Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 359.00 - Rates for Home and Community Based Services › Section 359.02 - Definitions

Current through Register 1525, July 5, 2024
As used in
				101 CMR
				359.00, unless the context requires otherwise, terms
				will have the meanings in
				101
				CMR 359.02.
Acquired Brain Injury Home- and Community-based
				Service Waiver (ABI Waiver)
. Two Massachusetts home- and
				community-based services waivers approved by the Centers for Medicare and
				Medicaid Services (CMS) under the Social Security Act, § 1915(c) for
				persons with acquired brain injury who are transitioning from long-stay
				facilities. The two separate ABI Waivers each with different covered services
				and eligibility requirements, are the Acquired Brain Injury with Residential
				Habilitation (ABI-RH) Waiver and the Acquired Brain Injury Nonresidential
				Habilitation (ABI-N) Waiver.
Activities of Daily Living (ADL)
.
				Certain basic tasks required for daily living, including the ability to bathe,
				dress/undress, eat, toilet, transfer in and out of bed or chair, get around
				inside the home, and manage incontinence.
Adult Companion Service
. Nonmedical
				care, supervision, and socialization provided to a participant. Companions may
				assist or supervise the participant with such light household tasks as meal
				preparation, laundry, and shopping.
Agency Rate
. The fee for services
				performed by a person whose wage is paid by a corporation or partnership that
				is a MassHealth provider.
Assisted Living Services
. Services
				consist of personal care and supportive services (homemaker, chore, personal
				care services, meal preparation) that are furnished to participants who reside
				in a qualified assisted living residence (ALR) that includes 24-hour on-site
				response capability to meet scheduled or unpredictable resident needs and to
				provide supervision, safety, and security. Services may also include social and
				recreational programs, and medication assistance (consistent with ALR
				certification and to the extent permitted under State law). Nursing and skilled
				therapy services are incidental rather than integral to the provision of
				Assisted Living Services. Intermittent skilled nursing services and therapy
				services may be provided to the extent allowed by applicable
				regulations.
Assistive Technology
. This service has
				two components: Assistive Technology devices and Assistive Technology
				evaluation and training. These components are defined as follows:
(a) Assistive Technology devices - an item,
			 piece of equipment, or product system that is used to develop, increase,
			 maintain, or improve functional capabilities of participants, and to support
			 the participant to achieve goals identified in their Plan of Care.
(b) Assistive Technology evaluation and
			 training - the evaluation of the Assistive Technology needs of the participant,
i.e
. functional evaluation of the impact of the provision of
			 appropriate Assistive Technology devices and services to the participant in the
			 customary environment of the participant; the selection, customization and
			 acquisition of Assistive Technology devices for participants; selection,
			 design, fitting, customization, adaption, maintenance, repair, and/or
			 replacement of Assistive Technology devices; coordination and use of necessary
			 therapies, interventions, or services with Assistive Technology devices that
			 are associated with other services contained in the Plan of Care; training and
			 technical assistance for the participant, and, where appropriate, the family
			 members, guardians, advocates, or authorized representatives of the
			 participant; and training or technical assistance for professionals or other
			 individuals who provide services to, employ, or are otherwise substantially
			 involved in the major life functions of participants.
Center
. The Center for Health
				Information and Analysis established under M.G.L. c. 12C.
Chore.
An unusual or infrequent
				household maintenance task that is needed to maintain the participant's home in
				a clean, sanitary, and safe environment.
Chore
includes heavy household chores such as washing floors, windows, and walls;
				tacking down loose rugs and tiles; and moving heavy items of furniture in order
				to provide safe access and egress.
Community-based Day Supports (CBDS)
. A
				service designed to enable an individual to enrich his or her life and enjoy a
				full range of community activities by providing opportunities for developing,
				enhancing, and maintaining competency in personal and social interactions and
				community engagement. Community-based Day Supports uses a small group model to
				provide a flexible array of individualized supports through activities
				primarily in non-center-based settings, separate from the participant's private
				residence or other residential living arrangement. The service may include
				career exploration, including assessment of interests through volunteer
				experiences or situational assessments; participant-driven experiences to
				support fuller participation in community life; development and support of
				activities of daily living and independent living skills, socialization
				experiences, and enhancement of interpersonal skills; and pursuit of personal
				interests and hobbies.
Community Family Training
. A service
				designed to provide training and instruction about the treatment regimes,
				behavior plans, and the use of specialized equipment that support a participant
				in the community. Community family training may also include training in family
				leadership, support of self-advocacy, and independence for the family member.
