Definitions

As used in 101 CMR 614.00, unless the context otherwise requires, terms have the meanings in 101 CMR 614.02. 340B Provider. An acute hospital or community health center eligible to purchase discounted drugs through a program established by § 340B of United States Public Law 102-585, the Veterans Health Care Act of 1992, permitting certain grantees of federal agencies access to reduced cost drugs for their patients, and registered and listed as a 340B provider within the United States Department of Health and Human Services, Office of Pharmacy Affairs (OPA) database. Services of a 340B pharmacy may be provided at on-site or off-site locations. Acute Hospital. A hospital licensed under M.G.L. c. 111, § 51 that contains a majority of medical-surgical, pediatric, obstetric, and maternity beds, as defined by the Department of Public Health. Administrative Day. A day of inpatient hospitalization on which a patient's care needs can be provided in a setting other than an inpatient acute hospital in accordance with the standards in 130 CMR 415.000: Acute Inpatient Hospital Services and on which the patient is clinically ready for discharge. Allowable Health Safety Net Payment. Total maximum, for all eligible services that would be payable if there were no shortfall. Bad Debt. An account receivable based on services provided to a patient that is (a) regarded as uncollectible, following reasonable collection efforts consistent with the requirements in 101 CMR 613.06: Allowable Bad Debt; (b) charged as a credit loss; (c) not the obligation of a governmental unit or the federal government or any agency thereof; and (d) not a reimbursable health service. Center for Health Information and Analysis (CHIA). The Center for Health Information and Analysis established under M.G.L. c. 12C. Centers for Medicare & Medicaid Services (CMS). The federal agency that administers Medicare, Medicaid, and the State Children's Health Insurance Program. Charge. The uniform price for a specific service charged by a provider. Community Health Center. A health center operating in conformance with the requirements of § 330 of the Public Health Service Act (42 U.S.C. § 254b), including all community health centers that file cost reports with CHIA. Such a health center must (a) be licensed as a freestanding clinic by the Massachusetts Department of Public Health pursuant to M.G.L. c. 111, § 51; (b) meet the qualifications for certification (or provisional certification) by the MassHealth agency and enter into a Provider agreement pursuant to 130 CMR 405.000: Community Health Center Services; and (c) operate in conformance with the requirements of 42 U.S.C. § 254b. Disproportionate Share Hospital (DSH). An acute hospital with a minimum public payer mix of 63%. Eligible Services. Services eligible for Health Safety Net payment pursuant to 101 CMR 613.03: Eligible Services Requirements, which include (a) reimbursable health services to low income patients; (b) medical hardship; and (c) bad debt. Emergency Bad Debt. The amount of uncollectible debt for emergency services that meets the criteria set forth in 101 CMR 613.06: Allowable Bad Debt. Emergency Services. Medically necessary services provided to an individual with an emergency medical condition as defined in 101 CMR 613.02: Emergency Services and eligible for payment pursuant to 101 CMR 613.03: Eligible Services Requirements. EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A. Federal Poverty Level (FPL). Income standards issued annually in the Federal Register to account for the last calendar year's increase in prices as measured by the Consumer Price Index. Financial Requirements. An acute hospital's requirement for revenue that includes, but is not limited to, reasonable operating, capital, and working capital costs, and the reasonable costs associated with changes in medical practice and technology. Fiscal Year (FY). The time period of 12 months beginning on October 1st of any calendar year and ending on September 30th of the following calendar year. Governmental Unit. The Commonwealth, any department, agency, board, or commission of the Commonwealth, and any political subdivision of the Commonwealth. Gross Patient Service Revenue. The total dollar amount of a hospital's charges for services rendered in a fiscal year. Guarantor. A person or group of persons who assumes the responsibility of payment for all or part of an acute hospital’s or community health center's charge for services. Health Connector. Commonwealth Health Insurance Connector Authority or Health Connector established pursuant to M.G.L. c. 176Q, § 2. Health Insurance Plan. Medicare, MassHealth, the Premium Assistance Payment Program operated by the Health Connector, a qualified health plan, or an individual or group contract or other plan providing coverage of health care services issued by a health insurance company, as defined in M.G.L. c. 175, 176A, 176B, 176G, or 176I. Health Safety Net. The payment program established and administered in accordance with M.G.L. c. 118E, §§ 8A, and 64 through 69 and regulations promulgated thereunder, and other applicable legislation. Health Safety Net Office. The office within the Office of Medicaid established under M.G.L. c. 118E, § 65. Health Safety Net Trust Fund. The fund established under M.G.L. c. 118E, § 66. Health Services. Medically necessary inpatient and outpatient services as authorized under Title XIX of the Social Security Act. Health services do not include (a) nonmedical services, such as social, educational, and vocational services; (b) cosmetic surgery; (c) canceled or missed appointments; (d) telephone conversations and consultations; (e) court testimony; (f) research or the provision of experimental or unproven procedures; and (g) the provision of whole blood, but the administrative and processing costs associated with the provision of blood and its derivatives are payable. Hospital Cost Report. The Massachusetts Hospital Statement of Costs, Revenues, and Statistics reported to CHIA pursuant to 957 CMR 9.00: Hospital Financial Data Reporting Requirements. Hospital Licensed Health Center. A satellite clinic, as defined in 101 CMR 613.02: Satellite Clinic, that (a) meets MassHealth requirements for reimbursement as a Hospital Licensed Health Center as provided at 130 CMR 410.413: Medical Services Required On Site at a Hospital Licensed Health Center; and (b) is approved by and enrolled with MassHealth’s Provider Enrollment Unit as a hospital licensed health center. Hospital Services. Services listed on an acute hospital’s license by the Department of Public Health. This does not include services provided in transitional care units; services provided in skilled