Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 614.00 - Health Safety Net Payments and Funding › Section 614.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				101 CMR
				614.00, unless the context otherwise requires, terms
				have the following meanings. All defined terms in
				101 CMR
				614.00 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 Provider within the
				United States Department of Health and Human Services, Office of Pharmacy
				Affairs (OPA) database. Services of a 340B pharmacy may be provided 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.
Ambulatory Surgical Center
. Any
				distinct entity that operates exclusively for the purpose of providing surgical
				services to Patients not requiring hospitalization and meets the Centers for
				Medicare and Medicaid Services (CMS) requirements for participation in the
				Medicare program.
Ambulatory Surgical Center Services
.
				Services described for purposes of the Medicare program pursuant to
				42 U.S.C. §
									1395k(a)(2)(F)(i). These
				services include only facility services and do not include physician
				fees.
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:
Allowable Bad
			 Debt;
(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.
Center
. The Center for Health
				Information and Analysis established under M.G.L. c. 12C.
Centers for Medicare & Medicaid Services
				(CMS)
. The federal agency that administers Medicare, Medicaid, and
				the State Children's Health Insurance Program.
Charge
. The uniform price for a
				specific service charged by a Provider.
Community Health Center
. A health
				center operating in conformance with the requirements of § 330 of the
				Public Health Service Act (42 U.S.C. §
										254b), including
				all Community Health Centers that file cost reports with the Center. 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.
Disproportionate Share Hospital (DSH)
.
				An Acute Hospital where a minimum of 63% of the Gross Patient Service Revenue
				is attributable to Title XVIII and Title XIX of the Social Security Act or
				other government payers, including the Premium Assistance Payment Program
				Operated by the Health Connector and the Health Safety Net.
Eligible Services
. Services eligible
				for Health Safety Net payment pursuant to
				101
				CMR 613.03:
Eligible Services
				Requirements.
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:
Health Safety Net Eligible Services
and 614.00.
Emergency Bad Debt
. The amount of
				uncollectible debt for Emergency Services that meets the criteria set forth in
				101
				CMR 613.06:
Allowable Bad
				Debt.
Emergency Services
. Medically
				Necessary Services provided to an individual with an Emergency Medical
				Condition as defined in
				101
				CMR 613.02:
Definitions.
Federal Poverty Level (FPL)
. The
				federal poverty income guidelines issued annually in the
Federal
				Register.
Financial Requirements
. An Acute
				Hospital's requirement for revenue that includes, but is not limited to,
				reasonable operating, capital, and working capital costs, and the reasonable
				costs associated with changes in medical practice and technology.
Fiscal Year (FY)
. 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 Patient Service Revenue
. The
				total dollar amount of a hospital's charges for services rendered in a Fiscal
				Year.
Guarantor
. A person or group of
				persons who assumes the responsibility of payment for all or part of an Acute
				Hospital's or Community Health Center's charge for services.
Health Connector
. Commonwealth Health
				Insurance Connector Authority or Health Connector established pursuant to
				M.G.L. c. 176Q, § 2.
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
. The office
				within the Office of Medicaid established under M.G.L. c. 118E, §
				65.
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 Cost Report
. The
				Massachusetts Hospital Statement of Costs, Revenues, and Statistics reported to
				the Center pursuant to
				957 CMR 9.00:
Hospital
				Financial Data Reporting Requirements
.
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.
Indirect Payment
. A payment made by an
				entity licensed or approved under M.G.L. chs. 175, 176A, 176B, 176G, or 176I to
				a group of Providers, including one or more Massachusetts Acute Hospitals or
				Ambulatory Surgical Centers, that then forward the payment to member Acute
				Hospitals or Ambulatory Surgical Centers; or a payment made to an individual to
				reimburse him or her for a payment made to an Acute Hospital or Ambulatory
				Surgical Center.
Individual Medical Visit
. A
				face-to-face meeting at a Community Health Center between a Patient and a
				physician, physician assistant, nurse practitioner, nurse midwife, registered
				nurse, or paraprofessional for medical examination, diagnosis, or
				treatment.
Individual Payer
. A Patient or
				Guarantor who pays his or her own Acute Hospital or Ambulatory Surgical Center
				bill and is not eligible for reimbursement from an insurer or any other
				source.
Institutional Payer
. A Surcharge Payer
				that is an entity other than an Individual Payer.
Low Income Patient
. A Patient who
				meets the criteria in
				101 CMR
				613.04(1):
General
.
Managed Care Organization
. A managed
				care organization, as defined in
				42
				CFR 438.2, and any eligible health insurance
				plan, as defined in M.G.L. c. 118H, § 1, that contracts with MassHealth or
				the Commonwealth Health Insurance Connector Authority; provided, however, that
				a managed care organization does not include a senior care organization, as
				defined in M.G.L. c. 118E, § 9D, or an integrated care organization as
				defined in M.G.L. c. 118E, § 9F.
