Conn. Agencies Regs. § 17b-262-957

Current through December 27, 2024

Section 17b-262-957 - Definitions

As used in sections 17b-262-956 to 17b-262-965, inclusive, of the Regulations of Connecticut State Agencies:

(1) "Birth center" means a free-standing, separately licensed health care facility that is not a hospital, where a licensed practitioner performs low-risk deliveries;

(2) "Chronic disease hospital" has the same meaning as provided in section 19a-550 of the Connecticut General Statutes;

(3) "Client" means a person eligible for goods or services under Medicaid;

(4) "Commissioner" means the Commissioner of Social Services or the commissioner's designee;

(5) "Department" means the Department of Social Services or its agent;

(6) "Early Periodic Screening, Diagnosis and Treatment special services" or "EPSDT special services" means services that are not otherwise covered under Medicaid but which are nevertheless covered as EPSDT services for Medicaid-eligible children pursuant to 42 USC 1396d(r)(5) when the service is medically necessary, the need for the service is identified in an EPSDT screen, the service is provided by a participating provider, and the service is a type of service that may be covered by a state Medicaid agency and qualify for federal reimbursement under 42 USC 1396d;

(7) "Home" means the client's place of residence, including, but not limited to, a boarding house, community living arrangement or residential care home. "Home" does not include facilities such as hospitals, chronic disease hospitals, nursing facilities, intermediate care facilities for the mentally retarded or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client;

(8) "Hospital" means a "short-term hospital" as defined in section 19-13-D1 of the Regulations of Connecticut State Agencies;

(9) "Intermediate care facility for the mentally retarded" or "ICF/MR" means a residential facility for individuals with intellectual disabilities licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in Medicaid as an intermediate care facility for the mentally retarded pursuant to 42 CFR 442.101, as amended from time to time;

(10) "Licensed practitioner" means a physician, physician assistant, nurse practitioner, nurse midwife or such other category of practitioner licensed by the Department of Public Health pursuant to Title 20 of the Connecticut General Statutes and whose scope of practice includes the ante-partum, intra-partum and post-partum care of pregnant women and the care of newborns;

(11) "Low-risk delivery" means a delivery following a low-risk pregnancy that is anticipated to be normal, as determined by the mother's licensed practitioner acting within the licensed practitioner's scope of practice under state law;

(12) "Low-risk pregnancy" means a pregnancy that is anticipated to be normal, as determined by the mother's licensed practitioner acting within the licensed practitioner's scope of practice under state law;

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

(14) "Medical necessity" or "medically necessary" has the same meaning as provided in section 17b-259b of the Connecticut General Statutes;

(15) "Nursing facility" has the same meaning as provided in 42 USC 1396r(a) and is licensed pursuant to section 19-13-D8t of the Regulations of Connecticut State Agencies as a chronic and convalescent home or rest home with nursing supervision;

(16) "Nurse midwife" means a person licensed pursuant to section 20-86c of the Connecticut General Statutes;

(17) "Nurse practitioner" or "advance practice registered nurse" or "APRN" means a person licensed pursuant to section 20-94a of the Connecticut General Statutes;

(18) "Physician" means a person licensed pursuant to section 20-13 of the Connecticut General Statutes;

(19) "Physician assistant" means a person licensed pursuant to section 20-12b of the Connecticut General Statutes;

(20) "Prescription" means an original written order documenting medical necessity issued, signed and dated by a licensed practitioner;

(21) "Prior authorization" means approval from the department for the provision of a service or the delivery of goods before the provider actually provides the service or delivers the goods;

(22) "Provider" means a birth center enrolled with Medicaid pursuant to a valid provider enrollment agreement with the department; and

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

Conn. Agencies Regs. § 17b-262-957

Effective October 2, 2012