Md. Code Regs. 10.67.01.01

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

Section 10.67.01.01 - Definitions

A. Except as expressly limited, in COMAR 10.67.62 -10.67.75 the following terms have the meanings indicated.

B. Terms Defined.

(1) "ACOG guidelines" means the American College of Obstetricians and Gynecologists' Guidelines for Perinatal Care that specify the recommended periodicity and content of prenatal, perinatal, and postpartum care, and are incorporated by reference in COMAR 10.67.65.01.

(2) "Acquired immune deficiency syndrome (AIDS)" has the meaning stated in COMAR 10.52.06.01B.

(3) "Action" means:

(a) Denial or limited authorization of a requested service, including:

(i) The type or level of service;

(ii) Requirements for medical necessity;

(iii) Appropriateness;

(iv) Setting; or

(v) Effectiveness of a covered benefit.

(b) Reduction, suspension, or termination of a previously authorized service;

(c) Denial, in whole or part, of payment for a service, except for administrative denials of unclean claims;

(d) Failure to provide services in a timely manner;

(e) Failure of an MCO to act within the required time frames; or

(f) The denial of an enrollee's request to dispute a financial liability, including:

(i) Cost sharing;

(ii) Copayments;

(iii) Premiums;

(iv) Deductibles;

(v) Coinsurance; or

(vi) Other enrollee financial liabilities.

(4) "Activities of daily living" means, in the context of COMAR 10.67.69, bathing, feeding, toileting, dressing, and ambulation;

(5) "Adjusted clinical group (ACG)" means a method for categorizing individuals into a case mix category based on the diagnoses assigned by their clinicians over a predetermined period of time.

(6) Administrative Services Organization.

(a) "Administrative services organization (ASO)" means an organization with which MHA and the CSAs contract to assist in the management of the specialty mental health system.

(b) "Administrative services organization" does not mean an organization that directly provides health care services to waiver-eligible individuals.

(7) "Advanced practice nurse" means a nurse practitioner, nurse midwife, nurse anesthetist, or nurse psychotherapist who is licensed and certified under Health Occupations Article, Title 8, Annotated Code of Maryland, and COMAR 10.27.01

(8) "Aged" has the meaning stated in COMAR 10.67.24.02B.

(9) "AIDS payment category" means one of the two payment categories represented as individual rate cells within the rate table set forth in COMAR 10.67.65.19B(4)(b) to which enrollees with AIDS are assigned pursuant to COMAR 10.67.65.19B(2)(c)(ii).

(10) "Alcohol abuse" has the meaning stated in Health-General Article, §8-101(e), Annotated Code of Maryland.

(11) "Ancillary services" means diagnostic and somatic therapeutic services, including but not limited to radiology, laboratory services, cardiac diagnostics, neurology diagnostics, occupational therapy, physical therapy, durable medical equipment, disposable medical supplies, audiology, speech therapy, and cardiac rehabilitation therapy.

(12) "Annual quality assurance (QA) audit" means a systems performance review and a clinical care review.

(13) "Appeal" means a request for review of an action.

(14) "Applicant" means an entity that seeks approval from the Department to operate as a managed care organization in the Maryland Medicaid Managed Care Program.

(15) "Benefits package" means a set of health care services to which an MCO's enrollees are entitled, when the services are medically necessary, and which the MCO delivers to its enrollees either through providers with which it has employment or contractual relationships, or through reimbursement for services provided to the MCO's enrollees.

(16) "Blind" means having a condition in which a person is certified by an ophthalmologist as having either central visual acuity of 20/200 or less in the better eye with correcting glasses, or a field defect in which the peripheral field has contracted to such an extent that the widest diameter of the visual field subtends an angular distance of no greater than 20 degrees.

(17) "Business day" means any day except Saturday, Sunday, or a holiday on which State offices are closed.

(18) "Caller abandonment rates" means the percentage of calls terminated by callers without speaking to a live operator.

(19) "Caller average hold time" means an average amount of time a call is on hold after being answered.

(20) "Caller service level" means the speed of answering the telephone.

(21) "Capitation payment" means the sum of money paid in advance on a monthly per capita basis by the Department for a fixed benefit package.

(22) "CARF" means the Commission on Accreditation of Rehabilitation Facilities (also known as the Rehabilitation Accreditation Commission), which is an organization that:

(a) Establishes quality standards for rehabilitative services; and

(b) Determines, in the context of its accreditation process, the extent to which rehabilitative service providers are in compliance with CARF quality standards.

(23) "Case management " means, assessing, planning, coordinating, monitoring, and arranging the delivery of medically necessary health-related services.

(24) "Case management contractor" means, in the context of COMAR 10.67.69, the Department's designee, or a subcontractor of the designee, which provides case management to participants assigned to it by the Department.

