§ 64 — Definitions for Secs. 64 through 69

Massachusetts § 64

• Jurisdiction: Massachusetts
• Part I: ADMINISTRATION OF THE GOVERNMENT
• Title XVII: PUBLIC WELFARE
• Ch. 118E: DIVISION OF MEDICAL ASSISTANCE

Text

Section 64. As used in sections 64 to 69, inclusive, the following words shall, unless the context clearly requires otherwise, have the following meanings:"Acute hospital'', the teaching hospital of the University of Massachusetts medical school and any hospital licensed under section 51 of chapter 111 and which contains a majority of medical-surgical, pediatric, obstetric and maternity beds, as defined by the department of public health."Allowable reimbursement'', payment to acute hospitals and community health centers for health services provided to uninsured or underinsured patients of the commonwealth under section 69 and any further regulations promulgated by the health safety net office."Ambulatory surgical center'', a distinct entity that operates exclusively to provide surgical services to patients not requiring hospitalization and meets the requirements of the federal Health Care Financing Administration for participation in the Medicare program."Ambulatory surgical center services'', services described for purposes of the Medicare program under 42 U.S.C. 1395k(a)(2)(F)(I); provided that "ambulatory surgical center services'' shall include facility services only and shall not include surgical procedures."Assessed charges'', gross patient service revenue attributable to all patients less gross patient service revenue attributable to Title XVIII, XIX and XXI programs."Bad debt'', an account receivable based on services furnished to a patient which: (i) is regarded as uncollectible, following reasonable collection efforts consistent with regulations of the office, which regulations shall allow third party payers to negotiate with hospitals to collect the bad debts of its enrollees; (ii) is charged as a credit loss; (iii) is not the obligation of a governmental unit or the federal government or any agency thereof; and (iv) is not a reimbursable health care service.[ Definition of "Center for health information and analysis revenue amount'' inserted following definition of "Bad debt'' by 2024, 140, Sec. 120 effective the later of one full calendar month following the calendar month in which the secretary receives all federal approvals deemed necessary to implement said sections or January 1, 2025 until April 8, 2025. See 2024, 140, Sec. 252. For text effective April 8, 2025, see below.]"Center for health information and analysis revenue amount'', an amount equal to the sum of the amount collected by the center for health information and analysis from acute hospitals and ambulatory surgical centers pursuant to section 7 of chapter 12C.[ Definition of "Center for health information and analysis revenue amount'' inserted as amended by 2024, 342, Sec. 29 effective April 8, 2025. For text effective until April 8, 2025, see above.]"Center for health information and analysis revenue amount'', an amount equal to the sum of the amount collected by the center for health information and analysis from acute hospitals, ambulatory surgical centers and non-hospital provider organizations pursuant to section 7 of chapter 12C."Community health center'', a health center operating in conformance with the requirements of Section 330 of United States Public Law 95-626, including all community health centers which file cost reports as requested by the center for health information and analysis."Director'', the director of the health safety net office."DRG'', a patient classification scheme known as diagnosis related grouping, which provides a means of relating the type of patients a hospital treats, such as its case mix, to the cost incurred by the hospital."Emergency bad debt'', bad debt resulting from emergency services provided by an acute hospital to an uninsured or underinsured patient or other individual who has an emergency medical condition that is regarded as uncollectible, following reasonable collection efforts consistent with regulations of the office."Emergency medical condition'', a medical condition, whether physical, behavioral, related to a substance use disorder 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 woman."Emergency services'', medically necessary health care services provided to an individual with an emergency medical condition."Financial requirements'', a hospital's requirement for revenue which shall include, but not be limited to, reasonable operating, capital and working capital costs, the reasonable costs of depreciation of plant and equipment and the reasonable costs associated with changes in medical practice and technology."Fund'', the Health Safety Net Trust Fund established under section 66."Fund fiscal year'', the 12-month period starting in October and ending in September."Gross patient service revenue'', the total dollar amount of a hospital's charges for services rendered in a fiscal year.[ Definitions of "Group 1 safety net hospital'', "Group 2 safety net hospital'' and "Health policy commission revenue amount'' inserted following definition of "Gross patient service revenue'' by 2024, 140, Sec. 121 effective the later of one full calendar month following the calendar month in which the secretary receives all federal approvals deemed necessary to implement said sections or October 1, 2024 or January 1, 2025. See 2024, 140, Secs. 248 and 252.]"Group 1 safety net hospital'', a hospital identified as a group 1 safety net hospital in the MassHealth demonstration waiver approved under subsection (a) of section 1115 of Title XI of the Social Security Act."Group 2 safety net hospital'', a hospital identified as a group 2 safety net hospital in the MassHealth demonstration waiver approved under subsection (a) of section 1115 of Title XI of the Social Security Act.