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Massachusetts Medicaid Outpatient Therapy Definitions

Accountable Care Organization (ACO) – An entity that enters into a population-based payment model contract with EOHHS as an accountable care organization, wherein the entity is held financially accountable for the cost and quality of care for an attributed or enrolled member population. ACOs include Accountable Care Partnership Plans, Primary Care ACOs, and MCO administered ACOs.

Capitated Program – An ICO, SCO, ACO, or PACE organization, or any other entity that, according to a contract with EOHHS, covers home health and other medical services for members on a capitated basis.

Co-treatment – Therapy performed by two (2) therapy providers, who work together as a team to treat one (1) member, when appropriate. The providers may only bill for a maximum of four (4) units per member treatment session. 

Group Therapy – Simultaneous therapy services provided to two to six patients who may or may not be doing the same activities.

Integrated Care Organization (ICO) – An organization with a comprehensive network of medical, behavioral health care, and long-term services and supports (LTSS) providers that integrates all components of care, either directly or through subcontracts, and has contracted with EOHHS and the Centers for Medicare and Medicaid Services (CMS) and been designated as an ICO to provide services to dual eligible individuals under M.G.L. c. 118E. ICOs are responsible for providing enrolled members with the full continuum of Medicare- and MassHealth-covered services.

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

Managed Care Organization (MCO) – Any entity with which the MassHealth agency contracts under its MCO program to provide, arrange for, and coordinate care and certain other medical services to members on a capitated basis, and is approved by the Massachusetts Division of Insurance as a health maintenance organization (HMO), and is organized primarily for the purpose of providing health care services.

Marketing – Any communication from a therapy provider, or its agent, to a member, or their family or caregivers, that can reasonably be interpreted as intended to influence the member’s choice of therapy provider, whether by inducing that member:

    • To retain that therapy provider to provide therapy services to the member;
    • Not to retain therapy services from another therapy provider; or
    • To cease receiving therapy services from another therapy provider.

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. 

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.

Prescribing Provider – The member’s physician, nurse practitioner, or physician assistant who prescribes and writes the prescription for therapy services in accordance with 130 CMR 432.415.

Programs of All-inclusive Care for the Elderly (PACE) – The Programs of All-inclusive Care for the Elderly (PACE), as described in 42 CFR 460 and 130 CMR 519.007(C): Program of All inclusive Care for the Elderly (PACE).

Provider Portal – The online site by which LTSS providers, as applicable, submit all MassHealth LTSS prior authorization requests to a MassHealth designated vendor.

Senior Care Organization (SCO) – A managed care organization that participates in MassHealth under a contract with the MassHealth agency to provide coordinated care and medical services through a comprehensive network to eligible members 65 years of age or older. SCOs are responsible for providing enrolled members with the full continuum of MassHealth-covered services, and for dual eligible members, the full continuum of MassHealth and Medicare-covered services.

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 functions 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 presence of a communication disability), and those that impair comprehension, spoken, written, or other symbol systems used for communication.

Therapy Provider (Therapist) – A MassHealth enrolled provider of physical therapy, occupational therapy, or speech/language therapy. Therapy Provider may refer to an individual practitioner or a group practice consisting of therapy providers.

Therapy Visit – A personal contact with a member provided by a licensed physical therapist, licensed physical therapy assistant, licensed occupational therapist, licensed occupational therapy assistant, licensed speech/language pathologist, or licensed speech/language pathologist assistant for the purpose of providing a covered service.

Unfair or Deceptive Acts or Practices – Any unfair or deceptive acts or practices, as that term is referred to in M.G.L. c. 93A, § 2 and in the regulations promulgated thereunder by the Massachusetts Attorney General.

Reference

130 CMR 432.402

About Us

Zachary Edgar JD, LLM is the managing partner for Therapy Comply.  Zachary is a healthcare attorney that specializes in federal and state healthcare regulatory issues particularly for physical, occupational, and speech therapy practices.  

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