Definitions

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 comply with federal quality reporting requirements established in accordance with the Social Security Act, sections 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 & 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 will 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, sections 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 include 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 categories. Routine Home Care (Days More 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 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 their life expectancy is six months or fewer.