Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 501.000 - Health Care Reform: MassHealth: General Policies › Section 501.001 - Definition of Terms

Current through Register 1525, July 5, 2024
The terms listed in
				130
				CMR 501.001 have the following meanings for
				the purposes of MassHealth, as described in
				130 CMR
				501.000 through
				508.000. In the event that
				a definition conflicts with federal law, the federal law supersedes.
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
- 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 which is approved by the Massachusetts
				Division of Insurance as a health-maintenance organization (HMO) and which is
				organized primarily for the purpose of providing health care services.
Access to Health Insurance
- the
				ability to obtain employer-sponsored health insurance for an uninsured family
				member where an employer would contribute at least 50% of the premium cost, and
				the health insurance offered would meet the basic-benefit level.
American Indian or Alaska Native
- a
				person who
(1) is a member of a
			 federally recognized tribe, band, or group as defined in Title 25 of
			 U.S.C.;
(2) is an Eskimo, Aleut, or
			 other Alaska Native enrolled by the Secretary of the Interior, pursuant to the
			 Alaska Native Claims Settlement Act at
			 43 U.S.C.
			 1601
et seq
.; or
(3) has been determined eligible to receive
			 health care services from Indian Health Care Providers as an Indian pursuant to
			 42 CFR
			 136.12 or Title V of the Indian Health Care
			 Improvement Act.
Appeal
- a written request, by an
				aggrieved applicant or member, for a fair hearing.
Appeal Representative
- an Appeal
				Representative as defined in
				130
				CMR 610.004:
Definitions
.
Applicant
- an individual who
				completes and submits an application for MassHealth.
Application
- a request for health
				benefits that is received by the MassHealth agency and includes all required
				information and a signature by the applicant or their authorized
				representative. The application may be submitted at
www.MAHealthConnector.org
, or
				the applicant may complete a paper application, complete a telephone
				application, or apply in person at a MassHealth Enrollment Center (MEC).
Authorized Representative
(1) a person or an organization identified as
			 the authorized representative of an applicant or member in a completed
			 Authorized Representative Designation Form or another form prescribed by the
			 MassHealth agency that has been signed by the authorized representative and, if
			 applicable, the applicant or member and submitted to the MassHealth agency and
			 in which the authorized representative agrees to comply with applicable rules
			 regarding confidentiality and conflicts of interest in the course of
			 representing the applicant or member; provided that such person or organization
			 must be
(a) a person or organization
			 designated by the applicant or member in writing to act responsibly on their
			 behalf in connection with the eligibility process and other ongoing
			 communications with the MassHealth agency;
(b) a person acting responsibly on behalf of
			 the applicant or member and who is sufficiently aware of such applicant's or
			 member's circumstances to assume responsibility for the accuracy of the
			 statements made on their behalf during the eligibility process and in other
			 communications with the MassHealth agency, such as a family member or friend;
			 provided that the applicant or member in this case cannot provide written
			 designation and does not otherwise have an individual who can act on their
			 behalf such as an existing authorized representative, guardian, conservator,
			 personal representative of the estate, holder of power of attorney, or an
			 invoked health care proxy; or
(c) a
			 person who has, under applicable law, authority to act on behalf of the
			 applicant or member 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.