Code of Massachusetts Regulations
101 CMR - EXECUTIVE OFFICE FOR HEALTH AND HUMAN SERVICES
Title 101 CMR 613.00 - Health Safety Net Eligible Services
Section 613.02 - Definitions
As used in 101 CMR 613.00, unless the context otherwise requires, terms have the following meanings. All defined terms in 101 CMR 613.00 are capitalized.
340B Provider. An Acute Hospital or Community Health Center eligible to purchase discounted drugs through a program established by § 340B of United States Public Law 102-585, the Veterans Health Act of 1992, permitting certain grantees of federal agencies access to reduced cost drugs for their Patients, and registered and listed as a 340B Pharmacy within the United States Department of Health and Human Services, Office of Pharmacy Affairs database. Pharmacy services may be provided by a 340B Provider at on-site or off-site locations.
Acute Hospital. A hospital licensed under M.G.L. c. 111, § 51 that contains a majority of medical-surgical, pediatric, obstetric, and maternity beds, as defined by the Department of Public Health.
Administrative Day. A day of inpatient hospitalization on which a Patient's care needs can be provided in a setting other than an inpatient Acute Hospital in accordance with the standards in 130 CMR 415.000: Acute Inpatient Hospital Services and on which the Patient is clinically ready for discharge.
Adult Dental Services. Dental services provided to individuals 21 years of age and older and billed using the codes listed in the Health Safety Net claims specifications for Acute Hospitals and Community Health Centers.
Ancillary Services. Nonroutine services for which charges are customarily made in addition to routine charges that include, but are not limited to, laboratory, diagnostic and therapeutic radiology, surgical services, and physical, occupational, or speech-language therapy. Generally, ancillary services are billed as separate items when the Patient receives these services.
Application. A request for health benefits that is received by the MassHealth Agency and includes all required information and a signature by the applicant or his or her authorized representative. The application may be submitted online at www.MAHealthConnector.org, or the applicant may complete a paper application, complete a telephone application, or apply in person at a MassHealth Enrollment Center (MEC). The date of application for an online, telephonic, or in-person application is the date the application is submitted to the MassHealth Agency. The date of application for a paper application that is either mailed or faxed is the date the application is received by the MassHealth Agency.
Assets. As defined in 130 CMR 515.001: Definition of Terms.
Bad Debt. An account receivable based on services furnished to a Patient that is
(a) regarded as uncollectible, following reasonable collection efforts consistent with the requirements in 101 CMR 613.06;
(b) charged as a credit loss;
(c) not the obligation of a governmental unit or the federal government or any agency thereof; and
(d) not a Reimbursable Health Service.
Caretaker Relative. An adult who is the primary care giver for a child, is related to the child by blood, adoption, or marriage, or is a spouse or former spouse of one of those relatives, and lives in the same home as that child, provided that neither parent is living in the home.
Charge. The uniform price for a specific service charged by a Provider.
Children's Medical Security Plan (CMSP). A program of primary and preventive pediatric health care services for eligible children, from birth through 18 years old, administered by the MassHealth Agency pursuant to M.G.L. c. 118E, § 10F.
Collection Action. Any activity by which a Provider or designated agent requests payment for services from a Patient, a Patient's guarantor, or a third-party responsible for payment. Collection Actions include activities such as preadmission or pretreatment deposits, billing statements, collection follow-up letters, telephone contacts, personal contacts, and activities of collection agencies and attorneys.
Community Health Center. A health center operating in conformance with the requirements of § 330 of United States Public Law 95-626, including a Community Health Center that files a cost report as requested by the Center for Health Information and Analysis. Such a health center must
(a) be licensed as a freestanding clinic by the Massachusetts Department of Public Health pursuant to M.G.L. c. 111, § 51;
(b) meet the qualifications for certification (or provisional certification) by the MassHealth Agency and enter into a Provider agreement pursuant to 130 CMR 405.000: Community Health Center Services; and
(c) operate in conformance with the requirements of 42 U.S.C. § 254b.
Confidential Services. Services for the treatment of sexually transmitted diseases provided under M.G.L. c. 112, § 12F and family planning services provided under M.G.L. c. 111, § 24E.
Countable Income. Income as defined in 101 CMR 613.05(1)(b).
Dental-only Low Income Patient. An uninsured Low Income Patient for whom payment from the Health Safety Net Trust Fund is only allowable for dental services, as specified in 101 CMR 613.04(6)(a)2.a.