				The service enhances the skills of the family to assist the waiver participant
				to function in the community and at home.
Community Support and Navigation
. A
				service that provides outreach and support services to enable participants to
				access and utilize clinical behavioral health treatment services and other
				supports. These services are staffed by paraprofessionals, supported by
				clinical supervision, and are designed to be maximally flexible in supporting
				participants to implement the goals in their plan of care and attain the skills
				and resources needed to successfully maintain community tenure. Such services
				may include:
(a) Fostering
			 empowerment, recovery, and wellness, including developing recovery strategies,
			 identifying and assisting participants in accessing self-help options, and
			 creating crisis prevention plans and relapse prevention plans;
(b) Assisting participants in improving
			 skills that enhance independence or accessing services to support them in
			 enhancing independence;
(c)
			 Supporting service exploration and linkage;
(d) Providing temporary assistance with
			 transportation to essential medical and behavioral health appointments while
			 transitioning to community-based transportation resources
			 (
e.g
., public transportation resources, PT-1 forms,
etc
.)
(e)
			 Assisting with connecting the participant to necessary behavioral health and
			 other health care services (including, as applicable, supporting initial
			 engagement with coordination provided by the participant's ACO or
			 MCO);
(f) Providing linkages to
			 recovery-oriented peer supports and/or self-help supports and
			 services;
(g) Assisting with
			 self-advocacy skills to improve communication and participation in
			 treatment/service planning discussions and meetings; and
(h) Collaborating with Emergency Services
			 Programs/Mobile Crisis Intervention (ESP/ MCIs) and/or outpatient providers,
			 including working with ESP/MCIs to develop, revise, or utilize participant
			 crisis prevention plans or safety plans.
Cost Report
. The document used to
				report costs and other financial and statistical data. The Uniform Financial
				Statements and Independent Auditor's Report (UFR) are used when
				required.
Day Services
. A structured,
				site-based, group program for participants that fosters community integration
				and offers assistance with the acquisition, retention, or improvement in
				self-help, socialization, and adaptive skills, and that takes place in a
				nonresidential setting separate from the participant's private residence or
				other residential living arrangement. Services often include assistance to
				learn activities of daily living and functional skills; language and
				communication training; compensatory, cognitive and other strategies;
				interpersonal skills; prevocational skills; and recreational and socialization
				skills.
Employer Expense Component (EEC)
. The
				portion of the Self-directed Service rate that is designated for the mandated
				employer share of the Federal Insurance Contributions Act (FICA), federal and
				state unemployment taxes, Medicare, and Workers' Compensation premiums.
EOHHS.
The Executive Office of Health
				and Human Services established under M.G.L. c. 6A.
Governmental Unit
. The Commonwealth,
				any board, commission, department, division, or agency of the Commonwealth and
				any political subdivision of the Commonwealth.
Home Accessibility Adaptations
.
				Physical modifications to the participant's home that are necessary to ensure
				the health, welfare, and safety of the participant or that enable the
				participant to function with greater independence in the home.
Home and Community-based Services (HCBS)
				Waiver
. A federally approved program operated under the Social
				Security Act, § 1915(c) 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
				Disabilities (ICF/ID). For purposes of
				101 CMR
				359.00, Home- and Community-based Service Waiver
				refers to the two ABI waivers and the two MFP waivers.
Home Delivered Meals
. Services to a
				participant which provides well-balanced meals and maintains optimal
				nutritional and health status. Home Delivered Meals service includes the
				preparation, packaging, and delivery of meals by trained and supervised
				staff.
Home Health Aide
. A person who
				performs certain personal care and other health-related services as described
				in 130 CMR
				403.000:
Home Health Agency
.
Homemaker
. A person who performs light
				housekeeping duties (for example: cooking, cleaning, laundry, and shopping) for
				the purpose of maintaining a household.
Independent Living Supports
. A service
				that ensures 24-hour seven days per week access to supportive services for
				participants who have intermittent, scheduled and unscheduled needs for various
				forms of assistance, but who do not require 24-hour supervision. It provides
				participants with services and supports in a variety of activities such as:
				ADLs and instrumental activities of daily living (IADLs), support and
				companionship, emotional support, and socialization. This service is provided
				by a site-based provider, and is available to participants who choose to reside
				in locations where a critical mass of individuals reside who require such
				support and where providers of such supports are available.
Individual Consideration (I.C)
.