[ Definition of "Health policy commission revenue amount'' effective until April 8, 2025. For text effective April 8, 2025, see below.]"Health policy commission revenue amount'', the amount collected by the health policy commission from hospitals and ambulatory surgical centers pursuant to section 6 of chapter 6D.[ Definition of "Health policy commission revenue amount'' as amended by 2024, 342, Sec. 30 effective April 8, 2025. For text effective until April 8, 2025, see above.]"Health policy commission revenue amount'', the amount collected by the health policy commission from acute hospitals, ambulatory surgical centers and non-hospital provider organizations pursuant to section 6 of chapter 6D."Health services'', medically necessary inpatient and outpatient services as mandated under Title XIX of the federal Social Security Act; provided, that "health services'' shall not include: (i) nonmedical services, such as social, educational and vocational services; (ii) cosmetic surgery; (iii) canceled or missed appointments; (iv) telephone conversations and consultations; (v) court testimony; (vi) research or the provision of experimental or unproven procedures including, but not limited to, treatment related to sex-reassignment surgery and pre-surgery hormone therapy; and (vii) the provision of whole blood, but the administrative and processing costs associated with the provision of blood and its derivatives shall be payable.[ Definitions of "Managed care organization'' and "Payments subject to surcharge'' effective until the later of one full calendar month following the calendar month in which the secretary receives all federal approvals deemed necessary to implement said sections or January 1, 2025. Deleted by 2024, 140, Sec. 122. See 2024, 140, Sec. 252.]"Managed care organization'', a managed care organization, as defined in 42 CFR 438.2, and any eligible health insurance plan, as defined in section 1 of chapter 118H, that contracts with MassHealth or the commonwealth health insurance connector authority; provided, however, that "managed care organization'' shall not include a senior care organization, as defined in section 9D or an integrated care organization as defined in section 9F."Payments subject to surcharge'', all amounts paid, directly or indirectly, by surcharge payors to acute hospitals for health services and ambulatory surgical centers for ambulatory surgical center services; provided, however, that "payments subject to surcharge'' shall not include: (i) payments, settlements and judgments arising out of third party liability claims for bodily injury which are paid under the terms of property or casualty insurance policies; and (ii) payments made on behalf of Medicaid recipients, Medicare beneficiaries or persons enrolled in policies issued under chapter 176K or similar policies issued on a group basis; provided further, that "payments subject to surcharge'' shall include payments made by a managed care organization on behalf of Medicaid recipients under age 65 who are not enrolled in an integrated care organization; and provided further, that "payments subject to surcharge'' may exclude amounts established under regulations promulgated by the executive office for which the costs and efficiency of billing a surcharge payor or enforcing collection of the surcharge from a surcharge payor would not be cost effective.[ Definitions of "Health safety net managed care organization revenue amount'', "Immunization revenue amount'', "Managed care organization'', "Managed care organization reinvestment revenue amount'', "Managed care organization services subject to assessment'', "Massachusetts Child Psychiatry Access Project revenue amount'', "Medicaid managed care organization'', and "Medicaid managed care organization services subject to assessment'' inserted following definition of "Payments subject to surcharge'' by 2024, 140, Sec. 122 effective the later of one full calendar month following the calendar month in which the secretary receives all federal approvals deemed necessary to implement said sections or January 1, 2025. See 2024, 140, Sec. 252.]"Health safety net managed care organization revenue amount'', an amount equal to $160,000,000 plus 50 per cent of the estimated cost, as determined by the secretary for administration and finance, of administering the health safety net and related assessments in accordance with sections 65 to 69, inclusive."Immunization revenue amount'', the estimated costs to purchase, store and distribute vaccines for routine childhood immunizations and to administer the Vaccine Purchase Fund, established in section 24N of chapter 111, and the computerized immunization registry, established in section 24M of chapter 111, taking into consideration the limitations on expenditures described in subsection (b) of section 24N of chapter 111, as well as any anticipated surplus or deficit in said Vaccine Purchase Fund, but excluding any costs anticipated to be covered by federal contribution."Managed care organization'', any of the following