Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 437.000 - Hospice Services › Section 437.402 - Definitions

Current through Register 1525, July 5, 2024
The following terms used in
				130 CMR
				437.000 have the meanings given in
				130 CMR
				437.000, unless the context clearly requires a
				different meaning.
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.
Adult Day Health (ADH)
. A
				community-based and non-residential service that provides nursing care,
				supervision, and health related support services in a structured group setting
				to MassHealth members who have physical, cognitive, or behavioral health
				impairments. The ADH service has a general goal of meeting the ADL, and/or
				skilled nursing therapeutic needs of MassHealth members delivered by a
				MassHealth agency approved ADH provider that meets the conditions of
				130 CMR
				404.000:
Adult Day Health
				Services.
Adult Foster Care (AFC)
. A service
				ordered by a primary care provider delivered to a member in a qualified setting
				as described in
				130
				CMR 408.435:
Adult Foster Care
				Qualified Setting Requirements
by a multidisciplinary team (MDT) and
				qualified AFC caregiver, that includes assistance with ADLs, IADLs, other
				personal care as needed, nursing oversight, and AFC care management, as
				described in
				130
				CMR 408.415(C):
Care
				Management.
Attending Physician
. A doctor of
				medicine or osteopathy legally authorized to practice medicine and surgery by
				the Commonwealth, a nurse practitioner who meets the training, education, and
				experience requirements as described in
				42 CFR §
									410.75(b), or a physician
				assistant who meets the requirements of
				42 CFR §
									410.74(c) who is identified
				by the member at the time of election of hospice services as having the most
				significant role in the determination and delivery of the member's medical
				care.
Bereavement Counseling
.. Emotional,
				psychosocial, and spiritual support and services provided before and after the
				death of the member to assist with issues related to grief, loss, and
				adjustment.
Capitated Program
. An ICO, SCO, ACO,
				MCO, or PACE organization, or any other entity that, according to a contract
				with EOHHS, covers hospice and other medical services for members on a
				capitated basis.
Comprehensive Assessment
. A thorough
				evaluation of the patient's physical, psychosocial, emotional and spiritual
				status related to the terminal illness and related conditions. This includes a
				thorough evaluation of the caregiver's and family's willingness and capability
				to care for the patient.
Day Habilitation (DH)
. A service, for
				individuals with an intellectual disability (ID) or a developmental disability
				(DD), that is based on a day habilitation service plan that sets forth
				measurable goals and objectives, and prescribes an integrated program of
				activities and therapies necessary to reach the stated goals and
				objectives.
Dual-eligible Member
. Individuals who
				are entitled to Medicare Part A and/or Part B and are eligible for a MassHealth
				coverage type as listed in
				130
				CMR 450.105:
Coverage Types
that includes MassHealth hospice services.
Election Period
. One of three or more
				periods of care for which a MassHealth member may elect to receive MassHealth
				coverage of hospice services. The periods consist of an initial 90-day election
				period, a subsequent 90-day election period, and an unlimited number of
				subsequent 60-day election periods.
Employee
. An employee of the hospice
				or, if the hospice is a subdivision of an agency or organization, an employee
				of the agency or organization who is appropriately trained and assigned to the
				hospice unit. An employee may also be a volunteer under the direction of the
				hospice.
Group Adult Foster Care (GAFC)
.
				Services ordered by a physician delivered to a member in a qualified GAFC
				setting by a multidisciplinary team and qualified GAFC caregiver, that includes
				assistance with activities of daily living (ADLs), instrumental activities of
				daily living (IADLs), nursing oversight and care management of GAFC
				services.
Home and Community-based Services (HCBS)
				Waiver
. A federally approved program operated under Section
				1915(c) of the Social Security Act that authorizes the U.S. Secretary of Health
				and Human Services to grant waivers of certain Medicaid statutory requirements
				so that a state may furnish home and community based services to certain
				Medicaid beneficiaries who need a level of care that is provided in a hospital,
				nursing facility, or Intermediate Care Facility for Individuals with
				Intellectual Disability (ICF/IID).