Eligible Services. Services eligible for Health Safety Net payment pursuant to 101 CMR 613.03. Eligible Services include
(a) Reimbursable Health Services to Low Income Patients;
(b) Medical Hardship; and
(c) Bad Debt as further specified in 101 CMR 613.00 and 130 CMR 614.00: Health Safety Net Payments and Funding.
Emergency Aid to the Elderly, Disabled and Children (EAEDC). A program of governmental benefits under M.G.L. c. 117A.
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 person 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 42 U.S.C. § 1395dd(e)(1)(B).
Emergency Services. Medically Necessary Services provided to an individual with an Emergency Medical Condition.
EMTALA. The federal Emergency Medical Treatment and Active Labor Act under 42 U.S.C. § 1395dd.
EVS. The MassHealth Eligibility Verification System.
Federal Poverty Level (FPL). Income standards issued annually in the Federal Register to account for the last calendar year's increase in prices as measured by the Consumer Price Index.
Fiscal Year. The time period of 12 months beginning on October 1st of any calendar year and ending on September 30th of the following calendar year.
Governmental Unit. The Commonwealth, any department, agency, board, or commission of the Commonwealth, and any political subdivision of the Commonwealth.
Gross Income. The total money earned or unearned, such as wages, salaries, rents, pensions, or interest, received from any source without regard to deductions.
Guarantor. A person or group of persons that assumes the responsibility of payment for all or part of a Provider's charge for services.
Health Connector. Commonwealth Health Insurance Connector Authority or Health Connector established pursuant to M.G.L. c. 176Q, § 2.
Health Insurance Plan. Medicare, MassHealth, the Premium Assistance Payment Program Operated by the Health Connector, a Qualified Health Plan, or an individual or group contract or other plan providing coverage of health care services issued by a health insurance company, as defined in M.G.L. c. 175, 176A, 176B, 176G, or 176I.
Health Safety Net. The payment program established and administered in accordance with M.G.L. c. 118E, §§ 8A, and 64 through 69 and regulations promulgated thereunder, and other applicable legislation.
Health Safety Net Office (Office). The office within the Office of Medicaid established under M.G.L. c. 118E, § 65.
Health Safety Net - Partial. A Low Income Patient eligible for either Health Safety Net - Primary or Health Safety Net - Secondary who documents MassHealth MAGI Household income or Medical Hardship Family Countable Income, as described in 101 CMR 613.04(2), greater than 150% and less than or equal to 300% of the FPL, is considered Health Safety Net - Partial as described in 101 CMR 613.04(6)(b)3.
Health Safety Net - Partial Deductible (Deductible). Annual deductible applied as described in 101 CMR 613.04(8)(c).
Health Safety Net - Primary. A Health Safety Net eligibility category for uninsured Low Income Patients as described in 101 CMR 613.04(6)(a)1.
Health Safety Net - Secondary. A Health Safety Net eligibility category for Low Income Patients with primary health insurance as described in 101 CMR 613.04(6)(a)2.
Health Safety Net Trust Fund. The fund established under M.G.L. c. 118E, § 66.
Health Services. Medically necessary inpatient and outpatient services as authorized under Title XIX of the Social Security Act. Health services do not include
(a) nonmedical services, such as social, educational, and vocational services;
(b) cosmetic surgery;
(c) canceled or missed appointments;
(d) telephone conversations and consultations;
(e) court testimony;
(f) research or the provision of experimental or unproven procedures; and
(g) the provision of whole blood, but the administrative and processing costs associated with the provision of blood and its derivatives are payable.
Hospital Licensed Health Center. A Satellite Clinic that
(a) meets MassHealth requirements for reimbursement as a Hospital Licensed Health Center as provided at 130 CMR 410.413: Medical Services Required on Site at a Hospital-licensed Health Center; and
(b) is approved by and enrolled with MassHealth's Provider Enrollment Unit as a Hospital Licensed Health Center.
Hospital Services. Services listed on an Acute Hospital's license by the Department of Public Health. This does not include services provided in transitional care units; services provided in skilled nursing facilities; and home health services, or separately licensed services, including residential treatment programs and ambulance services.
Hospital Visit. A face-to-face meeting between a Patient and a physician, physician assistant, nurse practitioner, or registered nurse or when the Patient has been admitted to a hospital by a physician on a Community Health Center's staff.
Low Income Patient. An individual who meets the criteria under 101 CMR 613.04(2).