entities, as defined in regulations promulgated by the secretary of health and human services: (i) an entity that is accredited pursuant to chapter 1760 and that is: (A) licensed or otherwise authorized to transact accident or health insurance pursuant to chapter 175; (B) a nonprofit hospital service corporation organized pursuant to chapter 176A; (C) a nonprofit medical service corporation organized pursuant to chapter 176B; (D) a health maintenance organization organized pursuant to chapter 176G; or (E) an organization entering into a preferred provider arrangement pursuant to chapter 176I; (ii) a Medicaid managed care organization; (iii) a health care organization, as defined in section 2 of chapter 32A; (iv) a self-insured group for which a carrier provides administrative services pursuant to section 21 of chapter 1760; and (v) a health insurance plan that contracts with the commonwealth health insurance connector authority."Managed care organization reinvestment revenue amount'', a fixed amount equal to $246,000,000."Managed care organization services subject to assessment'', services rendered by a managed care organization for which a premium or membership payment is made by or on behalf of the member; provided, however, that managed care organization services subject to assessment shall not include services: (i) rendered to members enrolled per month in Medicare managed care organizations; (ii) rendered to members dually enrolled per month in both Medicaid and Medicare; (iii) rendered to members in a Medicaid managed care organization who are age 65 or older; (iv) rendered as part of limited benefit plans, including, but not limited to, dental only or vision only member months, which are paid for as part of a subcontract under another managed care organization; or (v) services which are preempted from taxation by 5 U.S.C. section 8909(f); and provided further, that managed care organization services subject to assessment may be based on a tax base of managed care organization member months, premiums, claims, or charges, as determined by the secretary of health and human services and established consistently across the assessment groups that may be established pursuant to section 68."Massachusetts Child Psychiatry Access Project revenue amount'', an amount equal to the amounts expended for the Massachusetts Child Psychiatry Access Project that are related to services provided on behalf of commercially insured clients."Medicaid managed care organization'', a managed care organization, as defined in 42 CFR 438.2, that contracts with MassHealth pursuant to an approved state plan or federal waiver."Medicaid managed care organization services subject to assessment'', managed care organization services subject to assessment provided to a Medicaid member."Pediatric hospital'', an acute care hospital which limits services primarily to children and which qualifies as exempt from the Medicare Prospective Payment system regulations."Pediatric specialty unit'', a pediatric unit of an acute care hospital in which the ratio of licensed pediatric beds to total licensed hospital beds as of July 1, 1994 exceeded 0.20; provided that in calculating that ratio, licensed pediatric beds shall include the total of all pediatric service beds, and the total of all licensed hospital beds shall include the total of all licensed acute care hospital beds, consistent with Medicare's acute care hospital reimbursement methodology as put forth in the Provider Reimbursement Manual Part 1, Section 2405.3G."Private sector charges'', gross patient service revenue attributable to all patients less gross patient service revenue attributable to Titles XVIII and XIX, other public-aided patients, reimbursable health services and bad debt."Reimbursable health services'', health services provided to uninsured and underinsured patients who are determined to be financially unable to pay for their care, in whole or part, under applicable regulations of the office; provided that the health services are services provided by acute hospitals or services provided by community health centers; and provided further, that such services shall not be eligible for reimbursement by any other public or private third-party payer."Resident'', a person living in the commonwealth, as defined by the office by regulation; provided, however, that such regulation shall not define as a resident a person who moved into the commonwealth for the sole purpose of securing health insurance under this chapter. Confinement of a person in a nursing home, hospital or other medical institution shall not in and of itself, suffice to qualify such person as a resident.[ Definition of "Surcharge payor'' effective until the later of one full calendar month following the calendar month in which the secretary receives all federal approvals deemed necessary to implement said sections or January 1, 2025. Deleted by 2024, 140, Sec. 123. See 2024, 140, Sec. 252.]"Surcharge payor'', an individual or entity that pays for or arranges for the purchase of health care services provided by acute hospitals and ambulatory surgical center services provided by ambulatory surgical centers, as defined in this section; provided, however, that the term "surcharge payor'' shall include a managed care organization; and provided further, that "surcharge payor'' shall not include Title XVIII and Title XIX programs and their beneficiaries or recipients, other governmental programs of public assistance and their beneficiaries or recipients and the workers' compensation program established under chapter 152.