Code of Massachusetts Regulations › 130 CMR - DIVISION OF MEDICAL ASSISTANCE › Title 130 CMR 610.000 - MassHealth: Fair Hearing Rules › Section 610.004 - Definitions

Current through Register 1525, July 5, 2024
For purposes of
				130 CMR 610.000, the
				following terms are defined as follows:
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.
Accountable Care Partnership Plan
				(ACPP)
- a type of ACO with which the MassHealth agency contracts
				under its ACO 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.
Acting Entity
- the MassHealth agency,
				a MassHealth managed care contractor, or a nursing facility responsible for
				making a determination that can be appealed. The acting entity also includes
				the Department of Mental Health and the Department of Developmental Services
				when making a PASRR determination. The acting entity includes the Department of
				Developmental Services for purposes of denial, suspension, reduction,
				modification, or termination of services or for failure to act on a waiver
				participant's request for services for the following HCBS Waiver Programs:
				Acquired Brain Injury - Residential Habilitation (ABI-RH) and Moving Forward
				Plan - Residential Supports (MFP-RS). The acting entity includes the
				Massachusetts Rehabilitation Commission for purposes of denial, suspension,
				reduction, modification, or termination of services or for failure to act on a
				waiver participant's request for services for the following HCBS Waiver
				Programs: Acquired Brain Injury - Nonresidential Habilitation (ABI-N), Moving
				Forward Plan - Community Living (MFP-CL), and Traumatic Brain Injury
				(TBI).
Adequate Notice
- a notice concerning
				an intended appealable action that states the intended action by the MassHealth
				agency; the reason or reasons for the intended action; the MassHealth
				regulation supporting the action; an explanation of the right to request a fair
				hearing; and the circumstances under which assistance is continued as set out
				in
				130 CMR
				610.026.
Appealable Action
- certain actions or
				inactions, as further described in
				130 CMR
				610.032, by the MassHealth agency, a
				MassHealth managed care contractor, a nursing facility, the Department of
				Mental Health, or the Department of Developmental Services.
Appeal Representative
-
(1) a person or an organization who agrees to comply with
				applicable rules regarding confidentiality and conflicts of interest in the
				course of representing an applicant or member, provided such person or
				organization
(a) has provided the BOH with written authorization from the
				applicant or member to act responsibly on his or her behalf during the appeal
				process; or
(b) has, under applicable law, authority to act on behalf of an
				applicant or member at an appeal or otherwise in making decisions related to
				health care or payment for health care including, but not limited to, a
				guardian, conservator, personal representative of the estate of an applicant or
				member, holder of power of attorney, or an invoked health care proxy; or
(2) a person or organization who has been designated an
				authorized representative, as defined in 130 CMR 610.004:
Authorized Representative
, pursuant to a valid
				Authorized Representative Designation Form.
Appellant
- an applicant, member, or
				nursing facility resident requesting a fair hearing, including individuals who
				are appealing a PASRR determination. An appellant may also include a community
				spouse of an institutionalized applicant when the community spouse is
				exercising a fair hearing appeal right that he or she has under
				130 CMR 520.016:
Long-term-care: Treatment of Assets
or
				130
				CMR 520.017:
Right to Appeal the
				Asset Allowance or Minimum-monthly-maintenance-needs Allowance
.
Applicant
- a person, including a
				waiver applicant, who has applied or attempted to apply for an assistance
				program administered by the MassHealth agency.
Application
- an application as
				defined in
				130 CMR
				501.001:
Definition of Terms
and
				130 CMR
				515.001:
Definition of
				Terms
.
Assistance
- any medical assistance or
				benefits provided to a member by the MassHealth agency.
Authorized Representative
- an
				authorized representative as defined in
				130 CMR
				501.001:
Definition of Terms
and
				130 CMR
				515.001:
Definition of
				Terms
.
Behavioral Health Contractor
- the
				entity contracted with EOHHS to provide, arrange for, and coordinate behavioral
				health care and other services to members on a capitated basis.
