Md. Code Regs. 31.11.06.02

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

Section 31.11.06.02 - Definitions

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

B. Terms Defined.

(1) "Anniversary date" means the date that is the same date, excluding year, as the effective date of the health benefit plan.

(2) "Carrier" has the meaning stated in Insurance Article, § 15-1201(c), Annotated Code of Maryland.

(3) "Case management" means a form of utilization review used with high cost cases to monitor and manage treatment and suggest appropriate medical services.

(4) "Chlamydia screening test" has the meaning stated in Insurance Article, § 15-829, Annotated Code of Maryland.

(5) "Coinsurance percentage" or "coinsure" means the percentage of allowable charges allocated to the carrier and to the covered person.

(6) "Congenital or genetic birth defect" means a defect existing at or from birth, including a hereditary defect, which includes, but is not limited to, autism or an autism spectrum disorder and cerebral palsy.

(7) "Controlled clinical trial" means a treatment that is:

(a) Approved by an institutional review board;

(b) Conducted for the primary purpose of determining whether or not a particular treatment is safe and efficacious; and

(c) Approved by:

(i) An institute or center of the National Institutes of Health,

(ii) The Food and Drug Administration,

(iii) The Department of Veterans' Affairs, or

(iv) The Department of Defense.

(8) "Covered person" means an employee or a dependent of an employee covered by a carrier under the comprehensive standard health benefit plan.

(9) "Copayment" means a specified charge that a covered person must pay each time services of a particular type or in a designated setting are received.

(10) "Deductible" means the amount of allowable charges that must be incurred by an individual or a family per year before a carrier begins payment.

(11) "Delivery system" means the method that a carrier uses to provide the comprehensive standard health benefit plan to covered persons.

(12) "Dependent" means a covered person's lawful spouse or dependent child.

(13) Dependent Child.

(a) For plan years beginning before September 23, 2010, "dependent child" means an individual who is unmarried, younger than 25 years old, a dependent of the covered employee as that term is used in 26 U.S.C §§ 104, 105, and 106, and any regulations adopted under those sections, and is a:

(i) Biological child, stepchild, grandchild, or foster child of the covered employee;

(ii) Lawfully adopted child of the covered employee, or, from the date of placement, a child in the process of being adopted by the covered employee;

(iii) Child for whom the covered employee has been granted legal custody, including custody as a result of a guardianship, other than a temporary guardianship of less than 12 months duration, by a court or testamentary appointment; or

(iv) Child for whom the covered person has the legal obligation to provide coverage pursuant to court order, court-approved agreement, or testamentary appointment.

(b) For plan years beginning on or after September 23, 2010, "dependent child" means an individual who is younger than 26 years old and is a:

(i) Biological child, stepchild, grandchild, or foster child of the covered employee;

(ii) Lawfully adopted child of the covered employee or, from the date of placement, a child in the process of being adopted by the covered employee;

(iv) Child for whom the covered person has the legal obligation to provide coverage pursuant to a court-ordered, court-approved agreement, or testamentary appointment.

(c) Notwithstanding the age limitation stated in §B(13)(a) and (b) of this regulation, "dependent child" includes an unmarried child who is dependent upon the covered employee for more than 50 percent of the child's support and who, at the time of reaching the age limitation set forth in §B(13)(a) or (b) of this regulation, is incapable of self-support because of mental or physical incapacity that began before the dependent child's attaining the limiting age.

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

(15) "Durable medical equipment" means equipment furnished by a supplier or a home health agency that:

(a) Can withstand repeated use;

(b) Is primarily and customarily used to serve a medical purpose;

(c) Generally is not useful to an individual in the absence of a disability, illness, or injury; and

(d) Is appropriate for use in the home.

(16) "Eligible employee" has the meaning stated in Insurance Article, § 15-1201(e), Annotated Code of Maryland.

(17) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) so that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:

(a) Placing the health of the individual (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.

(18) "Emergency services" means, with respect to an emergency medical condition:

(a) A medical screening examination (as required under section 1867 of the Social Security Act, 42 U.S.C. 1395 dd) that is within the capability of the emergency department of a hospital, including ancillary services routinely available to the emergency department to evaluate the emergency medical condition; and

(b) Such further medical examination and treatment, to the extent they are within the capabilities of the staff and facilities available at the hospital, as are required under section 1867 of the Social Security Act (42 U.S.C. 1395 dd(e)(3)).

(19) "Exclusive provider" means a delivery system offered by an insurer or nonprofit health service plan that provides services to a covered person through preferred providers in accordance with Insurance Article, § 14-205.1, Annotated Code of Maryland.

(20) Experimental Services.

(a) "Experimental services" means services that are not recognized as efficacious as that term is defined in the edition of the Institute of Medicine Report on Assessing Medical Technologies that is current when the care is rendered.

