Sec. 10.01.04.01. Definitions

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

B. Terms Defined.

(1) “Administrative law judge” means an individual appointed by the Chief Administrative Law Judge under State Government Article, §9-1604, Annotated Code of Maryland, or designated by the Chief Administrative Law Judge under State Government Article, §9-1607, Annotated Code of Maryland, to adjudicate contested cases at the Maryland Office of Administrative Hearings.

(2) “Action by an MCO” 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;

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

(e) Failure 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.

(3) “Affordable Care Act” means the Patient Protection and Affordable Care Act of 2010 (Pub.L. 111-148), as amended by the Health Care and Education Reconciliation Act of 2010 (Pub.L. 111-152), as amended by the Three Percent Withholding Repeal and Job Creation Act (Pub.L. 112-56).

(4) “Appellant” means any individual who requests a fair hearing for the reasons specified in Regulation .02 of this chapter or that individual’s authorized representative.

(5) “Authorized representative” has the same meaning as in Regulation .12.

(6) “Consolidated Services Center” means a call center operated by the Maryland Health Benefit Exchange to assist consumers who apply for, or participate in, Insurance Affordability Programs offered through the Maryland Health Connection.

(7) “Delegate agency” means the:

(a) Department of Human Services and its affiliated local departments which, under contractual agreements with the Department, determine initial and continuing eligibility in the Program; and

(b) Maryland Health Benefit Exchange and its designated affiliates.

(8) “Department” means the Maryland Department of Health, the single state agency which, pursuant to Title XIX of the Social Security Act, implements fair hearing requirements for Program applicants and recipients.

(9) “Insurance affordability program” means a program that is one of the following:

(a) The Maryland State Medicaid program;

(b) The Maryland Children’s Health Insurance Program (CHIP), including the program known as Maryland Children’s Health Program (MCHP) Premium;

(c) A State basic health program established under §1331 of the Affordable Care Act;

(d) A program that makes available to eligible individuals coverage in a qualified health plan through the Maryland Health Benefit Exchange with advance payments of the premium tax credit established under §36B of the Internal Revenue Code; and

(e) A program that makes available to eligible individuals coverage in a qualified health plan through the Maryland Health Benefit Exchange with cost-sharing reductions established under §1402 of the Affordable Care Act.

(10) “Maryland Health Benefit Exchange” means the unit of State government that determines initial and continuing eligibility for the MAGI-based insurance affordability programs, including, by delegation, certain eligibility in the Program.

(11) “Maryland Health Connection” means the electronic eligibility system maintained by the Maryland Health Benefit Exchange.

(12) “MCO” means a managed care organization qualified to participate in the Program under COMAR 10.67.04.

(13) “Program" means the Department’s Medical Assistance Program.