Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 403.000 - Home Health Agency › Section 403.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR
				403.000 have the meanings given in 130 CMR 403.402,
				unless the context clearly requires a different meaning. The reimbursed
				services defined in 130 CMR 403.402 are not determined by these definitions,
				but by the application of regulations elsewhere in
				130 CMR
				403.000 and
				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.
Activities of Daily Living (ADL)
-
				activities related to personal care, specifically bathing, grooming, dressing,
				toileting/continence, transferring/ambulation, and eating.
Branch Office
- a location or site
				from which a home health agency provides services within a portion of the total
				geographic area served by the parent home health agency. The parent home health
				agency must provide supervision and administrative control of any branch office
				on a daily basis.
Calendar Week
- seven consecutive days
				beginning Sunday at midnight and ending Saturday at 11:59 P.M.
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.
Care Management
- a function performed
				by the MassHealth agency or its designee that assesses and reassesses the
				medical needs of complex-care members and authorizes or coordinates long term
				services and supports (LTSS) that are medically necessary for such members to
				remain safely in the community.
Certification Period
- a period of no
				more than 60 days in which the member's physician or ordering non-physician
				practitioner certified that the plan of care is medically appropriate and
				necessary.
Clinical Manager
- a registered nurse
				employed by the MassHealth agency or its designee, who performs the in-person
				assessment of a member for MassHealth coverage of continuous skilled nursing
				(CSN) services and, if it is determined that CSN services are medically
				necessary, coordinates the authorization of medically necessary long term
				services and supports (LTSS) services for the member.
Complex-care Member
- a MassHealth
				member whose medical needs, as determined by the MassHealth agency or its
				designee, are such that he or she requires a nurse visit of more than two
				continuous hours of nursing services to remain in the community.
Continuous Skilled Nursing (CSN)
				Services
- skilled nursing care provided by a licensed nurse to
				complex-care members who require more than two continuous hours of nursing
				services per day.
Co-vending
- an arrangement through
				which a member's CSN services are provided by one or more home health agencies
				or independent nurses, with each provider possessing its own MassHealth prior
				authorization to provide nursing services to the member.
Home Health Agency
- a public or
				private organization that provides nursing and other therapeutic services to
				individuals whose place of residence conforms to the requirements of
				42 CFR
				440.70(c). Home health
				agency providers are governed by
				130 CMR
				403.000.
Home Health Aide
- a person who is
				employed or contracted by a home health agency and meets the qualifications of
				a Home Health Aide to perform certain personal-care and other health-related
				services as described in
				130 CMR 403.416(B)
				 and according to
				42 CFR
				484.80.
Homemaker
- a person who performs
				light housekeeping duties (for example, cooking, cleaning, laundry) for the
				purpose of maintaining a household.
Household
- place of residence where
				two or more people are living that is in a group home, a residential care home,
				or other group living situation; at the same street address if it is a single
				family house that is not divided into apartments or units; or at the same
				apartment number or unit number if members live in a building that is divided
				into apartments or units.
Independent Nurse
- a licensed nurse
				who independently enrolls as a provider in MassHealth to provide CSN services.
				Independent nurse providers are governed by MassHealth regulations at
				130
				CMR 414.000:
Independent Nurse
				Services
.
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 the Centers for Medicare & 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.
Intermittent Skilled Nursing Visits
-
				nursing services provided by a licensed nurse that are necessary to provide
				targeted skilled nursing assessment for a specific member medical need, and/or
				discrete procedures and/or treatments, typically for less than two consecutive
				hours, and limited to the time required to perform those duties.
Long-term Services and Supports (LTSS)
- certain MassHealth-covered services intended to enable a member to remain
				safely in the community. Such services include, but are not limited to, home
				health, durable medical equipment, oxygen and respiratory equipment,
				personal-care attendant, and other health-related services as determined by the
				MassHealth agency or its designee.
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.
Maintenance Program
- repetitive
				services, required to maintain or prevent the worsening of function, that do
				not require the judgment and skill of a licensed therapist for safety and
				effectiveness.
Marketing
- any communication from a
				home health agency provider, or its agent, to a member, or his or her family or
				caregivers, that can reasonably be interpreted as intended to influence the
				member's choice of home health agency provider, whether by inducing that
				member
(1) to retain that home health
			 agency provider to provide home health agency services to the member;
(2) not to retain home health agency services
			 from another home health agency provider; or
(3) to cease receiving home health agency
			 services from another home health agency provider.
Medical History
- a component of the
				member's medical record that provides a summary of all health-related
				information about the member. A history includes, but is not limited to,
				medical and nursing care histories.
Medical Record
- documentation,
				maintained by the home health agency, that includes medical history, diagnoses,
				physician or ordering non-physician practitioner orders, discipline-specific
				progress notes, member assessments, the member's plan(s) of care, and other
				information related to the member in accordance with
				130 CMR
				403.419(C).