(b) "Experimental services" do not include controlled clinical trials as defined in §B(6) of this regulation.

(21) "Family" means:

(a) An individual and spouse;

(b) An individual and dependent minor or minors; or

(c) An individual, spouse, and dependent minor or minors.

(22) "Family planning services" means counseling, implanting or fitting birth control devices, and follow-up visits after a covered person selects a birth control method.

(23) "Federally qualified health maintenance organization" means a health maintenance organization which meets the requirements of Title XIII of the Public Health Service Act, 42 U.S.C. § 3000e et seq.

(24) "Habilitative services" means services, including occupational therapy, physical therapy, and speech therapy, for the treatment of children with congenital and genetic birth defects to enhance the child's ability to function.

(25) "Health benefit plan" has the meaning stated in Insurance Article, § 15-1201(f), Annotated Code of Maryland.

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

(27) "Health care facility" has the meaning stated in Health-General Article, §19-114, Annotated Code of Maryland.

(28) "Home health care" means the continued care and treatment of a covered person in the home if:

(a) The institutionalization of the covered person in a hospital or related institution or skilled nursing facility would otherwise have been required if home health care were not provided; and

(b) The plan of treatment covering the home health care service is established and approved in writing by the health care practitioner.

(29) "Hospice care" has the meaning stated in 42 U.S.C. § 1395x(dd).

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

(31) "Health savings account" means a health savings account as defined in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, Title 12, § 1201(a) as codified at Part VII, subchapter B, chapter 1, §223(d) of the Internal Revenue Code of 1986.

(32) "Health savings account compatible delivery system" or "HSA-compatible delivery system" means a health benefit plan which:

(a) To be used with a health savings account, meets the requirements of a high deductible health plan as defined in the Medicare Prescription Drug, Improvement and Modernization Act of 2003, codified at §223(c)(2) of the Internal Revenue Code of 1986; and

(b) May be:

(i) A preferred provider organization delivery system to be used with a health savings account (PPO-HSA);

(ii) A health maintenance organization delivery system to be used with a health savings account (HMO-HSA); or

(iii) An exclusive provider delivery system to be used with a health savings account (EPO-HSA).

(33) "Indemnity" means a delivery system in which:

(a) Payment is made on an expense-incurred basis; and

(b) The covered person's choice of health care practitioner is not limited to a network of providers.

(34) "Insulin-using beneficiary" means a beneficiary who uses insulin as part of a treatment plan prescribed by the beneficiary's medical care provider.

(35) "Insurer" has the meaning stated in Insurance Article, § 1-101(v), Annotated Code of Maryland.

(36) "Late enrollee" has the meaning stated in Insurance Article, § 15-1201(h), Annotated Code of Maryland.

(37) "Lifetime maximum" means the maximum amount the carrier is obligated to pay for all services in the lifetime of a covered person.

(38) "Limited out-of-network additional benefit" means an additional benefit offered by an insurer or nonprofit health service plan that:

(a) Permits a covered person enrolled in an exclusive provider delivery system to receive certain health care services out-of-network that would be covered in network; and

(b) Conditions the payment of benefits as required under Insurance Article, § 14-205.1, Annotated Code of Maryland.

(39) "Maintenance drug" has the meaning set forth in Insurance Article, § 15-824(a)(3), Annotated Code of Maryland.

(40) "Managed care system" means a method that a carrier uses to review and preauthorize a treatment plan that a health care practitioner develops for a covered person using a variety of cost containment methods to control utilization, quality, and claims.

(41) "Mandated benefit" means:

(a) A health care service, benefit, coverage, or reimbursement for covered health care services that is required under the Insurance Article or the Health-General Article, Annotated Code of Maryland, to be provided or offered in a health benefit plan that is issued or delivered in the State by a carrier; or

(b) Reimbursement, required by statute, by a health benefit plan for a service when that service is performed by a care provider who is licensed under the Health Occupations Article and whose scope of practice includes that service.

(42) "Multiple risk factors" has the meaning stated in Insurance Article, § 15-829, Annotated Code of Maryland.

(43) "Network" means providers who have entered into a provider service contract with a carrier to provide services on a preferential basis.

(44) "Out-of-network option" means an additional benefit offered by an insurer or nonprofit health service plan that:

(a) Permits a covered person enrolled in an exclusive provider delivery system to receive any healthcare service that would be covered from network providers also to be covered when received from non-network providers; and

(b) Conditions the payment of benefits as required under Insurance Article, § 14-205.1, Annotated Code of Maryland.

(45) "Out-of-pocket limit" means the maximum amount of copayments, deductibles, and coinsurance that an individual or family is obligated to pay for covered services per contract year.

