Long-Term Services and Supports (LTSS). A wide variety of services and supports that help certain members meet their daily needs for assistance and improve the quality of their lives. Examples include assistance with bathing, dressing and other basic activities of daily life and self-care, as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over an extended period, predominantly in homes and communities, but also in facility-based settings such as nursing facilities. LTSS CP – Long-Term Services and Supports Community Partner Managed Care Organization (MCO) – any entity that provides, or arranges for the provision of, covered services under a capitated payment arrangement, that is licensed and accredited by the Massachusetts Division of Insurance as a Health Maintenance Organization (HMO), and is organized primarily for the purpose of providing health care services, that (a) meets advance directives requirements of 42 CFR Part 489, subpart I; (b) makes the services it provides to its Enrollees as accessible (in terms of timeliness, amount, duration, and scope) as those services are to other Members within the area served by the entity; (c) meets the EOHHS’s solvency standards; (d) assures that Enrollees will not be liable for the Contractor’s debts if the Contractor becomes insolvent; (e) is located in the United States; (f) is independent from EOHHS’ enrollment broker, as identified by EOHHS; and (g) is not an excluded entity described in 42 CFR 438.808(b) Marketing – any communication from the Contractor, its employees, Providers, agents or Material Subcontractors to a Member who is not enrolled in the Contractor’s Plan that EOHHS can reasonably interpret as influencing the Member to enroll in the Contractor’s Plan or either not to enroll in, or to disenroll from, another Accountable Care Partnership Plan, MassHealth- contracted accountable care organization, MassHealth-contracted MCO, or the PCC Plan. Marketing shall not include any personal contact between a Provider and a Member who is a prospective, current or former patient of that Provider regarding the provisions, terms or requirements of MassHealth as they relate to the treatment needs of that particular member.
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Samples: Accountable Care Partnership Plan Contract, Contract
Long-Term Services and Supports (LTSS). A wide variety of services and supports that help certain members meet their daily needs for assistance and improve the quality of their lives. Examples include assistance with bathing, dressing and other basic activities of daily life and self-care, as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over an extended period, predominantly in homes and communities, but also in facility-based settings such as nursing facilities. LTSS CP – Long-Term Services and Supports Community Partner Managed Care Organization (MCO) – any entity that provides, or arranges for the provision of, covered services under a capitated payment arrangement, that is licensed and accredited by the Massachusetts Division of Insurance as a Health Maintenance Organization (HMO), and is organized primarily for the purpose of providing health care services, that (a) meets advance directives requirements of 42 CFR Part 489, subpart I; (b) makes the services it provides to its Enrollees as accessible (in terms of timeliness, amount, duration, and scope) as those services are to other Members within the area served by the entity; (c) meets the EOHHS’s solvency standards; (d) assures that Enrollees will not be liable for the Contractor’s debts if the Contractor becomes insolvent; (e) is located in the United States; (f) is independent from EOHHS’ enrollment broker, as identified by EOHHS; and (g) is not an excluded entity described in 42 CFR 438.808(b) Marketing – any communication from the Contractor, its employees, Providers, agents or Material Subcontractors to a Member who is not enrolled in the Contractor’s Plan that EOHHS can reasonably interpret as influencing the Member to enroll in the Contractor’s Plan or either not to enroll in, or to disenroll from, another Accountable Care Partnership Plan, MassHealth- MassHealth-contracted accountable care organization, MassHealth-contracted MCO, or the PCC Plan. Marketing shall not include any personal contact between a Provider and a Member who is a prospective, current or former patient of that Provider regarding the provisions, terms or requirements of MassHealth as they relate to the treatment needs of that particular member.
