Sec. 10.09.08.01. Definitions

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

B. Terms Defined.

(1) "All-inclusive cost-per-visit rate" means the rate that is established for Federally Qualified Health Centers (FQHCs) which includes all services that are rendered to a participant on a given date of service.

(2) "Clinic services" means preventive, diagnostic, therapeutic, rehabilitative or palliative items or services furnished by or under the direction of a licensed physician or dentist either in a freestanding clinic, or outside the clinic if the:

(a) Recipient does not reside in a permanent dwelling or have a fixed home or mailing address; and

(b) Service is provided by clinic personnel.

(3) "Dental services" means emergency, preventive, or therapeutic services for oral diseases which are administered by or under the general supervision of a dentist in the practice of the profession.

(4) "Department" means the Maryland Department of Health, the State agency designated to administer the Maryland Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.

(5) "Direct supervision" means that a physician is:

(a) Physically present in the same area of a facility as a nonphysician providing the services required in the physician's plan of care unless standing orders and protocols are provided for physician extenders such as nurse practitioners, nurse midwives, and physician assistants; and

(b) Readily available for consultation.

(6) "Early and periodic screening, diagnosis and treatment (EPSDT)" means the provision of preventive health care, including medical and dental services under 42 CFR §441.50 et seq. (1981), and COMAR 10.09.23 for assessing growth and development and for detecting and treating health problems in Medical Assistance enrollees younger than 21 years old.

(7) "Extraordinary one-time circumstance" means a highly unusual event beyond the control of a federally qualified health center (FQHC), such as an earthquake or flood, which results in an increase in the FQHC's operating costs.

(8) Freestanding Clinic.

(a) “Freestanding clinic” means a health care facility that is not licensed as a hospital, part of a hospital, or nursing home and is not administratively part of a physician's, dentist's, or osteopath's office, but which has a separate staff functioning under the direction of a clinic administrator or health officer and is organized and operated to provide ambulatory health services.

(b) “Freestanding clinic” does not include a clinic or clinic site located in a recipient's home.

(9) Home.

(a) “Home” means the house, apartment, trailer, licensed health care facility, or other dwelling in which a recipient resides.

(b) “Home” does not include dedicated commercial space in a high-rise apartment building.

(10) "Hospital" means an institution which:

(a) Falls within the jurisdiction of Health-General Article, Title 19, Subtitle 3, Annotated Code of Maryland; and

(b) Is licensed under COMAR 10.07.01 or is licensed by the state in which the service is provided.

(11) "Medicare" means the insurance program administered by the federal government under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.

(12) "Mental health services" means those services described in COMAR 10.09.70.10C that are rendered to treat an individual for a diagnosis as set forth in COMAR 10.09.70.10A.

(13) "Out-stationed eligibility worker" means an employee of a federally qualified health center who is responsible for the receipt and initial processing of applications for Medical Assistance for pregnant women, and children born after September 30, 1983, who are younger than 19 years old in accordance with 42 CFR 435.904.

(14) "Participant" means an individual who is certified as eligible for, and is receiving, Medical Assistance benefits.

(15) "Patient care policies" means written policies and protocols, describing patient care practices and procedures:

(a) Established for the clinic's operation by a group of professional personnel, including one or more physicians affiliated with the freestanding clinic; and

(b) Approved by the signature of the clinic's medical director.

(16) "Plan of care" means a written plan for the evaluation, treatment, and follow-up of each patient, maintained in the individual's medical record and containing, at a minimum, the following information where applicable:

(a) Patient identification data, dates of service, and medical history;

(b) Chief complaint, physical findings, and presumptive diagnosis;

(c) Plan of treatment;

(d) Results of all laboratory tests and diagnostic radiology procedures ordered and performed;

(e) Referral to consultant specialist and consultants report;

(f) Medications administered and prescribed, with notations indicating quantity, strength, dosage, and refill instructions; and

(g) Final diagnoses, other therapy ordered, and follow-up plan.

(17) "Preauthorization" means the approval required from the Department or its designee before services can be rendered.

(18) "Primary care services" means those medical care services which address a patient's general health needs, including the coordination of the individual's health care with the responsibility for the:

(a) Prevention of disease;

(b) Promotion and maintenance of health;

(c) Treatment of illness; and

(d) When appropriate, referral to other specialists for more intensive care.

(19) "Program" means the Maryland Medical Assistance Program.

(20) "Provider" means a freestanding clinic which, through appropriate agreement with the Department, has been identified as a Program provider by the issuance of a provider number.

(21) "Rural health clinic" means a facility that meets the definition of a rural health clinic as contained in 42 CFR §491.2(f).

(22) "Scope of services change" means a permanent and substantial change in the services or practices of a FQHC that results from one or more of the following:

(a) The addition or deletion of a Medicaid-covered FQHC service as described in §1905(a)(2)(B) and (C) of the federal Social Security Act;

(b) The addition, elimination, expansion, or reduction of a Health Resources and Service Administration (HRSA) approved FQHC practice location; or

(c) A change in costs for out-stationed eligibility worker services.