MassHealth. The medical assistance and benefit programs administered by the MassHealth Agency pursuant to Title XIX of the Social Security Act (42 U.S.C. §§ 1396 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 in accordance with the provisions of M.G.L. c. 118E.
MassHealth CarePlus. A program of health care services for eligible adults, 21 through 64 years old, administered by the MassHealth Agency pursuant to 130 CMR 505.000: MassHealth: Coverage Types.
MassHealth CommonHealth. A MassHealth program for disabled adults and disabled children administered by the MassHealth Agency pursuant to M.G.L. c. 118E.
MassHealth Family Assistance. A program of health care services for eligible children, young adults and adults administered by the MassHealth Agency pursuant to 130 CMR 505.000: MassHealth: Coverage Types.
MassHealth Family Assistance - Children. A program of health care services for eligible minors administered by the MassHealth Agency pursuant to 130 CMR 505.000: MassHealth: Coverage Types.
MassHealth Limited. A program of emergency health care services for individuals administered by the MassHealth Agency pursuant to 130 CMR 505.000: MassHealth: Coverage Types.
MassHealth MAGI Household. A household as defined in 130 CMR 506.002(B): MassHealth MAGI Household Composition.
MassHealth Standard. A program of health care services for eligible individuals administered by the MassHealth Agency pursuant to 130 CMR 505.000: MassHealth: Coverage Types.
Medical Coverage Date.
(a) The medical coverage date begins on the tenth day before the date the Application is received as described in 130 CMR 502.003: Verification of Eligibility Factors, if all required verifications, including a completed disability supplement, have been received within 90 days of the receipt of the Request for Information, as described at 130 CMR 502.003(C): Request for Information Notice except for applicants otherwise subject to rules detailed in 130 CMR 516.001: Application for Benefits, the medical coverage date is outlined in 130 CMR 516.006: Coverage Date if all required verifications have been received within the guidelines listed in 130 CMR 516.003: Verification of Eligibility Factors.
(b) If these required verifications listed on the Request for Information are received after the periods referenced in 101 CMR 613.02, the begin date of medical coverage is ten days before the date on which the verifications were received, if such verifications are received within one year of receipt of the Application, or as outlined in 130 CMR 516.003: Verification of Eligibility Factors, if applicable.
(c) For children younger than 21 years old and pregnant individuals receiving Provisional Eligibility as described in 130 CMR 502.003: Verification of Eligibility Factors, the medical coverage date begins ten days prior to the date of Application. For all other applicants receiving Provisional Eligibility as described in 130 CMR 502.003: Verification of Eligibility Factors, the medical coverage date begins on the date of the provisional eligibility determination. If all required verifications are received before the end of the provisional eligibility period, the medical coverage date of the verified coverage type will be ten days prior to the date of the Application.
Medical Hardship. Health Safety Net eligibility type available to Massachusetts Residents at any Countable Income level whose allowable medical expenses have so depleted his or her Countable Income that he or she is unable to pay for Eligible Services as described in 101 CMR 613.05.
Medical Hardship Family. Persons who live together, and consist of
(a) a child or children younger than 19 years old, any of their children, and their parents;
(b) siblings younger than 19 years old and any of their children who live together even if no adult parent or Caretaker Relative is living in the home; or
(c) a child or children younger than 19 years old, any of their children, and their Caretaker Relative when no parent is living in the home. A Caretaker Relative may choose whether or not to be part of the Medical Hardship Family. A parent may choose whether or not to be included as part of the Medical Hardship Family of a child younger than 19 years old only if that child is
1. pregnant; or
2. a parent.
A child who is absent from the home to attend school is considered as living in the home. A parent may be a natural, step, or adoptive parent. Two parents are members of the same family as long as they are both mutually responsible for one or more children that live with them.
Medically Necessary Service. A service that is reasonably expected to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions that endanger life, cause suffering or pain, cause physical deformity or malfunction, threaten to cause or to aggravate a disability, or result in illness or infirmity. Medically Necessary Services include inpatient and outpatient services as authorized under Title XIX of the Social Security Act.
Medicare Advantage. A type of Medicare health plan established by Title II of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
Medicare Program (Medicare). The medical insurance program established by Title XVIII of the Social Security Act.
Mental Health Services. A comprehensive group of diagnostic and psychotherapeutic treatment services to mentally or emotionally disturbed persons and their families by an interdisciplinary team under the medical direction of a psychiatrist.
Minor. A person younger than 19 years old.
