§ 8A — Definitions for Secs. 13C to 13K and Secs. 64 to 70

Massachusetts § 8A

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

Text

Section 8A. For the purposes of sections 13C to 13K, inclusive, and sections 64 to 70, inclusive, the following terms and phrases shall, unless the context clearly requires otherwise, have the following meanings:''Actual costs'', all direct and indirect costs incurred by a hospital or a community health center in providing medically necessary care and treatment to its patients, determined in accordance with generally accepted accounting principles.''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.''Case mix'', the description and categorization of a hospital's patient population according to criteria approved by the center for health information and analysis including, but not limited to, primary and secondary diagnoses, primary and secondary procedures, illness severity, patient age and source of payment.''Charge'', the uniform price for specific services within a revenue center of a hospital.''Child'', a person who is under 18 years of age.''Community health centers'', health centers operating in conformance with Section 330 of United States Public Law 95–626 and shall include all community health centers which file cost reports as requested by the center.''Comprehensive cancer center'', the hospital of any institution so designated by the national cancer institute organized solely for the treatment of cancer, and offered exemption from the Medicare diagnosis related group payment system.''Disproportionate share hospital'', an acute hospital that exhibits a payer mix where a minimum of 63 per cent of the acute hospital's gross patient service revenue is attributable to Title XVIII and Title XIX of the federal Social Security Act, other government payers and free care.''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 woman, as further defined in 42 U.S.C. section 1395dd(e)(1)(B).''Emergency services'', medically necessary health care services provided to an individual with an emergency medical condition.''Employee'', a person who performs services primarily in the commonwealth for remuneration for a commonwealth employer; provided, that ''employee'' shall not include a person who is self-employed.''Employer'', an employer as defined in section 1 of chapter 151A.''Enrollee'', a person who becomes a member of an insurance program of the division either individually or as a member of a family.''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.''Fiscal year'', the 12 month period during which a hospital keeps its accounts and which ends in the calendar year by which it is identified.''Free care'', the following medically necessary services provided to individuals determined to be financially unable to pay for care, in whole or in part, under applicable regulations of the executive office: (i) services provided by acute hospitals; (ii) services provided by community health centers; and (iii) patients in situations of medical hardship in which major expenditures for health care have depleted or can reasonably be expected to deplete the financial resources of the individual to the extent that medical services cannot be paid, as determined by regulations of the executive office.''General health supplies, care or rehabilitative services and accommodations'', all supplies, care and services of medical, optometric, dental, surgical, chiropractic, podiatric, psychiatric, therapeutic, diagnostic, rehabilitative, supportive or geriatric nature, including inpatient and outpatient hospital care and services and accommodations in hospitals, sanatoria, infirmaries, convalescent and nursing homes, retirement homes, facilities established, licensed or approved under chapter 111B and providing services of a medical or health-related nature and similar institutions including those providing treatment, training, instruction and care of children and adults; provided, however, that rehabilitative service shall include only rehabilitative services of a medical or health-related nature which are eligible for reimbursement under Title XIX of the federal Social Security Act.''Governmental mandate'', a state or federal statutory requirement, administrative rule, regulation, assessment, executive order, judicial order or other governmental requirement that directly or indirectly imposes an obligation and associated compliance cost upon a provider to take an action or to refrain from taking an action in order to fulfill the provider's contractual duty to a procuring governmental unit.''Governmental unit'', the commonwealth, any department, agency board, commission or poltical subdivision of the commonwealth.''Gross patient service revenue'', the total dollar amount of a hospital's charges for services rendered in a fiscal year.''Health care services'', supplies,, care and services of a medical, surgical, optometric, dental, podiatric, chiropractic, psychiatric, therapeutic, diagnostic, preventative, rehabilitative, supportive or geriatric nature including, but not limited to, inpatient and outpatient acute hospital care and services, services provided by a community health center or by a sanatorium, included in the definition of ''hospital'' in Title XVIII of the federal Social Security Act and treatment and care compatible with such services or by a health maintenance organization.''Health insurance company'', a company as defined in section 1 of chapter 175 which engages