Definitions

The following terms used in 130 CMR 408.503 through 408.527 have the meanings given in 130 CMR 408.502, unless the context clearly requires a different meaning. Payment for services defined in 130 CMR 408.000 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 408.000 and 130 CMR 450.000: Administrative and Billing Regulations. Activities of Daily Living (ADLs). Fundamental personal-care tasks performed daily as part of an individual’s routine of self-care. ADLs include, but are not limited to, eating, toileting, dressing, bathing, transferring, and mobility/ambulation. Assisted Living Residence (ALR). Any entity that meets the requirements for certification pursuant to M.G.L. c. 19D and 651 CMR 12.00: Certification Procedures and Standards for Assisted Living Residences. Clinical Assessment. The screening process of cataloging a member’s need for GAFC using a tool designated by the MassHealth agency and that forms the basis for prior authorization. Clinical Evaluations. Nursing, fall risk, nutritional, skin, and other clinical or psychosocial evaluations conducted by the MDT that serve as the basis for the development of the GAFC plan of care. Electronic Visit Verification (EVV). The method or system designated or approved by EOHHS to electronically verify service delivery in the form and format as required by EOHHS. Executive Office of Health and Human Services (EOHHS). The Executive Office of Health and Human Services established under M.G.L. c. 6A. Family Member. A spouse, parent of a minor member, including adoptive parent, or any legally responsible relative of the member. Group Adult Foster Care (GAFC). A service ordered by a PCP delivered to a member in a member’s home by a MDT and a qualified GAFC direct care aide, that includes assistance with ADLs and IADLs, nursing oversight and care management, as described under 130 CMR 408.505. GAFC Direct Care Aide. A person who is employed or contracted by a GAFC provider and meets the qualifications and responsibilities provided in 130 CMR 408.524(C). Hospital. A facility that is licensed or operated as a hospital by the Massachusetts Department of Public Health (DPH) or the Massachusetts Department of Mental Health (DMH) that provides diagnosis and treatment on an inpatient or outpatient basis for patients who have any of a variety of medical conditions. Instrumental Activities of Daily Living (IADLs). Activities related to independent living that are incidental to the care of the member and that include, but are not limited to, household-management tasks, laundry, shopping, housekeeping, meal preparation and cleanup, transportation (accompanying the member to medical providers and other appointments), care and maintenance of wheelchairs and adaptive devices, medication management, and any paperwork required for receiving prescribed medications within the member’s residence, or any other medical need determined by the provider as being instrumental to the health care and general well-being of the member. Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID). A facility, or distinct part of a facility, that provides intermediate care facility services as defined under 42 CFR § 440.150, and that meets federal conditions of participation, and is licensed by the state primarily for the diagnosis, treatment, or rehabilitation for individuals with intellectual disabilities; and provides, in a protected residential setting, ongoing evaluation, planning, 24-hour supervision, coordination, and integration for health or rehabilitative services to help individuals function at their greatest ability. MassHealth. The medical assistance and benefit programs administered by EOHHS 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. Member. A person determined by the MassHealth agency to be eligible for MassHealth. Multidisciplinary Professional Team (MDT). A team employed or contracted by the provider including, but not limited to, a program director, a registered nurse or a licensed practical nurse, and a care manager. Nursing Facility. An institution (or a distinct part of an institution) that is primarily engaged in providing skilled nursing care and related services for residents who require medical or nursing care, rehabilitation services for the rehabilitation of injured people, people with disabilities, or sick persons, or on a regular basis, health-related care and services to individuals who, because of their mental or physical condition require care and services that meet the requirements of Sections 1919(a), through (d) of the Social Security Act, and is licensed under and certified by the Massachusetts Department of Public Health. Plan of Care. A person-centered, written plan based on clinical and psychosocial evaluations, describing activities to meet a member’s medical, physical, emotional, and social needs and goals for GAFC. Provider. An organization that meets the requirements of 130 CMR 408.504 and contracts with MassHealth as the provider for GAFC. Primary Care Provider (PCP). A physician or a physician assistant or nurse practitioner who operates under the supervision of a physician. Primary Care Provider (PCP) Summary Form. The form that a PCP uses to order GAFC. Significant Change. A major change in the member’s status that (1) is permanent; (2) impacts more than one area of the member’s health status; and (3) requires a multidisciplinary review or revision of the care plan. A significant change is presumed when a member authorized to receive services does not receive services for 90 days or more, or when the provider is seeking a change in service amount or payment level.