Definitions

As used in 101 CMR 359.00, unless the context requires otherwise, terms 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 (IC). Payment rates for certain services are designated as Individual Consideration (IC). Where IC 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 decision- making 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 do not include 24-hour care. Shared home supports include 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 per day/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 Waiver Services for participants enrolled under an ABI or MFP waiver.