C.M.R. 10, 144, ch. 101, ch. VI, 144-101-VI-01, subsec. 144-101-VI-01.03

Current through 2024-51, December 18, 2024

Subsection 144-101-VI-01.03 - DEFINITIONS

1.03-1Children with Adoption Assistance are children for whom there is a written Adoption Assistance Agreement between the Department of Health and Human Services (DHHS) and the child's adoptive parent(s).

1.03-2Chronic and Debilitating Condition is a disease or impairment that is expected to require on-going care.

1.03-3Complaint is a written or verbal statement by a member or provider to the Office of MaineCare Services (OMS) expressing dissatisfaction with some aspect of Primary Care Case Management and requesting resolution of the situation.

1.03-4Early and Periodic Screening, Diagnosis, and Treatment Services, or EPSDT, (or its successor, Chapter II, Section 94, Prevention, Health Promotion and Optional Treatment Services) is the benefit where MaineCare members under age twenty-one (21) receive certain services under 42 U.S.C. Sections 1396d(a) and (r).

1.03-5Emergency Medical Condition means a medical condition, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent lay person, who possesses an average knowledge of health and medicine could reasonably expect that the absence of immediate medical attention could reasonably be expected to result in the following:

(i) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy; or

(ii) serious impairment of bodily functions, or serious dysfunction of any bodily organ or part.

1.03-6Emergency Medical Condition for a Non Citizen means a medical condition (including emergency labor and delivery) characterized by sudden onset, and manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in the following:

(i) placing the member's health in serious jeopardy,

(ii) serious impairment to bodily functions; or

(iii) serious dysfunction of any bodily organ or part.

1.03-7Emergency Services means those covered inpatient and outpatient health care services that are furnished by a provider that is qualified to furnish such services and are needed to evaluate or stabilize an emergency medical condition.

1.03-8Exempt Services set forth in Section 1.05 are services that do not require a PCP's referral in order to be payable by MaineCare. Reimbursement for provision of these services will be made in accordance with the policies set forth in Chapters II and III of this Manual.

1.03-9Foster Care Children are children who are in the voluntary care or legal custody of the DHHS and for whom the Department is responsible for custodial and parental decisions.

1.03-10Grievance is a formal, written request to the DHHS for resolution of a complaint by a member enrolled in Primary Care Case Management.

1.03-11Homeless person means a person who lacks a fixed, regular place of residence or has a residence that is one of the following:

1) a supervised shelter providing temporary accommodations;

2) a halfway house or similar institution providing temporary residence for individuals intended to be institutionalized;

3) a temporary accommodation in another person's residence; or

4) a place not designed or ordinarily used for regular sleeping accommodations for human beings.

1.03-12Maine Enrollment and Capitation System (MECAPS), is the OMS' automated system for tracking managed care enrollment.

1.03-13MaineCare Member Services is, for the purposes of Primary Care Case Management, responsible for functions including, but not limited to: educating and enrolling members in Primary Care Case Management; and performing transfer, complaint resolution and PCP selection/change functions for members, as appropriate.

1.03-14Managed Services, set forth in Section 1.04, are the services defined in Chapter II of the MaineCare Benefits Manual (MBM).These services are payable by MaineCare only when provided by the member's PCP or his/her designee or by other MaineCare providers with a referral by the PCP or his/her designee. Reimbursement for provision of these services will be made in accordance with the policies set forth in Chapters I, II, and III of this Manual and will only be made to providers enrolled with MaineCare, in accordance with Chapter I of this Manual.

1.03-15Migrant means a farm worker whose principal employment is in agriculture on a seasonal basis who has been so employed within the last twenty-four (24) months and who establishes, for the purposes of such employment, a temporary abode.

1.03-16Post-Stabilization Services means covered services, related to an emergency medical condition, that are provided after a member is stabilized in order to maintain the stabilized condition or to improve or resolve the member's condition.

1.03-17Primary Care Provider (PCP) is a provider who has contracted with the Department to provide primary care case management services.

1.03-18Primary Care Provider (PCP) Panel is the number of members (caseload) for which the PCP provides PCCM services (a medical home).

1.03-19Primary Care Provider Sites (PCP sites) means each medical facility that offers PCCM services.

1.03-20Terminal Illness is a condition in which the individual's prognosis is for a life expectancy of six (6) months or less if the individual's illness runs its normal course.

C.M.R. 10, 144, ch. 101, ch. VI, 144-101-VI-01, subsec. 144-101-VI-01.03