(25) "Case manager" means, in the context of COMAR 10.67.69, the individual who:

(a) Is employed by the Department's designee or a case management contractor;

(b) Is assigned by a case management contractor to manage the care of some or all of the participants assigned to that case management contractor;

(c) Participates in the meetings of the interdisciplinary team;

(d) Is responsible for the development of an individual's case management plan by the interdisciplinary team;

(e) Is responsible for implementing the participant's case management plan; and

(f) Is responsible for modifying the case management plan when information regarding a change in the participant's condition or status is received.

(26) "CDS license" means the State licensure authorizing a health care practitioner to prescribe controlled dangerous substances.

(27) "Certified nursing assistant" means, in the context of COMAR 10.67.69, an individual:

(a) Certified as a nursing assistant by the Maryland Board of Nursing; and

(b) Who performs nursing tasks delegated by a registered nurse or licensed practical nurse pursuant to Health Occupations Article, Title 8, Annotated Code of Maryland.

(28) "Child in State-supervised care" means a waiver-eligible child who is in the care and custody of a State agency pursuant to a court order or a voluntary placement agreement, including, but not limited to, waiver-eligible children:

(a) Under the supervision of the Department of Juvenile Services;

(b) In kinship or foster care under the Department of Human Resources; and

(c) In residential treatment centers or psychiatric hospitals for the first 30 days after admission.

(29) "Child with a special health care need" means an individual younger than 21 years old, regardless of marital status, suffering from a moderate to severe chronic health condition:

(a) With significant potential or actual impact on health and ability to function;

(b) Which requires special health care services; and

(c) Which is expected to last longer than 6 months.

(29-1) "CHIP Health Services Initiative" means services offered to improve the health of low-income children pursuant to 5 U.S.C. § 2105(a)(1)(D)(ii) of the Social Security Act.

(30) "Chronic hospital" has the meaning stated in COMAR 10.67.06.01B(4).

(31) "Clinical care review" means a review of the quality of clinical health care delivered by an MCO, which is:

(a) Required by federal law; and

(b) A component of an annual quality assurance (QA) audit.

(32) "CMS" means Centers for Medicare and Medicaid Services.

(33) "Cold call marketing" means any unsolicited personal contact by the MCO with a potential enrollee for the purpose of marketing.

(33-1) "Collaborative Care Model" means the Psychiatric Collaborative Care Model, a patient-centered, evidence-based approach for integrating physical and behavioral health services in primary care settings that includes:

(a) Care coordination and management;

(b) Regular, systematic monitoring and treatment using a validated clinical rating scale;

(c) Regular, systematic psychiatric or substance use disorder caseload reviews, or both; and

(d) Regular, systematic consultation for patients who do not show clinical improvement.

(34) "Commissioner" means the Maryland Insurance Commissioner of the Maryland Insurance Administration.

(35) "Community-based substance abuse program" means a program that:

(a) Is certified by the Office of Health Care Quality (OHCQ); and

(b) Provides services in community settings not regulated by the Health Services Cost Review Commission.

(36) "Complaint" means an expression of dissatisfaction that results in either an appeal or a grievance.

(37) "Contract year" means the period of time to which the Maryland Medicaid Managed Care Program agreement between the Department and an MCO applies.

(38) "Core service agency (CSA)" means, in the context of COMAR 10.67.70, the county or multicounty authority, designated under Health-General Article, Title 10, Subtitle 12, Annotated Code of Maryland, and approved by the Department, that is responsible for planning, managing, and monitoring publicly funded mental health services.

(39) "Corporation" means:

(a) An entity formed under and meeting the requirements of Corporations and Associations Article, § 2-101 et seq., Annotated Code of Maryland; or

(b) A foreign corporation registered with the Maryland Department of Assessments and Taxation.

(40) "County" means a county of this State and, unless expressly provided otherwise, Baltimore City.

(40-1) "Credibility adjustment" means an adjustment to the MLR for a partially credible MCO to account for a difference between the actual and target MLRs that may be due to random statistical variation.

(41) "Days" means, unless otherwise expressly indicated, calendar days.

(42) "DEA license" means the federal license authorizing a health care practitioner to prescribe controlled substances.

(42-1) "Definitive drug test" means drug screening tests that include:

(a) The ability to identify individual drugs and distinguish between structural isomers, but not necessarily stereoisomers, using:

(i) Gas chromatography or mass spectrometry; and

(ii) Liquid chromatography or mass spectrometry;

(b) Qualitative or quantitative results;

(c) All source types for specimen selection;

(d) Specimen validity testing, per day, 1-22 or more drug classes including metabolites, if performed.

(43) "Department" means the Department of Health and Mental Hygiene, as defined in COMAR 10.67.36.01, or its authorized agents acting on behalf of the Department.

(44) "Diagnostic evaluation services (DES)" has the meaning stated in COMAR 10.67.32.01B, and includes the services described in COMAR 10.67.32.04A.

(45) Direct Medical Education Costs (DME Costs).

(a) "Direct medical education costs (DME costs)" means costs associated with providing graduate medical education that are measurable using accounting data.

(b) "Direct medical education costs (DME costs)" includes, but is not limited to:

(i) Salaries;

(ii) Supervision costs; and

(iii) Allocated overhead.

