Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 432.000 - Therapist Services › Section 432.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR
				432.000 have the meanings given in 130 CMR 432.402,
				unless the context clearly requires a different meaning. The reimbursability of
				services defined in
				130 CMR
				432.000 is not determined by these definitions, but by
				application of regulations elsewhere in
				101 CMR
				339.00:
Restorative Services
,
				130 CMR
				432.000, and in
				130 CMR 450.000:
Administrative and Billing Regulations
.
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.
Capitated Program
- an ICO, SCO, ACO,
				or PACE organization, or any other entity that, according to a contract with
				EOHHS, covers home health and other medical services for members on a capitated
				basis.
Co-treatment
- therapy performed by
				two therapy providers, who work together as a team to treat one member, when
				appropriate. The providers may only bill for a maximum of four units per member
				treatment session.
Group Therapy
- simultaneous therapy
				services provided to two to six patients who may or may not be doing the same
				activities.
Integrated Care Organization (ICO)
-
				an organization with a comprehensive network of medical, behavioral health
				care, and long-term services and supports (LTSS) 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.
Maintenance Program
- repetitive
				services, required to maintain or prevent the worsening of function, that do
				not require the judgment of a licensed therapist for safety and
				effectiveness.
Managed Care Organization (MCO)
- any
				entity with which the MassHealth agency contracts under its MCO program to
				provide, arrange for, and coordinate care and certain other medical services to
				members on a capitated basis, and is approved by the Massachusetts Division of
				Insurance as a health maintenance organization (HMO), and is organized
				primarily for the purpose of providing health care services.
Marketing
- any communication from a
				therapy provider, or its agent, to a member, or their family or caregivers,
				that can reasonably be interpreted as intended to influence the member's choice
				of therapy provider, whether by inducing that member
(1) to retain that therapy provider to provide therapy services
				to the member;
(2) not to retain therapy services from another therapy
				provider; or
(3) to cease receiving therapy services from another therapy
				provider.
Occupational Therapy
- therapy
				services, including diagnostic evaluation and therapeutic intervention,
				designed to improve, develop, correct, rehabilitate, or prevent the worsening
				of functions that affect the activities of daily living that have been lost,
				impaired, or reduced as a result of acute or chronic medical conditions,
				congenital anomalies, or injuries. Occupational therapy programs are designed
				to improve quality of life by recovering competence, preventing further injury
				or disability, and to improve the individual's ability to perform tasks
				required for independent functioning, so that the individual can engage in
				activities of daily living.
Physical Therapy
- therapy services,
				including diagnostic evaluation and therapeutic intervention, designed to
				improve, develop, correct, rehabilitate, or prevent the worsening of physical
				functions that have been lost, impaired, or reduced as a result of acute or
				chronic medical conditions, congenital anomalies, or injuries. Physical therapy
				emphasizes a form of rehabilitation focused on treatment of dysfunctions
				involving neuromuscular, musculoskeletal, cardiovascular/pulmonary, or
				integumentary systems through the use of therapeutic interventions to optimize
				functioning levels.
Prescribing Provider
- the member's
				physician, nurse practitioner, or physician assistant who prescribes and writes
				the prescription for therapy services in accordance with
				130 CMR
				432.415.
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)
.
Provider Portal
- the online site by
				which LTSS providers, as applicable, submit all MassHealth LTSS prior
				authorization requests to a MassHealth designated vendor.
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.
Speech/Language Therapy
- therapy
				services, including diagnostic evaluation and therapeutic intervention, that
				are designed to improve, develop, correct, rehabilitate, or prevent the
				worsening of speech/language communication and swallowing functions that have
				been lost, impaired, or reduced as a result of acute or chronic medical
				conditions, congenital anomalies, or injuries. Speech and language disorders
				are those that affect articulation of speech, sounds, fluency, voice,
				swallowing (regardless of presence of a communication disability), and those
				that impair comprehension, spoken, written, or other symbol systems used for
				communication.
Therapy Provider (Therapist)
- a
				MassHealth enrolled provider of physical therapy, occupational therapy, or
				speech/language therapy.
Therapy Provider
may refer to
				an individual practitioner or a group practice consisting of therapy
				providers.
Therapy Visit
- a personal contact
				with a member provided by a licensed physical therapist, licensed physical
				therapy assistant, licensed occupational therapist, licensed occupational
				therapy assistant, licensed speech/language pathologist, or licensed
				speech/language pathologist assistant for the purpose of providing a covered
				service.
Unfair or Deceptive Acts or Practices
- any unfair or deceptive acts or practices, as that term is referred to in
				M.G.L. c. 93A, § 2 and in 940 CMR:
Office of the Attorney
				General
.