Definitions

The following terms used in 130 CMR 438.000 have the meanings given in 130 CMR 438.402, unless the context clearly requires a different meaning. The reimbursed services defined in 130 CMR 438.402 are not determined by these definitions, but by the application of regulations elsewhere in 130 CMR 438.000 and 130 CMR 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 (MCO)–administered ACOs. Branch Office – a location or site from which a CSN agency provides services within a portion of the total geographic area served by the parent CSN agency. The parent CSN agency must provide supervision and administrative control of any branch office on a daily basis. 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 (ICO), senior care organization, ACO, or Program of All-inclusive Care for the Elderly (PACE) 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 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 – a person who is employed or contracted by a CSN agency and meets the qualifications of a complex care assistant to perform certain health-related services as described at 130 CMR 438.415(C). Complex Care Assistant Services – medically necessary services as described at 130 CMR 438.000 and identified in the plan of care delivered to complex care members. Continuous Skilled Nursing (CSN) Agency – a public or private organization that provides CSN services, or CSN agency services to complex care members within the members’ homes. Continuous Skilled Nursing (CSN) Agency Services – CSN services and complex care assistant services as described at 130 CMR 438.402 and delivered to MassHealth-eligible members. Continuous Skilled Nursing (CSN) Services – skilled nursing care provided by a licensed nurse to complex care members who require more than two continuous hours of nursing services per day. Co-vending – an arrangement through which a member’s CSN services are provided by more than one CSN agency or independent nurse, with each provider obtaining its own MassHealth prior authorization to provide CSN 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. Home health agencies providing CSN services must also comply with 130 CMR 438.000 for the provision of those services. 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: Independent Nurse. Integrated Care Organization (ICO) – an organization with a comprehensive network of medical care, behavioral health care, and LTSS 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. 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), and other health-related services as determined by the MassHealth agency or its designee. LTSS Needs Assessment – the standardized assessment the MassHealth agency or its designee uses to determine a member’s eligibility for CSN services and if found eligible, quantifies the medically necessary CSN, complex care assistant services, and other LTSS services. 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 CSN agency provider, or its agent, to a member, or their family or caregivers, that can reasonably be interpreted as intended to influence the member’s choice of CSN agency provider, whether by inducing that member (1) to retain that CSN agency provider to provide CSN agency services to the member; (2) not to retain CSN agency services from another CSN agency provider; or (3) to cease receiving CSN agency services from another CSN agency provider. 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 CSN agency, 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 release 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 licensed practical nurse (LPN) by a state’s board of registration in nursing. 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 the state of Massachusetts to perform and order medical services according to their scope of practice and who has a collaborative practice agreement with a physician. Ordering non-physician practitioners are also allowed to conduct face-to-face encounters. 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. Program of All-inclusive Care for the Elderly (PACE) – PACE, as described at 42 CFR 460 and 130 CMR 519.007(C): Program of All-inclusive Care for the Elderly (PACE). Registered Nurse (RN) Supervisor – a person who is familiar with the member and the member’s plan of care as described at 130 CMR 438.416 and is designated by the CSN agency as a supervisor of complex care assistant service delivery. Senior Care Organization (SCO) – an MCO 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. 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.