Md. Code Regs. 10.25.16.02

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.25.16.02 - Definitions

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

B. Terms Defined.

(1) "Achieved NCQA level two recognition" means a primary care practice has received recognition from NCQA for meeting NCQA's 2011 or later standards for a level two patient-centered medical home.

(2) "Attested to meaningful use" means a physician or nurse practitioner within a primary care practice has achieved the meaningful use requirements under either the Medicaid or Medicare EHR Incentive Program and has received confirmation of the attestation from:

(a) The Centers for Medicare and Medicaid Services; or

(b) The Maryland Medical Assistance Program (Medicaid).

(3) "EHR adoption incentive" means a payment that an eligible primary care practice can receive from a payor to assist the primary care practice in adopting an electronic health record and attaining a required use level that:

(a) Consists of a one-time cash payment not to exceed $15,000 or an incentive of equivalent value agreed upon by the primary care practice and payor; and

(b) Is based on a $25 per-patient payment applied to the total number of patients on the practice panel who are Maryland residents.

(4) "Electronic health record" or "EHR" means a complete electronic record system that is certified by an authorized testing and certification body designated by the Office of the National Coordinator for Health Information Technology and that contains health-related information on an individual.

(5) Fully Insured Health Benefit Plan.

(a) "Fully insured health benefit plan" means a medical policy, contract, or certificate for which an:

(i) Employer pays a per-employee premium to a payor and the payor assumes the risk of providing health coverage for insured events and incurred administrative costs; or

(ii) Individual pays a premium to a payor.

(b) "Fully insured health benefit plan" does not include a self-insured health plan or a health plan for which a payor is acting only as a third-party administrator.

(6) Health Care Provider.

(a) "Health care provider" means a person who is licensed, certified, or otherwise authorized under Health Occupations Article, Annotated Code of Maryland, to provide health care services in the ordinary course of business or practice of a profession or in an approved education or training program.

(b) "Health care provider" includes a facility where health care is provided to patients or recipients, including:

(i) A facility, as defined in Health-General Article, §10-101(e), Annotated Code of Maryland;

(ii) A hospital, as defined in Health-General Article, §19-301, Annotated Code of Maryland;

(iii) A related institution, as defined in Health-General Article, §19-301, Annotated Code of Maryland;

(iv) An outpatient clinic;

(v) A freestanding medical facility, as defined in Health-General Article, § 19-3 A-01, Annotated Code of Maryland;

(vi) An ambulatory surgical facility, as defined in Health-General Article, § 19-3 B-01, Annotated Code of Maryland; and

(vii) A nursing home, as defined in Health-General Article, §19-1401, Annotated Code of Maryland.

(c) For purposes of this chapter, "health care provider" does not include a health maintenance organization as defined in Health-General Article, §19-701, Annotated Code of Maryland.

(7) "Implementation period" means the first 120 days after the effective date of this chapter.

(8) "Incentive of equivalent value" means:

(a) Specific services;

(b) A gain-sharing arrangement;

(c) Rewards for quality and efficiency;

(d) In-kind payment; or

(e) Other items or services that can be assigned a specific monetary value.

(9) "Meaningful use" means the criteria and requirements established by the Centers for Medicare and Medicaid Services as detailed under 42 CFR 142, 143, 422, et al. (2010) and subsequent regulations.

(10) "Medicare and Medicaid EHR Incentive Programs" means the programs described at 42 CFR 412, 413, 422, and 495 (2010) and 42 CFR 412, 413, and 495 (2012), adopted by the Centers for Medicare and Medicaid Services (CMS) to implement provisions of the American Recovery and Reinvestment Act of 2009, the Medicare EHR Incentive Program as administered by CMS, and the Medicaid EHR Incentive Program as administered by Medicaid.

(11) "MHCC" or "Commission" means the Maryland Health Care Commission.

(12) "NCQA" means the National Committee for Quality Assurance, a health care quality accreditation, certification, and recognition body.

(13) "NPI" or "national provider identifier" means the unique individual identification number issued by the National Provider System to a health care provider typically used in administrative and financial transactions.

(14) Payor.

(a) "Payor" means a State-regulated carrier that issues or delivers health benefit plans in the State and includes:

(i) Aetna, Inc;

(ii) CareFirst BlueCross BlueShield;

(iii) CIGNA HealthCare Mid-Atlantic;

(iv) Coventry Health Care;

(v) Kaiser Permanente; and

(vi) United Healthcare, Mid-Atlantic Region.

(b) "Payor" does not include a managed care organization as defined in Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland.

(15) "Practice panel" means:

(a) The patients who are Maryland residents and enrolled in a fully insured health benefit plan assigned by a payor to a provider within a primary care practice at the time the primary care practice requests an EHR incentive payment; or

(b) When a payor does not assign patients enrolled in a fully insured health benefit plan to a provider within a primary care practice, the patients who are Maryland residents and enrolled with that payor in a fully insured health benefit plan who have been treated by the primary care practice within the 24 months preceding a primary care practice's request for an EHR adoption incentive payment.

(16) "Primary care practice" means a medical practice located in the State that is composed of:

(a) One or more physicians who provide health care in family practice, general practice, geriatric medicine, internal medicine, pediatric medicine, or gynecologic practice and that uses one of the following CMS specialty codes in claims submissions:

(i) Family practice (08);

(ii) General practice (01);

(iii) Geriatric medicine (38);

(iv) Internal medicine (11);

(v) Pediatric medicine (37); or

(vi) Obstetrics & Gynecology (16); or

(b) One or more nurse practitioners who provide health care in family practice, general practice, geriatric medicine, internal medicine, pediatric medicine, or gynecologic practice and that uses CMS taxonomy code in claims submissions:

(i) Adult Health (363LA2100X);

(ii) Family (363LF0000X);

(iii) Gerontology (363LG0600X);

(iv) Obstetrics & Gynecology (363LX0001X);

(v) Pediatric (363LP0200X);

(vi) Primary Care (363LP2300X); or

(vii) Women's Health (363LW0102X).

(17) "State" means the State of Maryland.

(18) "Third-party administrator" means a person that is registered as an administrator under Insurance Article, Title 8, Subtitle 3, Annotated Code of Maryland.

Md. Code Regs. 10.25.16.02

Regulation .02B amended as an emergency provision effective October 21, 2011 (38:24 Md. R. 1495); amended permanently effective January 9, 2012 (38:27 Md. R. 1764)
Regulations .02 adopted effective 41:11 Md. R. 605, eff.6/9/2014