH Director).
Discharge - the removal from a nursing facility of an individual who is a resident where the discharging nursing facility ceases to be legally responsible for the care of that individual.
Dual Eligible Individual - for purposes of the Duals Demonstration Program, a MassHealth member who meets all of the following criteria:
(1) is 21 through 64 years of age at the time of enrollment in the Duals Demonstration Program;
(2) is eligible for MassHealth Standard as defined in 130 CMR 450.105(A): MassHealth Standard or MassHealth Common Health as defined in 130 CMR 450.105(E): MassHealth Common Health;
(3) is enrolled in Medicare Parts A and B, is eligible for Medicare Part D, and has no access to other health insurance that meets the basic-benefit level as defined in 130 CMR 501.001: Definition of Terms; and
(4) lives in a designated service area of an ICO.
Duals Demonstration Program - the MassHealth state demonstration to integrate care for Dual Eligible Individuals, also known as One Care.
Fair Hearing - the process for appeals conducted according to 130 CMR 610.000 to determine the legal rights, duties, benefits, or privileges of applicants, members, or nursing facility residents.
Fair Hearing Regulations - the regulations at 130 CMR 610.000.
Health Connector - the Commonwealth Health Insurance Connector Authority established under M.G.L. c. 176Q.
Hearing - a fair hearing.
Hearing Officer - an impartial and independent person designated by the BOH Director to conduct hearings and render decisions pursuant to 130 CMR 610.000.
Home- and Community-based Services (HCBS) Waiver Program - one of the following programs established pursuant to 42 USC 1396n: Acquired Brain Injury - Residential Habilitation (ABI-RH); Acquired Brain Injury - Nonresidential Habilitation (ABI-N); Young Children with Autism; Persons with an Intellectual Disability - Intensive Supports; Persons with an Intellectual Disability - Community Living; Persons with an Intellectual Disability - Adult Supports; Frail Elder Waiver (FEW); Moving Forward Plan - Residential Supports (MFP-RS); Moving Forward Plan - Community Living (MFP-CL); and Traumatic Brain Injury (TBI).
Integrated Care Organization (ICO, also known as a One Care Plan) - 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 the Executive Office of Health and Human Services (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.
Independent Review Entity (IRE) - the external review entity for the Centers for Medicare & Medicaid Services (CMS) appeals.
Interpreter - a person who is either a Qualified Interpreter for an Individual with Limited English, or a Qualified Interpreter for an Individual with a Disability as defined in 130 CMR 610.004.
Managed Care Contractor - any MassHealth-contracted managed care organization (MCO), including a SCO or an ICO, or behavioral health contractor.
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.
Massachusetts Rehabilitation Commission (MRC) - the state agency organized under M.G.L. c. 6, § 74, or its agent.
MassHealth - the medical assistance and benefit programs administered by the MassHealth agency 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.
MassHealth Agency - the Executive Office of Health and Human Services in accordance with the provisions of M.G.L. c. 118E.
Member - a person who is or had been receiving assistance under a program administered by the MassHealth agency.
Nursing Facility - a Medicare- or Medicaid-certified nursing facility or certified unit within a nursing facility that is licensed by the Department of Public Health to operate in Massachusetts.
Party - the appellant, the managed care contractor, the nursing facility as respondent in a nursing facility initiated transfer, discharge, or failure to readmit the respondent to a complaint of coercive behavior, the MassHealth agency, DMH, MRC, or DDS.
PASRR Determination - a determination, made by DMH or DDS, that an individual does or does not require the level of services provided by a nursing facility or that the individual does or does not require specialized services as defined by 42 CFR 483.120.
PASRR Evaluation - the medical review of an individual for mental illness, developmental disability, or conditions related to developmental disability and conducted pursuant to 42 CFR 483 Subpart C.
Policy Memoranda - written explanations issued by the Medicaid director or the General Counsel's office, of the MassHealth agency's intent and interpretation or application of its regulations under 130 CMR, or a written explanation, issued by the Health Connector or its designee, of the Health Connector's intent and interpretation of its regulations under 956 CMR.
Preadmission Screening and Resident Review (PASRR) - a federally mandated program for screening individuals seeking admission to and residents of Medicaid-certified nursing facilities for mental illness, developmental disability, or conditions related to developmental disability. The federal requirements for PASRR are provided at 42 CFR 483 Subpart C and 42 U.S.C. 1396r(e)(7).
Provider - any entity that furnishes medical services to MassHealth members.
Qualified Interpreter for an Individual with a Disability -
(1) A qualified interpreter for an individual with a disability is an interpreter who via a remote interpreting service or an on-site appearance
(a) adheres to generally accepted interpreter ethics principles, including client confidentiality; and
(b) is able to interpret effectively, accurately, and impartially, both receptively and expressively, using any necessary specialized vocabulary, terminology, and phraseology.
(2) For an individual with a disability, qualified interpreters can include, for example, sign language interpreters, oral transliterators (individuals who represent or spell in the characters of another alphabet), and cued language transliterators (individuals who represent or spell by using a small number of handshapes).
Qualified Interpreter for an Individual with Limited English Proficiency - an interpreter who via a remote interpreting service or an on-site appearance
(1) adheres to generally accepted interpreter ethics principles, including client confidentiality;
(2) has demonstrated proficiency in speaking and understanding both spoken English and at least one other spoken language; and
(3) is able to interpret effectively, accurately, and impartially, both receptively and expressly, to and from such language(s) and English, using any necessary specialized vocabulary, terminology, and phraseology.
Record Open - a period of time determined by the hearing officer that, if allowed by the hearing officer within his or her discretion, permits either party to a fair hearing the opportunity to submit post-hearing documentation, relevant evidence, or legal arguments.
Resident - an individual who lives in a nursing facility, regardless of whether he or she is a MassHealth member.
Resident Record - that portion of a nursing facility's records in which the nursing facility has documented the reason for an intended discharge or transfer of a resident.
Rural Service Area - any geographic area other than an urban area, as that term is defined in 42 CFR 412.62(f)(ii).
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-Medicare-covered services.
Timely Notice - adequate notice of an intended appealable action by the MassHealth agency that meets the requirements set forth in 130 CMR 610.015(A).
Timely Request - a request for a fair hearing received by BOH within the timely notice period set forth in 130 CMR 610.015(B).
Transfer - except for the movement of a resident within the same facility from one certified bed to another bed with the same certification, a transfer is the movement of a resident from
(1) a Medicaid- or Medicare-certified bed to a noncertified bed;
(2) a Medicaid-certified bed to a Medicare-certified bed;
(3) a Medicare-certified bed to a Medicaid-certified bed;
(4) one nursing facility to another nursing facility; or
(5) a nursing facility to a hospital, or any other institutional setting.
Waiver Applicant - a person who submits an application for enrollment in a HCBS Waiver Program.
Waiver Participant - a member who is enrolled in a HCBS Waiver Program.
130 CMR, § 610.004