C.M.R. 10, 144, ch. 272, II
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.
C.M.R. 10, 144, ch. 272, II