(46) "Disabled" has the meaning stated in COMAR 10.67.24.02B.

(47) "Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)" means the provision, to individuals younger than 21 years old, of preventive health care pursuant to 42 CFR § 441.50 et seq. (1981), and other health care services, diagnostic services, and treatment services that are necessary to correct or ameliorate defects and physical and mental illnesses and conditions discovered by EPSDT screening services.

(48) "Emergency medical condition" means a medical condition characterized by sudden onset and symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine, to result in:

(a) Placing the patient's health, or with respect to a pregnant woman, the health of the woman or unborn child in serious jeopardy;

(b) Serious impairment to bodily functions; or

(c) Serious dysfunction of any bodily organ or part.

(49) "Emergency services" means those health care services that are provided in a hospital emergency facility after the sudden onset of a medical condition that manifests itself by symptoms of sufficient severity, including severe pain, that the absence of immediate medical attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine, to result in:

(a) Placing the patient's health, or with respect to a pregnant woman, the health of the woman, or her unborn child, in serious jeopardy;

(b) Serious impairment to bodily functions; or

(c) Serious dysfunction of any bodily organ or part.

(50) "Encounter data" means information documenting a service to an enrollee.

(51) "Enrollee" has the meaning indicated in Health-General Article, §15-101(b), Annotated Code of Maryland.

(52) "EPSDT-certified provider" means a physician or nurse practitioner who is certified by the Department's EPSDT program to provide comprehensive well-child services according to the Department's periodicity schedule and program standards to enrollees younger than 21 years old.

(53) "EPSDT comprehensive well-child services" means:

(a) All the screening services provided by an EPSDT-certified provider that are required or recommended on the EPSDT periodicity schedule; and

(b) Health care services to diagnose, treat, or refer problems or conditions discovered during the comprehensive well-child service.

(54) "EPSDT partial or interperiodic well-child service" means:

(a) A well-child service provided at times different than those outlined in the EPSDT periodicity schedule; or

(b) Any encounter by a health care practitioner necessary to diagnose or identify a condition and recommend a course of treatment.

(55) "EPSDT periodicity schedule" means the Departmentally approved list of required or recommended preventive health care services which are to be performed at specified ages.

(56) "Evaluations" means, in the context of COMAR 10.67.69, a determination of the health status of a patient in a patient's home or any other appropriate setting by a licensed professional for the purpose of designing an individual plan of care which incorporates the modalities of treatment which will promote optimal functional ability and recuperation.

(57) "External quality review organization (EQRO)" means a utilization and quality control peer review entity or a private review agent meeting the requirements of §1902(a)(30) of the Social Security Act, 42 U.S.C. § 1396a(a)(30), which performs an independent external review of health care services furnished under a contract under §1903(m) of the Social Security Act, 42 U.S.C. § 1396b.

(58) "Family planning" means providing individuals with the information and means to prevent unwanted pregnancy and maintain reproductive health.

(59) "Federally qualified health center (FQHC)" means a clinic which either:

(a) Receives a grant under §329, 330, or 340 of the Public Health Services Act, 42 U.S.C. § 254c;

(b) Meets the requirements for a grant under §329, 330, or 340 of the Public Health Services Act, 42 U.S.C. § 254c; or

(c) Qualifies as a FQHC pursuant to a waiver from the Secretary of the U.S. Department of Health and Human Services of one or more of the requirements for receiving a grant under §329, 330, or 340 of the Public Health Services Act, 42 U.S.C. § 254c.

(60) "Fiscal year (FY)" means the time period beginning the preceding July 1 and ending on June 30 of the referenced year.

(61) "Free-standing birth center" means a free-standing facility not associated with a hospital that provides nurse midwife services under Health Occupations Article, Title 8, Subtitle 6, Annotated Code of Maryland.

(61-1) "Full credibility" means a standard for which the experience of an MCO is determined to be sufficient for the calculation of an MLR with a minimal chance that the difference between the actual and target MLR is not statistically significant.

(62) "Graduate medical education (GME)" means the training of physician interns and residents after completion of a medical degree program.

(63) "Graduate medical education costs (GME costs)" means the amount it costs a hospital to train physician interns and residents after their completion of a medical degree program, including both direct medical education costs and indirect medical education costs.

(64) "Grievance" means an expression of dissatisfaction about any matter other than an action, including but not limited to:

(a) The quality of care or services provided, and aspects of interpersonal relationships such as rudeness of a provider or employee;

(b) Failure to respect the enrollee's rights regardless of whether remedial action is requested; or

(c) A dispute over an extension of time proposed by the MCO to make an authorized decision.

(65) "HCQIS" means the Health Care Quality Improvement System produced by the Centers for Medicare and Medicaid Services.

(66) "Health care service" has the meaning stated in Health-General Article, §19-132, Annotated Code of Maryland.