Medical Records Release Form
- a
				signed authorization from the member or the member's parent or legal guardian,
				if the member is a minor, that allows the designated releasee to access the
				member's confidential health information from other health-care
				providers.
Medication Administration Visit
- a
				nursing visit for the sole purpose of administration of medications where the
				targeted nursing assessment is medication administration and patient response
				only, and when the member is unable to perform the task due to impaired
				physical, cognitive, behavioral, and/or emotional issues, no able caregiver is
				present, the member has a history of failed medication compliance resulting in
				a documented exacerbation of the member's condition, and/or the task including
				the route of administration of medication requires a licensed nurse to provide
				the service. A medication administration visit may include administration of
				oral, intramuscular, and/or subcutaneous medication or administration of
				medications other than oral, intramuscular and/or subcutaneous medication, but
				does not include intravenous administration.
Nurse
- a person licensed as a
				registered nurse or a licensed practical nurse by a state's board of
				registration in nursing of the state in which they practice.
Nursing Services
- the assessment,
				planning, intervention, and evaluation of goal-oriented nursing care that
				requires specialized knowledge and skills acquired under the established
				curriculum of a school of nursing approved by a board of registration in
				nursing. Such services include only those services that require the skills of a
				nurse.
Occupational Therapist
- a person who
				is currently licensed by and in good standing with the Massachusetts Division
				of Professional Licensure, Board of Allied Health Professionals, and is
				qualified in accordance with 42 CFR 484.4.
Occupational Therapy
- therapy
				services, including diagnostic evaluation and therapeutic intervention,
				designed to improve, develop, correct, rehabilitate, or prevent, maintain, or
				slow 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.
Occupational Therapy Assistant
- a
				person who is currently licensed and in good standing with the Massachusetts
				Division of Professional Licensure, Board of Allied Health Professionals, must
				work under the supervision of a licensed occupational therapist as described in
				130 CMR
				432.404(B), and is qualified
				in accordance with 42 CFR 484.4.
Ordering Non-physician Practitioner
-
				a nurse practitioner, physician's assistant, or clinical nurse specialist who
				is licensed in the state of Massachusetts to perform medical services according
				to their scope of practice. Ordering non-physician practitioners are also
				allowed to conduct face-to-face encounters. Nurse midwives are not allowed to
				order home health services.
Physical Therapist
- a person who is
				currently licensed by and in good standing with the Massachusetts Division of
				Professional Licensure, Board of Allied Health Professionals, and is qualified
				in accordance with 42 CFR 484.4.
Physical Therapy
- therapy services,
				including diagnostic evaluation and therapeutic intervention, designed to
				improve, develop, correct, rehabilitate, or prevent, maintain, or slow 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.
Physical Therapy Assistant
- a person
				who is currently licensed by and in good standing with the Massachusetts
				Division of Professional Licensure, Board of Allied Health Professionals, and
				must work under the supervision of a licensed physical therapist as described
				in
				130 CMR
				432.404(A), and is qualified
				in accordance with 42 CFR 484.4.
Primary Caregiver
- the individual,
				other than the nurse or home health aide, who is primarily responsible for
				providing ongoing care to the member.
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.
Request and Justification for Nursing and Home
				Health Aide Services Form
- the form describing the nursing and
				home health aide needs of a member that a home health agency is required to
				submit to the MassHealth agency or its designee, when requesting prior
				authorization (PA) for intermittent nursing service through a paper PA.
Request and Justification for Therapy Services and
				Home Health Aide Services Form
- the form describing the therapy
				and home health aide needs of a member that a home health agency may submit to
				the MassHealth agency or its designee, when requesting prior authorization for
				therapy services.
Respite Services
- a range of services
				provided on a short-term or intermittent basis in response to the need for
				relief of those persons who normally provide this care.
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.
Skilled Nursing Visit
- a nursing
				visit that is necessary to provide targeted skilled nursing assessment for a
				specific member medical need, and/or discrete procedures and/or treatments,
				typically for less than two consecutive hours, and limited to the time required
				to perform those duties.
Speech/Language Therapist (Speech/Language
				Pathologist)
- a person who is currently licensed by and in good
				standing with the Massachusetts Board of Registration in Speech-language
				Pathology and Audiology and is qualified in accordance with 42 CRF
				484.4.
Speech/Language Therapy
- therapy
				services, including diagnostic evaluation and therapeutic intervention, that
				are designed to improve, develop, correct, rehabilitate, or prevent, maintain,
				or slow the worsening of speech/language communication and swallowing disorders
				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, and those that impair comprehension, spoken, written, or other
				symbol systems used for communication.
Unfair or Deceptive Acts or Practices
- any unfair or deceptive acts or practices, as that term is defined in M.G.L.
				c. 93A, § 2, and the regulations promulgated thereunder by the
				Massachusetts Attorney General.
Visit
- a personal contact in the
				member's home or other non-institutional setting, for the purpose of providing
				a covered service by a registered or licensed nurse, home health aide, or
				physical, occupational, or speech/language therapist employed by, or
				contracting with, the home health agency.