Definitions

The following terms used in 130 CMR 437.000 have the meanings given in 130 CMR 437.000 unless the context clearly requires a different meaning. 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. Adult Day Health (ADH) — a community-based and non-residential service that provides nursing care, supervision, and health related support services in a structured group setting to MassHealth members who have physical, cognitive, or behavioral health impairments. The ADH service has a general goal of meeting the ADL, and/or skilled nursing therapeutic needs of MassHealth members delivered by a MassHealth agency approved ADH provider that meets the conditions of 130 CMR 404.000: Adult Day Health Services. Adult Foster Care (AFC) — a service ordered by a primary care provider delivered to a member in a qualified setting as described in 130 CMR 408.435: Adult Foster Care Qualified Setting Requirements by a multidisciplinary team (MDT) and qualified AFC caregiver, that includes assistance with ADLs, IADLs, other personal care as needed, nursing oversight, and AFC care management, as described in 130 CMR 408.415(C): Care Management. Attending Physician — a doctor of medicine or osteopathy legally authorized to practice medicine and surgery by the Commonwealth, a nurse practitioner who meets the training, education, and experience requirements as described in 42 CFR § 410.75(b), or a physician assistant who meets the requirements of 42 CFR § 410.74(c) who is identified by the member at the time of election of hospice services as having the most significant role in the determination and delivery of the member’s medical care. Bereavement Counseling — emotional, psychosocial, and spiritual support and services provided before and after the death of the member to assist with issues related to grief, loss, and adjustment. Capitated Program — an ICO, SCO, ACO, MCO, or PACE organization, or any other entity that, according to a contract with EOHHS, covers hospice and other medical services for members on a capitated basis. Comprehensive Assessment — a thorough evaluation of the patient's physical, psychosocial, emotional and spiritual status related to the terminal illness and related conditions. This includes a thorough evaluation of the caregiver's and family's willingness and capability to care for the patient. Day Habilitation (DH) — a service, for individuals with an intellectual disability (ID) or a developmental disability (DD), that is based on a day habilitation service plan that sets forth measurable goals and objectives, and prescribes an integrated program of activities and therapies necessary to reach the stated goals and objectives. Dual-Eligible Member — individuals who are entitled to Medicare Part A and/or Part B and are eligible for a MassHealth coverage type as listed in 130 CMR 450.105: Coverage Types that includes MassHealth hospice services. Election Period — one of three or more periods of care for which a MassHealth member may elect to receive MassHealth coverage of hospice services. The periods consist of an initial 90-day election period, a subsequent 90-day election period, and an unlimited number of subsequent 60- day election periods. Employee — an employee of the hospice or, if the hospice is a subdivision of an agency or organization, an employee of the agency or organization who is appropriately trained and assigned to the hospice unit. An employee may also be a volunteer under the direction of the hospice. Group Adult Foster Care (GAFC) — services ordered by a physician delivered to a member in a qualified GAFC setting by a multidisciplinary team and qualified GAFC caregiver, that includes assistance with activities of daily living (ADLs), instrumental activities of daily living (IADLs), nursing oversight and care management of GAFC services. Home and Community-based Services (HCBS) Waiver — a federally approved program operated under Section 1915(c) of the Social Security Act 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 Disability (ICF/IID). Hospice Care — a comprehensive set of services, as described in 130 CMR 437.423, identified and coordinated by an interdisciplinary team to provide for the physical, psychosocial, spiritual, and emotional needs of a terminally ill member or family members as delineated in a specific member plan of care. Hospice Election Form — a form that complies with election statement requirements established in 130 CMR 437.412 and 42 CFR 418.24(b) and allows the member to elect their MassHealth hospice benefit. Hospice Inpatient Facility — a palliative-care facility that cares solely for hospice members requiring short-term, general inpatient, or respite care and is owned and operated directly by a licensed hospice pursuant to 105 CMR 141.000: Licensure of Hospice Programs. Hospice Interdisciplinary Team — the interdisciplinary team of professionals who attend to the physical, medical, psychosocial, emotional, and spiritual needs of both the hospice member and the hospice member’s family. Requirements for the composition and duties of the interdisciplinary team are provided at 130 CMR 437.421(C). Hospice Provider — a public agency or private organization or subdivision of either of these that is primarily engaged in providing care to terminally ill individuals and meets the requirements of 130 CMR 437.000. 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 the Centers for Medicare & Medicaid Services (CMS) and been designated as an ICO to provide services to dual eligible individuals under M.G.L. c. 118E. ICOs are responsible for providing enrolled members with the full continuum of Medicare- and MassHealth-covered services. 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. Licensed Professional — a person licensed to provide patient-care services by the state in which the services are delivered. Managed Care Organization (MCO) — any entity with which the MassHealth agency contracts under its MCO program to provide, arrange for, and coordinate care and certain other medical services to members on a capitated basis, and is approved by the Massachusetts Division of Insurance as a health maintenance organization (HMO), and is organized primarily for the purpose of providing health care services. Marketing — any communication from a hospice provider, or its agent, to a member, or his or her family or caregivers, that can reasonably be interpreted as intended to influence the member’s choice of hospice provider, whether by inducing that member (1) to retain that hospice provider to provide hospice services to the member, (2) not to retain hospice services from another hospice provider, or (3) to cease receiving hospice services from another hospice provider. Nursing Facility — a facility that meets all criteria and certification requirements of 130 CMR 456.404: Requirements for Provider Participation; In-state or 456.405: Requirements for Provider Participation; Out-of-state. Palliative Care — member- and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, and spiritual needs and facilitating member autonomy, access to information, and choice. Personal Care Attendant (PCA) Program — a MassHealth program under which personal care management services, fiscal intermediary services, and PCA services are available to MassHealth members. Personal Care Attendant (PCA) Services — physical assistance with activities of daily living (ADLs) and instrumental activities of daily living (IADLs) provided to a member by a PCA in accordance with 130 CMR 422.000: Personal Care Attendant Services. Physician Designee — a doctor of medicine or osteopathy, designated by the hospice, who assumes the same responsibilities and obligations as the medical director when the medical director is not available. Program of All-inclusive Care for the Elderly (PACE) — a program of all-inclusive care for the elderly that is operated by an approved PACE Organization and that provides comprehensive healthcare services to PACE participants in accordance with a PACE Program Agreement and as described at 42 CFR Part 460. Provider Portal — the online site through which hospice providers submit information to MassHealth or to a MassHealth designated vendor. Representative — an individual who has the authority under state law to authorize or terminate medical care or to elect or revoke the election of hospice care on behalf of a terminally ill member who is mentally or physically incapacitated. Senior Care Organization (SCO) — a managed care organization that participates in MassHealth under a contract with the MassHealth agency to provide coordinated care and medical services through a comprehensive network to eligible members 65 years of age or older. SCOs are responsible for providing enrolled members with the full continuum of MassHealth-covered services, and for dual eligible members, the full continuum of MassHealth and Medicare-covered services. Terminal Illness — a condition in which the member has a medical prognosis of a life expectancy of six months or less if the illness runs its normal course. Unfair or Deceptive Acts or Practices — any unfair or deceptive acts or practices, as that term is defined in M.G.L. c. 93A, § 2, and the regulations promulgated thereunder by the Massachusetts Attorney General.