(67) "HealthChoice Financial Monitoring Report (HFMR)" means an annual financial report of an MCO's MMMCP-related activities during a specified calendar year that:

(a) Is submitted to the Department by an MCO pursuant to COMAR 10.67.65.15;

(b) Serves as a supplemental schedule to an MCO's quarterly and annual reports to the Maryland Insurance Administration; and

(c) Includes a completed HFMR form provided by the Department and any supplemental schedules required by the Department.

(68) "Health home" means a provider designated to offer enhanced care coordination and management services to individuals affected by, or at risk for, chronic conditions.

(69) "Health maintenance organization (HMO)" has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.

(70) Health Service Needs Information.

(a) "Health service needs information" means an instrument to identify new Maryland Medicaid Managed Care Program enrollees who require immediate or specialized health care services.

(b) "Health service needs information" does not mean an initial health screen performed by an MCO.

(71) "HEDIS" means the Healthcare Effectiveness Data Information Set, a set of indicators of managed care plan performance developed by the National Committee for Quality Assurance.

(72) "Hepatitis C" means having one of the following as a primary, secondary, tertiary, or level 4 diagnosis:

(a) 070.41-Acute or Unspecified Hepatitis C with hepatic coma;

(b) 070.44-Chronic Hepatitis C with hepatic coma;

(c) 070.51-Acute or unspecified Hepatitis C without mention of hepatic coma; or

(d) 070.54-Chronic Hepatitis C without mention of hepatic coma.

(73) "Hepatitis C plan risk factor" means an MCO-specific risk adjustment factor reflecting the level of risk associated with the proportion of the MCO's HIV/AIDS enrollees who also have Hepatitis C.

(74) "HIPAA" means the Health Insurance Portability and Accountability Act, a federal law enacted on August 21, 1996, whose purpose is to improve the efficiency and effectiveness of the health care system by standardizing the electronic exchange of administrative and financial data, provide security requirements for transmitted information, and protect the privacy of identifiable health information.

(75) "Historical diagnostic period" means the time period under consideration for the cumulative chronological determination of an enrollee's Hepatitis C status and ending:

(a) For the initial rate adjustment period, on June 30 of the calendar year before the rate year; or

(b) For the mid-year rate adjustment period, on December 31 of the calendar year before the rate year.

(76) "HIV" means infection with the human immunodeficiency virus.

(77) "HIV/AIDS" means:

(a) Infection with the human immunodeficiency virus; or

(b) Acquired immune deficiency syndrome.

(78) "HIV/AIDS enrollee" means an enrollee who is infected with HIV or has AIDS and is assigned to an HIV or AIDS payment category.

(79) "HIV payment category" means one of the four payment categories represented as individual rate cells within the rate tables set forth in COMAR 10.67.65.19B(4)(a) and (b), to which enrollees with HIV are assigned pursuant to COMAR 10.67.65.19B(1)(c)(ii) or (2)(c)(i).

(80) "Home", in the context of COMAR 10.67.69, has the meaning stated in COMAR 10.67.53.

(81) "Home health agency" means, in the context of COMAR 10.67.69, an agency licensed by the Department in accordance with COMAR 10.07.10.

(82) "Home health aide" means, in the context of COMAR 10.67.69, an individual who meets all the conditions of participation specified in:

(a) 42 CFR § 484.36 ; and

(b) Health Occupations Article, Title 8, Annotated Code of Maryland.

(83) "Homeless person" means an individual who, as defined by §340 of the Public Health Services Act, lacks housing, without regard to whether an individual is a member of a family, including an individual:

(a) Who is a resident in transitional housing; or

(b) Whose primary residence during the night is a supervised public or private facility that provides temporary living accommodations.

(84) "Hospital" has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

(85) "HSCRC" means the Health Services Cost Review Commission, an independent agency functioning in the Department with the powers and duties set forth in Health-General Article, §19-201 et seq., Annotated Code of Maryland.

(86) "Indirect medical education costs (IME costs)" means costs associated with providing graduate medical education that, although not measurable using accounting data, are subject to assessment by application of a regression analysis methodology that:

(a) Estimates teaching hospitals' extra costs attributable to factors including, but not necessarily limited to the:

(i) Lower productivity of inexperienced residents, and

(ii) Adoption of advanced technology; and

(b) Controls, where possible, for confounding variables such as differences in:

(i) Area labor costs,

(ii) Uncompensated care, and

(iii) Case mix.

(87) "Individualized education program (IEP)" means a written description of special education and related services developed by a multidisciplinary team to be implemented to meet the individual needs of a child pursuant to COMAR 13A.05.01.09.

(88) "Individualized family service plan (IFSP)" means a written plan for providing early intervention and other services to an eligible child and the child's family pursuant to COMAR 13A.13.01.02B.

(89) "Individual with a developmental disability" means an individual who, as defined in P.L. 101-330, Americans with Disabilities Act of 1990, 42 U.S.C. § 12101 et seq., has a physical or mental impairment arising before the age of 22, except for the sole diagnosis of mental disorder, that substantially limits one or more major life activities, and which may include, but is not limited to, an intellectual disability, specific learning disabilities, head injury, epilepsy, and muscular dystrophy.

