Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 410.000 - Outpatient hospital services › Section 410.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR
				410.000 have the meanings given in
				130
				CMR 410.402, unless the context clearly
				requires a different meaning. The reimbursability of services defined in
				130
				CMR 410.402 is not determined by these
				definitions, but by application of regulations elsewhere in
				130 CMR
				410.000, and in
				130 CMR
				415.000:
Acute Inpatient Hospital
				Services
and
				130 CMR
				450.000:
Administrative and Billing
				Regulations
.
340B-covered Entities
- facilities and
				programs eligible to purchase discounted drugs through a program established by
				Public Health Law 102-585, § 340B of the Veterans Health Act of
				1992.
340B Drug Pricing Program
- a program
				established by Public Health Law 102-585, § 340B of the Veterans Health
				Act of 1992.
Acupuncture
- the insertion of metal
				needles through the skin at certain points on the body, with or without the use
				of herbs, with or without the application of an electric current, and with or
				without the application of heat to the needles, skin, or both.
Acute Hospital
- a facility
				that:
(1) is licensed as a hospital by
			 the Massachusetts Department of Public Health (DPH) under M.G.L. c. 111, §
			 51 (if in-state) or by the governing or licensing agency in its state (if
			 out-of-state);
(2) is
			 Medicare-certified and participates in the Medicare program;
(3) has more than 50% of its beds licensed as
			 medical/surgical, intensive care, coronary care, burn, pediatric (Level I or
			 Level II), pediatric intensive care (Level III), maternal (obstetrics), or
			 neonatal intensive care beds (Level III) as determined by DPH (or if
			 out-of-state, the governing or licensing agency in its state, and as determined
			 by MassHealth) and;
(4) utilizes
			 more than 50% of its beds exclusively as either medical/surgical, intensive
			 care, coronary care, burn, pediatric (Level I or Level II), pediatric intensive
			 care (Level III), maternal (obstetrics), or neonatal intensive care beds (Level
			 III), as determined by MassHealth. An acute hospital is not a chronic disease
			 and rehabilitation hospital or a hospital licensed primarily to provide mental
			 health services, or any unit of a facility that is licensed as a nursing
			 facility, chronic disease unit, or rehabilitation unit.
Acute Inpatient Hospital
- an acute
				hospital that provides diagnosis and treatment on an inpatient basis for
				patients who have any of a variety of medical conditions requiring daily
				physician intervention as well as full-time availability of physician services;
				however, this does not include any chronic disease and rehabilitation hospital,
				any hospital that is licensed primarily to provide mental health services, or
				any unit of a facility that is licensed as a nursing facility, chronic disease
				unit, or a rehabilitation unit.
Chronic Disease and Rehabilitation Hospital
				(CDR)
- a hospital licensed by the Massachusetts Department of
				Public Health (DPH) under M.G.L. c. 111, § 51 (or by the governing or
				licensing agency in its state (if out-of-state)), with a majority of its beds
				licensed to provide chronic care services, or comprehensive rehabilitation
				services, or both, to patients with appropriate medical needs, or that is
				operated by DPH's Bureau of Public Health Facilities.
Chronic
				Disease and Rehabilitation Hospital (CDR)
includes such a hospital
				licensed with a pediatric specialty. Hospitals with 50% or more of their beds
				licensed as medical/surgical, intensive care, coronary care, burn, maternal
				(obstetrics) and neonatal intensive care beds (Level III) possess acute
				hospital licensure and do not meet the definition of a chronic disease and
				rehabilitation hospital.
Cosmetic Surgery
-a surgical procedure
				that is performed for the exclusive purpose of altering appearance and is
				unrelated to disease or physical defect, or traumatic injury.
Drug
- a substance as defined by the
				Food, Drug, and Cosmetic Act, containing one or more active ingredients in a
				specified dosage form and strength. Each dosage form and strength is a separate
				drug.
Emergency Medical Condition
- a
				medical condition, whether physical or mental, manifesting itself by symptoms
				of sufficient severity, including severe pain, that the absence of prompt
				medical attention could reasonably be expected by a prudent layperson who
				possesses an average knowledge of health and medicine, to result in placing the
				health of the member or another person in serious jeopardy, serious impairment
				to body function, or serious dysfunction of any body organ or part, or, with
				respect to a pregnant individual, as further defined in the Social Security Act
				§ 1867(e)(1)(B),
				42
				U.S.C. §
										1395dd(e)(1)(B).
Emergency Services
- medical services
				that are furnished by a provider that is qualified to furnish such services,
				and are needed to evaluate or stabilize an emergency medical condition.
Family Planning
- any medically
				approved means, including diagnosis, treatment, and related counseling, that
				assists individuals of childbearing age, including sexually active minors, in
				determining the number and spacing of their children.
Functional Level
- the degree to which
				an individual can function in the community. Progressive levels of impaired
				functioning are evaluated using a MassHealth-approved scale that has specific
				criteria for emotional stability, vocational/educational productivity, social
				relations, and self-care.
