Code of Maryland Regulations › Title 10 - MARYLAND DEPARTMENT OF HEALTH › Part 2 › Subtitle 09 - MEDICAL CARE PROGRAMS › Chapter 10.09.69 - Maryland Medicaid Managed Care Program: Rare and Expensive Case Management › Section 10.09.69.02 - 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) "Activities of daily living" means tasks
				  or activities that include but are not limited to bathing, feeding, toileting,
				  dressing, and ambulation.
(2)
				  "Business day" means any day except Saturday, Sunday, or a holiday on which
				  State offices are closed.
(3)
				  "Caregiver" means a willing and able individual who is trained in providing
				  care to the participant.
(4) "Case
				  management" means assessing, planning, coordinating, and monitoring the
				  delivery of medically necessary health-related services.
(5) "Case management provider" means the
				  Department's designee, or a subcontractor of the designee, which provides case
				  management to participants assigned to it by the Department.
(6) "Case manager" means, an individual who
				  is:
(a) A social worker with active and
				  nationally recognized certification in case management or an RN;
(b) Employed by the Department's designee;
				  and
(c) Assigned by the
				  Department's designee to manage the care of some or all of the
				  participants.
(7) "Cause"
				  means a significant change in medical condition such that it is no longer
				  medically efficacious for the individual to remain in the MCO as determined by
				  the Department.
(8) "Certified
				  medication technician (CMT)" means an individual who:
(a) Completes a 20-hour course in medication
				  administration approved by the Maryland Board of Nursing;
(b) Is certified by the Maryland Board of
				  Nursing under COMAR 10.39.04; and
(c) Performs medication administration tasks
				  delegated by a nurse in accordance with COMAR 10.27.11.
(9) "Certified nursing assistant (CNA)" means
				  an individual who:
(a) Is certified by the
				  Maryland Board of Nursing under COMAR 10.39.05; and
(b) Routinely performs nursing tasks
				  delegated by a nurse in accordance with COMAR 10.27.11.
(10) "Certified nursing assistant certified
				  as a CMT (CNA-CMT)" means an individual who:
(a) Is certified by the Maryland Board of
				  Nursing under COMAR 10.39.05 and 10.39.04;
(b) Completes a 20-hour course in medication
				  administration approved by the Maryland Board of Nursing; and
(c) Routinely performs nursing tasks
				  including medication administration tasks delegated by a nurse in accordance
				  with COMAR 10.27.11.
(11)
				  "Chiropractor" means an individual who is licensed by the Maryland State Board
				  of Chiropractic Examiners to practice chiropractic in Maryland.
(12) "Delegated nursing services" means
				  nursing services provided to a participant by a CNA, CNA-CMT, HHA, or HHA-CMT
				  under the supervision of an RN in accordance with COMAR 10.27.11.
(13) "Dental service provider" means an
				  individual who is licensed and legally authorized to practice dentistry in the
				  state in which the service is provided.
(14) "Department" means the Department of
				  Health, as defined in COMAR
				  10.09.36.01, or its authorized
				  agents acting on behalf of the Department.
(15) "Dietitian-nutritionist" means an
				  individual who is licensed as a dietitian-nutritionist by the Maryland State
				  Board of Dietetic Practice to practice dietetics in Maryland.
(16) "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., as amended, and other health
				  care services, diagnostic services, and treatment services that are necessary
				  to correct or ameliorate defects, physical and mental illnesses, and conditions
				  discovered by EPSDT screening services.
(17) "EPSDT-certified provider" means a
				  physician, physician assistant or nurse practitioner who is certified by the
				  Department's EPSDT program to provide well-child services according to the
				  Department's periodicity schedule and program standards to enrollees younger
				  than 21 years old.
(18) "EPSDT
				  periodicity schedule" means the list approved by the Department of required or
				  recommended preventive health care services for children and
				  adolescents.
(19) "EPSDT services"
				  means:
(a) Screening services provided by an
				  EPSDT-certified provider that are required or recommended on the EPSDT
				  periodicity schedule; and
(b)
				  Health care services performed to diagnose, treat, or refer problems or
				  conditions discovered during the comprehensive well-child service.
(20) "Evaluation" means 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 that will promote optimal functional ability and
				  recuperation.
(21) "Family member"
				  means an adult who:
(a) Lives with or provides
				  care to the participant; and
(b) Is
				  not paid to provide the care under the REM program.
(22) "HealthChoice" means Maryland Medicaid's
				  Statewide mandatory managed care program as defined in COMAR
				  10.09.65.
(23) "Home" means the
				  place of residence, occupied by the participant, other than a residence or
				  facility where nursing services are included in the living arrangement by
				  regulation or statute, or otherwise provided for payment.
(24) "Home health agency" means an agency
				  licensed by the Department in accordance with COMAR 10.07.10.
(25) "Home health aide (HHA)" means 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.
(26) "Home health aide certified as a CMT
				  (HHA-CMT)" means an individual who:
(a) Meets
				  all the conditions of participation specified in 42 CFR § 484.36 and
				  Health Occupations Article, Title 8, Annotated Code of Maryland; and
(b) Completes a 20-hour course in medication
				  administration approved by the Maryland Board of Nursing.
(27) "Hospital" means an institution licensed
				  by and providing services in accordance with Health-General Article,
				  §19-301, Annotated Code of Maryland.
(28) "Individualized education program (IEP)"
				  means a written description of special education and related services developed
				  by an IEP team to be implemented to meet the individual needs of a
				  child.