(90) "Individual with a physical disability" means an individual who, as defined in P.L. 101-330, the Americans with Disabilities Act of 1990, 42 U.S.C. § 12101 et seq., has a physical impairment, either sensory or motor, that substantially limits one or more major life activities, and which may include, but is not limited to, orthopedic impairment, vision, speech, or hearing impairment, cerebral palsy, epilepsy, muscular dystrophy, multiple sclerosis, cancer, heart disease, HIV/AIDS, and tuberculosis.

(91) "Initial health screen" means the comprehensive evaluation performed by the PCP, that includes a comprehensive history and physical examination to determine the new enrollee's baseline health status and health needs.

(92) "Initial rate adjustment period" has the meaning stated in COMAR 10.67.04.19-3A.

(93) "Inmate" means an individual who is serving time for a criminal offense and is confined involuntarily in State or federal prisons, jail, detention centers, or other penal facilities or who has been placed on home detention.

(94) Institution for Mental Disease.

(a) "Institution for mental disease (IMD)" means a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment, or care of persons with mental diseases or substance abuse problems, including medical attention, nursing care, and related health care services.

(b) "Institution for mental disease (IMD)" includes the following categories of facilities, if the particular facility has more than 16 beds:

(i) Psychiatric hospitals;

(ii) Residential treatment centers;

(iii) In the context of admissions of enrollees who are 21 years old or older, intermediate care facilities-alcoholic (ICF-A) facilities; and

(iv) Residential drug-free treatment programs.

(c) "Institution for mental disease" does not include intermediate care facilities-alcoholic (ICF-A) facilities, except in the context of admission of enrollees who are 21 years old or older.

(95) "Interdisciplinary team" means, in the context of COMAR 10.67.69, the group convened and conducted by the case manager, consisting of the case manager and relevant service providers, that established the case management plan under the overall direction and coordination of the case manager and in consultation with the participant and, when applicable, the participant's family.

(96) "Intermediate care facility for individuals with intellectual disabilities or persons with related conditions (ICF/IID)" means a residential facility providing care and services for individuals with an intellectual disability or developmental disabilities, or both.

(96-1) "Limited English proficiency" means the special need status of potential enrollees and enrollees who do not speak English as their primary language and who have a limited ability to read, write, speak, or understand English, and are therefore eligible to receive language assistance for a particular type of service, benefit, or encounter.

(97) "Local access area" means the local geographical area, as identified by the zip code groupings in COMAR 10.67.66.06E, that is located within the relevant MCO's service area and in which the relevant enrollee resides.

(98) "Local transportation grantee agency" means the county entity, usually the local health department, that receives transportation grant funds pursuant to COMAR 10.67.19.

(99) "Long-term care facility" means a chronic hospital, a chronic rehabilitation hospital, a nursing facility, or a special pediatric hospital.

(100) Long-Term Care Services.

(a) "Long-term care services" means the medical and support services required by an individual who, due to chronic illness or mental or physical disability, requires long-term care facility services over an extended period of time.

(b) "Long-term care services" includes services provided to a patient in a long-term care facility after the 30th day of continuous care following the enrollee's admission to the facility.

(c) "Long-term care services" do not include services provided to an enrollee admitted to a long-term care facility for a stay of less than 31 days of continuous care following the enrollee's admission to the facility.

(101) "Loss ratio" means the ratio of an MCO's:

(a) Net medical expenses plus medical management expenses which:

(i) Are quantified according to COMAR 10.67.04.19-4 ;

(ii) Relate solely to the MCO's MMMCP line of business; and

(iii) Are incurred during a specified period; and

(b) Net revenues which:

(i) Relate solely to the MCO's MMMCP line of business; and

(ii) Are earned during the same specified period in which the expenses referenced in §B(98)(a) of this regulation are incurred.

(102) "Managed care organization (MCO)" has the meaning stated in Health-General Article, §15-101, Annotated Code of Maryland.

(103) "Marketing" means any communication, from an MCO to a Medicaid recipient who is not enrolled in that MCO, that can reasonably be interpreted as intended to influence the recipient:

(a) To enroll in that particular MCO; or

(b) To not enroll in or to disenroll from another MCO.

(104) "Marketing materials" means materials that are produced in any medium, by or on behalf of an MCO, that can reasonably be interpreted as intended to market to potential enrollees.

(105) "Maryland Children's Health Program" means the State program for uninsured, low-income children with federal matching funds provided under Title XXI of the Social Security Act.

(106) "Maryland Medicaid Managed Care Program (MMMCP)" means the Medicaid reform program established in this subtitle, as authorized by Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland, and by a §1115 waiver issued by the federal government.

(107) "Medicaid" has the meaning stated in COMAR 10.67.24.02.

(108) "Medical Assistance" has the meaning stated in COMAR 10.67.24.02.

