Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 512.00 - Nursing Facility User Fees › Section 512.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				101 CMR
				512.00, unless the context otherwise requires, terms
				have the following meanings.
Assessment
. The total payment due each
				quarter for each non-Medicare patient day, as set forth in
				101 CMR
				512.00.
Centers for Medicare and Medicaid Services
				(CMS)
. The federal agency under the U.S. Department of Health and
				Human Services that is responsible for administering the Medicare and Medicaid
				programs.
Changes in Ownership (CHOW)
. Changes
				in ownership of a nursing facility will, in the case of a corporation, mean
				transfer of a majority of the stock thereof, and in all other cases, a transfer
				of a majority interest therein, pursuant to M.G.L. c. 111, § 71.
Continuing Care Retirement Community
				(CCRC)
. A community that furnishes board and lodging together with
				nursing services, medical services, or other health-related services,
				regardless of whether or not the lodging and services are provided at the same
				location, to individuals, other than those related by consanguinity or affinity
				to the person furnishing such care, pursuant to a contract effective for the
				life of the individual or for a period in excess of one year, and that has
				filed disclosure information with the Massachusetts Executive Office of Elder
				Affairs pursuant to M.G.L. c. 93, § 76(e). Licensed nursing facility beds
				not under the direct control of the board of the CCRC are not considered part
				of the CCRC.
Department of Public Health (DPH)
. An
				agency of the Commonwealth of Massachusetts, established under M.G.L. c. 17,
				§ 1.
Executive Office of Health and Human Services
				(EOHHS)
. The executive department of the Commonwealth of
				Massachusetts established under M.G.L. c. 6A, § 2 that, through the
				Department of Elder Affairs and other agencies within EOHHS, as appropriate,
				operates and administers the programs of medical assistance and medical
				benefits under M.G.L. c. 118E and that serves as the single state agency under
				§ 1902(a)(5) of the Social Security Act.
Facility
. A nursing facility licensed
				by DPH under M.G.L. c. 111, § 71, including nursing or convalescent homes,
				an infirmary maintained in a town, a charitable home for the aged, and
				transitional care units.
Fiscal Year (FY)
. The state fiscal
				year from July 1st through June
				30th.
MassHealth Program (MassHealth)
. The
				medical assistance benefits plans operated and administered by EOHHS pursuant
				to M.G.L. c. 118E, § 1
et seq.
and
				42 U.S.C. §
									1396
et seq.
Title XXI of
				the Social Security Act (42
				U.S.C. 1397), and other applicable laws and
				waivers to provide and pay for medical services to eligible members
				(Medicaid).
Medicaid Bed Day
. A patient day for
				which the primary payer is either MassHealth or a non-Massachusetts Medicaid
				program, including patient days paid for by a Senior Care Organization (SCO),
				One Care, the Program for All-inclusive Care for the Elderly (PACE), or a
				MassHealth-affiliated Accountable Care Organization (ACO). Medicaid bed days
				include patient days of individuals who elect hospice care for which Medicaid
				pays for room and board.
Medicare
. The federal health insurance
				program for people who are 65 years of age or older, certain younger people
				with disabilities, and people with end-stage renal disease (permanent kidney
				failure requiring dialysis or a transplant, sometimes called ESRD) established
				by Title XVIII of the Social Security Act.
Medicare Patient Day
. A patient day
				covered by Medicare Part A under either an indemnity fee-for-service
				arrangement (also known as "original Medicare") or a Medicare managed care plan
				(also known as Medicare Advantage plan).
MassHealth-affiliated 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.
Non-Medicare Patient Day
. A patient
				day that is not covered by Medicare Part A under either an indemnity
				fee-for-service arrangement (also known as "original Medicare") or a Medicare
				managed care plan (also known as Medicare Advantage plan). Non-Medicare patient
				days do not include residential care patient days
One Care (also known as an 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 CMS and has been designated as
				an ICO to provide services to dual eligible individuals under M.G.L. c. 118E.
				ICOs are responsible for providing enrollees with the full continuum of
				Medicare- and MassHealth-covered services.
Patient Day
. A day of care provided to
				an individual by a facility regardless of whether or not the facility has been
				paid for the day. The date an individual is admitted to the facility is a
				patient day. The date an individual is discharged is not a patient day, unless
				the individual is admitted and discharged on the same day. Patient days include
				days for which a facility reserves and customarily charges for a vacant bed for
				an individual temporarily placed in a different care situation ("bed hold
				days"). Patient days also include Medicaid "medical leave of absence days" and
				"non-medical leave of absence days" in accordance with
				130
				CMR 456.425:
Medical Leave of
				Absence: Introduction
through
				130
				CMR 456.433:
Nonmedical Leave of
				Absence: Payment.
Program of All-inclusive Care for the Elderly
				(PACE)
. A comprehensive service delivery and financing model that
				integrates medical and long-term services and supports (LTSS) under dual
				capitation agreements with Medicare and Medicaid as described under federal
				regulations for PACE at 42
				CFR 460. The PACE program is open to eligible
				MassHealth members 55 years of age and older who meet MassHealth's
				skilled-nursing-facility level of care criteria and reside in a PACE service
				area.
Residential Care
. The minimum basic
				care and services and protective supervision required by DPH in accordance with
				105 CMR
				150.000:
Licensing of Long-term Care
				Facilities
for residents who do not routinely require nursing or other
				medically related services.
Senior Care Organization (SCO)
. An
				organization that participates in MassHealth under a contract with the
				MassHealth agency and the Centers for Medicare & Medicaid Services (CMS) to
				provide a comprehensive network of medical, health-care, and social-service
				providers and that integrates components of care, either directly or through
				subcontracts. Senior Care Organizations are responsible for providing enrollees
				with the full continuum of Medicare- and MassHealth-covered
				services.