Board of Hearings (BOH)
- the
				designated hearing unit within the Executive Office of Health and Human
				Services (EOHHS) Office of Medicaid.
Department of Mental Health (DMH)
-
				the state agency organized under M.G.L. c. 19, or its agent.
Department of Developmental Services
				(DDS)
- the state agency organized under M.G.L. c. 19B, or its
				agent.
Director
- the Director of BOH (also
				known as BOH Director).
Discharge
- the removal from a nursing
				facility of an individual who is a resident where the discharging nursing
				facility ceases to be legally responsible for the care of that
				individual.
Dual Eligible Individual
- for
				purposes of the Duals Demonstration Program, a MassHealth member who meets all
				of the following criteria:
(1) is 21 through 64 years of age at the time of enrollment in
				the Duals Demonstration Program;
(2) is eligible for MassHealth Standard as defined in
				130 CMR
				450.105(A):
MassHealth Standard
or MassHealth Common Health as defined in
				130 CMR
				450.105(E):
MassHealth Common Health
;
(3) is enrolled in Medicare Parts A and B, is eligible for
				Medicare Part D, and has no access to other health insurance that meets the
				basic-benefit level as defined in
				130 CMR
				501.001:
Definition of
				Terms
; and
(4) lives in a designated service area of an ICO.
Duals Demonstration Program
- the
				MassHealth state demonstration to integrate care for Dual Eligible Individuals,
				also known as One Care.
Fair Hearing
- the process for appeals
				conducted according to
				130 CMR 610.000 to
				determine the legal rights, duties, benefits, or privileges of applicants,
				members, or nursing facility residents.
Fair Hearing Regulations
- the
				regulations at
				130 CMR 610.000.
Health Connector
- the Commonwealth
				Health Insurance Connector Authority established under M.G.L. c. 176Q.
Hearing
- a fair hearing.
Hearing Officer
- an impartial and
				independent person designated by the BOH Director to conduct hearings and
				render decisions pursuant to
				130 CMR 610.000.
Home- and Community-based Services (HCBS) Waiver
				Program
- one of the following programs established pursuant to
				42 USC
				1396n: Acquired Brain Injury - Residential
				Habilitation (ABI-RH); Acquired Brain Injury - Nonresidential Habilitation
				(ABI-N); Young Children with Autism; Persons with an Intellectual Disability -
				Intensive Supports; Persons with an Intellectual Disability - Community Living;
				Persons with an Intellectual Disability - Adult Supports; Frail Elder Waiver
				(FEW); Moving Forward Plan - Residential Supports (MFP-RS); Moving Forward Plan
				- Community Living (MFP-CL); and Traumatic Brain Injury (TBI).
Integrated Care Organization (ICO, also known as a
				One Care Plan)
- 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 the Executive Office of Health and Human
				Services (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.
Independent Review Entity (IRE)
- the
				external review entity for the Centers for Medicare & Medicaid Services
				(CMS) appeals.
Interpreter
- a person who is either a
				Qualified Interpreter for an Individual with Limited English, or a Qualified
				Interpreter for an Individual with a Disability as defined in 130 CMR
				610.004.
Managed Care Contractor
- any
				MassHealth-contracted managed care organization (MCO), including a SCO or an
				ICO, or behavioral health contractor.
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.
Massachusetts Rehabilitation Commission
				(MRC)
- the state agency organized under M.G.L. c. 6, § 74,
				or its agent.
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.
Member
- a person who is or had been
				receiving assistance under a program administered by the MassHealth
				agency.
Nursing Facility
- a Medicare- or
				Medicaid-certified nursing facility or certified unit within a nursing facility
				that is licensed by the Department of Public Health to operate in
				Massachusetts.
Party
- the appellant, the managed
				care contractor, the nursing facility as respondent in a nursing facility
				initiated transfer, discharge, or failure to readmit the respondent to a
				complaint of coercive behavior, the MassHealth agency, DMH, MRC, or DDS.
