Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 5 › Subtitle 67 - MARYLAND HEALTHCHOICE PROGRAM › Chapter 10.67.01 - Maryland Medicaid Managed Care Program: Definitions › Section 10.67.01.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. Except as
				  expressly limited, in COMAR 10.67.62 -10.67.75 the following terms have the
				  meanings indicated.
B. Terms
				  Defined.
(1) "ACOG guidelines" means the
				  American College of Obstetricians and Gynecologists' Guidelines for Perinatal
				  Care that specify the recommended periodicity and content of prenatal,
				  perinatal, and postpartum care, and are incorporated by reference in COMAR
				  10.67.65.01.
(2) "Acquired immune
				  deficiency syndrome (AIDS)" has the meaning stated in COMAR
				  10.52.06.01B.
(3) "Action" means:
(a) Denial or limited authorization of a
				  requested service, including:
(i) The type or
				  level of service;
(ii) Requirements
				  for medical necessity;
(iii) 
				  Appropriateness;
(iv) Setting;
				  or
(v) Effectiveness of a covered
				  benefit.
(b) Reduction,
				  suspension, or termination of a previously authorized service;
(c) Denial, in whole or part, of payment for
				  a service, except for administrative denials of unclean claims;
(d) Failure to provide services in a timely
				  manner;
(e) Failure of an MCO to
				  act within the required time frames; or
(f) The denial of an enrollee's request to
				  dispute a financial liability, including:
(i)
				  Cost sharing;
(ii)
				  Copayments;
(iii)
				  Premiums;
(iv)
				  Deductibles;
(v) Coinsurance;
				  or
(vi) Other enrollee financial
				  liabilities.
(4) "Activities of daily living" means, in
				  the context of COMAR 10.67.69, bathing, feeding, toileting, dressing, and
				  ambulation;
(5) "Adjusted clinical
				  group (ACG)" means a method for categorizing individuals into a case mix
				  category based on the diagnoses assigned by their clinicians over a
				  predetermined period of time.
(6)
				  Administrative Services Organization.
(a)
				  "Administrative services organization (ASO)" means an organization with which
				  MHA and the CSAs contract to assist in the management of the specialty mental
				  health system.
(b) "Administrative
				  services organization" does not mean an organization that directly provides
				  health care services to waiver-eligible individuals.
(7) "Advanced practice nurse" means a nurse
				  practitioner, nurse midwife, nurse anesthetist, or nurse psychotherapist who is
				  licensed and certified under Health Occupations Article, Title 8, Annotated
				  Code of Maryland, and COMAR 10.27.01
(8) "Aged" has the meaning stated in COMAR
				  10.67.24.02B.
(9) "AIDS payment
				  category" means one of the two payment categories represented as individual
				  rate cells within the rate table set forth in COMAR 10.67.65.19B(4)(b) to which
				  enrollees with AIDS are assigned pursuant to COMAR 10.67.65.19B(2)(c)(ii).
(10) "Alcohol abuse" has the
				  meaning stated in Health-General Article, §8-101(e), Annotated Code of
				  Maryland.
(11) "Ancillary services"
				  means diagnostic and somatic therapeutic services, including but not limited to
				  radiology, laboratory services, cardiac diagnostics, neurology diagnostics,
				  occupational therapy, physical therapy, durable medical equipment, disposable
				  medical supplies, audiology, speech therapy, and cardiac rehabilitation
				  therapy.
(12) "Annual quality
				  assurance (QA) audit" means a systems performance review and a clinical care
				  review.
(13) "Appeal" means a
				  request for review of an action.
(14) "Applicant" means an entity that seeks
				  approval from the Department to operate as a managed care organization in the
				  Maryland Medicaid Managed Care Program.
(15) "Benefits package" means a set of health
				  care services to which an MCO's enrollees are entitled, when the services are
				  medically necessary, and which the MCO delivers to its enrollees either through
				  providers with which it has employment or contractual relationships, or through
				  reimbursement for services provided to the MCO's enrollees.
(16) "Blind" means having a condition in
				  which a person is certified by an ophthalmologist as having either central
				  visual acuity of 20/200 or less in the better eye with correcting glasses, or a
				  field defect in which the peripheral field has contracted to such an extent
				  that the widest diameter of the visual field subtends an angular distance of no
				  greater than 20 degrees.
(17)
				  "Business day" means any day except Saturday, Sunday, or a holiday on which
				  State offices are closed.
(18)
				  "Caller abandonment rates" means the percentage of calls terminated by callers
				  without speaking to a live operator.
(19) "Caller average hold time" means an
				  average amount of time a call is on hold after being answered.
(20) "Caller service level" means the speed
				  of answering the telephone.
(21)
				  "Capitation payment" means the sum of money paid in advance on a monthly per
				  capita basis by the Department for a fixed benefit package.
(22) "CARF" means the Commission on
				  Accreditation of Rehabilitation Facilities (also known as the Rehabilitation
				  Accreditation Commission), which is an organization that:
(a) Establishes quality standards for
				  rehabilitative services; and
(b)
				  Determines, in the context of its accreditation process, the extent to which
				  rehabilitative service providers are in compliance with CARF quality
				  standards.
(23) "Case
				  management " means, assessing, planning, coordinating, monitoring, and
				  arranging the delivery of medically necessary health-related
				  services.
(24) "Case management
				  contractor" means, in the context of COMAR 10.67.69, the Department's designee,
				  or a subcontractor of the designee, which provides case management to
				  participants assigned to it by the Department.
