Sec. 10.02.01.03. Definitions

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

B. Terms Defined.

(1) "Charge" means the dollar amount set or approved by the Secretary for each clinic visit, day of care, hour, procedure, or other unit of service, as specified in the Schedule of Charges, which is the single rate to be charged all recipients of service, estates, third-party payers and insurers, or chargeable persons.

(2) "Chargeable person" means:

(a) Any responsible relative of a recipient of services;

(b) Except for a recipient of services, any other person who is legally responsible for the cost of care of the individual; and

(c) Any person who maintains a policy of health insurance under which a recipient of services is insured.

(3) "CPT" means a Current Procedural Terminology listing descriptive terms and identifying codes for reporting clinical services and procedures.

(4) "Daily per capita inpatient cost of care" means the cost of providing a day of care at a State-operated inpatient facility.

(5) "Department" means the Maryland Department of Health.

(6) "Division" means the Cost Accounting and Reimbursement Division of the Department.

(7) Federal Indirect Cost.

(a) "Federal indirect cost" means the cost the federal government recognizes as the costs of operating an inpatient facility that are not directly attributable to the operation of the inpatient facility.

(b) "Federal indirect cost" includes costs which benefit the Department as a whole and the inpatient facility indirectly, but cannot be readily identified with the inpatient facility without disproportionate effort.

(8) "Fee" means the charge or that part of the charge after an ability-to-pay determination or the elimination of disallowed costs by any third-party payer or insurer.

(9) "Health service" means any service for which a charge is established that is provided to any person, client, or resident in or by a unit of the Department, political subdivision, or grantee which is deemed appropriate by that unit to the care and treatment of an individual under its care or enrolled in its program.

(10) "Local health department" means a governmental agency that:

(a) Is funded wholly or partly by the Department;

(b) Assumes legal and financial responsibility and accountability both for funds awarded by the Department and for the provision of health services; and

(c) Operates under the general direction of a health officer who is duly appointed by and reports to the Secretary pursuant to Health-General Article, Title 3, Subtitle 3, Annotated Code of Maryland.

(11) "Medical Assistance " means the Maryland Medical Assistance Program, which is administered by the State and pays the medical bills of certain needy and low-income individuals pursuant to Health-General Article, Title 15, Subtitle 1, Annotated Code of Maryland, and 42 U.S.C. Chapter 7, Subchapter XIX.

(12) "Non-inpatient related costs" means costs at a State-operated facility which do not relate to the delivery of inpatient care.

(13) “Out-of-network services” means health services that are provided to a recipient of services which are not subject to payment at a negotiated rate under an agreement between the provider and a public or private third-party payer or insurer for the recipient of services.

(14) "Private provider" means:

(a) All private or non-local health department alcohol and drug abuse service providers funded by the Behavioral Health Administration;

(b) Adult day care service providers funded by the Office of Health Services; and

(c) Family planning service providers funded by the Prevention and Health Promotion Administration.

(15) "Provider" means a facility operated by:

(a) The Department;

(b) A local health department; or

(c) A private provider.

(16) Recipient of Services.

(a) "Recipient of services" means an individual who receives care, maintenance, treatment, or support from a facility, clinic, local health department, program, or other entity that is operated or funded wholly or partly by the Department.

(b) "Recipient of services" includes, but is not limited to an individual:

(i) In a public facility under Health-General Article, Title 10, Annotated Code of Maryland;

(ii) In a facility or Veterans' Administration hospital for comprehensive evaluation under Health-General Article, Title 7, Annotated Code of Maryland;

(iii) In a residential public facility or a facility from which this State obtains residential care under Health-General Article, Title 7, Annotated Code of Maryland; and

(iv) To whom juvenile screening or treatment services are provided under Human Services Article, §9-227(b)(1)(ii), Annotated Code of Maryland.

(17) "Responsible relative" means one or more of the following who are legally responsible for the cost of care of a recipient of services:

(a) The spouse of the recipient of services;

(b) A parent of the recipient of services who is a minor; and

(c) An adult child of the recipient of services.

(18) "Schedule of charges" means a list of charges for health services as determined pursuant to instructions provided by the Division and this chapter, and set or approved by the Secretary.

(19) "Secretary" means the Secretary of Health.

(20) "Shared costs" means costs arising out of shared functions between two State-operated inpatient facilities.

(21) Statewide and Departmental Overhead.

(a) "Statewide and departmental overhead" means those costs incurred by the State and allocated to the facility which benefit the State-operated inpatient facility's operation as a whole, but are not related to the delivery of direct patient care.

(b) "Statewide and departmental overhead" includes costs that are usually incurred for a common purpose benefiting the State-operated inpatient facility which are not readily identified with the State-operated inpatient facility without disproportionate effort, such as Statewide accounting, purchasing, and personnel functions.

(22) "Third-party payer disallowance" means the difference between the charge and the payment amount authorized by an agreement between a provider and a public or private third-party payer or insurer.