Section He-M 520.01 - Definitions(a) "Administrator" means the person who oversees the special medical services (SMS) section of the bureau of developmental services and its contractors.(b) "Allowable deduction" means the amount subtracted from a household's annual gross income, which represents expenses paid by a household member whose income is counted when determining financial eligibility, and is limited to: (1) Monthly court-ordered alimony payments;(2) Monthly court-ordered child support payments;(3) Monthly household child care expenses when both parents are employed or when one parent is employed and the other parent is functionally unable to care for the child;(4) Monthly private health and or dental insurance premiums;(5) Monthly food deduction for a household member with a specialty diet recommended by a licensed clinician, not to exceed $400 per month;(6) Annual deduction of $1,000 for each additional current recipient in the household, not to exceed $3,000 per household; and(7) Annual single head of household deduction not to exceed $1,000.(c) "Annual gross income" means the sum of all income received by the household as listed below: (1) Including, but not limited to: a. Wages, salaries, tips, commissions before deductions;b. Net earnings or Schedule C from self-employment, partnership or business;i. Government- or state-issued benefits, such as: 1.Public assistance;
2.State financial grants;
3.Social security benefits;
4.Unemployment compensation;
5.Workers compensation; and
6.Veterans Administration benefits;
j. Alimony or child support received;k. One time insurance payments or compensation for injury or death received;l. Medical settlements, and m.Non-medical trusts established for the applicant or any household member; and
(2) Excluding income from sale of property, tax refunds, gifts, scholarships, trainings or stipends.(d) "Applicant" means the person for whom the application is made and who, if determined to be eligible, becomes the recipient.(e) "Bureau" means the bureau of developmental services within the department of health and human services.(f) "Children with special health care needs" means "children with special health care needs" as defined in RSA 132:13, II, namely "children who have or are at risk for chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type or amount beyond that required by children generally."(g) "Chronic medical condition" means an ongoing physical, developmental, behavioral, or emotional illness or disability, which:(1) Is expected to last one year or longer;(2) Requires extended sequential, medical, surgical or rehabilitative intervention as determined by a diagnostic evaluation performed by a licensed clinician who is board eligible or board certified;(3) Is one of the following: b. Inborn error of metabolism;c. Pulmonary or respiratory condition;d. Genitourinary disorder;e. Musculoskeletal condition;f. Blindness as defined by 42 USC 416(i) (1) ;g. Deafness as defined by 34 CFR 300.7(c) (3) ;i. Developmental delay from birth to 6 years of age;j. Limb deficiency, including post amputation;k. Cranial facial anomaly;m. Digestive system condition;n. Endocrine abnormality, excluding conditions noted in (4) b. below;o. Cardiovascular condition;r. Hematological disorder;s. Immunological disorder;t. Malignant neoplastic disease; oru. Skin disorder as listed in 20 CFR 404, Subpart P, Appendix 1; and(4) Is not one of the following: a. An acute or recurrent condition encompassing the area of routine medical care;b. A hormonal condition for which long-term replacement therapy is required, such as short stature; andc. A dental or orthodontic condition except as related to conditions in (3) h. or (3) k. above.(h) "Date of application" means the date stamped on the SMS application as indication that the application was received by SMS.(i) "Department" means the New Hampshire department of health and human services.(j) "Durable medical equipment" means a non-disposable device that: (1) Can withstand repeated use;(2) Is appropriate for in-home use for the treatment of an acute or chronic medically diagnosed health condition, illness, or injury; and(3) Is not useful to a person in the absence of an acute or chronic medically diagnosed health condition, illness, or injury.(k) "Federal poverty guidelines" means the annual revision of the poverty income guidelines for the United States Department of Health and Human Services as published in the Federal Register (74 FR 4199) .(l) "Financial assistance" means a payment made by SMS in whole or in part for health-related services.(m) "Health-related service" means a service related to the treatment of a recipient's chronic medical condition, such as, but not limited to: (3) Hospitalizations; and(4) Durable medical equipment or medical supplies.(n) "Household" means one or more children under the age of 21 and the adults who are directly related to them by blood, by marriage, or by adoption or who assist in the personal care and rearing of an applicant, all of whom reside in the same home.(o) "Household income" means the annual gross income of the applicant and the adults included in the household.(p) "Medicaid" means the Title XIX and Title XXI programs administered by the department that makes medical assistance available to eligible individuals.(q) "Medical liability" means a household's accrued medically related debt or medical expenses paid within the past 12 months that are not covered by third party liability insurance (TPL), including, but not limited to: (1) Office visit or prescription co-payments;(2) Emergency department visits;(3) Insurance or COBRA payments;(4) TPL required deductibles; and(5) Other non-covered medical services.(r) "Medically necessary" means health care services and items that a licensed health care provider, exercising prudent clinical judgment, would provide, in accordance with generally accepted standards of medical practice, to a recipient for the purpose of evaluating, diagnosing, preventing, or treating an acute or chronic illness, injury, disease, or its symptoms, and that are: (1) Clinically appropriate in terms of type, frequency of use, extent, site, and duration;(2) Consistent with the established diagnosis or treatment of the recipient's illness, injury, disease, or its symptoms;(3) Not primarily for the convenience of the recipient or the recipient's family, caregiver, or health care provider;(4) No more costly than other items or services which would produce equivalent diagnostic, therapeutic, or treatment results as related to the recipient's illness, injury, disease, or its symptoms;(5) Not experimental, investigative, cosmetic, or considered alternative by current medical practices;(6) Not duplicative in nature; and(7) Proven to be safe and effective, as documented in medical peer review literature.(s) "Medical supplies" means consumable or disposable items appropriate for in-home use for relief or treatment of a specific medically diagnosed health condition, illness, or injury.(t) "Net income" means the household's annual gross income minus any allowable deductions, defined in (b) above.(u) "Provider" means an individual who provides a medical, therapeutic or other direct care service within his or her office, agency, practice, or during a home visit.(v) "Recipient" means a child with special health care needs who has met the established criteria as described in He-M 520.02.(w) "Resource(s) " means any funds available to the household, minus any penalties for withdrawal, including, but not limited to: (3) Certificates of deposit;(4) Investments, such as mutual funds, stocks, and bonds; and(x) "Special medical services (SMS) " means the administrative section of the bureau of developmental services that operates the Title V program for children and youth with special health care needs.(y) "Spend down" means the amount of a household's net income which exceeds 185% of that household's federal poverty guideline amount.(z) "Third party" means any private insurer, health maintenance organization, hospital service organization, medical service or health services corporation, governmental agency, or any individual, organization, entity, or agency which is authorized or under legal obligation to pay for medical services for an recipient. (aa) "Title V" means the program described in Title V of the Social Security Act. SMS administers the NH children with special health care needs component of Title V as part of the Health Resources and Services Administration, United States Department of Health and Human Services.(ab) "Title XIX" means the joint federal-state program described in Title XIX of the Social Security Act and administered in New Hampshire by the department under the Medicaid program.(ac) "Title XXI" means the joint federal-state program described in Title XXI of the Social Security Act and administered in New Hampshire by the department under the Medicaid programN.H. Admin. Code § He-M 520.01
#9748-A, eff 7-1-10; amd by #10138, eff 7-1-12
Amended by Volume XXXVIII Number 28, Filed July 12, 2018, Proposed by #12557, Effective 6/26/2018, Expires 12/24/2018.The amended version of this section by New Hampshire Register Volume 39, Number 02, eff.12/28/2018 is not yet available.