Definitions

As used in 101 CMR 512.00, unless the context requires otherwise, terms have the following meanings. Assessment. The total payment due each quarter for each non-Medicare patient day, as set forth in 101 CMR 512.00. Centers for Medicare and Medicaid Services (CMS). The federal agency under the U.S. Department of Health and Human Services that is responsible for administering the Medicare and Medicaid programs. Changes in Ownership (CHOW). Changes in ownership of a nursing facility will, in the case of a corporation, mean transfer of a majority of the stock thereof, and in all other cases, a transfer of a majority interest therein, pursuant to M.G.L. c. 111, s. 71. Continuing Care Retirement Community (CCRC). A community that furnishes board and lodging together with nursing services, medical services, or other health-related services, regardless of whether or not the lodging and services are provided at the same location, to individuals, other than those related by consanguinity or affinity to the person furnishing such care, pursuant to a contract effective for the life of the individual or for a period in excess of one year, and that has filed disclosure information with the Massachusetts Executive Office of Elder Affairs pursuant to M.G.L. c. 93, § 76(e). Licensed nursing facility beds not under the direct control of the board of the CCRC are not considered part of the CCRC. Department of Public Health (DPH). An agency of the Commonwealth of Massachusetts, established under M.G.L. c. 17, § 1. Executive Office of Health and Human Services (EOHHS). The executive department of the Commonwealth of Massachusetts established under M.G.L. c. 6A, § 2 that, through the Department of Elder Affairs and other agencies within EOHHS, as appropriate, operates and administers the programs of medical assistance and medical benefits under M.G.L. c. 118E and that serves as the single state agency under section 1902(a)(5) of the Social Security Act. Facility. A nursing facility licensed by DPH under M.G.L. c. 111, § 71, including nursing or convalescent homes, an infirmary maintained in a town, a charitable home for the aged, and transitional care units. Fiscal Year (FY). The state fiscal year from July 1st through June 30th. MassHealth Program (MassHealth). The medical assistance benefits plans operated and administered by EOHHS pursuant to M.G.L. c. 118E, § 1 et seq. and 42 U.S.C. § 1396 et seq. Title XXI of the Social Security Act (42 U.S.C. 1397), and other applicable laws and waivers to provide and pay for medical services to eligible members (Medicaid). Medicaid Bed Day. A patient day for which the primary payer is either MassHealth or a non- Massachusetts Medicaid program, including patient days paid for by a Senior Care Organization (SCO), One Care, the Program for All-inclusive Care for the Elderly (PACE), or a MassHealth- affiliated Accountable Care Organization (ACO). Medicaid bed days include patient days of individuals who elect hospice care for which Medicaid pays for room and board. Medicare. The federal health insurance program for people who are 65 years of age or older, certain younger people with disabilities, and people with end-stage renal disease (permanent kidney failure requiring dialysis or a transplant, sometimes called ESRD) established by Title XVIII of the Social Security Act. Medicare Patient Day. A patient day covered by Medicare Part A under either an indemnity fee- for-service arrangement (also known as “original Medicare”) or a Medicare managed care plan (also known as Medicare Advantage plan). MassHealth-affiliated 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. Non-Medicare Patient Day. A patient day that is not covered by Medicare Part A under either an indemnity fee-for-service arrangement (also known as “original Medicare”) or a Medicare managed care plan (also known as Medicare Advantage plan). Non-Medicare patient days do not include residential care patient days. One Care (also known as an Integrated Care Organization (ICO)). 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 EOHHS and CMS and has been designated as an ICO to provide services to dual eligible individuals under M.G.L. c. 118E. ICOs are responsible for providing enrollees with the full continuum of Medicare- and MassHealth-covered services. Patient Day. A day of care provided to an individual by a facility regardless of whether or not the facility has been paid for the day. The date an individual is admitted to the facility is a patient day. The date an individual is discharged is not a patient day, unless the individual is admitted and discharged on the same day. Patient days include days for which a facility reserves and customarily charges for a vacant bed for an individual temporarily placed in a different care situation (“bed hold days”). Patient days also include Medicaid “medical leave of absence days” and “non-medical leave of absence days” in accordance with 130 CMR 456.425: Medical Leave of Absence: Introduction through 130 CMR 456.433: Nonmedical Leave of Absence: Payment. Program of All-inclusive Care for the Elderly (PACE). A comprehensive service delivery and financing model that integrates medical and long-term services and supports (LTSS) under dual capitation agreements with Medicare and Medicaid as described under federal regulations for PACE at 42 CFR 460. The PACE program is open to eligible MassHealth members 55 years of age and older who meet MassHealth’s skilled-nursing-facility level of care criteria and reside in a PACE service area. Residential Care. The minimum basic care and services and protective supervision required by DPH in accordance with 105 CMR 150.000: Licensing of Long-term Care Facilities for residents who do not routinely require nursing or other medically related services. Senior Care Organization (SCO). An organization that participates in MassHealth under a contract with the MassHealth agency and the Centers for Medicare & Medicaid Services (CMS) to provide a comprehensive network of medical, health-care, and social-service providers and that integrates components of care, either directly or through subcontracts. Senior Care Organizations are responsible for providing enrollees with the full continuum of Medicare- and MassHealth covered services.