Functional Maintenance Program
- a
				planned combination of social, vocational, and recreational services designed
				for individuals disabled by a chronic mental illness who need continuing
				services to maintain skills that allow them to function within the community,
				but who do not require the more intensive care of inpatient or day treatment
				programs.
Gross Cost Per Utilizer Per Year
-
				annual cost per utilizer projected by EOHHS based on factors including actual
				or expected utilization, dosing information, duration of therapy, and the
				National Average Drug Acquisition Cost (NADAC) or Wholesale Acquisition Cost
				(WAC) (when NADAC is not available) of the covered drug prior to any federal or
				supplemental rebate.
Hospital
- a facility that is licensed
				or operated as a hospital by the Massachusetts Department of Public Health or
				the Massachusetts Department of Mental Health and that provides diagnosis and
				treatment on an outpatient basis for patients who have any of a variety of
				medical conditions.
Hospital-licensed Health Center (HLHC)
- a hospital satellite clinic that also
(1) meets all MassHealth requirements for
			 reimbursement as an HLHC as provided in
			 130
			 CMR 410.413; and
(2) is enrolled with the MassHealth agency as
			 a hospital-licensed health center.
Hospital Outpatient Department
.
(1) For an acute hospital, a department or
			 unit within the physical framework of the hospital's inpatient facility that
			 operates under the hospital's license and provides services to members on an
			 outpatient basis. Acute hospital outpatient departments include day-surgery
			 units, primary-care clinics, specialty clinics, and emergency
			 departments.
(2) For a CDR hospital,
			 a department or unit that operates under the hospital's license or is operated
			 by the Department of Public Health's Bureau of Public Health Facilities, and
			 provides services to members on an outpatient basis.
Hospital Satellite Clinic
- a facility
				that
(1) operates under a hospital's
			 license issued to an acute hospital (in the case of an acute hospital satellite
			 clinic) or to a CDR hospital (in the case of a CDR hospital satellite
			 clinic);
(2) is subject to the
			 fiscal, administrative, and clinical management of the hospital;
(3) provides services to members solely on an
			 outpatient basis;
(4) is not located
			 at the same site as the hospital's inpatient facility; and
(5) demonstrates to the MassHealth agency's
			 satisfaction that it has Centers for Medicare and Medicaid (CMS) provider-based
			 status in accordance with
			 42
			 CFR 413.65.
Institutionalized Individual
- an
				individual who is either:
(1)
			 involuntarily confined or detained, under a civil or criminal statute, in a
			 correctional or rehabilitative facility, including a psychiatric hospital or
			 other facility for the treatment of mental illness; or
(2) confined under a voluntary commitment in
			 a psychiatric hospital or other facility for the care and treatment of mental
			 illness.
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.
Mental Illness
- mental and emotional
				disorders as defined in the current
International Classification of
				Diseases, Clinical Modification
or the American Psychiatric
				Association's
Diagnostic and Statistical Manual
and manifested
				by impaired functioning in one or more of the following: emotional stability,
				vocational/educational productivity, social relations, and selfcare.
Mentally Incompetent Individual
- an
				individual who has been declared mentally incompetent by a federal, state, or
				local court of competent jurisdiction for any purpose, unless the individual
				has been declared competent for purposes that include the ability to consent to
				sterilization.
Observation Services
- outpatient
				hospital services provided anywhere in an acute inpatient hospital, to evaluate
				a member's condition and determine the need for admission to an acute inpatient
				hospital. Observation services are provided under the order of a physician,
				consist of the use of a bed and intermittent monitoring by professional
				licensed clinical staff, and may be provided for more than 24 hours.
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.
Outpatient Hospital Services
- medical
				services provided to a member in a hospital outpatient department, hospital
				licensed health center, or other hospital satellite clinic, by or under the
				direction of a physician or dentist. Such services include, but are not limited
				to, emergency services, primary-care services, observation services, ancillary
				services, and day-surgery services.
Outpatient Services
- medical services
				provided to a member in an outpatient setting including but not limited to
				hospital outpatient departments, hospital-licensed health centers or other
				hospital satellite clinics, physicians' offices, nurse practitioners' offices,
				freestanding ambulatory surgery centers, day treatment centers, or the member's
				home.
Outpatient Visit
- an in-person
				encounter between an eligible member and a licensed practitioner (such as a
				physician, optician, optometrist, dentist, or therapist) or other medical
				professional under the direction of a physician or dentist for the provision of
				outpatient services as defined in 130 CMR 410.402.
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.
Reconstructive Surgery
-a surgical
				procedure that is performed to correct, repair, or ameliorate the physical
				effects of disease or physical defect (for example, correction of a cleft
				palate), or traumatic injury.
Sheltered Workshop
- a program of
				vocational counseling and training in which the participants receive paid work
				experience or other supervised employment.
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 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 (regardless of the presence of a communication disability), and
				those that impair comprehension, or spoken, written, or other symbol systems
				used for communication.
Sterilization
- any medical procedure,
				treatment, or operation for the purpose of rendering an individual permanently
				incapable of reproducing.
Vocational Rehabilitative Services
-
				services such as vocational assessments, job training, career counseling, and
				job placement.