(25) "Case manager" means, in the context of
				  COMAR 10.67.69, the individual who:
(a) Is
				  employed by the Department's designee or a case management
				  contractor;
(b) Is assigned by a
				  case management contractor to manage the care of some or all of the
				  participants assigned to that case management contractor;
(c) Participates in the meetings of the
				  interdisciplinary team;
(d) Is
				  responsible for the development of an individual's case management plan by the
				  interdisciplinary team;
(e) Is
				  responsible for implementing the participant's case management plan;
				  and
(f) Is responsible for
				  modifying the case management plan when information regarding a change in the
				  participant's condition or status is received.
(26) "CDS license" means the State licensure
				  authorizing a health care practitioner to prescribe controlled dangerous
				  substances.
(27) "Certified nursing
				  assistant" means, in the context of COMAR 10.67.69, an individual:
(a) Certified as a nursing assistant by the
				  Maryland Board of Nursing; and
(b)
				  Who performs nursing tasks delegated by a registered nurse or licensed
				  practical nurse pursuant to Health Occupations Article, Title 8, Annotated Code
				  of Maryland.
(28) "Child
				  in State-supervised care" means a waiver-eligible child who is in the care and
				  custody of a State agency pursuant to a court order or a voluntary placement
				  agreement, including, but not limited to, waiver-eligible children:
(a) Under the supervision of the Department
				  of Juvenile Services;
(b) In
				  kinship or foster care under the Department of Human Resources; and
(c) In residential treatment centers or
				  psychiatric hospitals for the first 30 days after admission.
(29) "Child with a special health
				  care need" means an individual younger than 21 years old, regardless of marital
				  status, suffering from a moderate to severe chronic health condition:
(a) With significant potential or actual
				  impact on health and ability to function;
(b) Which requires special health care
				  services; and
(c) Which is expected
				  to last longer than 6 months.
(29-1) "CHIP Health Services Initiative"
				  means services offered to improve the health of low-income children pursuant to
				  5 U.S.C. §
												2105(a) (1)(D)(ii) of the
				  Social Security Act.
(30) "Chronic
				  hospital" has the meaning stated in COMAR
				  10.67.06.01B(4).
(31) "Clinical care review" means a review of
				  the quality of clinical health care delivered by an MCO, which is:
(a) Required by federal law; and
(b) A component of an annual quality
				  assurance (QA) audit.
(32) "CMS" means Centers for Medicare and
				  Medicaid Services.
(33) "Cold call
				  marketing" means any unsolicited personal contact by the MCO with a potential
				  enrollee for the purpose of marketing.
(34) "Commissioner" means the Maryland
				  Insurance Commissioner of the Maryland Insurance Administration.
(35) "Community-based substance abuse
				  program" means a program that:
(a) Is
				  certified by the Office of Health Care Quality (OHCQ); and
(b) Provides services in community settings
				  not regulated by the Health Services Cost Review Commission.
(36) "Complaint" means an
				  expression of dissatisfaction that results in either an appeal or a
				  grievance.
(37) "Contract year"
				  means the period of time to which the Maryland Medicaid Managed Care Program
				  agreement between the Department and an MCO applies.
(38) "Core service agency (CSA)" means, in
				  the context of COMAR 10.67.70, the county or multicounty authority, designated
				  under Health-General Article, Title 10, Subtitle 12, Annotated Code of
				  Maryland, and approved by the Department, that is responsible for planning,
				  managing, and monitoring publicly funded mental health services.
(39) "Corporation" means:
(a) An entity formed under and meeting the
				  requirements of Corporations and Associations Article, §
												2-101
				  et seq., Annotated Code of Maryland; or
(b) A foreign corporation registered with the
				  Maryland Department of Assessments and Taxation.
(40) "County" means a county of this State
				  and, unless expressly provided otherwise, Baltimore City.
(40-1) "Credibility adjustment" means an
				  adjustment to the MLR for a partially credible MCO to account for a difference
				  between the actual and target MLRs that may be due to random statistical
				  variation.
(41) "Days" means,
				  unless otherwise expressly indicated, calendar days.
(42) "DEA license" means the federal license
				  authorizing a health care practitioner to prescribe controlled
				  substances.
(42-1) "Definitive drug
				  test" means drug screening tests that include:
(a) The ability to identify individual drugs
				  and distinguish between structural isomers, but not necessarily stereoisomers,
				  using:
(i) Gas chromatography or mass
				  spectrometry; and
(ii) Liquid
				  chromatography or mass spectrometry;
(b) Qualitative or quantitative
				  results;
(c) All source types for
				  specimen selection;
(d) Specimen
				  validity testing, per day, 1-22 or more drug classes including metabolites, if
				  performed.
(43)
				  "Department" means the Department of Health and Mental Hygiene, as defined in
				  COMAR 10.67.36.01, or its authorized agents acting on behalf of the
				  Department.
(44) "Diagnostic
				  evaluation services (DES)" has the meaning stated in COMAR 10.67.32.01B, and
				  includes the services described in COMAR 10.67.32.04A.
(45) Direct Medical Education Costs (DME
				  Costs).
(a) "Direct medical education costs
				  (DME costs)" means costs associated with providing graduate medical education
				  that are measurable using accounting data.
(b) "Direct medical education costs (DME
				  costs)" includes, but is not limited to:
(i)
				  Salaries;
(ii) Supervision costs;
				  and
(iii) Allocated
				  overhead.
(46)
				  "Disabled" has the meaning stated in COMAR 10.67.24.02B.
(47) "Early and Periodic Screening,
				  Diagnosis, and Treatment (EPSDT)" means the provision, to individuals younger
				  than 21 years old, of preventive health care pursuant to
				  42 CFR §
												441.50 et seq. (1981), and other health care
				  services, diagnostic services, and treatment services that are necessary to
				  correct or ameliorate defects and physical and mental illnesses and conditions
				  discovered by EPSDT screening services.
