Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 438.000 - Continuous Skilled Nursing Agency › Section 438.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR
				438.000 have the meanings given in
				130
				CMR 438.402, unless the context clearly
				requires a different meaning. The reimbursed services defined in
				130
				CMR 438.402 are not determined by these
				definitions, but by the application of regulations elsewhere in
				130 CMR
				438.000 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.
Branch Office
- a location or site
				from which a CSN agency provides services within a portion of the total
				geographic area served by the parent CSN agency. The parent CSN agency must
				provide supervision and administrative control of any branch office on a daily
				basis.
Calendar Week
- seven consecutive days
				beginning Sunday at 12:00 A.M. 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 for which the member's physician has 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 CSN services and, if it is
				determined that CSN services are medically necessary, coordinates authorization
				of medically necessary LTSS for the member.
Complex Care Assistant
- a person who
				is employed or contracted by a CSN agency and meets the qualifications of a
				complex care assistant to perform certain health-related services as described
				at 130 CMR
				438.415(C).
Complex Care Assistant Services
-
				medically necessary services as described at
				130 CMR
				438.000 and identified in the plan of care delivered
				to complex care members.
Complex Care Member
- a MassHealth
				member whose medical needs, as determined by the MassHealth agency or its
				designee, are such that they require a nurse visit of more than two continuous
				hours of nursing services to remain in the community.
Continuous Skilled Nursing (CSN)
				Agency
- a public or private organization that provides CSN
				services, or CSN agency services to complex care members within the members'
				homes.
Continuous Skilled Nursing (CSN) Agency
				Services
- CSN services and complex care assistant services as
				described at
				130
				CMR 438.402 and delivered to
				MassHealth-eligible members.
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 more than one CSN agency or
				independent nurse, with each provider obtaining its own MassHealth prior
				authorization to provide CSN 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 MassHealth regulations at
				130 CMR
				403.000:
Home Health Agency
. Home
				health agencies providing CSN services must also comply with
				130 CMR
				438.000 for the provision of those services.
Household
- a place of residence where
				two or more people are living that is:
(1) a group home, a residential care home, or
			 other group living situation;
(2)
			 at the same street address if it is a single family house that is not divided
			 into apartments or units; or
(3) 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
				130 CMR
				414.000:
Independent Nurse
.
Integrated Care Organization (ICO)
-
				an organization with a comprehensive network of medical care, 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.
Long-term Services and Supports (LTSS)
- certain MassHealth-covered services intended to enable a member to remain 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.
LTSS Needs Assessment
- the
				standardized assessment the MassHealth agency or its designee uses to determine
				a member's eligibility for CSN services and if found eligible, quantifies the
				medically necessary CSN, complex care assistant services, and other LTSS
				services.
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
				CSN 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 CSN agency provider, whether by inducing that member
(1) to retain that CSN agency provider to
			 provide CSN agency services to the member;
(2) not to retain CSN agency services from
			 another CSN agency provider; or
(3)
			 to cease receiving CSN agency services from another CSN 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 as well as summaries of physician physical
				examination and nursing-assessment results.
Medical Record
- documentation,
				maintained by the CSN agency, that includes medical history, nursing progress
				notes, the member's plan of care, and other information related to the
				member.
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 release to access the
				member's confidential health information from other health care
				providers.
Nurse
- a person licensed as a
				registered nurse or a licensed practical nurse by a state's board of
				registration in nursing.
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.
Ordering Non-physician Practitioner
-
				a nurse practitioner, physician's assistant, or clinical nurse specialist who
				is licensed in the state of Massachusetts to perform and order medical services
				according to their scope of practice. Ordering non-physician practitioners are
				also allowed to conduct face-to-face encounters.
Primary Caregiver
- the individual,
				other than the nurse, 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 at 42
				CFR 460 and
				130
				CMR 519.007(C):
Program of All-inclusive Care for the Elderly (PACE)
.
Registered Nurse (RN) Supervisor
- a
				person who is familiar with the member and the member's plan of care as
				described at
				130
				CMR 438.416 and is designated by the CSN
				agency as a supervisor of complex care assistant service delivery.
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.
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.