Md. Code Regs. 31.10.44.02

Current through Register Vol. 51, No. 24, December 2, 2024

Section 31.10.44.02 - Definitions

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

B. Terms Defined.

(1) "Access plan" means the materials that each carrier is required to file annually with the Commissioner to demonstrate that each of the carrier's provider panels is adequate to meet the needs of its enrollees.

(2) "Ambulatory infusion therapy center" means any location authorized to administer chemotherapy or infusion services on an outpatient basis.

(3) "Behavioral health care" means care for mental health or a substance use disorder.

(4) "Carrier" means:

(a) An insurer authorized to sell health insurance;

(b) A nonprofit health service plan; or

(c) A health maintenance organization.

(5) "Certified registered nurse practitioner" means an individual who is licensed as a certified nurse practitioner under Health Occupations Article, Title 8, Subtitle 3, Annotated Code of Maryland.

(6) "Continuing care patient" means an individual who, with respect to a provider or facility:

(a) Is undergoing a course of treatment for a serious and complex condition from the provider or facility;

(b) Is undergoing a course of institutional or inpatient care from the provider or facility;

(c) Is scheduled to undergo nonelective surgery from the provider or facility, including receipt of postoperative care from such provider or facility with respect to such a surgery;

(d) Is pregnant and undergoing a course of treatment for the pregnancy from the provider or facility; or

(e) Is or was determined to be terminally ill, as determined under Section 1861(dd)(3)(A) of the Social Security Act, and is receiving treatment for such illness from such provider or facility.

(7) "Enrollee" means a person entitled to health care benefits from a carrier under a policy or contract subject to Maryland law.

(8) "Essential community provider" means a provider that serves predominantly low-income or medically underserved individuals. "Essential community provider" includes:

(a) Local health departments;

(b) Outpatient mental health and community based substance use disorder programs;

(c) Any entity listed in 45 CFR § 156.235(c); and

(d) School-based health centers.

(9) "Group model HMO " means a type of health maintenance organization that:

(a) Contracts with one multispecialty group of physicians who are employed by and shareholders of the multispecialty group; and

(b) Provides or arranges for the provision of physician and other health care services to patients at medical facilities operated by the HMO or employs its own physicians and other providers on a salaried basis in health maintenance organization buildings to provide care to enrollees of the health maintenance organization.

(10) "Health benefit plan" has the meaning stated in Insurance Article, § 15-112, Annotated Code of Maryland.

(11) "Health care facility" has the meaning stated in Insurance Article, § 15-112, Annotated Code of Maryland.

(12) "Health professional shortage area" means those geographic areas in Maryland which have been designated by the Health Resources and Services Administration as such, as a result of having a shortage of primary medical care or behavioral health providers.

(13) "HEDIS" means the Healthcare Effectiveness Data and Information Set of standardized performance measures, developed and used by the National Committee for Quality Assurance, to evaluate managed care health plan performance for care and services provided.

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

(15) "Hospital-based physician" has the meaning stated in Insurance Article, § 14-201, Annotated Code of Maryland.

(16) "Material change to an access plan" means a change to an access plan that affects a carrier's ability to comply with the requirements of this chapter.

(17) "Network" means:

(a) A carrier's participating providers and the health care facilities with which a carrier contracts to provide health care services to the carrier's enrollees under the carrier's health benefit plan.

(b) If a carrier uses a provider panel developed by a subcontracting entity, "network" includes providers and health care facilities that contract with the subcontracting entity to provide health care services to the carrier's enrollees under the carrier's health benefit plan.

(18) "Network adequacy waiver" means the Commissioner's decision to relieve a carrier of the obligation to comply with certain network adequacy standards in this chapter for 1 year.

(19) "On-call physician" has the meaning stated in Insurance Article, § 14-201, Annotated Code of Maryland.

(20) "Opioid treatment services provider" means a program with a valid and current accreditation-based license under COMAR 10.63 to provide community-based behavioral health services, and authorized to provide opioid treatment services.

