Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 613.00 - Health Safety Net Eligible Services › Section 613.02 - Definitions

Current through Register 1525, July 5, 2024
As used in 101 CMR 613.00, unless the context otherwise
				requires, terms have the following meanings. All defined terms in 101 CMR
				613.00 are capitalized.
340B Provider
. An Acute Hospital or
				Community Health Center eligible to purchase discounted drugs through a program
				established by § 340B of United States
				Public Law
				102-585, the Veterans Health Act of 1992,
				permitting certain grantees of federal agencies access to reduced cost drugs
				for their Patients, and registered and listed as a 340B Pharmacy within the
				United States Department of Health and Human Services, Office of Pharmacy
				Affairs database. Pharmacy services may be provided by a 340B Provider at
				on-site or off-site locations.
Acute Hospital
. A hospital licensed
				under M.G.L. c. 111, § 51 that contains a majority of medical-surgical,
				pediatric, obstetric, and maternity beds, as defined by the Department of
				Public Health.
Administrative Day
. A day of inpatient
				hospitalization on which a Patient's care needs can be provided in a setting
				other than an inpatient Acute Hospital in accordance with the standards in 130
				CMR 415.000:
Acute Inpatient Hospital Services
and on which
				the Patient is clinically ready for discharge.
Adult Dental Services
. Dental services
				provided to individuals 21 years of age and older and billed using the codes
				listed in the Health Safety Net claims specifications for Acute Hospitals and
				Community Health Centers.
Ancillary Services
. Nonroutine
				services for which charges are customarily made in addition to routine charges
				that include, but are not limited to, laboratory, diagnostic and therapeutic
				radiology, surgical services, and physical, occupational, or speech-language
				therapy. Generally, ancillary services are billed as separate items when the
				Patient receives these services.
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 his or her authorized
				representative. The application may be submitted online 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). The
				date of application for an online, telephonic, or in-person application is the
				date the application is submitted to the MassHealth Agency. The date of
				application for a paper application that is either mailed or faxed is the date
				the application is received by the MassHealth Agency.
Assets
. As defined in
				130
				CMR 515.001:
Definition of
				Terms
.
Bad Debt
. An account receivable based
				on services furnished to a Patient that is
(a) regarded as uncollectible, following
			 reasonable collection efforts consistent with the requirements in
			 101
			 CMR 613.06;
(b) charged as a credit loss;
(c) not the obligation of a governmental unit
			 or the federal government or any agency thereof; and
(d) not a Reimbursable Health
			 Service.
Caretaker Relative
. An adult who is
				the primary care giver for a child, is related to the child by blood, adoption,
				or marriage, or is a spouse or former spouse of one of those relatives, and
				lives in the same home as that child, provided that neither parent is living in
				the home.
Charge
. The uniform price for a
				specific service charged by a Provider.
Children's Medical Security Plan
				(CMSP)
. A program of primary and preventive pediatric health care
				services for eligible children, from birth through 18 years old, administered
				by the MassHealth Agency pursuant to M.G.L. c. 118E, § 10F.
Collection Action
. Any activity by
				which a Provider or designated agent requests payment for services from a
				Patient, a Patient's guarantor, or a third-party responsible for payment.
				Collection Actions include activities such as preadmission or pretreatment
				deposits, billing statements, collection follow-up letters, telephone contacts,
				personal contacts, and activities of collection agencies and attorneys.
Community Health Center
. A health
				center operating in conformance with the requirements of § 330 of United
				States Public Law 95-626, including a Community Health Center that files a cost
				report as requested by the Center for Health Information and Analysis. Such a
				health center must
(a) be licensed as
			 a freestanding clinic by the Massachusetts Department of Public Health pursuant
			 to M.G.L. c. 111, § 51;
(b)
			 meet the qualifications for certification (or provisional certification) by the
			 MassHealth Agency and enter into a Provider agreement pursuant to 130 CMR
			 405.000:
Community Health Center Services
; and
(c) operate in conformance with the
			 requirements of 42 U.S.C.
			 §
									254b.
Confidential Services
. Services for
				the treatment of sexually transmitted diseases provided under M.G.L. c. 112,
				§ 12F and family planning services provided under M.G.L. c. 111, §
				24E.
Countable Income
. Income as defined in
				101
				CMR 613.05(1)(b).
Dental-only Low Income Patient
. An
				uninsured Low Income Patient for whom payment from the Health Safety Net Trust
				Fund is only allowable for dental services, as specified in
				101
				CMR 613.04(6)(a)2.a.