(48) "Emergency medical condition" means a
				  medical condition characterized by sudden onset and symptoms of sufficient
				  severity, including severe pain, that the absence of immediate medical
				  attention could reasonably be expected by a prudent lay person, who possesses
				  an average knowledge of health and medicine, to result in:
(a) Placing the patient's health, or with
				  respect to a pregnant woman, the health of the woman or unborn child in serious
				  jeopardy;
(b) Serious impairment to
				  bodily functions; or
(c) Serious
				  dysfunction of any bodily organ or part.
(49) "Emergency services" means those health
				  care services that are provided in a hospital emergency facility after the
				  sudden onset of a medical condition that manifests itself by symptoms of
				  sufficient severity, including severe pain, that the absence of immediate
				  medical attention could reasonably be expected by a prudent lay person, who
				  possesses an average knowledge of health and medicine, to result in:
(a) Placing the patient's health, or with
				  respect to a pregnant woman, the health of the woman, or her unborn child, in
				  serious jeopardy;
(b) Serious
				  impairment to bodily functions; or
(c) Serious dysfunction of any bodily organ
				  or part.
(50) "Encounter
				  data" means information documenting a service to an enrollee.
(51) "Enrollee" has the meaning indicated in
				  Health-General Article, §15-101(b), Annotated Code of Maryland.
(52) "EPSDT-certified provider" means a
				  physician or nurse practitioner who is certified by the Department's EPSDT
				  program to provide comprehensive well-child services according to the
				  Department's periodicity schedule and program standards to enrollees younger
				  than 21 years old.
(53) "EPSDT
				  comprehensive well-child services" means:
(a)
				  All the screening services provided by an EPSDT-certified provider that are
				  required or recommended on the EPSDT periodicity schedule; and
(b) Health care services to diagnose, treat,
				  or refer problems or conditions discovered during the comprehensive well-child
				  service.
(54) "EPSDT
				  partial or interperiodic well-child service" means:
(a) A well-child service provided at times
				  different than those outlined in the EPSDT periodicity schedule; or
(b) Any encounter by a health care
				  practitioner necessary to diagnose or identify a condition and recommend a
				  course of treatment.
(55)
				  "EPSDT periodicity schedule" means the Departmentally approved list of required
				  or recommended preventive health care services which are to be performed at
				  specified ages.
(56) "Evaluations"
				  means, in the context of COMAR 10.67.69, a determination of the health status
				  of a patient in a patient's home or any other appropriate setting by a licensed
				  professional for the purpose of designing an individual plan of care which
				  incorporates the modalities of treatment which will promote optimal functional
				  ability and recuperation.
(57)
				  "External quality review organization (EQRO)" means a utilization and quality
				  control peer review entity or a private review agent meeting the requirements
				  of §1902(a)(30) of the Social Security Act,
				  42 U.S.C. §
												1396a(a)(30), which performs
				  an independent external review of health care services furnished under a
				  contract under §1903(m) of the Social Security Act,
				  42 U.S.C. §
												1396b.
(58) "Family planning" means providing
				  individuals with the information and means to prevent unwanted pregnancy and
				  maintain reproductive health.
(59)
				  "Federally qualified health center (FQHC)" means a clinic which either:
(a) Receives a grant under §329, 330, or
				  340 of the Public Health Services Act,
				  42 U.S.C. §
													254c;
(b) Meets the requirements for a grant under
				  §329, 330, or 340 of the Public Health Services Act,
				  42 U.S.C. §
													254c; or
(c) Qualifies as a FQHC pursuant to a waiver
				  from the Secretary of the U.S. Department of Health and Human Services of one
				  or more of the requirements for receiving a grant under §329, 330, or 340
				  of the Public Health Services Act,
				  42 U.S.C. §
													254c.
(60) "Fiscal year (FY)" means the time period
				  beginning the preceding July 1 and ending on June 30 of the referenced year.
(61) "Free-standing birth center"
				  means a free-standing facility not associated with a hospital that provides
				  nurse midwife services under Health Occupations Article, Title 8, Subtitle 6,
				  Annotated Code of Maryland.
(61-1)
				  "Full credibility" means a standard for which the experience of an MCO is
				  determined to be sufficient for the calculation of an MLR with a minimal chance
				  that the difference between the actual and target MLR is not statistically
				  significant.
(62) "Graduate medical
				  education (GME)" means the training of physician interns and residents after
				  completion of a medical degree program.
(63) "Graduate medical education costs (GME
				  costs)" means the amount it costs a hospital to train physician interns and
				  residents after their completion of a medical degree program, including both
				  direct medical education costs and indirect medical education costs.
(64) "Grievance" means an expression of
				  dissatisfaction about any matter other than an action, including but not
				  limited to:
(a) The quality of care or
				  services provided, and aspects of interpersonal relationships such as rudeness
				  of a provider or employee;
(b)
				  Failure to respect the enrollee's rights regardless of whether remedial action
				  is requested; or
(c) A dispute over
				  an extension of time proposed by the MCO to make an authorized
				  decision.
(65) "HCQIS"
				  means the Health Care Quality Improvement System produced by the Centers for
				  Medicare and Medicaid Services.
(66) "Health care service" has the meaning
				  stated in Health-General Article, §19-132, Annotated Code of
				  Maryland.