(109) "Medical day care for adults" means a program of medically supervised, health-related services provided in an ambulatory setting to medically handicapped adults who, due to their degrees of impairment, need health maintenance and restorative services supportive to their community living.

(110) "Medical day care for children" means a program of medically supervised health-related services provided in an ambulatory setting to children with complex medical needs who do not require 24-hour inpatient care, but, due to their specialized medical needs, cannot be managed in a typical day care setting.

(111) "Medical expense" means costs incurred by an MCO in connection with providing health care services to its enrollees.

(111-1) "Medical loss ratio (MLR)" means a formula that measures the ratio of MCO spending on medical and related benefits compared to revenue, to ensure MCOs are spending a sufficient amount of their premium revenue on medical expenses and other high-impact initiatives.

(112) "Medically necessary" means that the service or benefit is:

(a) Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;

(b) Consistent with current accepted standards of good medical practice;

(c) The most cost efficient service that can be provided without sacrificing effectiveness or access to care; and

(d) Not primarily for the convenience of the consumer, the consumer's family, or the provider.

(113) "Medically needy" has the meaning stated in COMAR 10.67.24.02.

(114) "Medical management expense" means costs incurred by an MCO in connection with outreach and utilization management activities as specified in COMAR 10.67.04.19-4.

(115) "Medical necessity" means what is medically necessary.

(115-1) "Medically underserved area" means an area designated by the Health Resources and Services Administration (HRSA) as having shortages of primary care, dental care, or mental health providers.

(116) "Medicare" means the federal program that provides benefits to the aged and disabled under Title XVIII of the Social Security Act.

(117) "MIA" means the Maryland Insurance Administration.

(118) "Mid-year rate adjustment period" has the meaning stated in COMAR 10.67.65.19-4A.

(119) "MIEMSS" means the Maryland Institute for Emergency Medical Service Systems.

(119-1) "MLR reporting year" means a period of 12 months consistent with the rating period selected by the Department.

(120) "Model Waiver Program" means the Home Care for Disabled Children under a Model Waiver as established in COMAR 10.67.27.

(120-1) "National Diabetes Prevention Program" means an evidence-based diabetes prevention program established by the Centers for Disease Control and Prevention.

(121) "Net medical expenses" means an MCO's total medical expenses less reinsurance recoveries.

(122) "Net revenues" means an MCO's total revenues less reinsurance premiums.

(123) "Network" has the same meaning as "provider panel", as specified in this regulation.

(123-1) "Network provider" means a provider that is a member of the MCO's provider panel.

(123-2) "No credibility" means a standard for which the experience of an MCO is determined to be insufficient for the calculation of an MLR.

(123-3) "Non-claims costs" means expenses for administrative services other than:

(a) Incurred claims;

(b) Expenditures on activities that improve health care quality;

(c) Licensing and regulatory fees; or

(d) Federal and State taxes.

(124) "Nursing facility" has the meaning stated in COMAR 10.67.10.01B.

(125) Nutritional Counseling.

(a) "Nutritional counseling" means, in the context of COMAR 10.67.69, the review of the patient's nutritional status and advice on its improvement when medically necessary.

(b) "Nutritional counseling" includes family education provided by either a licensed dietitian or licensed nutritionist.

(126) "Nutritional supplements" means, in the context of COMAR 10.67.69, enteral feeding which is either the sole source of nutrition or a supplement which enhances the physical well-being of the patient and is medically indicated.

(127) "Ombudsman" or "ombudsman program" has the meaning stated in Health-General Article, §15-101(g), Annotated Code of Maryland.

(128) "Out-of-plan provider" means a provider that is neither the employee nor the subcontractor of the enrollee's assigned MCO.

(129) "Outreach services" means efforts to contact enrollees and bring them into care, as described in COMAR 10.67.66.03.

(130) "Overpayment" means:

(a) Any payment made by the Program to a provider in excess of the correct Program payment amount for a service; or

(b) Any payment for services under COMAR 10.67.67 made by the Program or an MCO which at the time of payment, or at a subsequent date, is determined to be inappropriate, inaccurate or in excess of the correct amount of the procedural code billed, for reasons including but not limited to:

(i) Improper claiming;

(ii) Lack of medical necessity;

(iii) Unacceptable practices;

(iv) Fraud, waste, or abuse; or

(v) Provider mistake.

(130-1) "Partial credibility" means a standard for which the experience of an MCO is determined to be sufficient for the calculation of an MLR but with a non-negligible chance that the difference between the actual and target medical loss ratios is statistically significant.

(131) "Peer review organization" means an organization qualified by the Centers for Medicare and Medicaid Services in accordance with 42 CFR 462 that reviews health care practitioners, and the health care services they order or furnish, utilizing other practitioners from the same field of practice.

(132) "Personal care" has the meaning stated in COMAR 10.67.20.01B.