				Payment rates for certain services are designated as Individual Consideration
				(I.C.). Where I.C. rates are designated, the purchasing governmental unit will
				determine the appropriate payment rate in accordance with the following
				standards and criteria:
(a)
			 the amount of time required to complete the service or item;
(b) the degree of skill required to complete
			 the service or item;
(c) the
			 severity or complexity of the service or item;
(d) the lowest price charged or accepted from
			 any payer for the same or similar service or item including, but not limited
			 to, any shelf price, sale price, advertised price, or other price reasonably
			 obtained by a competitive market for the service or item; and
(e) the established rates, policies,
			 procedures, and practices of any other purchasing governmental unit in
			 purchasing the same or similar services or items.
Individual Provider (Self-employed Provider)
				Rate
. The fee for services performed by a person that is a
				Provider and is not paid a wage by another person or entity for services
				performed.
Individual Support and Community
				Habilitation
. Regular or intermittent services designed to
				develop, maintain, and/or maximize the participant's independent functioning in
				self-care, physical and emotional growth, socialization, communication, and
				vocational skills, to achieve objectives of improved health and welfare and to
				support the ability of the participant to establish and maintain a residence
				and live in the community.
Laundry
. Services provided to a
				participant which includes pick up, washing, drying, folding, wrapping, and
				returning of laundry.
Moving Forward Plan Waivers (MFP
				Waivers)
. Two Massachusetts Home- and Community-based Services
				Waivers approved by the CMS under the Social Security Act, § 1915(c) for
				persons with disabilities who are transitioning from long-stay facilities.
				Massachusetts operates two separate MFP Waivers - the Moving Forward Plan
				Residential Supports (MFP-RS) waiver, and the Moving Forward Plan Community
				Living (MFP-CL) waiver, each with different covered services and eligibility
				requirements.
Non-agency Rate
. The fee for services
				performed by Individual Providers (Self-employed Providers) or Self-directed
				Workers.
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 and 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.
Orientation and Mobility Services
.
				Services that teach an individual with vision impairment or legal blindness how
				to move or travel safely and independently in his or her home and community,
				and which includes assessment, training and education provided to participants,
				environmental evaluations, caregiver/direct care staff training on sensitivity
				to blindness/low vision, and information resource on community living for
				persons with vision impairment or legal blindness. Orientation and Mobility
				Services are tailored to the individual's need and may extend beyond the home
				setting to other community settings as well as public transportation
				systems.
Participant
. A MassHealth member
				determined by the MassHealth agency to be eligible for enrollment in one of the
				HCBS waivers, who chooses to receive HCBS waiver services, and for whom a
				service plan has been developed that includes one or more HCBS waiver
				services.
Peer Support
. Ongoing services and
				supports designed to assist participants to acquire, maintain or improve the
				skills necessary to live in a community setting. This service provides supports
				necessary for the participant to develop the skills that enable them to become
				more independent, integrated into, and productive in their communities. The
				service enables the participant to retain or improve skills related to personal
				finance, health, shopping, use of community resources, community safety, and
				other adaptive skills needed to live in the community.
Personal Care
. Services provided to a
				participant, which may include physical assistance, supervision or cueing of
				participants, for the purpose of assisting the participant to accomplish
				activities of daily living (ADLs) including, but not limited to, eating,
				toileting, dressing, bathing, transferring, and ambulation.
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.
Prevocational Services
. A service that
				consists of a range of learning and experimental type activities that prepares
				a participant for paid or unpaid employment in an integrated, community
				setting. Services are not job-task oriented, but instead aimed at a generalized
				result (
e.g
., attention span, motor skills). The service may
				include teaching such concepts as attendance, task completion, problem solving
				and safety as well as social skills training, improving attention span, and
				developing or improving motor skills. Basic skill-building activities are
				expected to specifically involve strategies to enhance a participant's
				employability in integrated, community settings.
Provider
. Any individual, group,
				partnership, trust, corporation or other legal entity that offers services for
				purchase by a governmental unit and that meets the conditions of purchase or
				licensure that have been or may be adopted by a purchasing governmental
				unit.
Reporting Year
. The Provider's fiscal
				year.
Residential Family Training
. A service
				designed to provide training and instruction about treatment regimes, behavior
				plans, and the use of specialized equipment that supports the participant to
				participate in the community. Residential family training may also include
				training in family leadership, support of self-advocacy, and independence for
				their family member. The service enhances the skill of the family to assist the
				waiver participant to function in the community and at home when the waiver
				participant visits his or her family.