(67) "HealthChoice
				  Financial Monitoring Report (HFMR)" means an annual financial report of an
				  MCO's MMMCP-related activities during a specified calendar year that:
(a) Is submitted to the Department by an MCO
				  pursuant to COMAR 10.67.65.15;
(b)
				  Serves as a supplemental schedule to an MCO's quarterly and annual reports to
				  the Maryland Insurance Administration; and
(c) Includes a completed HFMR form provided
				  by the Department and any supplemental schedules required by the
				  Department.
(68) "Health
				  home" means a provider designated to offer enhanced care coordination and
				  management services to individuals affected by, or at risk for, chronic
				  conditions.
(69) "Health maintenance
				  organization (HMO)" has the meaning stated in Health-General Article,
				  §19-701, Annotated Code of Maryland.
(70) Health Service Needs Information.
(a) "Health service needs information" means
				  an instrument to identify new Maryland Medicaid Managed Care Program enrollees
				  who require immediate or specialized health care services.
(b) "Health service needs information" does
				  not mean an initial health screen performed by an MCO.
(71) "HEDIS" means the Healthcare
				  Effectiveness Data Information Set, a set of indicators of managed care plan
				  performance developed by the National Committee for Quality
				  Assurance.
(72) "Hepatitis C" means
				  having one of the following as a primary, secondary, tertiary, or level 4
				  diagnosis:
(a) 070.41-Acute or Unspecified
				  Hepatitis C with hepatic coma;
(b)
				  070.44-Chronic Hepatitis C with hepatic coma;
(c) 070.51-Acute or unspecified Hepatitis C
				  without mention of hepatic coma; or
(d) 070.54-Chronic Hepatitis C without
				  mention of hepatic coma.
(73) "Hepatitis C plan risk factor" means an
				  MCO-specific risk adjustment factor reflecting the level of risk associated
				  with the proportion of the MCO's HIV/AIDS enrollees who also have Hepatitis
				  C.
(74) "HIPAA" means the Health
				  Insurance Portability and Accountability Act, a federal law enacted on August
				  21, 1996, whose purpose is to improve the efficiency and effectiveness of the
				  health care system by standardizing the electronic exchange of administrative
				  and financial data, provide security requirements for transmitted information,
				  and protect the privacy of identifiable health information.
(75) "Historical diagnostic period" means the
				  time period under consideration for the cumulative chronological determination
				  of an enrollee's Hepatitis C status and ending:
(a) For the initial rate adjustment period,
				  on June 30 of the calendar year before the rate year; or
(b) For the mid-year rate adjustment period,
				  on December 31 of the calendar year before the rate year.
(76) "HIV" means infection with the human
				  immunodeficiency virus.
(77)
				  "HIV/AIDS" means:
(a) Infection with the
				  human immunodeficiency virus; or
(b) Acquired immune deficiency
				  syndrome.
(78) "HIV/AIDS
				  enrollee" means an enrollee who is infected with HIV or has AIDS and is
				  assigned to an HIV or AIDS payment category.
(79) "HIV payment category" means one of the
				  four payment categories represented as individual rate cells within the rate
				  tables set forth in COMAR 10.67.65.19B(4)(a) and (b), to which enrollees with
				  HIV are assigned pursuant to COMAR 10.67.65.19B(1)(c)(ii) or
				  (2)(c)(i).
(80) "Home", in the
				  context of COMAR 10.67.69, has the meaning stated in COMAR 10.67.53.
(81) "Home health agency" means, in the
				  context of COMAR 10.67.69, an agency licensed by the Department in accordance
				  with COMAR 10.07.10.
(82) "Home
				  health aide" means, in the context of COMAR 10.67.69, an individual who meets
				  all the conditions of participation specified in:
(a) 42 CFR § 484.36 ; and
(b) Health Occupations Article, Title 8,
				  Annotated Code of Maryland.
(83) "Homeless person" means an individual
				  who, as defined by §340 of the Public Health Services Act, lacks housing,
				  without regard to whether an individual is a member of a family, including an
				  individual:
(a) Who is a resident in
				  transitional housing; or
(b) Whose
				  primary residence during the night is a supervised public or private facility
				  that provides temporary living accommodations.
(84) "Hospital" has the meaning stated in
				  Health-General Article, §19-301, Annotated Code of Maryland.
(85) "HSCRC" means the Health Services Cost
				  Review Commission, an independent agency functioning in the Department with the
				  powers and duties set forth in Health-General Article, §19-201 et seq.,
				  Annotated Code of Maryland.
(86)
				  "Indirect medical education costs (IME costs)" means costs associated with
				  providing graduate medical education that, although not measurable using
				  accounting data, are subject to assessment by application of a regression
				  analysis methodology that:
(a) Estimates
				  teaching hospitals' extra costs attributable to factors including, but not
				  necessarily limited to the:
(i) Lower
				  productivity of inexperienced residents, and
(ii) Adoption of advanced technology;
				  and
(b) Controls, where
				  possible, for confounding variables such as differences in:
(i) Area labor costs,
(ii) Uncompensated care, and
(iii) Case mix.
(87) "Individualized education
				  program (IEP)" means a written description of special education and related
				  services developed by a multidisciplinary team to be implemented to meet the
				  individual needs of a child pursuant to COMAR 13A.05.01.09.
(88) "Individualized family service plan
				  (IFSP)" means a written plan for providing early intervention and other
				  services to an eligible child and the child's family pursuant to COMAR
				  13A.13.01.02B.
(89) "Individual
				  with a developmental disability" means an individual who, as defined in
				  P.L.
				  101-330, Americans with Disabilities Act of 1990,
				  42 U.S.C. §
												12101 et seq., has a physical or mental
				  impairment arising before the age of 22, except for the sole diagnosis of
				  mental disorder, that substantially limits one or more major life activities,
				  and which may include, but is not limited to, an intellectual disability,
				  specific learning disabilities, head injury, epilepsy, and muscular
				  dystrophy.