nursing facilities; home health services; or separately licensed services, including residential treatment programs and ambulance services. Individual Medical Visit. A face-to-face meeting at a community health center between a patient and a physician, physician assistant, nurse practitioner, nurse midwife, or registered nurse for medical examination, diagnosis, or treatment. Low Income Patient. A patient who meets the criteria in 101 CMR 613.04(2): Low Income Patient Determination. MassHealth. The medical assistance and benefit programs administered by the MassHealth agency pursuant to Title XIX of the Social Security Act (42 U.S.C. 1396), Title XXI of the Social Security Act (42 U.S.C. 1397), M.G.L. c. 118E, and other applicable laws and waivers to provide and pay for medical services to eligible members. MassHealth Agency. The Executive Office of Health and Human Services in accordance with the provisions of M.G.L. c. 118E. MassHealth Drug List. The list of commonly prescribed drugs and therapeutic class tables published by EOHHS. The MassHealth Drug List specifies the drugs that are payable under MassHealth, and to the extent different, the Health Safety Net. The list also specifies which drugs require prior authorization. Medical Hardship. Health Safety Net status available to Massachusetts residents as defined in 101 CMR 613.02: Resident and for which eligible services are eligible for payment pursuant to 101 CMR 613.03: Eligible Services Requirements. Medically Necessary Service. A service that is reasonably expected to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a disability, or result in illness or infirmity. Medically necessary services include inpatient and outpatient services as authorized under Title XIX of the Social Security Act. Medicare Advantage. A type of Medicare health plan established by Title II of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003. Medicare Program (Medicare). The medical insurance program established by Title XVIII of the Social Security Act. Office of Pharmacy Affairs (OPA). The Office of Pharmacy Affairs, and any successor agencies, is a division within the United States Department of Health and Human Services that monitors the registration of 340B pharmacies. Patient. An individual who receives or has received medically necessary services at an acute hospital or community health center. Pediatric Hospital. An acute hospital that limits services primarily to children and that qualifies as exempt from the Medicare Prospective Payment System (PPS). Pharmacy Online Processing System (POPS). The MassHealth online, real-time computer network that adjudicates pharmacy claims, incorporating prospective drug utilization review, prior authorization, and patient eligibility verification. Premium Assistance Payment Program Operated by the Health Connector. An insurance subsidy program that provides state subsidies for low income individuals and families administered by the Health Connector. Prospective Payment System (PPS) Rate. The Medicare Prospective Payment System rate for community health centers set annually by CMS as described in 42 CFR 405.2467. Provider. An acute hospital or community health center that provides eligible services. Public Payer Mix. The percentage of an acute hospital’s gross patient service revenue attributable to Title XVII and Title XIX of the Social Security Act, the Health Safety Net or other government payers, as reported in the 2022 Hospital Cost Report published by CHIA; provided, however, that for each fiscal year beginning prior to October 1, 2025, public payer mix is determined as of the source year for each such fiscal year and, only for such fiscal years, other government payers include the Premium Assistance Payment Program operated by the Health Connector. Reimbursable Health Services. Eligible services provided by acute hospitals or community health centers to uninsured and underinsured patients who are determined to be financially unable to pay for their care, in whole or in part, and who meet the criteria for low income patient; provided that such services are not eligible for reimbursement by any other public or third-party payer. Relative Public Payer Mix Adjustment Factor. The factor that represents each hospital’s position, relative to other hospitals, with respect to public payer mix in the DSH and non- DSH groups, from a maximum of 1 to a minimum of 0.7 for DSH and a minimum of 0.1 for non-DSH, which is calculated using the following formula: Applicable relative public payer mix adjustment factor minimum + (1 – applicable relative public payer mix adjustment factor minimum) × [(hospital’s public payer mix % - lowest public payer mix % across all hospitals in the same group) / (highest public payer mix % - lowest public payer mix % across all hospitals in the same group)] Shortfall Amount. In a fiscal year, the positive difference between the sum of allowable Health Safety Net payments for all acute hospitals and the revenue available for distribution to acute hospitals. Sole Community Hospital. Any acute hospital classified as a sole community hospital by the U.S. Centers for Medicare & Medicaid Services' Medicare regulations, or any acute hospital that demonstrates to the Health Safety Net Office’s satisfaction that it is located more than 25 miles from other acute hospitals in the Commonwealth and that it provides services for at least 60% of its primary service area. Source Year. The fiscal year two years prior to the current fiscal year, from which data is collected to calculate current fiscal year payment rates, unless otherwise specified by the Health Safety Net Office through administrative bulletin. Underinsured Patient. A patient whose health insurance plan or self-insurance plan does not pay, in whole or in part, for health services that are eligible for payment from the Health Safety Net Trust Fund, provided that the patient meets income eligibility standards set forth in 101 CMR 613.04: Eligible Services to Low Income Patients. Uninsured Patient. A patient who is a resident of the Commonwealth, who is not covered by a health insurance plan or a self-insurance plan, and who is not eligible for a medical assistance program. A patient who has a policy of health insurance or is a member of a health insurance or benefit program that requires such patient to make payment of deductibles or copayments, or fails to cover certain medical services or procedures is not uninsured. Urgent Care Services. Medically necessary services provided in an acute hospital or community health center, as defined in 101 CMR 613.02: Community Health Center, and eligible for payment pursuant to 101 CMR 613.03: Eligible Services Requirements.