Residential Habilitation Room and
				Board
. The amount paid by a governmental unit purchasing
				Residential Habilitation services for the costs of building, maintenance,
				upkeep, improvements, and meals, which are not covered as part of the
				Residential Habilitation Waiver service.
Residential Habilitation Service
.
				Ongoing services and supports provided to a participant in a provider-operated
				residential setting that are designed to assist participants in acquiring,
				maintaining, or improving the skills necessary to live in a community setting.
				Residential habilitation provides participants with daily staff intervention
				including care, supervision, and skills training in activities of daily living,
				home management, and community integration in a qualified residential setting
				with 24-hour staffing. This service may include the provision of medical and
				health-care services that are integral to meeting the daily needs of
				participants.
Respite
. Services provided to
				individuals unable to care for themselves; furnished on a short-term basis
				because of the absence or need for relief of unpaid caregivers.
Self-directed Services
. A model of
				service delivery in which a waiver participant has decisionmaking authority
				over certain aspects of the delivery of their care.
Self-directed Worker
. Participants who
				choose to self-direct waiver services have the authority and responsibility for
				recruiting and hiring workers to provide their Self-directed Services. These
				workers are referred to as self-directed workers and are subject to the
				standards, requirements, policies, and procedures for such workers under the
				participant's Home- and Community-based Services (HCBS) Waiver.
Shared Home Supports
. An individually
				tailored supportive service that assists with the acquisition, retention, or
				improvement in skills related to living in the community. A participant is
				matched with a Shared Home Supports caregiver. This arrangement is overseen by
				a residential support agency. Shared Home Supports does not include 24-hour
				care. Shared Home Supports includes such supports as: adaptive skill
				development, assistance with ADLs and IADLs, adult educational supports, social
				and leisure skill development, and supervision.
Shared Living - 24-hour Supports
. A
				residential option that matches a participant with a Shared Living caregiver.
				This arrangement is overseen by a residential support agency. Shared Living is
				an individually tailored 24 hours/seven days per week, supportive service
				available to a participant who needs daily structure and supervision. Shared
				Living includes supportive services that assist with the acquisition,
				retention, or improvement of skills related to living in the community. This
				includes such supports as: adaptive skill development, assistance with ADLs and
				IADLs, adult educational supports, social and leisure skill development,
				protective oversight and supervision.
Skilled Nursing Services
. The
				assessment, planning, provision, 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. Skilled Nursing Services are provided by a person licensed as a
				registered nurse or a licensed practical nurse by a state's board of
				registration in nursing.
Specialized Medical Equipment and
				Supplies
. Devices, controls, or appliances to increase abilities
				in activities of daily living, or to control or communicate with the
				environment.
Speech 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 presence of a communication disability), and those that impair
				comprehension, spoken, written, or other symbol systems used for
				communication.
Supported Employment
. Regularly
				scheduled services that enable participants, through training and support, to
				work in integrated work settings in which individuals are working toward
				compensated work, consistent with the strengths, resources, priorities,
				concerns, abilities, capabilities, interests, and informed choice of the
				individuals.
Supportive Home Care Aide
. Services
				provided to participants with Alzheimer's/dementia or behavioral health needs
				to assist with ADLs and IADLs. These services include personal care, shopping,
				menu planning, meal preparation including special diets, laundry, light
				housekeeping, escort, and socialization/emotional support.
Transitional Assistance
. Nonrecurring
				residential set-up expenses for participants who are transitioning from a
				nursing facility or hospital to a community living arrangement where the
				participant is directly responsible for his or her own set-up expenses.
				Allowable expenses are those that are necessary to enable a person to establish
				a basic household and do not constitute room and board.
Transportation Services
. Conveyance of
				participants by vehicle from their residence to and from the site of HCBS
				waiver services and other community services, activities, and resources,
				including physical assistance to participants while entering and exiting the
				vehicle.
Vehicle Modification
. Necessary
				adaptations or alterations to an automobile or van that is the waiver
				participant's primary means of transportation and that is not owned or leased
				by an entity providing services to the participant. Vehicle modifications are
				necessary when they are required to accommodate the special needs of the
				participant. Examples of vehicle modifications include: van lift, tie downs,
				ramp, specialized seating equipment and seating/safety restraint.
Waiver Services
. Home- and
				community-based services that are covered in accordance with the requirements
				of 130 CMR
				630.000:
Home- and Community-based Services
				Waivers
for participants enrolled under an ABI or MFP
				waiver.