PASRR Determination
- a determination,
				made by DMH or DDS, that an individual does or does not require the level of
				services provided by a nursing facility or that the individual does or does not
				require specialized services as defined by
				42 CFR
				483.120.
PASRR Evaluation
- the medical review
				of an individual for mental illness, developmental disability, or conditions
				related to developmental disability and conducted pursuant to 42 CFR 483
				Subpart C.
Policy Memoranda
-
				written explanations issued by the Medicaid director or the General Counsel's
				office, of the MassHealth agency's intent and interpretation or application of
				its regulations under 130 CMR, or a written explanation, issued by the Health
				Connector or its designee, of the Health Connector's intent and interpretation
				of its regulations under 956 CMR.
Preadmission Screening and Resident Review
				(PASRR)
- a federally mandated program for screening individuals
				seeking admission to and residents of Medicaid-certified nursing facilities for
				mental illness, developmental disability, or conditions related to
				developmental disability. The federal requirements for PASRR are provided at 42
				CFR 483 Subpart C and
				42 U.S.C.
				1396r(e)(7).
Provider
- any entity that furnishes
				medical services to MassHealth members.
Qualified Interpreter for an Individual with a
				Disability
-
(1) A qualified interpreter for an individual with a disability
				is an interpreter who
via
a remote interpreting service or an
				on-site appearance
(a) adheres to generally accepted interpreter ethics
				principles, including client confidentiality; and
(b) is able to interpret effectively, accurately, and
				impartially, both receptively and expressively, using any necessary specialized
				vocabulary, terminology, and phraseology.
(2) For an individual with a disability, qualified interpreters
				can include, for example, sign language interpreters, oral transliterators
				(individuals who represent or spell in the characters of another alphabet), and
				cued language transliterators (individuals who represent or spell by using a
				small number of handshapes).
Qualified Interpreter for an Individual with
				Limited English Proficiency
- an interpreter who
via
a remote interpreting service or an on-site
				appearance
(1) adheres to generally accepted interpreter ethics
				principles, including client confidentiality;
(2) has demonstrated proficiency in speaking and understanding
				both spoken English and at least one other spoken language; and
(3) is able to interpret effectively, accurately, and
				impartially, both receptively and expressly, to and from such language(s) and
				English, using any necessary specialized vocabulary, terminology, and
				phraseology.
Record Open
- a period of time
				determined by the hearing officer that, if allowed by the hearing officer
				within his or her discretion, permits either party to a fair hearing the
				opportunity to submit post-hearing documentation, relevant evidence, or legal
				arguments.
Resident
- an individual who lives in
				a nursing facility, regardless of whether he or she is a MassHealth
				member.
Resident Record
- that portion of a
				nursing facility's records in which the nursing facility has documented the
				reason for an intended discharge or transfer of a resident.
Rural Service Area
- any geographic
				area other than an urban area, as that term is defined in
				42
				CFR 412.62(f)(ii).
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-Medicare-covered services.
Timely Notice
- adequate notice of an
				intended appealable action by the MassHealth agency that meets the requirements
				set forth in
				130 CMR
				610.015(A).
Timely Request
- a request for a fair
				hearing received by BOH within the timely notice period set forth in
				130 CMR
				610.015(B).
Transfer
- except for the movement of
				a resident within the same facility from one certified bed to another bed with
				the same certification, a transfer is the movement of a resident from
(1) a Medicaid- or Medicare-certified bed to a noncertified
				bed;
(2) a Medicaid-certified bed to a Medicare-certified
				bed;
(3) a Medicare-certified bed to a Medicaid-certified
				bed;
(4) one nursing facility to another nursing facility; or
(5) a nursing facility to a hospital, or any other
				institutional setting.
Waiver Applicant
- a person who
				submits an application for enrollment in a HCBS Waiver Program.
Waiver Participant
- a member who is
				enrolled in a HCBS Waiver Program.