in the business of health insurance.''Health insurance plan'', the Medicare program or an individual or group contract or other plan providing coverage of health care services and which is issued by a health insurance company, a hospital service corporation, a medical service corporation or a health maintenance organization.''Health maintenance organization'', a company which provides or arranges for health care services to enrolled members in exchange primarily for a prepaid per capita or aggregate fixed sum as defined in section 1 of chapter 176G.''Hospital'', a hospital licensed under section 51 of chapter 111, the teaching hospital of the University of Massachusetts Medical School and any psychiatric facility licensed under section 19 of chapter 19.''Medical assistance program'', the Medicaid program, the Veterans Administration health and hospital programs and any other medical assistance program operated by a governmental unit for persons categorically eligible for such program.''Medically necessary services'', medically necessary inpatient and outpatient services as mandated under Title XIX of the federal Social Security Act. Medically necessary services shall not include: (i) non-medical 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) providing whole blood; provided, however, that administrative and processing costs associated with providing blood and its derivatives shall be payable.''Medicare program'', the medical insurance program established by Title XVIII of the federal Social Security Act.''Non-acute hospital'', a hospital which is not an acute hospital.''Patient'', a natural person receiving health care services from a hospital.''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. 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.''Provider'', any person, corporation partnership, governmental unit, state institution or any other entity qualified under the laws of the commonwealth to perform or provide health care services.''Publicly aided patient'', a person who receives hospital care and services for which a governmental unit is liable, in whole or in part, under a statutory program of public assistance.''Purchaser'', a natural person responsible for payment for health care services rendered by a hospital.''Resident'', a person living in the commonwealth, as defined by the executive office through a regulation; provided, however, that such regulation shall not define a resident as a person who moved into the commonwealth for the sole purpose of securing health insurance under this chapter; and provided, further that 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.''Revenue center'', a functioning unit of a hospital which provides distinctive services to a patient for a charge.''Self-employed'', a person who, at common law, is not considered to be an employee and whose primary source of income is derived from the pursuit of a bona fide business.''Self-insurance health plan'', a plan which provides health benefits to the employees of a business, which is not a health insurance plan and in which the business is liable for the actual costs of the health care services provided by the plan and administrative costs.''Social service program'', a social, mental health, developmental disabilities, habilitative, rehabilitative, substance abuse, residential care, adult or adolescent day care, vocational, employment and training or elder service program or accommodations purchased by a governmental unit or political subdivision of the executive office of health and human services, but excluding any program, service or accommodation that: (i) is reimbursable under a Medicaid waiver granted under section 1115 of Title XI of the federal Social Security Act; or (ii) is funded exclusively by a federal grant.''Social service program provider'', a provider of social service programs in the commonwealth.''Sole community provider'', any acute hospital which qualifies as a sole community provider under Medicare regulations or under regulations promulgated by the executive office. Those regulations shall consider factors including, but not limited to, isolated location, weather conditions, travel conditions, percentage of Medicare, Medicaid and free care provided and the absence of other reasonably accessible hospitals in the area; provided, that such hospitals shall include those which are located more than 25 miles from other such hospitals in the commonwealth and which provide services for at least 60 per cent of the primary service area.''Specialty hospital'', an acute hospital which qualifies for an exemption from the Medicare prospective payment system regulations or an acute hospital which limits its admissions to patients under active diagnosis and treatment of eyes, ears, nose and throat or to children or patients under obstetrical care.''State institution'', a hospital, sanatorium, infirmary, clinic and other such facility owned, operated or administered by the commonwealth which furnishes general health supplies, care or rehabilitative services and accommodations.''Third party payer'', an entity including, but not limited to, Title XVIII and Title XIX programs, other governmental payers, insurance companies, health maintenance organizations and nonprofit hospital service corporations; provided, however, that ''third party payer'' shall not include a purchaser responsible for payment for health care services rendered by a hospital, either to the purchaser or to the hospital.