130 CMR, § 410.402

Current through Register 1533, October 25, 2024

Section 410.402 - Definitions

The following terms used in 130 CMR 410.000 have the meanings given in 130 CMR 410.402, unless the context clearly requires a different meaning. The reimbursability of services defined in 130 CMR 410.402 is not determined by these definitions, but by application of regulations elsewhere in 130 CMR 410.000, and in 130 CMR 415.000: Acute Inpatient Hospital Services and 130 CMR 450.000: Administrative and Billing Regulations.

340B-covered Entities - facilities and programs eligible to purchase discounted drugs through a program established by Public Health Law 102-585, § 340B of the Veterans Health Act of 1992.

340B Drug Pricing Program - a program established by Public Health Law 102-585, § 340B of the Veterans Health Act of 1992.

Acupuncture - the insertion of metal needles through the skin at certain points on the body, with or without the use of herbs, with or without the application of an electric current, and with or without the application of heat to the needles, skin, or both.

Acute Hospital - a facility that:

(1) is licensed as a hospital by the Massachusetts Department of Public Health (DPH) under M.G.L. c. 111, § 51 (if in-state) or by the governing or licensing agency in its state (if out-of-state);

(2) is Medicare-certified and participates in the Medicare program;

(3) has more than 50% of its beds licensed as medical/surgical, intensive care, coronary care, burn, pediatric (Level I or Level II), pediatric intensive care (Level III), maternal (obstetrics), or neonatal intensive care beds (Level III) as determined by DPH (or if out-of-state, the governing or licensing agency in its state, and as determined by MassHealth) and;

(4) utilizes more than 50% of its beds exclusively as either medical/surgical, intensive care, coronary care, burn, pediatric (Level I or Level II), pediatric intensive care (Level III), maternal (obstetrics), or neonatal intensive care beds (Level III), as determined by MassHealth. An acute hospital is not a chronic disease and rehabilitation hospital or a hospital licensed primarily to provide mental health services, or any unit of a facility that is licensed as a nursing facility, chronic disease unit, or rehabilitation unit.

Acute Inpatient Hospital - an acute hospital that provides diagnosis and treatment on an inpatient basis for patients who have any of a variety of medical conditions requiring daily physician intervention as well as full-time availability of physician services; however, this does not include any chronic disease and rehabilitation hospital, any hospital that is licensed primarily to provide mental health services, or any unit of a facility that is licensed as a nursing facility, chronic disease unit, or a rehabilitation unit.

Chronic Disease and Rehabilitation Hospital (CDR) - a hospital licensed by the Massachusetts Department of Public Health (DPH) under M.G.L. c. 111, § 51 (or by the governing or licensing agency in its state (if out-of-state)), with a majority of its beds licensed to provide chronic care services, or comprehensive rehabilitation services, or both, to patients with appropriate medical needs, or that is operated by DPH's Bureau of Public Health Facilities. Chronic Disease and Rehabilitation Hospital (CDR) includes such a hospital licensed with a pediatric specialty. Hospitals with 50% or more of their beds licensed as medical/surgical, intensive care, coronary care, burn, maternal (obstetrics) and neonatal intensive care beds (Level III) possess acute hospital licensure and do not meet the definition of a chronic disease and rehabilitation hospital.

Cosmetic Surgery -a surgical procedure that is performed for the exclusive purpose of altering appearance and is unrelated to disease or physical defect, or traumatic injury.

Drug - a substance as defined by the Food, Drug, and Cosmetic Act, containing one or more active ingredients in a specified dosage form and strength. Each dosage form and strength is a separate drug.

Emergency Medical Condition - a medical condition, whether physical or mental, manifesting itself by symptoms of sufficient severity, including severe pain, that the absence of prompt medical attention could reasonably be expected by a prudent layperson who possesses an average knowledge of health and medicine, to result in placing the health of the member or another person in serious jeopardy, serious impairment to body function, or serious dysfunction of any body organ or part, or, with respect to a pregnant individual, as further defined in the Social Security Act § 1867(e)(1)(B), 42 U.S.C. § 1395dd(e)(1)(B).

Emergency Services - medical services that are furnished by a provider that is qualified to furnish such services, and are needed to evaluate or stabilize an emergency medical condition.

Family Planning - any medically approved means, including diagnosis, treatment, and related counseling, that assists individuals of childbearing age, including sexually active minors, in determining the number and spacing of their children.

Functional Level - the degree to which an individual can function in the community. Progressive levels of impaired functioning are evaluated using a MassHealth-approved scale that has specific criteria for emotional stability, vocational/educational productivity, social relations, and self-care.

Functional Maintenance Program - a planned combination of social, vocational, and recreational services designed for individuals disabled by a chronic mental illness who need continuing services to maintain skills that allow them to function within the community, but who do not require the more intensive care of inpatient or day treatment programs.

Gross Cost Per Utilizer Per Year - annual cost per utilizer projected by EOHHS based on factors including actual or expected utilization, dosing information, duration of therapy, and the National Average Drug Acquisition Cost (NADAC) or Wholesale Acquisition Cost (WAC) (when NADAC is not available) of the covered drug prior to any federal or supplemental rebate.

