Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 404.000 - Adult Day Health Services › Section 404.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in 130 CMR 404.000 have the meanings
				given in 130 CMR 404.402 unless the context clearly requires a different
				meaning.
Activities of Daily Living (ADL)
-
				fundamental personal care tasks performed daily as part of an individual's
				routine self-care. ADLs include, but are not limited to, eating, toileting,
				dressing, bathing, transferring, and mobility/ambulation.
Adult Day Health (ADH)
- a
				community-based and non-residential service that provides nursing care,
				supervision, and health related support services in a structured group setting
				to MassHealth members who have physical, cognitive, or behavioral health
				impairments. The ADH service has a general goal of meeting the ADL, and/or
				skilled nursing therapeutic needs of MassHealth members delivered by a
				MassHealth agency approved ADH provider that meets the conditions of 130 CMR
				404.000.
Adult Day Health Program
- a
				site-based program that is licensed by the Department of Public Health (DPH)
				under 105 CMR 158.00:
Licensure of Adult Day Health Programs
and that has been reviewed and approved by the MassHealth agency and by other
				appropriate authorities for the provision of ADH for a specific number of daily
				participants. If a provider offers ADH in more than one location, each location
				is a separate ADH program and must meet the provisions of 130 CMR
				404.000.
Basic Payment Level
- the payment rate
				established by MassHealth for a ADH provider's provision of ADH services to
				members who meet the criteria set forth in
				130 CMR
				404.414(D)(1).
Capitated Program
- An ICO, SCO, or
				PACE organization, or any other entity that, pursuant to a contract with EOHHS,
				covers ADH and other medical services for members on a capitated basis.
Clinical Assessment
- the screening
				process of documenting a member's need for ADH using a tool designated by the
				MassHealth agency and which assessment forms the basis for prior authorization
				of ADH.
Complex Payment Level
- the payment
				rate established by the MassHealth agency for an ADH provider's provision of
				ADH services to members who meet the criteria set forth in
				130 CMR 404.414(D)(2)
				.
Department of Public Health
(DPH) - an
				agency of the Commonwealth of Massachusetts, established under M.G.L. c. 17,
				§ 1.
EOHHS
- the Executive Office of Health
				and Human Services established under M.G.L. c. 6A.
Hospital
- a facility that is licensed
				or operated as a hospital by the Massachusetts Department of Public Health or
				the Massachusetts Department of Mental Health that provides diagnosis and
				treatment on an inpatient or outpatient basis for patients who have any of a
				variety of medical conditions.
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 § 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,
				24hour supervision, coordination, and integration for health or rehabilitative
				services to help individuals function at their greatest ability.
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 and 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.
Marketing
- any communication from an
				ADH 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 ADH provider, whether by inducing that member
(1) to retain that ADH provider to provide ADH services to the
				member,
(2) not to retain ADH services from another ADH provider,
				or
(3) to cease receiving ADH services from another ADH
				provider.
Marketing
shall not include choice
				counseling or navigation services provided by community partners pursuant to
				their contracts with EOHHS.
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.
Member
- a person determined by the
				MassHealth agency to be eligible for MassHealth.
Nursing Facility
- an institution (or
				a distinct part of an institution) which 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 the meets the requirements of
				Sections 1919(a), (b), (c) and (d) of the Social Security Act and is licensed
				under and certified by the Massachusetts Department of Public Health.
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)
.
Primary Care Provider (PCP)
- a
				physician or a physician assistant or nurse practitioner who practices under
				the supervision of a physician.
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.
Significant Change
- a major change in
				the member's status that
(1) is permanent or will not normally resolve itself without
				further interventions;
(2) impacts more than one area of the member's health status;
				and
(3) requires an interdisciplinary review or revision of the
				care plan.
A significant change is presumed when a member authorized to
				receive ADH does not receive ADH for 90 days or more, or when the provider is
				seeking a change in service payment level.
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.