[ Definition of "Total hospital assessment amount'' effective until the later of one full calendar month following the calendar month in which the secretary receives all federal approvals deemed necessary to implement said sections or October 1, 2024. For text effective the later of one full calendar month following the calendar month in which the secretary receives all federal approvals deemed necessary to implement said sections or October 1, 2024, see below.]"Total hospital assessment amount'', a fixed amount equal to $880,000,000, which is the sum of $160,000,000 and the amounts transferred, pursuant to section 66, to the Safety Net Provider Trust Fund established in section 2AAAAA of chapter 29, the Hospital Investment and Performance Trust Fund established in section 2TTTTT of said chapter 29, the Population Health Investment Trust Fund established in section 2UUUUU of said chapter 29 and the Non-Acute Care Hospital Reimbursement Trust Fund established in section 2WWWW of said chapter 29, plus 50 per cent of the estimated cost, as determined by the secretary of administration and finance, of administering the health safety net and related assessments in accordance with sections 65 to 69, inclusive.[ Definition of "Total hospital assessment amount'' as amended by 2024, 140, Sec. 125 effective the later of one full calendar month following the calendar month in which the secretary receives all federal approvals deemed necessary to implement said sections or October 1, 2024 until October 1, 2027. Deleted by 2022, 126, Sec. 57. See 2022, 126, Secs. 185 and 186 and 2024, 140, Sec. 239. See also, 2024, 140, Sec. 248. For text effective until the later of one full calendar month following the calendar month in which the secretary receives all federal approvals deemed necessary to implement said sections or October 1, 2024, see above.]"Total hospital assessment amount'', a fixed amount equal to $1,484,050,000, which is the sum of $160,000,000 and the amounts transferred, pursuant to section 66, to the Safety Net Provider Trust Fund established in section 2AAAAA of chapter 29, the Hospital Investment and Performance Trust Fund established in section 2TTTTT of said chapter 29, the Population Health Investment Trust Fund established in section 2UUUUU of said chapter 29 and the Non-Acute Care Hospital Reimbursement Trust Fund established in section 2WWWW of said chapter 29, plus 50 per cent of the estimated cost, as determined by the secretary of administration and finance, of administering the health safety net and related assessments in accordance with sections 65 to 69, inclusive.[ Definition of "Total acute hospital assessment amount'' inserted by 2022, 126, Sec. 57 effective October 1, 2027 applicable as provided by 2022, 126, Sec. 186 and 2024, 140, Sec. 239.]"Total acute hospital assessment amount'', an amount equal to $160,000,000, plus 50 per cent of the estimated cost, as determined by the secretary of administration and finance, of administering the health safety net and related assessments in accordance with sections 65 to 69, inclusive.[ Definition of "Total surcharge amount'' effective until the later of one full calendar month following the calendar month in which the secretary receives all federal approvals deemed necessary to implement said sections or January 1, 2025. Deleted by 2024, 140, Sec. 124. See 2024, 140, Sec. 252.]"Total surcharge amount'', an amount equal to $160,000,000 plus 50 per cent of the estimated cost, as determined by the secretary of administration and finance, of administering the health safety net and related assessments in accordance with sections 65 to 69, inclusive.[ Definition of "Total managed care organization services assessment amount'' inserted following definition of "Total surcharge amount'' by 2024, 140, Sec. 124 effective the later of one full calendar month following the calendar month in which the secretary receives all federal approvals deemed necessary to implement said sections or January 1, 2025. See 2024, 140, Sec. 252.]"Total managed care organization services assessment amount'', an amount equal, for each year, to the sum of the following in the same year: (i) the managed care organization reinvestment revenue amount; (ii) the health safety net managed care organization revenue amount; (iii) the Massachusetts Child Psychiatry Access Project revenue amount; (iv) the immunization revenue amount; (v) the health policy commission revenue amount; (vi) the center for health information and analysis revenue amount; (vii) the amount transferred, pursuant to section 66, to the Behavioral Health Access and Crisis Intervention Trust Fund established in section 2WWWWW of chapter 29; and (viii) the amounts necessary to incorporate prospectively all adjustments or reconciliations to account for under-assessments in the prior year."Underinsured patient'', a patient whose health insurance plan or self-insurance health plan does not pay, in whole or in part, for health services that are eligible for reimbursement from the health safety net trust fund, provided that such patient meets income eligibility standards set by the office."Uninsured patient'', a patient who is a resident of the commonwealth, who is not covered by a health insurance plan or a self-insurance health plan and who is not eligible for a medical assistance program.