Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 1 › Subtitle 01 - PROCEDURES › Chapter 10.01.04 - Fair Hearing Appeals Under the Maryland State Medical Assistance Program › Section 10.01.04.01 - Definitions

Current through Register Vol. 51, No. 14, July 12, 2024
A. In this chapter,
				  the following terms have the meanings indicated.
B. Terms Defined.
(1) "Administrative law judge" means an
				  individual appointed by the Chief Administrative Law Judge under State
				  Government Article, §
											9-1604, Annotated
				  Code of Maryland, or designated by the Chief Administrative Law Judge under
				  State Government Article, §
											9-1607, Annotated
				  Code of Maryland, to adjudicate contested cases at the Maryland Office of
				  Administrative Hearings.
(2)
				  "Action by an MCO" 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;
(d) Failure to provide
				  services in a timely manner;
(e)
				  Failure 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.
(3) "Affordable Care Act" means the Patient
				  Protection and Affordable Care Act of 2010 (Pub.L. 111-148), as amended by
				  the Health Care and Education Reconciliation Act of 2010 (Pub.L. 111-152),
				  as amended by the Three Percent Withholding Repeal and Job Creation Act
				  (Pub.L.
				  112-56).
(4) "Appellant" means any individual who
				  requests a fair hearing for the reasons specified in Regulation .02 of this
				  chapter or that individual's authorized representative.
(5) "Authorized representative" has the same
				  meaning as in Regulation .12.
(6)
				  "Consolidated Services Center" means a call center operated by the Maryland
				  Health Benefit Exchange to assist consumers who apply for, or participate in,
				  Insurance Affordability Programs offered through the Maryland Health
				  Connection.
(7) "Delegate agency"
				  means the:
(a) Department of Human Services
				  and its affiliated local departments which, under contractual agreements with
				  the Department, determine initial and continuing eligibility in the Program;
				  and
(b) Maryland Health Benefit
				  Exchange and its designated affiliates.
(8) "Department" means the Maryland
				  Department of Health, the single state agency which, pursuant to Title XIX of
				  the Social Security Act, implements fair hearing requirements for Program
				  applicants and recipients.
(9)
				  "Insurance affordability program" means a program that is one of the following:
(a) The Maryland State Medicaid
				  program;
(b) The Maryland
				  Children's Health Insurance Program (CHIP), including the program known as
				  Maryland Children's Health Program (MCHP) Premium;
(c) A State basic health program established
				  under § 1331 of the Affordable Care Act;
(d) A program that makes available to
				  eligible individuals coverage in a qualified health plan through the Maryland
				  Health Benefit Exchange with advance payments of the premium tax credit
				  established under §36B of the Internal Revenue Code; and
(e) A program that makes available to
				  eligible individuals coverage in a qualified health plan through the Maryland
				  Health Benefit Exchange with cost-sharing reductions established under §
				  1402 of the Affordable Care Act.
(10) "Maryland Health Benefit Exchange" means the unit of State
				  government that determines initial and continuing eligibility for the
				  MAGI-based insurance affordability programs, including, by delegation, certain
				  eligibility in the Program.
(11)
				  "Maryland Health Connection" means the electronic eligibility system maintained
				  by the Maryland Health Benefit Exchange.
(12) "MCO" means a managed care organization qualified to
				  participate in the Program under COMAR 10.09.65.
(13) "Program" means the Department's Medical Assistance
				  Program.