(133) "Plan of care" means, in the context of COMAR 10.67.69, the document which governs a participant's care management, and which:

(a) Includes the:

(i) Case management assessment report;

(ii) Interdisciplinary plan of care; and

(iii) Case management plan;

(b) Is composed of the participant's health status and needs for medical, health-related, housing, and social services including, but not limited to:

(i) All pertinent diagnoses;

(ii) Functional status;

(iii) Type, frequency, and duration of services;

(iv) Treatment goals for each type of service;

(v) Medication;

(vi) Social support structure;

(vii) Current service providers;

(viii) Assigned level of care;

(ix) Diet;

(x) Current living arrangement; and

(xi) Emergency plan, if appropriate; and

(c) Is established in consultation with the interdisciplinary team.

(134) "Postpartum" means within 2 months after delivery of a child.

(135) "Poststabilization care services" means covered services, related to an emergency medical condition, that are provided after an enrollee is stabilized in order to maintain the stabilized condition, or under the circumstances described in 42 CFR § 438.114(e), as amended, to improve or resolve the enrollee's condition.

(136) "Potential enrollee" means a Medicaid recipient who is determined eligible for the HealthChoice program but is not yet an enrollee of a specific MCO.

(137) "Practitioner" means an individual who is licensed, certified, or otherwise authorized under Health Occupations Article, Annotated Code of Maryland, or under the laws of the District of Columbia or a state contiguous to 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.

(138) "Preauthorization", in the context of COMAR 10.67.69, has the meaning stated in COMAR 10.67.53.

(139) "Pregnant" means the period beginning with conception and ending at delivery.

(139-1) "Presumptive drug tests" means drug screening tests that include:

(a) Any number of drug classes;

(b) Any number of devices;

(c) Sample validation; and

(d) The use of:

(i) Direct optical observation;

(ii) Instrument assisted direct optical observation; or

(iii) Instrumented chemistry analyzers.

(140) "Primary care" means medical care that addresses a patient's general health needs, including the coordination of the patient's health care, with the responsibility for the prevention of disease, promotion and maintenance of health, treatment of illness, maintenance of the enrollee's health records, and referral for medically necessary specialty care.

(141) "Primary care provider (PCP)" means a practitioner who is the primary coordinator of care for the enrollee, and whose responsibility it is to provide accessible, continuous, comprehensive, and coordinated health care services covering the full range of benefits required by the Maryland Medicaid Managed Care Program, as specified in COMAR 10.67.67.

(142) "Primary care residency slots" means, in the context of COMAR 10.67.74, positions in a teaching hospital's residency program occupied after completion of a medical degree program by physicians who have trained in family medicine, internal medicine, pediatrics, or obstetrics and gynecology.

(143) "Primary mental health services" means the clinical evaluation and assessment of mental health services needed by an individual and the provision of services or referral for additional services as deemed medically necessary by a primary care provider.

(144) "Private duty nursing" means, in the context of COMAR 10.67.69, skilled nursing services for recipients who require more individual and continuous care than is available under the Medicaid State Plan, and which are provided by a registered nurse or a licensed practical nurse, in a recipient's own home or another setting when normal life activities take the recipient outside his or her home.

(145) "Program", unless the context indicates otherwise, has the meaning stated in COMAR 10.67.36.01B.

(146) "Progress note" means, in the context of COMAR 10.67.69, a signed and dated written notation by the home care nurse, home health aide, or certified nursing assistant which:

(a) Summarizes facts about the care given and the participant's response during a given period of time;

(b) Specifically addresses the established goals of treatment;

(c) Is consistent with the participant's case management plan; and

(d) Is written during the course of care.

(147) "Provider" has the same meaning as "health care provider", as stated in Health-General Article, §19-132, Annotated Code of Maryland.

(148) "Provider panel" means that group of providers employed by the MCO or with which the MCO contracts to provide services to the MCO's enrollees under the MCO's health benefit plan, which is at least equivalent to the benefits specified in COMAR 10.67.67.

(149) "Public institution" has the meaning stated in COMAR 10.67.24.02.

(150) "Quality assurance plan (QAP)" means a document or series of documents that set forth an MCO's strategy for systematically monitoring, evaluating, and improving all facets of MCO operations, including, but not limited to, clinical health care delivery, enrollee assistance and outreach services, and administrative services.

(151) "Rare and expensive case management" means the method of health care delivery provided to individuals with rare and expensive conditions.

(152) "Rare and expensive condition" means a medical diagnosis or condition identified in COMAR 10.67.69.

(153) "Rate adjustment period" has the meaning stated in COMAR 10.67.65.19-4A.

(153-1) "Rate year" has the meaning stated in COMAR 10.67.65.19-4A.

(154) "Readily accessible" means electronic information and services which comply with modern accessibility standards such as:

(a) Section 508 guidelines;

(b) Section 504 of the Rehabilitation Act; or

(c) W3C's Web Content Accessibility Guidelines (WCAG) 2.0 AA and successor versions.

(155) "Reasonable allowable costs" means costs that are related to the provision of covered Medicaid services and are determined to be allowable in accordance with Medicare principles of reasonable cost reimbursement in 42 CFR 413, subject to the limitations specified in COMAR 10.67.08.05C.