(21) "Participating provider" means a provider on a carrier's provider panel.

(22) "Preventive care" means health care provided for the prevention and early detection of disease, illness, injury or other health condition, and includes all of the services required by 42 U.S.C. § 300gg-13.

(23) "Primary care provider" means:

(a) A provider who is responsible for:

(i) Providing initial and primary care to patients;

(ii) Maintaining the continuity of patient care; or

(iii) Initiating referrals for specialist care.

(b) "Primary care provider" includes:

(i) A physician whose practice of medicine is limited to general practice; and

(ii) A board-certified or board-eligible internist, pediatrician, obstetrician-gynecologist or family practitioner.

(24) "Provider" means a person or group of persons licensed, certified, or otherwise authorized by law to provide health care services.

(25) "Provider panel" means the providers that contract either directly or through a subcontracting entity with a carrier to provide health care services to the carrier's enrollees under the carrier's health benefit plan. "Provider panel" does not include an arrangement in which any provider may participate solely by contracting with the carrier to provide health care services at a discountedfee-for-service rate.

(26) "Residential crisis services" has the meaning stated in Insurance Article, § 15-840, Annotated Code of Maryland.

(27) "Road travel distance" means:

(a) Actual driving distance measured between two geographic locations based on turn-by-turn directions along public roads; or

(b) Subject to approval by the Commissioner, driving distance between two geographic locations estimated using a methodology that, in the discretion of the Commissioner, sufficiently accounts for significant geographic barriers that are impassable by automobile, such as the Chesapeake Bay.

(28) "Rural area" means a region that, according to the Maryland Department of Planning, has a human population of less than 1,000 per square mile.

(29) "School-based health center" means a community health resource described in Health-General Article, §19-2101, Annotated Code of Maryland that is located within an elementary, middle, or high school and approved by the Maryland Department of Health.

(30) "Specialty provider" means a provider who:

(a) Focuses on a specific area of physical care or behavioral health care for a group of patients;

(b) Has successfully completed required professional training; and

(c) For a physician, has obtained Board certification or is Board eligible through the American Board of Medical Specialties.

(31) "Suburban area" means a zip code that, according to the Maryland Department of Planning, has a human population equal to or more than 1,000 per square mile, but less than 3,000 per square mile.

(32) "Telehealth" has the meaning stated in Insurance Article, § 15-139, Annotated Code of Maryland.,

(33) "Urban area" means a zip code that, according to the Maryland Department of Planning, has a human population equal to or greater than 3,000 per square mile.

(34) "Urgent care " means the treatment for a condition of an enrollee that satisfies either of the following:

(a) A medical condition, including a physical condition or a mental health condition, that, in the absence of medical care or treatment within 72 hours, could reasonably be expected by an individual, acting on behalf of a carrier and applying the judgment of a prudent layperson who possesses an average knowledge of health and medicine, would result in:

(i) Placing the enrollee's life or health in serious jeopardy;

(ii) The inability of the enrollee to regain maximum function;

(iii) Serious impairment to the enrollee's bodily function;

(iv) Serious dysfunction of any bodily organ or part of the enrollee; or

(v) The enrollee remaining seriously ill with behavioral health symptoms that cause the enrollee to be a danger to self or others; or

(b) A medical condition of an enrollee, including a physical condition or a behavioral health condition, that, in the absence of medical care or treatment within 72 hours, would, in the opinion of a provider with knowledge of the enrollee's medical condition, subject the enrollee to severe pain that cannot be adequately managed without the care or treatment.

(35) "Waiting time" means the time from the initial request for health care services by an enrollee or by the enrollee's treating provider to the earliest date offered for the appointment for services with a provider possessing the appropriate skill and expertise to treat the condition.

Md. Code Regs. 31.10.44.02

Regulation .02 adopted effective 44:25 Md. R. 1180, eff. 12/31/2017; amended effective 50:9 Md. R. 380, eff. 5/15/2023