Code of Maine Rules › 10 - DEPARTMENT OF HEALTH AND HUMAN SERVICES › 144 - DEPARTMENT OF HEALTH AND HUMAN SERVICES - GENERAL › Chapter 272 - COORDINATED CARE SERVICES FOR CHILDREN WITH SPECIAL HEALTH NEEDS › Chapter II - DEFINITIONS

Current through 2024-29, July 17, 2024
Unless otherwise indicated, the following terms shall have
				  the following meanings specific to Coordinated Care Services for Children with
				  Special Health Needs (C.C.S./C.S.H.N.) rules and regulations:
Applicant:
the child for whom application is
				  made.
Authorized Provider:
a licensed physician or
				  practitioner who is enrolled as a Maine Medicaid provider.
Authorized Services:
specific medical and/or
				  developmental therapeutic treatments including medical and/or adaptive
				  equipment and drugs which have been pre-approved for payment by Coordinated
				  Care Services for Children with Special Health Needs staff.
C.C.S./C.S.H.N.:
Coordinated Care Services For
				  Children With Special Health Needs.
Case Coordination and Management:
a partnership
				  process of assisting parents in the coordination of care for their child, in
				  implementing the approved subspecialty treatment plan and in obtaining
				  recommended services regardless of whether C.C.S./C.S.H.N. will pay for the
				  health care and related services.
Child:
an individual under 18 years of age who
				  is dependent on one or more persons for support and who resides with those
				  persons in the same household.
Children With Special Health Care Needs:
children who have a congenital or acquired chronic disease, condition
				  and/or physical disability unless otherwise specified that interferes with
				  effective functioning and requires subspecialty intervention.
Chronic Health Problem:
a disease or condition
				  that limits physical activity and requires subspecialty medical
				  treatment.
Collateral Contacts:
direct face-to-face
				  contacts on behalf of an eligible child by a prior authorized provider to
				  obtain information from or discuss the child's plan of care with others
				  involved in the child's treatment and or implementation of the plan of
				  care.
Date of Application:
the date on which the
				  Coordinated Care Services program receives the signed application for
				  assistance.
Date of Eligibility:
date on which both medical
				  and financial eligibility have been determined or:
Diagnostic Eligibility
: date of
				  primary care referral for a consultation or evaluation to determine a chronic
				  illness or physically handicapping condition if application for assistance has
				  been received or if application is received within thirty days of the physician
				  referral.
Newborn Eligibility
: date of birth
				  or up to thirty days of age retroactive to the date of birth if the
				  application, physician referral and medical center verification are received
				  during the neonatal period. (Chapter VII, Section G, p. 47)
Developmental Delay:
patterns of performance in
				  speech/language, fine and/or gross motor areas that are less than
				  expected/normed for the chronological age of the child, as set forth in these
				  rules and described in Chapter VI.
Diagnostic Services:
those prior approved
				  subspecialty physician evaluations or consultations that are needed to confirm
				  a chronic illness or physically handicapping condition as determined by the
				  specialist in that area or those therapeutic services that are needed to
				  confirm a developmental delay and determine the specific components of a
				  comprehensive plan of care.
Family:
a group of individuals, who are not
				  residents of an institution but who are living together in one household, as
				  one economic unit. An economic unit is defined as a group that jointly pools
				  its resources. The only exception to this definition is a child in the legal
				  custody of the State of Maine; this child shall be considered a one-member
				  family.
Function:
pertaining to the child's ability to
				  perform as expected at his/her chronological age.
Genetic counseling:
a process by which families
				  learn about the inheritance patterns regarding their families and the chances
				  of recurrence of their child's condition or disorder.
Gross annual income:
the sum of all income
				  before taxes of family members living in a household, and received during the
				  12 month period prior to the date of application. Income includes the
				  following:
1. Monetary compensation for services, including wages,
				  salaries, commissions, or fees: (Wages [salaries] means gross income before
				  deductions for income taxes), employees' social security taxes or insurance
				  premiums, etc;
2. Net income from self-employment: Net is gross income from
				  all sources less business deductions allowable by the Internal Revenue Service
				  (IRS), but excluding depreciation;
Gross annual income of self-employed Individuals: For the
				  purposes of the C.C.S./C.S.H.N. Program, gross annual income of self-employed
				  individuals means the previous tax year's annual gross income less business
				  deductions allowable by the IRS (Schedule B, C, or F) excluding depreciation.
