Sec. 10.09.43.02. Definitions

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

B. Terms Defined.

(1) “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).

(2) "Applicant" means a child or the child's representative who has filed a written, telephonic, or electronic application for health coverage in an Insurance Affordability Program to the Department or its designee but has not received final action.

(3) "Application" means the filing of a written, telephonic, or electronic signed application for health coverage in an Insurance Affordability Program to the Department or its designee.

(4) "Application date" means the date on which a written, telephonic, or electronic signed application is received by the Department or its designee.

(5) "Authorized representative" has the meaning stated in COMAR 10.01.04.12.

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

(7) “Designee" means any entity designated to act on behalf of the Department such as:

(a) Baltimore City or a county social services department under the supervision of the Department of Human Services;

(b) Baltimore City Health Department and its subgrantees, or a county health department; and

(c) The Maryland Health Benefit Exchange

(8) "Determination" means a decision regarding an applicant's eligibility for MCHP Premium.

(9) "Eligible individual" means a child who meets all nonfinancial eligibility requirements to participate in MCHP under COMAR 10.09.11 and whose family income is above 200 percent but at or below 300 percent of the federal poverty level.

(10) "Family contribution" means the portion of the premium cost paid for an eligible individual to enroll and participate in MCHP Premium.

(11) "Family member" means an individual living with the applicant whose income is counted, or would be counted as family income under Regulation .07 of this chapter.

(12) "Federal poverty level (FPL)" means the non-farm income official poverty level as defined by the Office of Management and Budget and revised annually in accordance with §673(2) of the Omnibus Budget Reconciliation Act of 1981.

(13) "Group health plan" has the meaning stated in 42 U.S.C. §300gg-91.

(14) "Hardship" means unreasonable financial adversity or misfortune.

(15) "Health insurance coverage" has the meaning stated in 42 U.S.C. §300gg-91.

(16) "Inpatient services" means services received by a recipient while in a medical institution, birthing center, or clinic for which Medical Assistance is provided.

(17) "Institution for mental disease (IMD)" has the meaning stated in COMAR 10.09.62.01B(78)(a).

(18) “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) An optional State basic health program established under §1331 of the Affordable Care Act;

(d) A program that makes available to qualified 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; or

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

(19) “MAGI” means modified adjusted gross income, as calculated for purposes of determining eligibility for insurance affordability programs under the Affordable Care Act.

(20) “MAGI Exempt Coverage Group” means coverage groups such as Aged, Blind, Disabled; Categorically Needy; and Medically Needy as defined under COMAR 10.09.24.02, whose eligibility is not determined by MAGI.

(21) "Managed care organization (MCO)" means:

(a) A certified health maintenance organization that is authorized to receive Medical Assistance prepaid capitation payments; or

(b) A corporation that:

(i) Is a managed care system that is authorized to receive Medical Assistance prepaid capitation payments;

(ii) Enrolls only program recipients, individuals, or families served under the Maryland Medicaid Managed Care Program; and

(iii) Is subject to the requirements of Health-General Article, §15-102.4, Annotated Code of Maryland.

(22) "Maryland Children's Health Program (MCHP)" means the program established in Health-General Article, §15-301(b)(1), Annotated Code of Maryland, to provide comprehensive medical care and other health care services to certain children.

(23) “Maryland Health Benefits 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.

(24) "Maryland Medicaid Managed Care Program" has the meaning stated in COMAR 10.09.62.01B(88).

(25) "MCHP Premium" means the program established in Health-General Article, §15-301.1 et seq., Annotated Code of Maryland, to provide access to health coverage to eligible individuals through managed care organizations (MCOs) under MCHP.

(26) "Medical institution" means an institution that:

(a) Is organized to provide medical care, including nursing and convalescent care;

(b) Has the necessary professional equipment and facilities to manage the medical, nursing, and other health needs of a patient on a continuing basis in accordance with accepted standards;

(c) Is authorized under State law to provide medical care; and

(d) Is staffed by medical and nursing professionals.

(27) "Period under consideration" means the specific months that are assessed in order to determine eligibility for MCHP Premium.

(28) Public Institution.

(a) "Public institution" means an:

(i) Institution that is the responsibility of a government unit or over which a government unit exercises administrative control; or

(ii) Establishment that furnishes, in single or multiple facilities, food, shelter, and some treatment or services to four or more individuals unrelated to the proprietor.

(b) "Public institution" does not include a medical institution, a skilled nursing facility, or a publicly operated community residence that serves fewer than 17 residents.

(29) "Qualified alien" means an individual who:

(a) Has been fully admitted for permanent residence in the United States under the Immigration and Nationality Act (INA);

(b) Has been granted asylum in the United States as a refugee under §208 of the INA;

(c) Has been admitted into the United States as a refugee under §207 of the INA;

(d) Has been paroled into the United States under §212(d)(5) of the INA for a period of at least 1 year;

(e) Has had deportation withheld under §243(h) of the INA;

(f) Has been granted conditional entry into the United States under §203(a)(7) of the INA which was in effect before April 1, 1980;

(g) Is a documented or undocumented immigrant who has been battered or subjected to extreme cruelty by the individual's U.S. citizen or lawful permanent resident spouse or parent, or by a member of the spouse's or parent's family residing in the same household as the alien, if:

(i) The spouse or parent consented to, or acquiesced in, the battery or cruelty;

(ii) The immigrant has filed a Violence Against Women Act (VAWA) immigration case or a family-based visa petition with INS; and

(iii) In the opinion of the agency providing benefits, there is a substantial connection between the battery or cruelty and the need for the benefits to be provided;

(h) Is a victim of a severe form of trafficking who has been subjected to:

(i) Sex trafficking, if the act is induced by force, fraud, or coercion, or if the individual induced to perform the act is younger than 18 years old; or

(ii) Involuntary servitude;

(i) Is a member of a federally recognized Indian tribe, as defined in 25 U.S.C. §450b(e); or

(j) Is an American Indian born in Canada to whom §289 of the Immigration and Nationality Act applies.

(30) "Recipient" means a child younger than 19 years old who is certified as eligible for MCHP Premium.

(31) "Redetermination" means a determination regarding the continuing eligibility of a recipient.

(32) "Representative" means:

(a) A parent or parents living with the applicant;

(b) The applicant's guardian; or

(c) The applicant's authorized representative.

(33) "Title XXI" means the title of the Social Security Act through which funding is provided, in part, for MCHP Premium.