Definitions

The following terms used in 130 CMR 414.000 have the meanings given in 130 CMR 414.402 unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 414.402 is not determined by these definitions, but by the application of regulations elsewhere in 130 CMR 414.000 and 450.000: Administrative and Billing Regulations. Accountable Care Organization (ACO) – an entity that enters into a population-based payment model contract with the Executive Office of Health and Human Services (EOHHS) as an ACO, 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 managed care organization–administered ACOs. Calendar Week – seven consecutive days beginning Sunday at 12:00 A.M. and ending Saturday at 11:59 P.M. Capitated Program – an integrated care organization, senior care organization, ACO, or Program of All-inclusive Care for the Elderly organization, or any other entity that, according to a contract with EOHHS, covers home health and other medical services for members on a capitated basis. Care Management – a function performed by the MassHealth agency or its designee that assesses and reassesses the medical needs of complex care members and authorizes or coordinates long- term services and supports (LTSS) that are medically necessary for such members to remain safely in the community. Certification Period – a period of no more than 60 days for which the member’s physician has certified that the plan of care is medically appropriate and necessary. Clinical Manager – a registered nurse (RN) employed by the MassHealth agency or its designee, who performs the in-person assessment of a member for MassHealth coverage of continuous skilled nursing (CSN) services and, if it is determined that CSN services are medically necessary, coordinates authorization of medically necessary LTSS for the member. Complex Care Assistant Services – medically necessary services as described in 130 CMR 438.000: Continuous Skilled Nursing Agency and identified in the CSN provider’s plan of care that is delivered to complex care members. Continuous Skilled Nursing (CSN) Agency – a public or private organization that provides CSN services to complex care members within their homes. CSN agency providers are governed by MassHealth regulations at 130 CMR 438.000: Continuous Skilled Nursing Agency. Continuous Skilled Nursing (CSN) Services – a nurse visit of more than two continuous hours of nursing services. Co-vending – an arrangement through which a member’s CSN services are provided by one or more CSN agencies or independent nurses, with each provider possessing its own MassHealth prior authorization to provide nursing services to the member. Home Health Agency – a public or private organization that provides nursing and other therapeutic services to individuals whose place of residence conforms to the requirements of 42 CFR 440.70(c). Home health agency providers are governed by MassHealth regulations at 130 CMR 403.000: Home Health Agency. Household – a place of residence where two or more people are living that is (1) a group home, a residential care home, or another group living situation; (2) at the same street address if it is a single-family house that is not divided into apartments or units; or (3) at the same apartment number or unit number if members live in a building that is divided into apartments or units. Independent Nurse – a licensed nurse who independently enrolls as a provider with MassHealth to provide CSN services. Independent nurse providers are governed by 130 CMR 414.000. Long-term Services and Supports (LTSS) – certain MassHealth-covered services intended to enable a member to remain in the community. Such services include, but are not limited to, home health, durable medical equipment (DME), oxygen and respiratory equipment, personal care attendant (PCA) services, and other health-related services as determined by the MassHealth agency or its designee. Medical History – a component of the member’s medical record that provides a summary of all health-related information about the member. A history includes, but is not limited to, medical and nursing-care histories as well as summaries of physician physical examination and nursing- assessment results. Medical Record – documentation, maintained by the independent nurse, that includes medical history, nursing progress notes, the member’s plan of care, and other information related to the member. Medical Records Release Form – a signed authorization from the member or the member’s parent or legal guardian, if the member is a minor, that allows the designated releasee to access the member’s confidential health information from other health care providers. Member with Medical Complexity – an individual who is a MassHealth member and whose medical needs, as determined by the MassHealth agency or its designee, are such that they require a nurse visit of more than two continuous hours of nursing services to remain in the community. Nurse – a person licensed as an RN or a licensed practical nurse (LPN) by a state's board of registration in nursing. Nursing Progress Notes – a component of the medical record that indicates the outcome of nursing interventions. Nursing Services – the assessment, planning, intervention, 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. Ordering Non-physician Practitioner – a nurse practitioner, physician’s assistant, or clinical nurse specialist who is licensed in Massachusetts to perform medical services according to their scope of practice. Ordering non-physician practitioners are also allowed to conduct face-to-face encounters. In the case of nurse practitioners and nursing specialists, ordering is permitted only when the nurse is under the supervision of a physician or has a collaborative practice agreement with a physician. Primary Natural Caregiver – the individual, other than the nurse, who is primarily responsible for providing ongoing care to the member and is also connected to the member in some other way, such as a parent, spouse, other family member, or close friend.