Code of Massachusetts Regulations › 114 CMR - DIVISION OF HEALTH CARE FINANCE AND POLICY › Title 114.6 CMR 10.00 - CRITERIA FOR DETERMINING ELIGIBILITY FOR FREE CARE AT ACUTE CARE HOSPITALS AND FREESTANDING COMMUNITY HEALTH CENTERS › Section 10.02 - Definitions

Current through Register 1525, July 5, 2024
Meaning of Terms
: As used in 114.6 CMR
				10.00, unless the context otherwise requires, terms shall have the meanings
				ascribed in 114.6 CMR 10.00.
Acute Hospital.
Any hospital licensed
				under M.G.L. c. 111, § 51 and the teaching hospital of the University of
				Massachusetts Medical School, which contains a majority of medical-surgical,
				pediatric, obstetric, and maternity beds as defined by the Department of Public
				Health.
Acute Hospital Services.
Services
				listed on an acute hospital's license by the Department of Public
				Health.
Allowable Medical Expenses.
Family
				medical bills from any provider that, if paid, would qualify as deductible
				medical expenses for federal income tax purposes. Unpaid bills for which the
				patient is still responsible, incurred prior to or after the date of a free
				care application, may be used. Paid bills, incurred after the date of the free
				care application, may also be included in the allowable medical
				expenses.
Bad Debt.
An account receivable based
				on services furnished to any patient which:
(a) is regarded as uncollectible, following reasonable
				collection efforts, pursuant to 114.6 CMR 10.05, and pursuant to the hospital's
				or community health center's established Credit and Collection policy, that
				conforms with 114.6 CMR 10.09;
(b) is charged as a credit loss;
(c) is not the obligation of any federal or state governmental
				unit; and
(d) is not free care.
Center Care Program
. Anambulatory
				managed care program that offers primary and preventive health care services to
				low-income, uninsured adult patients of independently licensed community health
				centers, administered by the Department of Public Health, pursuant to M.G.L.,
				c.111, § 24H.
Charge
. The uniform price for a
				specific service charged by a hospital or community health center.
Children's Medical Security Plan
. A
				program of primary and preventive pediatric health care services for eligible
				children, from birth to age 18, administered by the Department of Public Health
				pursuant to M.G.L. c. 111, § 24G.
Collection Action
. Any activity by
				which a hospital, community health center or a 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
				pre-admission or pretreatment deposits, billing statements, collection
				follow-up letters, telephone contacts, personal contacts and activities of
				collection agencies and attorneys.
Commissioner
. The Commissioner of the
				Division of Health Care Finance & Policy or designee.
CommonHealth
. A Medicaid program for
				disabled adults and disabled children administered by the Division of Medical
				Assistance pursuant to M.G.L. c. 118E.
Community Health Center.
A clinic
				which provides comprehensive ambulatory services and which:
(a) is licensed as a freestanding clinic by the Massachusetts
				Department of Public Health pursuant to M.G.L. c.111, § 51;
(b) meets the qualifications for certification (or provisional
				certification) by the Division of Medical Assistance and enters into a provider
				agreement pursuant to
				130
				CMR 405.000;
(c) operates in conformance with the requirements of
				42
				U.S.C. §
									254c; and
(d) files cost reports as requested by the Division.
Credit and Collection Policy
. A
				statement, in compliance with 114.6 CMR 10.09, of a hospital's or community
				health center's general policy and the principles that guide its billing and
				collection practices and procedures, as approved by its governing board.
Deductible
. The patient's liability to
				the provider for partial free care purposes.
Division
. The Division of Health Care
				Finance and Policy established under M.G.L. c. 118G.
Emergency Aid to the Elderly, Disabled and Children
				(EAEDC)
. A program of governmental benefits under M.G.L. c.
				117A.
EmergencyCare
. Medically necessary
				services provided after the sudden onset of a medical condition, whether
				physical or mental, manifesting itself by acute symptoms of sufficient
				severity, including severe pain, which a prudent lay person would reasonably
				believe is an immediate threat to life or has a high risk of serious damage to
				the individual's health. Conditions include, but are not limited to those which
				may result in jeopardizing the patient's health, serious impairment to bodily
				functions, serious dysfunction of any bodily organ or part, or active labor in
				women. Examination or treatment for emergency medical conditions or any such
				other service rendered to the extent required pursuant to
				42 USC
				1395(dd) qualifies as
				emergency care for Pool purposes.
EMTALA
. The federal Emergency Medical
				Treatment and Active Labor Act under
				42 USC
				1395(dd).
