Sec. 10.09.23.01. Definitions

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

B. Terms Defined.

(1) "American Academy of Pediatric Dentists" means the membership organization representing the specialty of pediatric dentistry.

(2) "Department" means the Maryland Department of Health, the single State agency designated to administer the Maryland Medical Assistance Program or its designee.

(3) "Early and Periodic Screening, Diagnosis, and Treatment (EPSDT)" means comprehensive and preventive health care pursuant to 42 CFR §441.50 et seq., as amended, and other diagnostic and treatment services that are necessary to correct or ameliorate defects and physical and mental illnesses in children younger than 21 years old.

(4) "EPSDT periodicity schedule" means the State-specified listing of the minimum required and recommended preventive health screening services that are to be performed at specified ages.

(5) "EPSDT screen" means the full scope of comprehensive well-child screening procedures, required by the State periodicity schedule that a recipient receives at a given age.

(6) "EPSDT screening provider" means a physician or nurse practitioner certified by the Department to provide EPSDT screens.

(7) "EPSDT treatment provider" means a health care provider that is enrolled to provide services that are not otherwise covered for individuals 21 years old or older.

(8) "EPSDT treatment services" means health care services that are covered for children younger than 21 years old that are not otherwise covered for individuals 21 years old or older.

(9) "Environmental lead investigation" means an inspection of the primary dwelling of a recipient that results in a report characterizing the hazards associated with identified lead-containing substances.

(10) Foster Care Child.

(a) "Foster care child" means a recipient who is in the care and custody of the Department of Human Services.

(b) "Foster care child" includes children who receive kinship care.

(11) "Health care practitioner" means an individual who is licensed, certified, or otherwise authorized under Health Occupations Article, Annotated Code of Maryland, or under the laws of the District of Columbia or another state, to provide health care services.

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

(13) "Healthy Kids Program" means the unit within the Maryland Medical Assistance Program that develops guidelines for and monitors EPSDT well-child screening services and certifies EPSDT screening providers.

(14) "Intermediate care facility" means a facility that provides a planned regimen of 24-hour professionally directed evaluation, observation, medical monitoring, and addiction treatment in an inpatient setting.

(15) "Jurisdiction" means a state or the District of Columbia.

(16) "Managed Care Organization (MCO)" has the meaning stated in Health-General Article, §15-101, Annotated Code of Maryland.

(17) "Medical Assistance Program" has the meaning stated in COMAR 10.09.36.01.

(18) "Medically necessary" means that the service or benefit is:

(a) Directly related to diagnostic, preventive, curative, palliative, rehabilitative, or ameliorative treatment of an illness, injury, disability, or health condition;

(b) Consistent with current accepted standards of good medical practice;

(c) The most cost-efficient service that can be provided without sacrificing effectiveness or access to care; and

(d) Not primarily for the convenience of the consumer, family, or provider.

(19) "Plan of treatment" means a written plan, updated at a minimum of every 6 months for ongoing care, to address identified problems to include:

(a) Diagnoses;

(b) Treatment goals;

(c) Frequency of visits;

(d) Duration of treatment; and

(e) Prognosis.

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

(21) "Preventive services" means primary health care designed to:

(a) Promote normal growth and development; and

(b) Detect, ameliorate, or delay diseases at an early stage before complications or serious disabilities develop.

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

(23) "Recipient" means a person younger than 21 years old who is determined eligible for, and is receiving, Medical Assistance benefits as provided in COMAR 10.09.24 or 10.09.11.

(24) "Screening services" means the EPSDT preventive health care and laboratory procedures required at specified ages by the State periodicity schedule.

(25) "Third-party payers" means insurers and other entities obligated either legally or contractually to pay for or to reimburse the recipient for service covered in this chapter.

(26) "Vaccines for Children Program" means the federal program that provides specific childhood vaccines to health care providers, at no cost, for administration to recipients younger than 19 years old.