(90) "Individual with a
				  physical disability" means an individual who, as defined in
				  P.L.
				  101-330, the Americans with Disabilities Act of
				  1990, 42 U.S.C. §
												12101 et seq., has a physical impairment,
				  either sensory or motor, that substantially limits one or more major life
				  activities, and which may include, but is not limited to, orthopedic
				  impairment, vision, speech, or hearing impairment, cerebral palsy, epilepsy,
				  muscular dystrophy, multiple sclerosis, cancer, heart disease, HIV/AIDS, and
				  tuberculosis.
(91) "Initial health
				  screen" means the comprehensive evaluation performed by the PCP, that includes
				  a comprehensive history and physical examination to determine the new
				  enrollee's baseline health status and health needs.
(92) "Initial rate adjustment period" has the
				  meaning stated in COMAR
				  10.67.04.19-3A.
(93) "Inmate" means an individual who is
				  serving time for a criminal offense and is confined involuntarily in State or
				  federal prisons, jail, detention centers, or other penal facilities or who has
				  been placed on home detention.
(94)
				  Institution for Mental Disease.
(a)
				  "Institution for mental disease (IMD)" means a hospital, nursing facility, or
				  other institution of more than 16 beds that is primarily engaged in providing
				  diagnosis, treatment, or care of persons with mental diseases or substance
				  abuse problems, including medical attention, nursing care, and related health
				  care services.
(b) "Institution for
				  mental disease (IMD)" includes the following categories of facilities, if the
				  particular facility has more than 16 beds:
(i) Psychiatric hospitals;
(ii) Residential treatment centers;
(iii) In the context of admissions of
				  enrollees who are 21 years old or older, intermediate care facilities-alcoholic
				  (ICF-A) facilities; and
(iv)
				  Residential drug-free treatment programs.
(c) "Institution for mental disease" does not
				  include intermediate care facilities-alcoholic (ICF-A) facilities, except in
				  the context of admission of enrollees who are 21 years old or older.
(95) "Interdisciplinary team"
				  means, in the context of COMAR 10.67.69, the group convened and conducted by
				  the case manager, consisting of the case manager and relevant service
				  providers, that established the case management plan under the overall
				  direction and coordination of the case manager and in consultation with the
				  participant and, when applicable, the participant's family.
(96) "Intermediate care facility for
				  individuals with intellectual disabilities or persons with related conditions
				  (ICF/IID)" means a residential facility providing care and services for
				  individuals with an intellectual disability or developmental disabilities, or
				  both.
(96-1) "Limited English
				  proficiency" means the special need status of potential enrollees and enrollees
				  who do not speak English as their primary language and who have a limited
				  ability to read, write, speak, or understand English, and are therefore
				  eligible to receive language assistance for a particular type of service,
				  benefit, or encounter.
(97) "Local
				  access area" means the local geographical area, as identified by the zip code
				  groupings in COMAR 10.67.66.06E, that is located within the relevant MCO's
				  service area and in which the relevant enrollee resides.
(98) "Local transportation grantee agency"
				  means the county entity, usually the local health department, that receives
				  transportation grant funds pursuant to COMAR 10.67.19.
(99) "Long-term care facility" means a
				  chronic hospital, a chronic rehabilitation hospital, a nursing facility, or a
				  special pediatric hospital.
(100)
				  Long-Term Care Services.
(a) "Long-term care
				  services" means the medical and support services required by an individual who,
				  due to chronic illness or mental or physical disability, requires long-term
				  care facility services over an extended period of time.
(b) "Long-term care services" includes
				  services provided to a patient in a long-term care facility after the 30th day
				  of continuous care following the enrollee's admission to the
				  facility.
(c) "Long-term care
				  services" do not include services provided to an enrollee admitted to a
				  long-term care facility for a stay of less than 31 days of continuous care
				  following the enrollee's admission to the facility.
(101) "Loss ratio" means the ratio of an
				  MCO's:
(a) Net medical expenses plus medical
				  management expenses which:
(i) Are quantified
				  according to COMAR
				  10.67.04.19-4;
(ii) Relate solely to the MCO's MMMCP line of
				  business; and
(iii) Are incurred
				  during a specified period; and
(b) Net revenues which:
(i) Relate solely to the MCO's MMMCP line of
				  business; and
(ii) Are earned
				  during the same specified period in which the expenses referenced in
				  §B(98)(a) of this regulation are incurred.
(102) "Managed care organization (MCO)" has
				  the meaning stated in Health-General Article, §15-101, Annotated Code of
				  Maryland.
(103) "Marketing" means
				  any communication, from an MCO to a Medicaid recipient who is not enrolled in
				  that MCO, that can reasonably be interpreted as intended to influence the
				  recipient:
(a) To enroll in that particular
				  MCO; or
(b) To not enroll in or to
				  disenroll from another MCO.
(104) "Marketing materials" means materials
				  that are produced in any medium, by or on behalf of an MCO, that can reasonably
				  be interpreted as intended to market to potential enrollees.
(105) "Maryland Children's Health Program"
				  means the State program for uninsured, low-income children with federal
				  matching funds provided under Title XXI of the Social Security Act.
(106) "Maryland Medicaid Managed Care Program
				  (MMMCP)" means the Medicaid reform program established in this subtitle, as
				  authorized by Health-General Article, Title 15, Subtitle 1, Annotated Code of
				  Maryland, and by a §1115 waiver issued by the federal
				  government.
(107) "Medicaid" has
				  the meaning stated in COMAR 10.67.24.02.