				  (Depreciation is considered in determining financial eligibility for
				  C.C.S./C.S.H.N.). For families with both self-employed and non-self-employed
				  individuals, the non-self-employed individual must provide additional
				  verification (other than the IRS 1040) of his or her employment status. For
				  those individuals reporting rental income, gross annual income includes rental
				  income (Schedule E) plus depreciation added to the total income on the IRS
				  1040.
3. Social Security;
4. Dividends or interest on savings or bonds, income from
				  estates or trusts, cash settlements, or net rental income excluding
				  depreciation;
5. Public assistance or welfare payments;
6. Unemployment or worker's compensation;
7. Government civilian employee or military retirement or
				  pensions or veterans' payments;
8. Private pensions or annuities;
9. Actual alimony or child support payments received;
10. Regular contributions from persons not living in the
				  household;
11. Net royalties; and
12. Other cash income including, but not limited to, cash
				  amounts received or withdrawn from any source including savings, investments,
				  trust accounts and other resources which are readily available to the family.
The following items are not included in gross annual income:
				  sale of property, house or car; tax funds, gifts, scholarships or training
				  stipends.
Infant:
a child under the age of twelve
				  months.
Medical Nutrition Therapy:
the process of
				  assessing physiological needs and current dietary habits, and providing
				  guidance and/or counseling services by a registered dietitian.
Monitoring:
those activities or services
				  recommended to keep track of a potential or stable health problem or
				  developmental delay.
Multiply handicapped:
those children with
				  chronic illness or physically handicapping disabilities who have two or more
				  chronic health problems that require medical care by more than one pediatric
				  specialist or subspecialist.
Neonatal:
newborn; the period of time covering
				  the first thirty (30) days of life.
Newborn Screening Program:
screens newborns and
				  provides information and service referral on hypothyroidism, phenylketonuria
				  (PKU), homocystinuria, maple syrup urine disease (MSUD), galactosemia and
				  sickle cell anemia, which if untreated can cause mental retardation or
				  death.
Pediatric specialist:
a pediatrician who through
				  additional training in a specific subspecialty and emphasis in their clinical
				  practice demonstrate expertise in the subspecialty field and are deemed
				  qualified to provide such care by the Public Health Physician Consultant to the
				  C.C.S./C.S.H.N. Program.
Plan of Care:
a medical or therapeutic treatment
				  evaluation and report that clearly define the recommendations for subspecialty
				  intervention.
Pre-schooler:
a child who has not yet reached
				  the age eligibility for entry into elementary school.
Primary care:
the physician from whom or medical
				  facility where the child receives basic routine medical services/treatment.
Prior authorization:
approval and arrangement
				  for payment of treatment services before the treatment service is
				  provided.
Program:
Coordinated Care Service for Children
				  with Special Health Needs (C.C.S./C.S.H.N.).
Provider:
a licensed health professional who is
				  an enrolled Maine Medicaid provider, unless otherwise specified in these rules,
				  and authorized by C.C.S./C.S.H.N. under the prior approval process of the
				  program.
Recipient:
a child who has met all the
				  eligibility requirements for the program or is currently receiving services
				  through the program.
Referral:
a contact with C.C.S/C.S.H.N. to
				  obtain eligible services for a child.
Referral source:
any individual who contacts the
				  C.C.S./C.S.H.N. Program on behalf of a potentially eligible child.
Specialized health professional:
a practitioner
				  or therapist who has additional certification by or eligibility for one of the
				  disciplines of the American boards of licensure and is registered and licensed
				  by the appropriate Boards.
Subspecialist:
a duly licensed medical
				  practitioner, registered with a State Board of Medicine, who has certification
				  or eligibility by one of the disciplines of the American Board of Specialists;
Pediatric subspecialist:
a licensed pediatrician
				  who has certification or eligibility in one of the disciplines of the American
				  Board of Pediatrics.
Subspecialty medical care:
those pre-authorized
				  secondary and tertiary medical services determined by the child's unique
				  eligible condition that improve, correct or are excepted to cure a child's
				  chronic illness or physically handicapping condition and are outlined in the
				  pediatric specialist's or subspecialist's plan of care.
SSI:
Supplemental Security Income benefits for
				  children with disabilities.
Third party payer:
any private or public insurer
				  which is under legal obligation to pay for medical services for an eligible
				  child.
Treatment services:
those services that
1 are related to the child's eligible chronic illness or
				  physical disability;
2 have been prior approved only when other payment sources
				  are not available; and
3 are delivered by the pre-authorized provider,
				  (authorizations delegated to other providers are not valid).
Unit:
a thirty minute interval of authorized
				  service.