Hospital - a facility that is licensed or operated as a hospital by the Massachusetts Department of Public Health or the Massachusetts Department of Mental Health and that provides diagnosis and treatment on an outpatient basis for patients who have any of a variety of medical conditions.

Hospital-licensed Health Center (HLHC) - a hospital satellite clinic that also

(1) meets all MassHealth requirements for reimbursement as an HLHC as provided in 130 CMR 410.413; and

(2) is enrolled with the MassHealth agency as a hospital-licensed health center.

Hospital Outpatient Department.

(1) For an acute hospital, a department or unit within the physical framework of the hospital's inpatient facility that operates under the hospital's license and provides services to members on an outpatient basis. Acute hospital outpatient departments include day-surgery units, primary-care clinics, specialty clinics, and emergency departments.

(2) For a CDR hospital, a department or unit that operates under the hospital's license or is operated by the Department of Public Health's Bureau of Public Health Facilities, and provides services to members on an outpatient basis.

Hospital Satellite Clinic - a facility that

(1) operates under a hospital's license issued to an acute hospital (in the case of an acute hospital satellite clinic) or to a CDR hospital (in the case of a CDR hospital satellite clinic);

(2) is subject to the fiscal, administrative, and clinical management of the hospital;

(3) provides services to members solely on an outpatient basis;

(4) is not located at the same site as the hospital's inpatient facility; and

(5) demonstrates to the MassHealth agency's satisfaction that it has Centers for Medicare and Medicaid (CMS) provider-based status in accordance with 42 CFR 413.65.

Institutionalized Individual - an individual who is either:

(1) involuntarily confined or detained, under a civil or criminal statute, in a correctional or rehabilitative facility, including a psychiatric hospital or other facility for the treatment of mental illness; or

(2) confined under a voluntary commitment in a psychiatric hospital or other facility for the care and treatment of mental illness.

Maintenance Program - repetitive services, required to maintain or prevent the worsening of function, that do not require the judgment and skill of a licensed therapist for safety and effectiveness.

Mental Illness - mental and emotional disorders as defined in the current International Classification of Diseases, Clinical Modification or the American Psychiatric Association's Diagnostic and Statistical Manual and manifested by impaired functioning in one or more of the following: emotional stability, vocational/educational productivity, social relations, and selfcare.

Mentally Incompetent Individual - an individual who has been declared mentally incompetent by a federal, state, or local court of competent jurisdiction for any purpose, unless the individual has been declared competent for purposes that include the ability to consent to sterilization.

Observation Services - 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 the order of a physician, consist of the use of a bed and intermittent monitoring by professional licensed clinical staff, and may be provided for more than 24 hours.

Occupational Therapy - therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct, rehabilitate, or prevent the worsening of functions that affect the activities of daily living that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Occupational therapy programs are designed to improve quality of life by recovering competence, preventing further injury or disability, and to improve the individual's ability to perform tasks required for independent functioning, so that the individual can engage in activities of daily living.

Outpatient Hospital Services - medical services provided to a member in a hospital outpatient department, hospital licensed health center, or other hospital satellite clinic, by or under the direction of a physician or dentist. Such services include, but are not limited to, emergency services, primary-care services, observation services, ancillary services, and day-surgery services.

Outpatient Services - medical services provided to a member in an outpatient setting including but not limited to hospital outpatient departments, hospital-licensed health centers or other hospital satellite clinics, physicians' offices, nurse practitioners' offices, freestanding ambulatory surgery centers, day treatment centers, or the member's home.

Outpatient Visit - an in-person encounter between an eligible member and a licensed practitioner (such as a physician, optician, optometrist, dentist, or therapist) or other medical professional under the direction of a physician or dentist for the provision of outpatient services as defined in 130 CMR 410.402.

Physical Therapy - therapy services, including diagnostic evaluation and therapeutic intervention, designed to improve, develop, correct, rehabilitate, or prevent the worsening of physical functions that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Physical therapy emphasizes a form of rehabilitation focused on treatment of dysfunctions involving neuromuscular, musculoskeletal, cardiovascular/pulmonary, or integumentary systems through the use of therapeutic interventions to optimize functioning levels.

Reconstructive Surgery-a surgical procedure that is performed to correct, repair, or ameliorate the physical effects of disease or physical defect (for example, correction of a cleft palate), or traumatic injury.

Sheltered Workshop - a program of vocational counseling and training in which the participants receive paid work experience or other supervised employment.

Speech/Language Therapy - therapy services, including diagnostic evaluation and therapeutic intervention, that are designed to improve, develop, correct, rehabilitate, or prevent the worsening of speech/language communication and swallowing disorders that have been lost, impaired, or reduced as a result of acute or chronic medical conditions, congenital anomalies, or injuries. Speech and language disorders are those that affect articulation of speech, sounds, fluency, voice, swallowing (regardless of the presence of a communication disability), and those that impair comprehension, or spoken, written, or other symbol systems used for communication.

Sterilization - any medical procedure, treatment, or operation for the purpose of rendering an individual permanently incapable of reproducing.

Vocational Rehabilitative Services - services such as vocational assessments, job training, career counseling, and job placement.