(29) "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 developed by an IFSP
				  team.
(30) "Interdisciplinary team"
				  means the group comprised of the case manager and relevant service providers to
				  develop the case management plan under the overall direction and coordination
				  of the case manager, in consultation with the participant and, when applicable,
				  the participant's family.
(31)
				  "Intermediate care facility for individuals with intellectual disabilities or
				  individuals with related conditions (ICF-IID)" means an institution licensed by
				  the Department under COMAR 10.07.20 that provides health-related services or
				  health rehabilitative services for individuals with intellectual disabilities
				  or related conditions.
(32)
				  "Licensed practical nurse (LPN)" means an individual licensed to practice
				  licensed practical nursing as defined in Health Occupations Article, §
											8-301, Annotated
				  Code of Maryland.
(33) "Managed
				  care organization (MCO)" has the meaning stated in Health-General Article,
				  §15-101, Annotated Code of Maryland.
(34) "Medical Assistance" means the program
				  administered by the State under Title XIX of the Social Security Act which
				  provides comprehensive medical and other health-related care for categorically
				  eligible and medically needy individuals.
(35) "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
				  participant, the participant's family, or the provider.
(36) "Medicare" means the federal program
				  that provides benefits to the aged and disabled under Title XVIII of the Social
				  Security Act, 42 U.S.C.
				  §
												1395 et seq.
(37) "Nurse" means an individual who is
				  licensed to practice as a registered nurse (RN) or a licensed practical nurse
				  (LPN) in the jurisdiction in which services are provided.
(38) "Nurse practitioner" means an individual
				  who is licensed and certified to practice as a nurse practitioner in the
				  jurisdiction in which services are provided.
(39) "Nursing facility" has the meaning
				  stated in COMAR 10.09.10.0IB.
(40)
				  "Nutritional counseling" means the assessment of the participant's nutritional
				  status and education about improving their nutritional status provided by a
				  licensed dietitian-nutritionist.
(41) "Nutritional supplements" means enteral
				  feeding which is medically indicated as either the sole source of nutrition or
				  a supplement that enhances the physical well-being of the
				  participant.
(42) "Occupational
				  therapist" means an individual licensed by the Maryland State Board of
				  Occupational Therapy Practice to practice occupational therapy in
				  Maryland.
(43) "Participant" means
				  an eligible individual who is enrolled in the Program.
(44) "Physician" means an individual who is
				  licensed or otherwise legally authorized to practice in the jurisdiction in
				  which the services are rendered.
(45) "Physician assistant" means an
				  individual who is licensed to practice medicine with physician supervision as
				  stated in the Health Occupations Article, §§
											15-301(d)
				  and (e) and §§15-302, Annotated Code of Maryland.
(46) "Plan of care" means the document which
				  governs a participant's care management which includes the:
(a) Case management assessment
				  report;
(b) Interdisciplinary plan
				  of care; and
(c) Case management
				  plan.
(47)
				  "Preauthorization" means the approval required from the Department or its
				  designee before specific services may be rendered.
(48) "Primary care provider (PCP)" means a
				  physician, physician assistant, or nurse practitioner who is the primary
				  coordinator of care for the participant, 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 10.09.67.
(49) "Private duty nursing" means skilled
				  nursing services for participants, who require more individual and continuous
				  care than is available under the home health program, which are provided by a
				  registered nurse (RN) or a licensed practical nurse (LPN), in a participant's
				  home or another setting when normal life activities take the participant
				  outside his or her home.
(50)
				  "Program", unless the context indicates otherwise, has the meaning stated in
				  COMAR 10.09.36.01B.
(51) "Progress note" means a
				  signed and dated written notation by the RN, LPN, CNA, CNA-CMT, HHA, or
				  HHA-CMT, 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 plan
				  of care; and
(d) Is written during
				  the course of care.
(52)
				  "Provider" means an individual, agency, or facility, which is enrolled in the
				  Program through an agreement with the Department, and has been identified as a
				  Program provider by the issuance of a provider number.
(53) "Rare and expensive case management
				  (REM)" means a Maryland Medical Assistance program that provides case
				  management services and optional services to eligible individuals with specific
				  rare and expensive conditions.
(54)
				  "Rare and expensive condition" means a medical diagnosis or condition
				  identified in Regulation .16 of this chapter.
(55) "Registered nurse (RN)" means an
				  individual licensed to practice registered nursing as defined in Health
				  Occupations Article, §
											8-301, Annotated
				  Code of Maryland.
(56) "REM
				  optional services" means the services listed in Regulations .10 and .11 of this
				  chapter, which meet the general requirements under Regulation .09 of this
				  chapter.
(57) "Residential service
				  agency" means an agency licensed by the Department in accordance with COMAR
				  10.07.05.
(58) "Residential
				  treatment center" means any institution which falls within the jurisdiction of
				  Health-General Article, §19-308, Annotated Code of Maryland, and is
				  licensed as required by COMAR 10.07.04 or other applicable standards
				  established by the state in which the service is provided.
(59) "School" means courses or classes for
				  the acquisition of a General Education Diploma, a high school diploma, an
				  associate degree, or a first-time bachelor's degree.
(60) "Social worker" means an individual who
				  is licensed by the Maryland State Board of Social Work Examiners to practice
				  social work in Maryland.
(61)
				  "Speech-language pathologist" means an individual who is licensed by the
				  Maryland Board of Examiners for Audiologists, Hearing Aid Dispensers, and
				  Speech-Language Pathologists to practice speech-language pathology in
				  Maryland.