(108) "Medical Assistance" has the meaning
				  stated in COMAR 10.67.24.02.
(109)
				  "Medical day care for adults" means a program of medically supervised,
				  health-related services provided in an ambulatory setting to medically
				  handicapped adults who, due to their degrees of impairment, need health
				  maintenance and restorative services supportive to their community
				  living.
(110) "Medical day care for
				  children" means a program of medically supervised health-related services
				  provided in an ambulatory setting to children with complex medical needs who do
				  not require 24-hour inpatient care, but, due to their specialized medical
				  needs, cannot be managed in a typical day care setting.
(111) "Medical expense" means costs incurred
				  by an MCO in connection with providing health care services to its
				  enrollees.
(111-1) "Medical loss
				  ratio (MLR)" means a formula that measures the ratio of MCO spending on medical
				  and related benefits compared to revenue, to ensure MCOs are spending a
				  sufficient amount of their premium revenue on medical expenses and other
				  high-impact initiatives.
(112)
				  "Medically necessary" means that the service or benefit is:
(a) Directly related to diagnostic,
				  preventive, curative, palliative, rehabilitative, or ameliorative treatment of
				  an illness, injury, disability, or health condition;
(b) Consistent with current accepted
				  standards of good medical practice;
(c) The most cost efficient service that can
				  be provided without sacrificing effectiveness or access to care; and
(d) Not primarily for the convenience of the
				  consumer, the consumer's family, or the provider.
(113) "Medically needy" has the meaning
				  stated in COMAR 10.67.24.02.
(114)
				  "Medical management expense" means costs incurred by an MCO in connection with
				  outreach and utilization management activities as specified in COMAR
				  10.67.04.19-4.
(115) "Medical necessity" means what is
				  medically necessary.
(115-1)
				  "Medically underserved area" means an area designated by the Health Resources
				  and Services Administration (HRSA) as having shortages of primary care, dental
				  care, or mental health providers.
(116) "Medicare" means the federal program
				  that provides benefits to the aged and disabled under Title XVIII of the Social
				  Security Act.
(117) "MIA" means the
				  Maryland Insurance Administration.
(118) "Mid-year rate adjustment period" has
				  the meaning stated in COMAR 10.67.65.19-4A.
(119) "MIEMSS" means the Maryland Institute
				  for Emergency Medical Service Systems.
(119-1) "MLR reporting year" means a period
				  of 12 months consistent with the rating period selected by the
				  Department.
(120) "Model Waiver
				  Program" means the Home Care for Disabled Children under a Model Waiver as
				  established in COMAR 10.67.27.
(120-1) "National Diabetes Prevention
				  Program" means an evidence-based diabetes prevention program established by the
				  Centers for Disease Control and Prevention.
(121) "Net medical expenses" means an MCO's
				  total medical expenses less reinsurance recoveries.
(122) "Net revenues" means an MCO's total
				  revenues less reinsurance premiums.
(123) "Network" has the same meaning as
				  "provider panel", as specified in this regulation.
(123-1) "Network provider" means a provider
				  that is a member of the MCO's provider panel.
(123-2) "No credibility" means a standard for
				  which the experience of an MCO is determined to be insufficient for the
				  calculation of an MLR.
(123-3)
				  "Non-claims costs" means expenses for administrative services other than:
(a) Incurred claims;
(b) Expenditures on activities that improve
				  health care quality;
(c) Licensing
				  and regulatory fees; or
(d) Federal
				  and State taxes.
(124)
				  "Nursing facility" has the meaning stated in COMAR
				  10.67.10.01B.
(125) Nutritional Counseling.
(a) "Nutritional counseling" means, in the
				  context of COMAR 10.67.69, the review of the patient's nutritional status and
				  advice on its improvement when medically necessary.
(b) "Nutritional counseling" includes family
				  education provided by either a licensed dietitian or licensed
				  nutritionist.
(126)
				  "Nutritional supplements" means, in the context of COMAR 10.67.69, enteral
				  feeding which is either the sole source of nutrition or a supplement which
				  enhances the physical well-being of the patient and is medically
				  indicated.
(127) "Ombudsman" or
				  "ombudsman program" has the meaning stated in Health-General Article,
				  §15-101(g), Annotated Code of Maryland.
(128) "Out-of-plan provider" means a provider
				  that is neither the employee nor the subcontractor of the enrollee's assigned
				  MCO.
(129) "Outreach services"
				  means efforts to contact enrollees and bring them into care, as described in
				  COMAR 10.67.66.03.
(130)
				  "Overpayment" means:
(a) Any payment made by
				  the Program to a provider in excess of the correct Program payment amount for a
				  service; or
(b) Any payment for
				  services under COMAR 10.67.67 made by the Program or an MCO which at the time
				  of payment, or at a subsequent date, is determined to be inappropriate,
				  inaccurate or in excess of the correct amount of the procedural code billed,
				  for reasons including but not limited to:
(i)
				  Improper claiming;
(ii) Lack of
				  medical necessity;
(iii)
				  Unacceptable practices;
(iv) Fraud,
				  waste, or abuse; or
(v) Provider
				  mistake.
(130-1) "Partial credibility" means a
				  standard for which the experience of an MCO is determined to be sufficient for
				  the calculation of an MLR but with a non-negligible chance that the difference
				  between the actual and target medical loss ratios is statistically significant.
(131) "Peer review organization"
				  means an organization qualified by the Centers for Medicare and Medicaid
				  Services in accordance with 42 CFR 462 that reviews health care practitioners,
				  and the health care services they order or furnish, utilizing other
				  practitioners from the same field of practice.