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) , Title XXI of the Social Security Act
				(42 U.S.C.
				1397) , 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.
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 disability, or result in illness or infirmity. Medically Necessary
				Services include inpatient and outpatient services as authorized under Title
				XIX of the Social Security Act.
Medicare Advantage
. A type of Medicare
				health plan established by Title II of the Medicare Prescription Drug,
				Improvement, and Modernization Act of 2003.
Medicare Program (Medicare)
. The
				medical insurance program established by Title XVIII of the Social Security
				Act.
Non-acute Hospital
. A nonpublic
				hospital that is
(a) licensed by the Department of Public Health under M.G.L. c.
				111, § 51 but not defined as an acute-care hospital under M.G.L. c. 111,
				§ 25B; or
(b) licensed as an inpatient facility by the Department of
				Mental Health under M.G.L. c. 19, § 19 and regulations promulgated
				thereunder but not categorized as Class VII licensees under the regulations.
Office of Pharmacy Affairs (OPA)
. The
				Office of Pharmacy Affairs, and any successor agencies, is a division within
				the United States Department of Health and Human Services that monitors the
				registration of 340B pharmacies.
Patient
. An individual who receives or
				has received Medically Necessary Services at an Acute Hospital or Community
				Health Center.
Pediatric Hospital
. An Acute Hospital
				that limits services primarily to children and that qualifies as exempt from
				the Medicare Prospective Payment System (PPS).
Premium Assistance Payment Program Operated by the
				Health Connector
. An insurance subsidy program that provides state
				subsidies for low-income individuals and families administered by the Health
				Connector.
Prospective Payment System (PPS) Rate
. The Medicare Prospective Payment System rate for Community Health Centers set
				annually by CMS as described in
				42 CFR
				405.2467.
Provider
. An Acute Hospital or
				Community Health Center that provides Eligible Services.
Publicly Aided Patient
. A person who
				receives Acute Hospital or Community Health Center care and services for which
				a Governmental Unit is liable in whole or in part under a statutory
				obligation.
Registered Payer List
. A list of
				Institutional Payers as defined in
				101 CMR
				614.05(3)(b).
Reimbursable Health Services
. Eligible
				Services provided by Acute Hospitals or Community Health Centers to Uninsured
				and Underinsured Patients who are determined to be financially unable to pay
				for their care, in whole or in part and who meet the criteria for Low Income
				Patient; provided that such services are not eligible for reimbursement by any
				other public or third party payer.
Shortfall Amount
. In a Fiscal Year,
				the positive difference between the sum of allowable Health Safety Net costs
				for all Acute Hospitals and the revenue available for distribution to Acute
				Hospitals.
Sole Community Hospital
. Any Acute
				Hospital classified as a Sole Community Hospital by the U.S. Centers for
				Medicare & Medicaid Services', Medicare regulations, or any Acute Hospital
				that demonstrates to the Health Safety Net Office's satisfaction that it is
				located more than 25 miles from other Acute Hospitals in the Commonwealth and
				that it provides services for at least 60% of its primary service area.
Source Year
. The Fiscal Year two
				Fiscal Years prior to the regulation effective date, from which data is
				collected to calculate current payment rates, unless otherwise specified by the
				Health Safety Net Office through administrative bulletin.
Surcharge Payer
. An individual or
				entity that
(a) makes
			 payments for the purchase of health care Hospital Services and Ambulatory
			 Surgical Center Services; and
(b)
			 meets the criteria set forth in
			 101
			 CMR 614.05(1)(a).
Surcharge Percentage
. The percentage
				assessed on certain payments to Acute Hospitals and Ambulatory Surgical Centers
				determined pursuant to
				101
				CMR 614.05(2).
Third Party Administrator
. An entity
				that administers payments for health care services on behalf of a client plan
				in exchange for an administrative fee. A Third Party Administrator may provide
				client services for a self-insured plan or an insurance carrier's plan. A Third
				Party Administrator is deemed to use a client plan's funds to pay for health
				care services whether the Third Party Administrator pays Providers with funds
				from a client plan, with funds advanced by the Third Party Administrator
				subject to reimbursement by the client plan, or with funds deposited with the
				Third Party Administrator by a client plan.
Total Surcharge Amount
. An amount
				equal to $160,000,000 plus 50% of the estimated cost, as determined by the
				Secretary of Administration and Finance, of administering the Health Safety Net
				and related assessments in accordance with M.G.L. c. 118E, §§ 65
				through 69.
Urgent Care Services
. Medically
				Necessary Services provided in an Acute 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 layperson would believe that the absence of medical
				attention within 24 hours could reasonably expect to result in placing a
				Patient's health in jeopardy, impairment to bodily function, or 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. Urgent Care Services do not include Primary or Elective
				Care, as defined in
				101
				CMR 613.02:
Definitions.