Code of Massachusetts Regulations › 101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES › Title 101 CMR 343.00 - Rates for Hospice Services › Section 343.02 - Definitions

Current through Register 1525, July 5, 2024
A number of common words and expressions are specifically
				defined in 101 CMR 343.02. Whenever one of them is used in
				101 CMR
				343.00, it will have the meaning given in the
				definition, unless the context clearly requires a different meaning. When
				appropriate, definitions may include a reference to federal and state laws and
				regulations.
Center
. The Center for Health
				Information and Analysis established under M.G.L. c. 12C.
Compliant Rate
. Hospice service rates
				for eligible providers that are in compliance with federal quality reporting
				requirements established in accordance with the Social Security Act,
				§§ 1814(i)(5)(A)(i).
Continuous Home Care
. Care provided
				only during a period of crisis in which a patient requires continuous care,
				predominantly nursing care, at home to achieve palliation or management of
				acute medical symptoms. Homemaker and/or home health aide services may also be
				covered on a continuous basis. The continuous home care rate is paid on an
				hourly rate basis for each day, or portion thereof, that an individual
				qualifies for and receives such care. A minimum of eight hours must be provided
				in a 24-hour period to qualify for the continuous home care rate.
Eligible Provider
. Any
				Medicare-certified organization licensed under state law as a provider of
				hospice services.
EOHHS
. The Executive Office of Health
				and Human Services established under M.G.L. c. 6A.
General Inpatient Care
. Care provided
				in a participating hospice inpatient unit, hospital, or skilled nursing
				facility that additionally meets the Centers for Medicare and Medicaid Services
				(CMS) special hospice standards for staffing and patient areas. Services
				provided in an inpatient setting must conform to the written plan of care.
				General inpatient care may be required for procedures necessary for pain
				control or acute or chronic symptom management that cannot be managed in other
				settings.
Governmental Unit
. The Commonwealth;
				any department, agency, board, or commission of the Commonwealth; and any
				political subdivision of the Commonwealth.
Hospice
. A public agency or private
				organization or a subdivision of either that is providing care to terminally
				ill individuals and meets the Medicare conditions of participation specified in
				42 CFR
				418.52 through
				418.116
				for hospices. If it is a freestanding hospice that provides inpatient care
				directly, it must meet the conditions of
				42
				CFR 418.110.
(a) Core services (provided directly by hospice employees)
				include
1. nursing services;
2. physician services;
3. medical social services; and
4. counseling services.
(b) Supplemental services (may be on a contract basis)
				include
1. short-term inpatient care;
2. medical appliances and supplies, including drugs and
				biologicals;
3. home health aide and homemaker services;
4. physical therapy, occupational therapy, and speech-language;
				and
5. pathology services.
Inpatient Care Limitation
. For
				Medicaid, the total payment to the hospice for inpatient care (general or
				respite) is subject to a limitation that total inpatient care days for all
				Medicaid patients for a 12-month period may not exceed 20% of total days for
				which all Medicaid patients have elected hospice care; however, days to be used
				by individuals with Acquired Immune Deficiency Syndrome (AIDS) are exempt from
				the number of inpatient care days counted toward the 20% limitation.
Inpatient Respite Care
. Short-term
				inpatient care provided to the individual in an approved inpatient facility
				only when necessary to relieve the family members or other persons caring for
				that individual. Respite care may be provided only on an occasional basis and
				shall be limited to no more than five consecutive days. Reimbursement for the
				sixth and any subsequent days is made at the routine home care rate.
Noncompliant Rate
. Hospice service
				rates for eligible providers that are not in compliance with the federal
				quality reporting requirements established in accordance with the Social
				Security Act, §§ 1814(i)(5)(A)(i).
Publicly Aided Individual
. A person
				who receives medical services for which a governmental unit is liable, in whole
				or in part, under a statutory program.
Room and Board
. An additional
per diem
amount that equals at least 95% of the amount the
				Commonwealth would pay the facility for a non-hospice Medicaid beneficiary, for
				routine or continuous-care days in an intermediate care or skilled nursing
				facility. Room and board includes performance of personal care services,
				including assistance in activities of daily living, socializing activities,
				administration of medication, maintaining the cleanliness of a resident's room,
				and supervision and assistance in the use of durable medical equipment and
				prescribed therapies.
Routine Home Care (RHC)
. Payment for
				each day the patient is at home, under the care of the hospice, and not
				receiving continuous home care. There are two rates for RHC: one rate for days
				one through 60 and a lower rate for days greater than 60. Rates for RHC are
				paid without regard to the volume or intensity of RHC services provided on any
				day.
Routine Home Care (Days from One to
				60)
. Payment for each day (one through 60 days) when the member
				has elected to receive hospice in their home and is not receiving continuous
				home care. This rate is paid without regard to the volume or intensity of RHC
				services provided on any day. A 60-day gap in hospice services is required to
				reset the counter that determines if a patient is qualified for the one through
				60 payment category.
Routine Home Care (Days Greater than
				60)
. Payment for each day (61+ days) when the member has elected
				to receive hospice in their home and is not receiving continuous home care.
				This rate is paid without regard to the volume or intensity of RHC services
				provided on any day.
Service Intensity Add-on (SIA)
. The
				SIA rate is an addition to the RHC rate, for a minimum of 15 minutes and up to
				four hours per day (excluding a social worker's phone calls), when all of the
				following criteria are met
(a) The day is a RHC level of care day;
(b) The RHC day occurs during the last seven days of the
				member's life, and the member is discharged deceased; and
(c) Direct patient care is furnished by a registered nurse (RN)
				or social worker that RHC day.
Terminally Ill
. The individual has a
				medical prognosis that his or her life expectancy is six months or
				less.