Appears in 2 contracts
Samples: Accountable Care Partnership Plan Contract, Accountable Care Partnership Plan Contract
Long-Term Services and Supports (LTSS). A wide variety of services and supports that help certain members meet their daily needs for assistance and improve the quality of their lives. Examples include assistance with bathing, dressing and other basic activities of daily life and self-care, as well as support for everyday tasks such as laundry, shopping, and transportation. LTSS are provided over an extended period, predominantly in homes and communities, but also in facility-based settings such as nursing facilities. LTSS CP – Long-Term Services and Supports Community Partner Managed M anaged Care Organization (MCO) – any entity that provides, or arranges for the provision of, covered services under a capitated payment arrangement, that is licensed and accredited by the Massachusetts Division of Insurance as a Health Maintenance Organization (HMO), and is organized primarily for the purpose of providing health care services, that (a) meets advance directives requirements of 42 CFR Part 489, subpart I; (b) makes the services it provides to its Enrollees as accessible (in terms of timeliness, amount, duration, and scope) as those services are to other Members within the area served by the entity; (c) meets the EOHHS’s solvency standards; (d) assures that Enrollees will not be liable for the Contractor’s debts if the Contractor becomes insolvent; (e) is located in the United States; (f) is independent from EOHHS’ enrollment broker, as identified by EOHHS; and (g) is not an excluded entity described in 42 CFR 438.808(b) Marketing M arketing – any communication from the Contractor, its employees, Providers, agents or Material Subcontractors to a Member who is not enrolled in the Contractor’s Plan that EOHHS can reasonably interpret as influencing the Member to enroll in the Contractor’s Plan or either not to enroll in, or to disenroll from, another Accountable Care Partnership Plan, MassHealth- MassHealth-contracted accountable care organization, MassHealth-contracted MCO, or the PCC Plan. Marketing shall not include any personal contact between a Provider and a Member who is a prospective, current or former patient of that Provider regarding the provisions, terms or requirements of MassHealth as they relate to the treatment needs of that particular member. M arketing Materials – Materials that are produced in any medium, by or on behalf of the Contractor and that EOHHS can reasonably interpret as Marketing to Members. This includes the production and dissemination by or on behalf of the Contractor of any promotional material or activities by any medium including, but not limited to, oral presentations and statements, community events, print media, audio visual tapes, radio, television, billboards, online, Yellow Pages, and advertisements that explicitly or implicitly refer to MassHealth Managed Care or Title XIX and Title XXI of the Social Security Act, and are targeted in any way toward Members. M assachusetts Health Information Highway (Mass HIway) – Massachusetts’ statewide electronic health information exchange. M assachusetts Health Quality Partners (MHQP) – a broad-based coalition of physicians, hospitals, health plans, purchasers, consumers, and government agencies working together to promote improvement in the quality of health care services in Massachusetts. M assHealth – the medical assistance or benefit programs administered by EOHHS. M assHealth CarePlus – a MassHealth Coverage Type that offers health benefits to certain individuals at least the age of 21 and under the age of 65 who qualify under EOHHS’s MassHealth CarePlus eligibility criteria. M assHealth CommonHealth – a MassHealth Coverage Type that offers health benefits to certain disabled children under age 18, and certain working or non-working disabled adults between the ages of 18 and 64. M assHealth DRG Weight– The MassHealth relative weight developed by EOHHS for each unique combination of All Patient Refined Diagnosis Related Group and severity of illness (SOI). M assHealth Family Assistance – a MassHealth Coverage Type that offers health benefits to certain eligible Members, including families and children under the age of 18. M assHealth Managed Care Program – all Accountable Care Partnership Plans, other ACOs, MassHealth Managed Care Organization (MCO) Plans and the Primary Care Clinician (PCC) Plan that serve all managed care eligible Members under age 65. M assHealth Standard – a MassHealth Coverage Type that offers a full range of health benefits to certain eligible Members, including families, children under age 18, pregnant individuals, and disabled individuals under age 65. M aterial Subcontractor – any entity from which the Contractor procures, re-procures, or proposes to subcontract with, for the provision of all, or part, of its Administrative Services for any program area or function that relates to the delivery or payment of ACO Covered Services including, but not limited to, behavioral health, claims processing, Care Management, Utilization Management or pharmacy benefits, including specialty pharmacy providers. M edicaid – see “MassHealth.” In addition, Medicaid shall mean any other state’s Title XIX program. M edicaid Fraud Division (MFD) – a division of the Massachusetts Office of the Attorney General that is dedicated to investigating cases of suspected Provider Fraud or Abuse. M edicaid Management Information System (MMIS) – the management information system of software, hardware and manual processes used to process claims and to retrieve and produce eligibility information, service utilization and management information for Members. M edically Necessary or Medical Necessity – in accordance with 130 CMR 450.204, Medically Necessary services are those services (1) which are reasonably calculated to prevent, diagnose, prevent the worsening of, alleviate, correct, or cure conditions in the Enrollee 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; and (2) for which there is no other medical service or site of service, comparable in effect, available, and suitable for the Enrollee requesting the service, that is more conservative or less costly. Medically Necessary services must be of a quality that meets professionally recognized standards of health care, and must be substantiated by records including evidence of such medical necessity and quality. M edicare ACO – Accountable care contracts administered by the Medicare program, including the Medicare Shared Savings Program, the Pioneer ACO program, and the CMS Next Generation ACO program M edication for Addiction Treatment (MAT) Services – The use of FDA-approved medications for the treatment of substance use disorders. M ember – a person determined by EOHHS to be eligible for MassHealth. M obile Crisis Intervention (MCI) (also referred to as Youth Mobile Crisis Intervention) – As set forth in Appendix C, Youth Mobile Crisis Intervention services include a short-term mobile, on-site, and face-to- face therapeutic service provided for youth experiencing a behavioral health crisis and for the purpose of identifying, assessing, treating, and stabilizing the situation and reducing the immediate risk of danger to the youth or others consistent with the youth’s risk management/safety plan, if any. Mobile Crisis Intervention utilizes a multidisciplinary model, with both professional and paraprofessional staff. Services are available 24 hours a day, 7 days a week. Network Management – refers to the activities, strategies, policies and procedures, and other tools used by the Contractor in the development, administration, and maintenance of the collective group of health care Providers under contract to deliver Contractor ACO Covered Services.
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