(132) "Personal care" has the meaning stated
				  in COMAR 10.67.20.01B.
(133) "Plan
				  of care" means, in the context of COMAR 10.67.69, the document which governs a
				  participant's care management, and which:
(a)
				  Includes the:
(i) Case management assessment
				  report;
(ii) Interdisciplinary plan
				  of care; and
(iii) Case management
				  plan;
(b) Is composed of
				  the participant's health status and needs for medical, health-related, housing,
				  and social services including, but not limited to:
(i) All pertinent diagnoses;
(ii) Functional status;
(iii) Type, frequency, and duration of
				  services;
(iv) Treatment goals for
				  each type of service;
(v)
				  Medication;
(vi) Social support
				  structure;
(vii) Current service
				  providers;
(viii) Assigned level of
				  care;
(ix) Diet;
(x) Current living arrangement; and
(xi) Emergency plan, if appropriate;
				  and
(c) Is established in
				  consultation with the interdisciplinary team.
(134) "Postpartum" means within 2 months
				  after delivery of a child.
(135)
				  "Poststabilization care services" means covered services, related to an
				  emergency medical condition, that are provided after an enrollee is stabilized
				  in order to maintain the stabilized condition, or under the circumstances
				  described in 42 CFR §
												438.114(e), as amended, to
				  improve or resolve the enrollee's condition.
(136) "Potential enrollee" means a Medicaid
				  recipient who is determined eligible for the HealthChoice program but is not
				  yet an enrollee of a specific MCO.
(137) "Practitioner" means an individual who
				  is licensed, certified, or otherwise authorized under Health Occupations
				  Article, Annotated Code of Maryland, or under the laws of the District of
				  Columbia or a state contiguous to Maryland, to provide health care services in
				  the ordinary course of business or practice of a profession or in an approved
				  education or training program.
(138) "Preauthorization", in the context of
				  COMAR 10.67.69, has the meaning stated in COMAR 10.67.53.
(139) "Pregnant" means the period beginning
				  with conception and ending at delivery.
(139-1) "Presumptive drug tests" means drug
				  screening tests that include:
(a) Any number
				  of drug classes;
(b) Any number of
				  devices;
(c) Sample validation;
				  and
(d) The use of:
(i) Direct optical observation;
(ii) Instrument assisted direct optical
				  observation; or
(iii) Instrumented
				  chemistry analyzers.
(140) "Primary care" means medical care that
				  addresses a patient's general health needs, including the coordination of the
				  patient's health care, with the responsibility for the prevention of disease,
				  promotion and maintenance of health, treatment of illness, maintenance of the
				  enrollee's health records, and referral for medically necessary specialty
				  care.
(141) "Primary care provider
				  (PCP)" means a practitioner who is the primary coordinator of care for the
				  enrollee, and whose responsibility it is to provide accessible, continuous,
				  comprehensive, and coordinated health care services covering the full range of
				  benefits required by the Maryland Medicaid Managed Care Program, as specified
				  in COMAR 10.67.67.
(142) "Primary
				  care residency slots" means, in the context of COMAR 10.67.74, positions in a
				  teaching hospital's residency program occupied after completion of a medical
				  degree program by physicians who have trained in family medicine, internal
				  medicine, pediatrics, or obstetrics and gynecology.
(143) "Primary mental health services" means
				  the clinical evaluation and assessment of mental health services needed by an
				  individual and the provision of services or referral for additional services as
				  deemed medically necessary by a primary care provider.
(144) "Private duty nursing" means, in the
				  context of COMAR 10.67.69, skilled nursing services for recipients who require
				  more individual and continuous care than is available under the Medicaid State
				  Plan, and which are provided by a registered nurse or a licensed practical
				  nurse, in a recipient's own home or another setting when normal life activities
				  take the recipient outside his or her home.
(145) "Program", unless the context indicates
				  otherwise, has the meaning stated in COMAR 10.67.36.01B.
(146) "Progress note" means, in the context
				  of COMAR 10.67.69, a signed and dated written notation by the home care nurse,
				  home health aide, or certified nursing assistant which:
(a) Summarizes facts about the care given and
				  the participant's response during a given period of time;
(b) Specifically addresses the established
				  goals of treatment;
(c) Is
				  consistent with the participant's case management plan; and
(d) Is written during the course of
				  care.
(147) "Provider" has
				  the same meaning as "health care provider", as stated in Health-General
				  Article, §19-132, Annotated Code of Maryland.
(148) "Provider panel" means that group of
				  providers employed by the MCO or with which the MCO contracts to provide
				  services to the MCO's enrollees under the MCO's health benefit plan, which is
				  at least equivalent to the benefits specified in COMAR 10.67.67.
(149) "Public institution" has the meaning
				  stated in COMAR 10.67.24.02.
(150)
				  "Quality assurance plan (QAP)" means a document or series of documents that set
				  forth an MCO's strategy for systematically monitoring, evaluating, and
				  improving all facets of MCO operations, including, but not limited to, clinical
				  health care delivery, enrollee assistance and outreach services, and
				  administrative services.
(151)
				  "Rare and expensive case management" means the method of health care delivery
				  provided to individuals with rare and expensive conditions.
(152) "Rare and expensive condition" means a
				  medical diagnosis or condition identified in COMAR 10.67.69.
(153) "Rate adjustment period" has the
				  meaning stated in COMAR 10.67.65.19-4A.
(153-1) "Rate year" has the meaning stated in
				  COMAR 10.67.65.19-4A.
(154)
				  "Readily accessible" means electronic information and services which comply
				  with modern accessibility standards such as:
(a) Section 508 guidelines;
(b) Section 504 of the Rehabilitation Act;
				  or
(c) W3C's Web Content
				  Accessibility Guidelines (WCAG) 2.0 AA and successor versions.