Eligible Services
. Services eligible
				for Health Safety Net payment pursuant to
				101
				CMR 613.03. Eligible Services include
(a) Reimbursable Health Services to Low
			 Income Patients;
(b) Medical
			 Hardship; and
(c) Bad Debt as
			 further specified in 101 CMR 613.00 and 101 CMR 614.00:
Health Safety
			 Net Payments and Funding
.
Emergency Aid to the Elderly, Disabled and Children
				(EAEDC)
. A program of governmental benefits under M.G.L. c.
				117A.
Emergency Medical Condition
. A medical
				condition, whether physical or mental, manifesting itself by symptoms of
				sufficient severity, including severe pain, that the absence of prompt medical
				attention could reasonably be expected by a prudent layperson who possesses an
				average knowledge of health and medicine to result in placing the health of the
				person or another person in serious jeopardy, serious impairment to body
				function, or serious dysfunction of any body organ or part, or, with respect to
				a pregnant individual, as further defined in
				42 U.S.C. §
									1395dd(e)(1)(B).
Emergency Services
. Medically
				Necessary Services provided to an individual with an Emergency Medical
				Condition.
EMTALA
. The federal Emergency Medical
				Treatment and Active Labor Act under
				42
				U.S.C. §
									1395dd.
EVS
. The MassHealth Eligibility
				Verification System.
Federal Poverty Level (FPL)
. Income
				standards issued annually in the
Federal Register
to account
				for the last calendar year's increase in prices as measured by the Consumer
				Price Index.
Fiscal Year
. The time period of 12
				months beginning on October 1st of any calendar year
				and ending on September 30th of the following
				calendar year.
Governmental Unit
. The Commonwealth,
				any department, agency, board, or commission of the Commonwealth, and any
				political subdivision of the Commonwealth.
Gross Income
. The total money earned
				or unearned, such as wages, salaries, rents, pensions, or interest, received
				from any source without regard to deductions.
Guarantor
. A person or group of
				persons that assumes the responsibility of payment for all or part of a
				Provider's charge for services.
Health Connector
. Commonwealth Health
				Insurance Connector Authority or Health Connector established pursuant to
				M.G.L. c. 176Q, § 2.
Health Insurance Plan
. Medicare,
				MassHealth, the Premium Assistance Payment Program Operated by the Health
				Connector, a Qualified Health Plan, or an individual or group contract or other
				plan providing coverage of health care services issued by a health insurance
				company, as defined in M.G.L. c. 175, 176A, 176B, 176G, or 176I.
Health Safety Net
. The payment program
				established and administered in accordance with M.G.L. c. 118E, §§
				8A, and 64 through 69 and regulations promulgated thereunder, and other
				applicable legislation.
Health Safety Net Office (Office)
. The
				office within the Office of Medicaid established under M.G.L. c. 118E, §
				65.
Health Safety Net - Partial
. A Low
				Income Patient eligible for either Health Safety Net - Primary or Health Safety
				Net - Secondary who documents MassHealth MAGI Household income or Medical
				Hardship Family Countable Income, as described in
				101 CMR
				613.04(2), greater than 150%
				and less than or equal to 300% of the FPL, is considered Health Safety Net -
				Partial as described in
				101 CMR
				613.04(6)(b)3.
Health Safety Net - Partial Deductible
				(Deductible)
. Annual deductible applied as described in
				101 CMR
				613.04(8)(c).
Health Safety Net - Primary
. A Health
				Safety Net eligibility category for uninsured Low Income Patients as described
				in
				101 CMR
				613.04(6)(a)1.
Health Safety Net - Secondary
. A
				Health Safety Net eligibility category for Low Income Patients with primary
				health insurance as described in
				101 CMR
				613.04(6)(a)2.
Health Safety Net Trust Fund
. The fund
				established under M.G.L. c. 118E, § 66.
Health Services
. Medically necessary
				inpatient and outpatient services as authorized under Title XIX of the Social
				Security Act. Health services do not include
(a) nonmedical services, such as social,
			 educational, and vocational services;
(b) cosmetic surgery;
(c) canceled or missed
			 appointments;
(d) telephone
			 conversations and consultations;
(e)
			 court testimony;
(f) research or the
			 provision of experimental or unproven procedures; and
(g) the provision of whole blood, but the
			 administrative and processing costs associated with the provision of blood and
			 its derivatives are payable.
Hospital Licensed Health Center
. A
				Satellite Clinic that
(a) meets
			 MassHealth requirements for reimbursement as a Hospital Licensed Health Center
			 as provided at
			 130
			 CMR 410.413:
Medical Services
			 Required on Site at a Hospital-licensed Health Center
; and
(b) is approved by and enrolled with
			 MassHealth's Provider Enrollment Unit as a Hospital Licensed Health
			 Center.
