Conn. Agencies Regs. § 17b-262-780

Current through December 27, 2024

Section 17b-262-780 - Definitions

As used in sections 17b-262-779 to 17b-262-791, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Applied income" means the amount of income that each client receiving chronic disease hospital services is expected to pay each month toward the cost of his or her care, calculated according to the department's Uniform Policy Manual, section 5045.20;

(2) "Assessment" means a comprehensive written evaluation of an individual's functional performance in relation to a set of measurable medical or physical criteria;

(3) "Client" means a person eligible for goods or services under the department's Medicaid program;

(4) "Chronic disease" means a disease having one or more of the following characteristics:

(a) is permanent;

(b) leaves residual disability;

(c) is caused by non-reversible pathological alteration;

(d) requires special training of the client for rehabilitation; or

(e) is expected to require a long period of supervision, observation or care;

(5) "Chronic disease hospital" means "chronic disease hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;

(6) "Commissioner" means the commissioner of social services or his or her designee;

(7) "Department" means the department of social services or its agent;

(8) "Durable medical equipment" means equipment that meets all of the following requirements:

(a) can withstand repeated use;

(b) is primarily and customarily used to serve a medical purpose;

(c) is generally not useful to a person in the absence of an illness or injury; and

(d) is non-disposable;

(9) "Institution for mental diseases" means "institution for mental diseases" as defined in 42 CFR 435.1009, as amended from time to time;

(10) "Licensed practitioner" means any person licensed by the state of Connecticut, any other state, the District of Columbia or the Commonwealth of Puerto Rico and authorized to prescribe treatments within the scope of his or her practice as defined and limited by federal and state law;

(11) "Medicaid" means the program operated by the Department of Social Services pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act;

(12) "Medical appropriateness" or "medically appropriate" means health care that is provided in a timely manner and meets professionally recognized standards of acceptable medical care; is delivered in the appropriate medical setting; and is the least costly of multiple, equally-effective, alternate treatments or diagnostic modalities;

(13) "Medical necessity" or "medically necessary" means health care provided to correct or diminish the adverse effects of a medical condition or mental illness; to assist an individual in attaining or maintaining an optimal level of health; to diagnose a condition; or to prevent a medical condition from occurring;

(14) "Preadmission assessment" means a clinical assessment of ongoing needs and prognosis as necessary to determine the chronic disease hospital's ability to provide for a client's expected needs;

(15) "Provider" means a chronic disease hospital that is enrolled in Medicaid;

(16) "Provider agreement" means the signed, written, contractual agreement between the department and the provider;

(17) "Physician" means a physician licensed pursuant to section 20-10 of the Connecticut General Statutes;

(18) "Rehabilitation" means any medical or remedial services recommended by a physician or other licensed practitioner for maximum reduction of physical or mental disability and restoration of an individual to his or her best possible functional level;

(19) "Resident" means a client living in a chronic disease hospital;

(20) "Team" means a group of individuals employed by or under contract to the chronic disease hospital and may include physiatrists, specialized skilled nurses, physical therapists, occupational therapists or other rehabilitation specialists, such as speech therapists, respiratory specialists, prosthetists, orthotists, physiatrists or respiratory specialists. Other practitioners, including but not limited to, mental health practitioners, may be part of the team as appropriate;

(21) "Team conference" means a meeting of the team to develop a treatment plan of care;

(22) "Treatment plan of care" means the written description of services designed to meet a resident's medical, nursing and rehabilitation needs that are identified in the resident's assessment. The treatment plan of care shall include measurable objectives and a specific timetable; and

(23) "Usual and customary charge" means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases. If the provider varies the charges so that no one amount is charged in the majority of cases, "usual and customary" shall be defined as the median charge. Token charges for charity patients and other exceptional charges are to be excluded.

Conn. Agencies Regs. § 17b-262-780

Adopted effective October 6, 2009