(46) "Outpatient rehabilitative services" means occupational therapy, speech therapy, and physical therapy, provided to covered persons not admitted to a hospital or related institution.

(47) "Partial hospitalization" means the provision of medically directed intensive or intermediate short-term psychiatric treatment for a period of less than 24 hours but more than 4 hours in a day for an individual patient in a hospital, psychiatric day-care treatment center, or community mental health facility.

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

(49) "Plan" means the comprehensive standard health benefit plan described in this chapter.

(50) "Plan year" means a 12-month period that begins:

(a) For the first year of the plan, on the effective date of the plan; and

(b) For plans that have been in effect for 1 year or longer, on the anniversary date of the plan.

(51) "Point-of-service (POS)" means a delivery system that permits a covered person to receive services outside the network in accordance with the recommendations of the primary care physician within a managed care system.

(52) "Point-of-service option" means an additional benefit offered by a health maintenance organization that permits a covered person enrolled in a health maintenance organization to receive any health care service outside the provider panel of the health maintenance organization that is covered under the covered person's contract with the health maintenance organization.

(53) "Preferred provider organization" means a delivery system offered by an insurer or nonprofit health service plan that provides services to a covered person through a network and permits the covered person to select services outside the network.

(54) "Preexisting condition" has the meaning stated in Insurance Article, § 15-1201(k), Annotated Code of Maryland.

(55) "Primary care" means services rendered by a health care practitioner in the following disciplines:

(a) General internal medicine;

(b) Family practice medicine;

(c) Pediatrics; or

(d) Obstetrics/gynecology.

(56) "Provider" means a health care practitioner or a health care facility licensed or otherwise authorized by law to provide health care services.

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

(58) "Religious organization" means an entity that is organized and operated exclusively for religious purposes and has obtained a tax exemption under § 501(c)(3) of the U.S. Internal Revenue Code.

(59) "Residential crisis services" means intensive mental health and support services that are:

(a) Provided to a child or an adult with a mental illness who is experiencing or is at risk of a psychiatric crisis that would impair the individual's ability to function in the community;

(b) Designed to prevent a psychiatric inpatient admission, provide an alternative to psychiatric inpatient admission, or shorten the length of inpatient stay;

(c) Provided out of the individual's residence on a short-term basis in a community-based residential setting; and

(d) Provided by entities that are licensed by the Department of Health and Mental Hygiene to provide residential crisis services.

(60) "Service" means a health care diagnosis, procedure, treatment, or item.

(61) "Skilled nursing facility" means an institution, or a distinct part of an institution, licensed by the Department of Health and Mental Hygiene, which is:

(a) Primarily engaged in providing:

(i) Skilled nursing care, and related services, for residents who require medical or nursing care, or

(ii) Rehabilitation services for the rehabilitation of injured, disabled, or sick persons; and

(b) Certified by the Medicare Program as a skilled nursing facility.

(62) "Small employer" has the meaning stated in Insurance Article, § 15-1201(o), Annotated Code of Maryland.

(63) "Specialty services" means care provided by a health care practitioner who is not providing primary care services.

(64) "Triple option point-of-service (triple option POS)" means a delivery system that permits a covered person to select an indemnity, preferred provider, or health maintenance organization delivery system at the time of medical need.

Md. Code Regs. 31.11.06.02

Regulation .02B amended as an emergency provision effective July 1, 1994 (21:13 Md. R. 1151); amended permanently effective November 7, 1994 (21:22 Md. R. 1876)
Regulation .02B amended as an emergency provision effective February 2, 1996 (23:4 Md. R. 270); emergency status expired August 2, 1996; amended permanently effective October 21, 1996 (23:21 Md. R. 1467)
Regulation .02B amended as an emergency provision effective April 1, 1997 (24:9 Md. R. 653); emergency status extended at 24:21 Md. R. 1444; amended permanently effective September 22, 1997 (24:19 Md. R. 1340)
Regulation .02B amended effective May 18, 1998 (25:10 Md. R. 746)
Regulation .02B amended effective February 7, 2000 (27:2 Md. R. 148); February 5, 2001 (28:2 Md. R. 106); March 18, 2002 (29:5 Md. R. 506); April 14, 2003 (30:7 Md. R. 489)
Regulation .02B amended as an emergency provision effective May 21, 2004 (31:12 Md. R. 909); amended permanently effective August 16, 2004 (31:16 Md. R. 1257)
Regulation .02B amended effective February 28, 2005 (32:4 Md. R. 412); April 10, 2006 (33:7 Md. R. 676); March 24, 2008 (35:6 Md. R. 702); April 20, 2009 (36:8 Md. R. 598)
Regulation .02B amended as an emergency provision effective September 23, 2010 (37:23 Md. R. 1608); amended permanently effective January 13, 2011 (38:1 Md. R. 13)