Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 304.00 - Rates For Community Health Centers › Section 304.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				101 CMR
				304.00, unless the context requires otherwise, terms
				have the meanings in
				101
				CMR 304.02.
340B Drug Pricing Program
. A program
				established by Section 340B of Public Health Law 102-585, the Veterans Health
				Act of 1992.
Community Health Center (CHC)
. A
				facility licensed as a freestanding clinic by the Massachusetts Department of
				Public Health pursuant to M.G.L. c. 111, § 51 and, for the purposes of
				rates paid by MassHealth, meeting the definition and requirements established
				under
				130 CMR
				405.000:
Community Health Center
				Services
, that provides comprehensive ambulatory services and that is
				not financially or physically an integral part of a hospital.
Cost Report
. The document used to
				report cost and other financial and statistical data in a format requested by
				and approved by the Center for Health Information and Analysis or EOHHS.
Early and Periodic Screening, Diagnostic and
				Treatment (EPSDT) Services
. A program of health screening and
				other medical services for publicly aided individuals younger than 21 years old
				as required by federal law. Payment for such services is in accordance with
				101
				CMR 304.04.
Emergency Care
. Medical care required
				immediately due to illness or injury with symptoms of sufficient severity that
				a prudent layperson would believe there is an immediate threat to life or high
				risk of permanent damage to the individual's health. Emergency conditions are
				those that require immediate medical treatment at the most accessible hospital
				equipped to provide emergency services. Emergency care does not include
				elective, primary, or urgent care.
Enhanced Global Delivery
. The
				provision and supervision of case management, perinatal counseling (including,
				but not limited to, obstetrical-risk assessment and monitoring), in addition to
				pelvic or cesarean delivery, all routine prenatal visits, and one postpartum
				visit.
EOHHS.
The Executive Office of Health
				and Human Services, established under M.G.L. c. 6A.
Governmental Unit
. The Commonwealth of
				Massachusetts and any department, agency, board, commission, division, or
				political subdivision of the Commonwealth.
Group Behavioral Health Visit
. A
				session conducted between two or more patients and an independently licensed
				mental or behavioral health clinician, a licensed mental or behavioral health
				clinician with supervision as required under such practitioners' licensure
				requirements, or an unlicensed clinician who completed a masters from an
				accredited educational institution and such degree allows eligibility for
				licensure as a behavioral health practitioner qualified to deliver outpatient
				behavioral health services, including clinical social work, mental health
				counseling, psychology, rehabilitative counseling or counseling education, and
				who is under appropriate supervision, and who must be actively moving toward
				licensure, within the community health center setting, conducted in-person or
via
a clinically appropriate telehealth modality in accordance
				with formal written guidance issued by MassHealth or EOHHS, for the purposes of
				examination, diagnosis or treatment for each patient in the session, and
				lasting a minimum of 30 minutes.
Group Medical Visit
. A session
				conducted between two or more patients and a physician other than a
				psychiatrist; a physician assistant; a nurse practitioner; or a registered
				nurse, conducted in-person or
via
a clinically appropriate
				telehealth modality in accordance with formal written guidance issued by
				MassHealth or EOHHS, to introduce appropriate health care topics that could
				include, but are not limited to, preventive medicine approaches to personal
				health and safety and to present self-help and personal management information
				concerning family medicine, adult medicine, sex education, and chronic
				illness.
Individual Behavioral Health Visit
. A
				meeting between a patient and an independently licensed mental or behavioral
				health clinician, a licensed mental or behavioral health clinician with
				supervision as required under such practitioners' licensure requirements, or an
				unlicensed clinician who completed a masters from an accredited educational
				institution and such degree allows eligibility for licensure as a behavioral
				health practitioner qualified to deliver outpatient behavioral health services,
				including clinical social work, mental health counseling, psychology,
				rehabilitative counseling or counseling education, and who is under appropriate
				supervision, and who must be actively moving toward licensure, within the
				community health center setting, conducted face-to-face or
via
a clinically appropriate telehealth modality in accordance with formal written
				guidance issued by MassHealth or EOHHS, for purposes of psychological
				assessment, diagnosis or treatment, and lasting a minimum of 16 minutes.
Individual Dental Visit
. A meeting
				between a patient and a clinician licensed to provide dental services payable
				under
				101 CMR
				314.00:
Dental Services
within the
				community health center setting, conducted face-to-face or
via
a clinically appropriate telehealth modality in accordance with formal written
				guidance issued by MassHealth or EOHHS, for purposes of providing such dental
				services and for which the CHC dental add-on, as described under
				101
				CMR 304.04(2)(b)1., is
				applied.
Individual Medical Visit
. A meeting
				between a patient and a physician other than a psychiatrist, a physician
				assistant, a nurse practitioner, or a registered nurse within the community
				health center setting, conducted face-to-face or
via
a
				clinically appropriate telehealth modality in accordance with formal written
				guidance issued by MassHealth or EOHHS, for purposes of examination, diagnosis,
				or treatment.
Individual Mental Health Visit
. A
				meeting between a patient and either a psychiatrist or an advanced practice
				registered nurse (APRN) with a graduate degree and advanced training in
				psychiatric care (a psychiatric clinical nurse specialist or a psychiatric
				mental health nurse practitioner) within the community health center setting,
				conducted face-to-face or
via
a clinically appropriate
				telehealth modality in accordance with formal written guidance issued by
				MassHealth or EOHHS, for purposes of examination, diagnosis, or
				treatment.
Industrial Accident Patient
. A person
				who receives medical services for which persons, corporations, or other
				entities are in whole or part liable under M.G.L. c. 152 (the Workers'
				Compensation Act).
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.
Nurse-midwife Medical Visit
. A meeting
				between a patient and a nurse-midwife for prenatal and postpartum services,
				conducted at a community health center or
via
a clinically
				appropriate telehealth modality in accordance with formal written guidance
				issued by MassHealth or EOHHS. If a community health center chooses to be
				reimbursed by the enhanced global delivery rate set forth in
				101 CMR
				316.00:
Rates for Surgery and
				Anesthesia
, a nurse-midwife medical visit is not reimbursable.
Primary or Elective Care
. Medical care
				required by individuals or families that is appropriate for the maintenance of
				health and the prevention of illness. This care includes, but is not limited
				to, physical examination, diagnosis and management of illness, ongoing health
				maintenance, accident prevention, and referral when necessary. This care does
				not require the specialized resources of a hospital emergency
				department.
Publicly Aided Individual
. A person
				who receives health care and other services for which a governmental unit is in
				whole or in part liable under a statutory program of public assistance.
Purchaser under M.G.L. c. 152
. An
				insurance company, self-insurer, or worker's compensation agent of a department
				of the Commonwealth, county, city, or district that purchases medical services
				subject to M.G.L. c. 152, § 1.
Supporting Services
. Services
				including, but not limited to, health education, health outreach, medical
				social work services, nutrition services (other than the WIC program), and
				translation services.
Urgent Care
. Services required
				promptly to prevent impairment of health due to symptoms that a prudent
				layperson would believe require medical attention, but are not life threatening
				and do not pose a high risk of permanent damage to an individual's health.
				Urgent care does not include emergency care or primary or elective care.