Hospital Services
. Services listed on
				an Acute Hospital's license by the Department of Public Health. This does not
				include services provided in transitional care units; services provided in
				skilled nursing facilities; and home health services, or separately licensed
				services, including residential treatment programs and ambulance
				services.
Hospital Visit
. A face-to-face meeting
				between a Patient and a physician, physician assistant, nurse practitioner, or
				registered nurse or when the Patient has been admitted to a hospital by a
				physician on a Community Health Center's staff.
Low Income Patient
. An individual who
				meets the criteria under
				101 CMR
				613.04(2).
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
et seq
.),
				Title XXI of the Social Security Act (42 U.S.C. §§
									1397aa
et seq
.), 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.
MassHealth Care Plus
. A program of
				health care services for eligible adults, 21 through 64 years old, administered
				by the MassHealth Agency pursuant to
				130 CMR 505.000:
MassHealth: Coverage Types
.
MassHealth Common Health
. A MassHealth
				program for disabled adults and disabled children administered by the
				MassHealth Agency pursuant to M.G.L. c. 118E.
MassHealth Family Assistance
. A
				program of health care services for eligible children, young adults and adults
				administered by the MassHealth Agency pursuant to
				130 CMR 505.000:
MassHealth: Coverage Types
.
MassHealth Family Assistance -
				Children
. A program of health care services for eligible minors
				administered by the MassHealth Agency pursuant to
				130 CMR 505.000:
MassHealth: Coverage Types
.
MassHealth Limited
. A program of
				emergency health care services for individuals administered by the MassHealth
				Agency pursuant to
				130 CMR 505.000:
MassHealth: Coverage Types
.
MassHealth MAGI Household
. A household
				as defined in
				130 CMR
				506.002(B):
MassHealth MAGI Household Composition
.
MassHealth Standard
. A program of
				health care services for eligible individuals administered by the MassHealth
				Agency pursuant to
				130 CMR 505.000:
MassHealth: Coverage Types
.
Medical Coverage Date
.
(a) The medical coverage date begins on the
			 tenth day before the date the Application is received as described in
			 130 CMR
			 502.003:
Verification of Eligibility
			 Factors
, if all required verifications, including a completed
			 disability supplement, have been received within 90 days of the receipt of the
			 Request for Information, as described at
			 130 CMR
			 502.003(C):
Request
			 for Information Notice
except for applicants otherwise subject to
			 rules detailed in
			 130 CMR
			 516.001:
Application for
			 Benefits
, the medical coverage date is outlined in
			 130 CMR 516.006:
Coverage Date
if all required verifications have been received
			 within the guidelines listed in
			 130 CMR
			 516.003:
Verification of Eligibility
			 Factors
.
(b) If these
			 required verifications listed on the Request for Information are received after
			 the periods referenced in 101 CMR 613.02, the begin date of medical coverage is
			 ten days before the date on which the verifications were received, if such
			 verifications are received within one year of receipt of the Application, or as
			 outlined in
			 130 CMR
			 516.003:
Verification of Eligibility
			 Factors
, if applicable.
(c)
			 For children younger than 21 years old and pregnant individuals receiving
			 Provisional Eligibility as described in
			 130 CMR
			 502.003:
Verification of Eligibility
			 Factors
, the medical coverage date begins ten days prior to the date
			 of Application. For all other applicants receiving Provisional Eligibility as
			 described in
			 130 CMR
			 502.003:
Verification of Eligibility
			 Factors
, the medical coverage date begins on the date of the
			 provisional eligibility determination. If all required verifications are
			 received before the end of the provisional eligibility period, the medical
			 coverage date of the verified coverage type will be ten days prior to the date
			 of the Application.
Medical Hardship
. Health Safety Net
				eligibility type available to Massachusetts Residents at any Countable Income
				level whose allowable medical expenses have so depleted his or her Countable
				Income that he or she is unable to pay for Eligible Services as described in
				101 CMR
				613.05.
Medical Hardship Family
. Persons who
				live together, and consist of
(a) a
			 child or children younger than 19 years old, any of their children, and their
			 parents;
(b) siblings younger than
			 19 years old and any of their children who live together even if no adult
			 parent or Caretaker Relative is living in the home; or
(c) a child or children younger than 19 years
			 old, any of their children, and their Caretaker Relative when no parent is
			 living in the home. A Caretaker Relative may choose whether or not to be part
			 of the Medical Hardship Family. A parent may choose whether or not to be
			 included as part of the Medical Hardship Family of a child younger than 19
			 years old only if that child is
1. pregnant;
			 or
2. a parent.