Modified Adjusted Gross Income (MAGI). Income as defined in 130 CMR 501.001: Definition of Terms.
Patient. An individual who receives or has received Medically Necessary Services at an Acute Hospital or Community Health Center.
Pharmacy Online Processing System (POPS). The MassHealth online, real-time computer network that adjudicates pharmacy claims, incorporating prospective drug utilization review, prior authorization, and Patient eligibility verification.
Premium Assistance Payment Program Operated by the Health Connector. An insurance subsidy program that provides state subsidies for low-income individuals and families administered by the Health Connector.
Premium Billing Family Group (PBFG). A group of persons who live together as defined in 130 CMR 501.001: Definition of Terms.
Primary or Elective Care. Medical care that is not an Urgent Care Service and is required by individuals or families for the maintenance of health and the prevention of illness. Primary Care consists of health care services customarily provided by general practitioners, family practitioners, general internists, general pediatricians, and primary care nurse practitioners or physician assistants. Primary Care does not require the specialized resources of an Acute Hospital emergency department and excludes Ancillary Services and maternity care services.
Provider. An Acute Hospital or Community Health Center that provides Eligible Services.
Provider Affiliate. An individual practitioner, practice group, or any other entity that provides emergency or medically necessary care in an Acute Hospital, including in affiliated Satellite Clinics or Hospital Licensed Health Centers.
Provisional Eligibility. Initial approval for Low Income Patient status when an applicant's certain self-attested circumstances show eligibility for the Health Safety Net, pending further eligibility verification for continued eligibility in accordance with 130 CMR 502.003: Verification of Eligibility Factors.
Qualified Health Plan (QHP). A health plan licensed under M.G.L. c. 175, 176A, 176B, or 176G that has received the Commonwealth Health Insurance Connector's Seal of Approval as meeting the criteria under 45 CFR § 155.1000 and is offered through the Health Connector in accordance with the provisions of 45 CFR § 155.1010.
Reimbursable Health Services. Eligible Services provided by Acute Hospitals or Community Health Centers to Uninsured and Underinsured Patients who are determined to be financially unable to pay for their care, in whole or in part and who meet the criteria for Low Income Patient; provided that such services are not eligible for reimbursement by any other public or third-party payer.
Resident. A person living in the Commonwealth of Massachusetts with the intention to remain as defined by 130 CMR 503.002(A) through (D). Persons who are not considered residents are
(a) individuals who came to Massachusetts for the purpose of receiving medical care in a setting other than a nursing facility, and who maintain a residence outside of Massachusetts;
(b) persons whose whereabouts are unknown; or
(c) inmates of penal institutions except in the following circumstances:
1. they are inpatients of a medical facility; or
2. they are living outside of the penal institution, are on parole, probation, or home release, and are not returning to the institution for overnight stays.
Satellite Clinic. A facility that operates under an Acute Hospital's license, is subject to the fiscal, administrative, and clinical management of the Acute Hospital, provides services solely on an outpatient basis, is not located at the same site as the Acute Hospital's inpatient facility, and has CMS Provider-based status in accordance with 42 CFR § 413.65.
Student Health Plan. Student health insurance plan operated in compliance with M.G.L. c. 15A, § 18.
Third-party. Any individual, entity, or program that is or may be responsible to pay all or part of the cost for medical services.
Underinsured Patient. A Patient whose Health Insurance Plan or self-insurance plan does not pay, in whole or in part, for Health Services that are eligible for payment from the Health Safety Net Trust Fund, provided that the Patient meets income eligibility standards set forth in 101 CMR 613.04.
Uninsured Patient. A Patient who is a resident of the Commonwealth, who is not covered by a Health Insurance Plan or a self-insurance plan, and who is not eligible for a medical assistance program. A Patient who has a policy of health insurance or is a member of a health insurance or benefit program that requires such Patient to make payment of deductibles or copayments, or fails to cover certain medical services or procedures is not uninsured.
Urgent Care Services. Medically Necessary Services provided in an Acute Hospital or Community Health Center after the sudden onset of a medical condition, whether physical or mental, manifesting itself by acute symptoms of sufficient severity (including severe pain) that a prudent layperson would believe that the absence of medical attention within 24 hours could reasonably expect to result in placing a Patient's health in jeopardy, impairment to bodily function, or dysfunction of any bodily organ or part. Urgent Care Services are provided for conditions that are not life threatening and do not pose a high risk of serious damage to an individual's health. Urgent Care Services do not include Primary or Elective Care.
