Definitions

Board of Hearings (BOH). The unit within MassHealth that is responsible for administering the fair hearing process under 130 CMR 610.000: MassHealth: Fair Hearing Rules and claims for adjudication hearings under 130 CMR 450.241: Hearings: Claim for an Adjudicatory Hearing, including hearings about transfers and discharges of residents by nursing facilities. Department of Developmental Services (DDS). An agency of the Commonwealth of Massachusetts, established under M.G.L. c. 19B. DDS also serves as the Preadmission and Resident Review (PASRR) authority for intellectual disabilities and developmental disabilities. Department of Mental Health (DMH). An agency of the Commonwealth of Massachusetts, established under M.G.L. c. 19. DMH also serves as the PASRR authority for serious mental illness. Department of Public Health (DPH). An agency of the Commonwealth of Massachusetts, established under M.G.L. c. 17. Discharge. Movement of a resident from a nursing facility to a noninstitutional setting resulting in the cessation of the discharging nursing facility’s legal responsibility for the care of that individual. A nursing facility’s failure to resume care of or to readmit an individual following hospitalization or other medical leave of absence is considered a discharge. DPH Multi-disciplinary Medical Review Team (MRT). A multi-disciplinary interagency team, established pursuant to M.G.L. c. 111 § 4J, and authorized to make determinations about nursing facility eligibility for individuals younger than 22 years old. EOHHS. The Executive Office of Health and Human Services established under M.G.L. c. 6A. Fair Hearing. An administrative, adjudicatory proceeding conducted pursuant to 130 CMR 610.000: MassHealth: Fair Hearing Rules to determine the legal rights, duties, benefits, or privileges of applicants, members, or residents. Hospital. A facility that is licensed or operated as a hospital by DPH or DMH, and provides diagnosis and treatment on an inpatient or outpatient basis for patients who have any variety of medical conditions. Length of Stay. The duration of a member's inpatient hospital stay at a Medicare hospital level of care during a medical leave of absence. MassHealth. The medical assistance and benefit programs administered by EOHHS pursuant to Title XIX of the Social Security Act (42 U.S.C. 1396a et seq.), Title XXI of the Social Security Act (42 U.S.C. 1397aa et seq.), 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, which is the state that is designated under the state plan as the Single State Agency responsible for the administration of MassHealth, in accordance with the provisions of M.G.L. c. 118E. Medical Leave of Absence (MLOA). An inpatient hospital stay for an individual who is a resident of a nursing facility. Medical leave of absence also includes an observation stay. Medicare Hospital Level of Care. A level of care that meets all criteria, as determined by the Centers for Medicare & Medicaid Services or its designee, for Medicare payment for hospital care. Member. A person determined by MassHealth to be eligible for MassHealth. Mobility System. A manual or power wheelchair or other wheeled device, such as a scooter, including a base, a seating system, its components, accessories, and modifications. Non-medical Leave of Absence (NMLOA). A temporary absence from the nursing facility for non-medical reasons subject to the requirements in 130 CMR 456.431 and 456.432. Nursing Facility (NF). An institution or a distinct part of an institution that meets the provider eligibility and certification requirements of 130 CMR 456.404 or 456.405. Observation Stay. Outpatient hospital services provided anywhere in an acute inpatient hospital to evaluate a member’s condition and determine the need for admission to an acute inpatient hospital. Observation services are provided under order of a physician or PCP, consistent with the use of a bed and intermittent monitoring by professional licensed clinical staff, and may be provided for more than 24 hours. Patient-paid Amount (PPA). The portion of monthly income that a member in a nursing facility must contribute to the cost of care. Personal Needs Allowance (PNA). The designated portion of monthly income that a member in a facility is allowed to keep for personal expenses. Personal Needs Allowance Account. An account or accounts administered by a nursing facility on behalf of a member. The account may be used to deposit the PNA and any other money, such as a gift, belonging to the member. Primary Care Provider (PCP). Any of the following: a physician, a physician assistant, or a nurse practitioner operating within the scope of their licensure and supervision requirements, as applicable. Resident. An individual receiving care in a nursing facility regardless of whether the individual is a MassHealth member. Transfer. Movement of a resident from (1) a Medicaid- or Medicare-certified bed to a noncertified bed; (2) a Medicaid-certified bed to a Medicare-certified bed; (3) a Medicare-certified bed to a MassHealth-certified bed; (4) one nursing facility to another nursing facility; or (5) a nursing facility to a hospital, or any other institutional setting. A nursing facility’s failure to readmit a resident following hospitalization or other medical leave of absence resulting in the resident being moved to another institutional setting is also a transfer. Movement of a resident within the same facility from one certified bed to another bed with the same certification is not a transfer. Working Days. Monday through Friday except for legal holidays.