Family
. The patient, spouse and any
				minor dependents living in the household, and unborn children.
Family Income
. The sum of annual
				earnings and cash benefits from all sources before taxes, less payments made
				for alimony and child support.
Federal Poverty Income Guidelines
. The
				Federal Poverty Income Guidelines published annually by the federal Department
				of Health and Human Services.
Fiscal Year
. The time period of 12
				months beginning on October 1 of any calendar year and ending on September 30
				of the immediately following calendar year.
Free Care
. Unpaid hospital or
				community health center charges formedically necessary services which are
				eligible for reimbursement from the Pool pursuant to the criteria set forth in
				114.6 CMR 10.03. Types of free care include: full free care, partial free care,
				medical hardship, and emergency bad debt.
Governmental Unit
. The Commonwealth,
				and any department, agency, board, or commission of the Commonwealth, and any
				political subdivision of the Commonwealth.
Guarantor.
A person or group of
				persons who assumes the responsibility of payment for all or part of a hospital
				or community health center's charge for services.
Health Insurance Plan
. The Medicare
				program, the Medicaid program, or an individual or group contract or other plan
				providing coverage of health care services which is issued by a health
				insurance company, as defined in M.G.L. c. 175, c. 176A, c. 176B, c. 176G, or
				c. 176I.
Healthy Start
. A health care program
				for pregnant women and infants administered by the Department of Public Health
				pursuant to M.G.L. c. 111, § 24D.
Hospital
. An acute hospital.
MassHealth
. A Medicaid program
				administered by the Division of Medical Assistance pursuant to M.G.L. c. 118E
				and in accordance with Title XIX of the Federal Social Security Act, and a §
				1115 Demonstration Waiver.
Medicaid Program
. The medical
				assistance program administered by the Division of Medical Assistance pursuant
				to M.G.L. c. 118E and in accordance with Title XIX of the Federal Social
				Security Act.
Medical Assistance Program
. The
				Medicaid program, the Veterans Administration health, hospital, and community
				health programs and any other medical assistance program operated by a
				Governmental Unit for persons categorically eligible for such program.
Medically Necessary Service
. A service
				that is reasonably expected to prevent, diagnose, prevent the worsening of,
				alleviate, correct, or cure conditions that endanger life, cause suffering or
				pain, cause physical deformity or malfunction, threaten to cause or to
				aggravate a handicap, or result in illness or infirmity. Medically necessary
				services shall include inpatient and outpatient services as mandated under
				Title XIX of the Federal Social Security Act. Medically necessary services
				shall not include:
(a) non-medical 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 including, but not limited to, treatment related to sex-reassignment
				surgery, and pre-surgery hormone therapy, and
(g) the provision of whole blood; provided, however, that
				administrative and processing costs associated with the provision of blood and
				its derivatives shall be payable.
Medicare Program
. The medical
				insurance program established by Title XVIII of the Federal Social Security
				Act.
Pool.
The Uncompensated Care Pool
				established pursuant to M.G.L. c. 118G, §18.
Provider
. Any person, corporation,
				partnership, governmental unit, state institution and other entity qualified
				under the laws of the commonwealth to perform or provide health care
				services.
Publicly Aided Patient
. A person who
				receives hospital or community health center care and services for which a
				Governmental Unit is liable in whole or in part under a statutory
				program.
Resident
. A person living in
				Massachusetts with the intention of remaining in the state indefinitely. A
				resident is not required to maintain a fixed address. The following conditions
				do not meet the requirements for residency:
(a) confinement in a nursing home, hospital or other medical
				institution, and
(b) relocation to Massachusetts for the sole purpose of
				receiving health care benefits.
Uninsured Patient
. A patient who does
				not have a policy of health insurance or is not a member of a health insurance
				or benefit program. A patient who has a policy of health insurance or is a
				member of a health insurance or benefit program which requires such patient to
				make payment of deductibles, or co-payments, or fails to cover certain medical
				services or procedures is not uninsured.
Urgent Care
. Medically necessary
				services provided in a hospital or community health center after the sudden
				onset of a medical condition, whether physical or mental, manifesting itself by
				acute symptoms of sufficient severity (including severe pain) that a prudent
				lay person would believe that the absence of medical attention within 24 hours
				could reasonably expect to result in:
(a) placing a patient's health in jeopardy;
(b) impairment to bodily function; or
(c) dysfunction of any bodily organ or part.
Urgent care services are provided for conditions that are not
				life-threatening and do not pose a high risk of serious damage to an
				individual's health.