(156) "Recipient" or "Program recipient" means an individual who is certified as eligible to receive Medical Assistance benefits, as provided in COMAR 10.67.24.

(157) "REM optional services" means, in the context of COMAR 10.67.69, the services which meet the general requirements under Regulation .08 and are listed in Regulations .10 and .11 of that chapter.

(158) "School-based health center (SBHC)" means a provider located on school grounds that meets the requirements set forth in COMAR 10.67.76.

(159) "Secretary" means the Secretary of Health and Mental Hygiene.

(160) "Self-referral services" are the health care services listed in COMAR 10.67.67.28 for which, under specified circumstances, the MCO is required to pay, without any requirement of referral by the PCP or MCO, when the enrollee accesses the service through a provider other than the enrollee's PCP.

(160-1) "Separate CHIP Program" means the program for targeted low-income children established under Title XXI of the Social Security Act.

(161) "Service area" means a geographical area, comprised of one or more of Maryland's counties, with each selected county included in its entirety.

(162) "Service year" in the context of COMAR 10.67.04.19-4, means the calendar year in which an MCO incurs the expenses reported pursuant to COMAR 10.67.04.15E(5)(c).

(163) "Somatic care" means medical care that addresses an individual's physical health care needs, including substance abuse treatment.

(164) "Special needs population" means a group of recipients who share a special health care need and which is specified in COMAR 10.67.65.04-.11.

(165) "Special rehabilitation hospital" has the meaning stated in Health-General Article, §19-307(a)(iii), Annotated Code of Maryland.

(166) "Specialty behavioral health services" means any behavioral health services other than primary behavioral health services.

(167) "Specialty care" means health care services that are either outside the PCP's scope of practice or, in the judgment of the PCP, are not services that the PCP customarily provides, is specifically trained for, or is experienced in.

(168) "Specialty care residency slots" means, in the context of COMAR 10.67.74, positions in a teaching hospital's residency program occupied after completion of a medical degree program by physicians who have trained in specialties other than family medicine, internal medicine, pediatrics, or obstetrics and gynecology.

(169) "Spend down" means a procedure by which an individual applying for Medical Assistance who is otherwise ineligible due to excess income becomes eligible by deducting incurred medical expenses from excess income.

(170) "State fair hearing" means a hearing, conducted by the Office of Administrative Hearings, for the purpose of ensuring the right of recipients to be treated in a fair and unbiased manner in their efforts to resolve disputes with the Department or an MCO.

(171) "Subcontract" means a written agreement between an MCO and a third party, under which the third party performs any one or more of the MCO's obligations required by the Department.

(172) "Subcontractor" means an individual or entity that has a contract with an MCO that relates directly or indirectly to the performance of the MCO's obligations under its contract with the Department; provided, however, that a contract does not by itself cause an MCO's network provider to be a subcontractor.

(173) "Substantial minority" means an ethnic or linguistic group that comprises 5 percent or more of the Medicaid population in the county to be served.

(174) "Supplemental Security Income (SSI)" means a federally administered program providing benefits to needy aged, blind, and disabled individuals under Title XVI of the Social Security Act, 42 U.S.C. § 1381 et seq.

(175) "Systems performance review (SPR)" means an assessment, as a component of the annual quality assurance (QA) audit, of quality assurance operations taking place in the MCO.

(176) "Teaching hospital" means a hospital that:

(a) Had HSCRC-approved rates for FY 1995 that included an allowance for GME costs; and

(b) During the contract year, operates a graduate medical education program that is accredited by the Accreditation Council for Graduate Medical Education.

(177) "Temporary Cash Assistance (TCA)" means a form of cash assistance provided, pursuant to Article 88A, § 44A et seq., Annotated Code of Maryland, to assistance units which are technically and financially eligible.

(178) "Tertiary care" means health care services provided by highly specialized health care providers which are usually diagnostic or therapeutic in nature and often require highly sophisticated technological and support facilities.

(179) "Urgent care" means health care services for a medical condition that manifests itself by symptoms of sufficient severity that the absence of medical attention within 48 hours could reasonably be expected, by a prudent layperson who possesses an average knowledge of health and medicine, to result in an emergency medical condition.

(180) "Waiver-eligible" means an individual who qualifies for enrollment in the Maryland Medicaid Managed Care Program.

(181) "Whistleblower" means an individual who exposes any kind of information or activity that alleges any violation of regulation, statute, contract, policy, or unethical behavior that may be indicative of an individual or entity committing fraud, waste, or abuse against the Medicaid program.

(182) "Witness", in the context of COMAR 10.67.69, has the meaning stated in COMAR 10.67.53.

Md. Code Regs. 10.67.01.01

Regulations .01 recodified from 10.09.62.01 effective 46:22 Md. R. 976, eff. 11/1/2019; amended effective 49:12 Md. R. 641, eff. 6/13/2022; amended effective 50:22 Md. R. 974, eff. 11/13/2023; amended effective 51:15 Md. R. 707, eff. 8/5/2024.