Hospice Care
. A comprehensive set of
				services, as described in
				130
				CMR 437.423, identified and coordinated by an
				interdisciplinary team to provide for the physical, psychosocial, spiritual,
				and emotional needs of a terminally ill member or family members as delineated
				in a specific member plan of care.
Hospice Election Form
. A form that
				complies with election statement requirements established in
				130
				CMR 437.412 and
				42 CFR
				418.24(b) and allows the
				member to elect their MassHealth hospice benefit.
Hospice Inpatient Facility
. A
				palliative-care facility that cares solely for hospice members requiring
				short-term, general inpatient, or respite care and is owned and operated
				directly by a licensed hospice pursuant to
				105 CMR
				141.000:
Licensure of Hospice
				Programs.
Hospice Interdisciplinary Team
. The
				interdisciplinary team of professionals who attend to the physical, medical,
				psychosocial, emotional, and spiritual needs of both the hospice member and the
				hospice member's family. Requirements for the composition and duties of the
				interdisciplinary team are provided at
				130
				CMR 437.421(C).
Hospice Provider
. A public agency or
				private organization or subdivision of either of these that is primarily
				engaged in providing care to terminally ill individuals and meets the
				requirements of
				130 CMR
				437.000.
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.
Intermediate Care Facilities for Individuals with
				Intellectual Disabilities (ICF/IID)
. A facility, or distinct part
				of a facility, that provides intermediate care facility services as defined
				under 42 CFR §
									440.150, and that meets federal conditions of
				participation, and is licensed by the State primarily for the diagnosis,
				treatment, or rehabilitation for individuals with intellectual disabilities;
				and provides, in a protected residential setting, ongoing evaluation, planning,
				24-hour supervision, coordination, and integration for health or rehabilitative
				services to help individuals function at their greatest ability.
Licensed Professional
. A person
				licensed to provide patient-care services by the state in which the services
				are delivered.
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
				hospice 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 hospice provider, whether by inducing that member
(1) to retain that hospice provider to
			 provide hospice services to the member,
(2) not to retain hospice services from
			 another hospice provider, or
(3) to
			 cease receiving hospice services from another hospice provider.
Nursing Facility
. A facility that
				meets all criteria and certification requirements of
				130
				CMR 456.404 or
				456.405.
Palliative Care
. A member- and
				family-centered care that optimizes quality of life by anticipating,
				preventing, and treating suffering. Palliative care throughout the continuum of
				illness involves addressing physical, intellectual, emotional, and spiritual
				needs and facilitating member autonomy, access to information, and
				choice.
Personal Care Attendant (PCA) Program
.
				A MassHealth program under which personal care management services, fiscal
				intermediary services, and PCA services are available to MassHealth
				members.
Personal Care Attendant (PCA)
				Services
. Physical assistance with activities of daily living
				(ADLs) and instrumental activities of daily living (IADLs) provided to a member
				by a PCA in accordance with
				130 CMR
				422.000:
Personal Care Attendant
				Services.
Physician Designee
. A doctor of
				medicine or osteopathy, designated by the hospice, who assumes the same
				responsibilities and obligations as the medical director when the medical
				director is not available.
Program of All-inclusive Care for the Elderly
				(PACE)
. A program of all-inclusive care for the elderly that is
				operated by an approved PACE Organization and that provides comprehensive
				healthcare services to PACE participants in accordance with a PACE Program
				Agreement and as described at 42 CFR Part 460.
Provider Portal
. The online site
				through which hospice providers submit information to MassHealth or to a
				MassHealth designated vendor.
Representative
. An individual who has
				the authority under state law to authorize or terminate medical care or to
				elect or revoke the election of hospice care on behalf of a terminally ill
				member who is mentally or physically incapacitated.
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.
Terminal Illness
. A condition in which
				the member has a medical prognosis of a life expectancy of six months or less
				if the illness runs its normal course.
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.