(155) "Reasonable
				  allowable costs" means costs that are related to the provision of covered
				  Medicaid services and are determined to be allowable in accordance with
				  Medicare principles of reasonable cost reimbursement in 42 CFR 413, subject to
				  the limitations specified in COMAR 10.67.08.05C.
(156) "Recipient" or "Program recipient"
				  means an individual who is certified as eligible to receive Medical Assistance
				  benefits, as provided in COMAR 10.67.24.
(157) "REM optional services" means, in the
				  context of COMAR 10.67.69, the services which meet the general requirements
				  under Regulation .08 and are listed in Regulations .10 and .11 of that
				  chapter.
(158) "School-based health
				  center (SBHC)" means a provider located on school grounds that meets the
				  requirements set forth in COMAR 10.67.76.
(159) "Secretary" means the Secretary of
				  Health and Mental Hygiene.
(160)
				  "Self-referral services" are the health care services listed in COMAR
				  10.67.67.28 for which, under specified circumstances, the MCO is required to
				  pay, without any requirement of referral by the PCP or MCO, when the enrollee
				  accesses the service through a provider other than the enrollee's
				  PCP.
(160-1) "Separate CHIP
				  Program" means the program for targeted low-income children established under
				  Title XXI of the Social Security Act.
(161) "Service area" means a geographical
				  area, comprised of one or more of Maryland's counties, with each selected
				  county included in its entirety.
(162) "Service year" in the context of COMAR
				  10.67.04.19-4, means the calendar
				  year in which an MCO incurs the expenses reported pursuant to COMAR
				  10.67.04.15E(5)(c).
(163) "Somatic care" means medical care that
				  addresses an individual's physical health care needs, including substance abuse
				  treatment.
(164) "Special needs
				  population" means a group of recipients who share a special health care need
				  and which is specified in COMAR 10.67.65.04-.11.
(165) "Special rehabilitation hospital" has
				  the meaning stated in Health-General Article, §19-307(a)(iii), Annotated
				  Code of Maryland.
(166) "Specialty
				  behavioral health services" means any behavioral health services other than
				  primary behavioral health services.
(167) "Specialty care" means health care
				  services that are either outside the PCP's scope of practice or, in the
				  judgment of the PCP, are not services that the PCP customarily provides, is
				  specifically trained for, or is experienced in.
(168) "Specialty care residency slots" means,
				  in the context of COMAR 10.67.74, positions in a teaching hospital's residency
				  program occupied after completion of a medical degree program by physicians who
				  have trained in specialties other than family medicine, internal medicine,
				  pediatrics, or obstetrics and gynecology.
(169) "Spend down" means a procedure by which
				  an individual applying for Medical Assistance who is otherwise ineligible due
				  to excess income becomes eligible by deducting incurred medical expenses from
				  excess income.
(170) "State fair
				  hearing" means a hearing, conducted by the Office of Administrative Hearings,
				  for the purpose of ensuring the right of recipients to be treated in a fair and
				  unbiased manner in their efforts to resolve disputes with the Department or an
				  MCO.
(171) "Subcontract" means a
				  written agreement between an MCO and a third party, under which the third party
				  performs any one or more of the MCO's obligations required by the
				  Department.
(172) "Subcontractor"
				  means an individual or entity that has a contract with an MCO that relates
				  directly or indirectly to the performance of the MCO's obligations under its
				  contract with the Department; provided, however, that a contract does not by
				  itself cause an MCO's network provider to be a subcontractor.
(173) "Substantial minority" means an ethnic
				  or linguistic group that comprises 5 percent or more of the Medicaid population
				  in the county to be served.
(174)
				  "Supplemental Security Income (SSI)" means a federally administered program
				  providing benefits to needy aged, blind, and disabled individuals under Title
				  XVI of the Social Security Act,
				  42 U.S.C. §
												1381 et seq.
(175) "Systems performance review (SPR)"
				  means an assessment, as a component of the annual quality assurance (QA) audit,
				  of quality assurance operations taking place in the MCO.
(176) "Teaching hospital" means a hospital
				  that:
(a) Had HSCRC-approved rates for FY 1995
				  that included an allowance for GME costs; and
(b) During the contract year, operates a
				  graduate medical education program that is accredited by the Accreditation
				  Council for Graduate Medical Education.
(177) "Temporary Cash Assistance (TCA)" means
				  a form of cash assistance provided, pursuant to Article 88A, §44A et seq.,
				  Annotated Code of Maryland, to assistance units which are technically and
				  financially eligible.
(178)
				  "Tertiary care" means health care services provided by highly specialized
				  health care providers which are usually diagnostic or therapeutic in nature and
				  often require highly sophisticated technological and support
				  facilities.
(179) "Urgent care"
				  means health care services for a medical condition that manifests itself by
				  symptoms of sufficient severity that the absence of medical attention within 48
				  hours could reasonably be expected, by a prudent layperson who possesses an
				  average knowledge of health and medicine, to result in an emergency medical
				  condition.
(180) "Waiver-eligible"
				  means an individual who qualifies for enrollment in the Maryland Medicaid
				  Managed Care Program.
(181)
				  "Whistleblower" means an individual who exposes any kind of information or
				  activity that alleges any violation of regulation, statute, contract, policy,
				  or unethical behavior that may be indicative of an individual or entity
				  committing fraud, waste, or abuse against the Medicaid program.
(182) "Witness", in the context of COMAR
				  10.67.69, has the meaning stated in COMAR 10.67.53.