Md. Code Regs. 10.11.03.02

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.11.03.02 - Definitions

A. In this chapter, the following terms have the meanings indicated.

B. Terms Defined.

(1) "Agency" means a legally incorporated body or governmental unit which provides services to disabled children or their families, or both.

(2) "Allowable cost" means the maximum amount which the Program will reimburse for the drug or product portion of the prescription.

(3) "Appeal" means the process by which a child with special health care needs, as defined in §B(9) of this regulation, or the family on the child's behalf, obtains a review of a decision, action, or lack of action on the part of the CMS Program or one of its designees.

(4) "Applicant " means a child with special health care needs, as defined in §B(9) of this regulation, or the parent or guardian of a child, for whom a written application has been submitted to the CMS Program for services, but for whom eligibility has not yet been determined.

(5) "Authorized services" means that care which is approved by the CMS Program for an eligible child.

(6) "Care coordination services" means services to promote the effective and efficient utilization of resources to assure access to necessary comprehensive services.

(7) "Care management plan (CMP)" means a written document that lists recommendations for care as specified by a licensed and boarded provider

(8) "Children's Medical Services Program (CMS Program)" means that program which is administered by the Department pursuant to Health-General Article, §15-125, Annotated Code of Maryland, to:

(a) Provide for specialized medical, surgical pharmacologic, and related rehabilitative evaluation and treatment services for children with special health care needs younger than 22 years old who:

(i) Meet the residential, identification, financial, and medical eligibility requirements; and

(ii) Are uninsured or do not have coverage in their existing health insurance plans that cover certain types of medical care;

(b) Provide and promote family-centered, community-based coordinated care for children with special health care needs, and promote development of community-based, culturally competent systems of services for those children and their families throughout the State; and

(c) Distribute funds to cover specialty diagnostic and treatment services for eligible children with special health care needs in Maryland

(9) "Children with special health care needs " means individuals, birth to 22 years old, who have or who are at increased risk for a chronic physical development, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.

(10) "Departmenf means the Department of Health and Mental Hygiene, the single State agency designated to administer the CMS Program.

(11) "Disabling condition" means a health-related condition or impairment that may hinder achievement of normal growth and development.

(12) "Disposable medical supplies" means consumable or disposable items with minimal or no potential for reuse which are used to serve a medical purpose.

(13) "Durable medical equipment" means equipment which satisfies all of the following requirements:

(a) It can withstand repeated use;

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

(c) It is appropriate for use in the home.

(14) "Federal poverty level" means the poverty guidelines, as amended, which are updated periodically in the Federal Register by the U.S. Department of Health and Human Services.

(15) "Financial eligibility guidelines" means the schedule based upon the federal poverty level which is used to determine financial eligibility for the CMS Program.

(16) "General hospital" means an institution which falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, and is licensed as a general hospital by the Department of Health and Mental Hygiene, Division of Licensing and Certification, in accordance with COMAR 10.07.01.

(17) "Health Services Cost Review Commission (HSCRC)" means the independent organization within the Department of Health and Mental Hygiene which is responsible for reviewing and approving rates for hospitals pursuant to Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland.

(18) "Hospital" means an institution which falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland, and is licensed pursuant to COMAR 10.07.01, or other applicable standards established by the state in which the services are provided.

(19) "Income" means any property or service received by a person in cash or in kind which can be applied directly to meet basic needs for food, shelter, and medical expenses.

(20) "Long-term hospitalization" means an inpatient stay of more than 2 weeks.

(21) "Medical assistance" has the meaning stated in COMAR 10.09.24.02.

(22) "Medical care" means medical services and specialized care provided by physicians and allied health professionals in hospitals, convalescent facilities, clinics, private physicians' offices, in home and other community-based settings. Medical care may include the services rendered by dentists, nurses, medical social workers, childlife specialists, nutritionists, dietitians, psychologists, physical therapists, occupational therapists, speech-language pathologists, audiologists, optometrists, ophthalmologists, technicians, and other pertinent personnel whose services may be needed by those children who are served by the CMS Program.

(23) "Medically necessary dental care" means reasonable and appropriate diagnosis, treatment, and follow-up care as determined and prescribed by qualified, appropriate health care providers in treating a condition, disease, injury, birth defect, or development malformation to restore facial configuration or function necessary for speech, swallowing, or chewing.

(24) "Physician specialist" means a:

(a) Licensed medical doctor who is qualified to practice medicine in a specialty area and who is either board certified or board eligible and who has experience in the care of children; or

(b) Resident physician under the supervision of a licensed board-certified physician.

(25) "Preauthorization" means an approval required from the Department or its designee before the provision of services.

(26) "Provider" means an individual or entity duly licensed or certified to render a health care service or product pursuant to these regulations through an appropriate agreement with the Department, and identified as a CMS Program provider by the issuance of an individual vendor number.

(27) "Residency" means living in the State voluntarily with the intention of making the State the individual's permanent home for an indefinite period and not for a temporary purpose.

Md. Code Regs. 10.11.03.02

Regulations .02 repealed effective November 28, 1988 (15:24 Md. R. 2769)
Regulation .02A, B amended as an emergency provision effective November 5, 2007 (34:24 Md. R. 2154); amended permanently effective January 14, 2008 (35:1 Md. R. 19)
Regulations .02 adopted effective November 28, 1988 (15:24 Md. R. 2769)
Regulations .02 amended and recodified from Regulation .03 effective 42:7 Md. R. 568, eff.4/13/2015