Sec. 10.09.69.02. Definitions

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

B. Terms Defined.

(1) "Activities of daily living" means tasks or activities that include but are not limited to bathing, feeding, toileting, dressing, and ambulation.

(2) "Business day" means any day except Saturday, Sunday, or a holiday on which State offices are closed.

(3) "Caregiver" means a willing and able individual who is trained in providing care to the participant.

(4) "Case management" means assessing, planning, coordinating, and monitoring the delivery of medically necessary health-related services.

(5) "Case management provider" means the Department's designee, or a subcontractor of the designee, which provides case management to participants assigned to it by the Department.

(6) "Case manager" means, an individual who is:

(a) A social worker with active and nationally recognized certification in case management or an RN;

(b) Employed by the Department's designee; and

(c) Assigned by the Department’s designee to manage the care of some or all of the participants.

(7) "Cause" means a significant change in medical condition such that it is no longer medically efficacious for the individual to remain in the MCO as determined by the Department.

(8) "Certified medication technician (CMT)" means an individual who:

(a) Completes a 20-hour course in medication administration approved by the Maryland Board of Nursing;

(b) Is certified by the Maryland Board of Nursing under COMAR 10.39.04; and

(c) Performs medication administration tasks delegated by a nurse in accordance with COMAR 10.27.11.

(9) "Certified nursing assistant (CNA)" means an individual who:

(a) Is certified by the Maryland Board of Nursing under COMAR 10.39.05; and

(b) Routinely performs nursing tasks delegated by a nurse in accordance with COMAR 10.27.11.

(10) "Certified nursing assistant certified as a CMT (CNA-CMT)" means an individual who:

(a) Is certified by the Maryland Board of Nursing under COMAR 10.39.05 and 10.39.04;

(b) Completes a 20-hour course in medication administration approved by the Maryland Board of Nursing; and

(c) Routinely performs nursing tasks including medication administration tasks delegated by a nurse in accordance with COMAR 10.27.11.

(11) "Chiropractor" means an individual who is licensed by the Maryland State Board of Chiropractic Examiners to practice chiropractic in Maryland.

(12) "Delegated nursing services" means nursing services provided to a participant by a CNA, CNA-CMT, HHA, or HHA-CMT under the supervision of an RN in accordance with COMAR 10.27.11.

(13) "Dental service provider" means an individual who is licensed and legally authorized to practice dentistry in the state in which the service is provided.

(14) "Department" means the Department of Health, as defined in COMAR 10.09.36.01, or its authorized agents acting on behalf of the Department.

(15) "Dietitian-nutritionist" means an individual who is licensed as a dietitian-nutritionist by the Maryland State Board of Dietetic Practice to practice dietetics in Maryland.

(16) "Early and periodic screening, diagnosis, and treatment (EPSDT)" means the provision, to individuals younger than 21 years old, of preventive health care pursuant to 42 CFR §441.50 et seq., as amended, and other health care services, diagnostic services, and treatment services that are necessary to correct or ameliorate defects, physical and mental illnesses, and conditions discovered by EPSDT screening services.

(17) "EPSDT-certified provider" means a physician, physician assistant or nurse practitioner who is certified by the Department's EPSDT program to provide well-child services according to the Department's periodicity schedule and program standards to enrollees younger than 21 years old.

(18) "EPSDT periodicity schedule" means the list approved by the Department of required or recommended preventive health care services for children and adolescents.

(19) "EPSDT services" means:

(a) Screening services provided by an EPSDT-certified provider that are required or recommended on the EPSDT periodicity schedule; and

(b) Health care services performed to diagnose, treat, or refer problems or conditions discovered during the comprehensive well-child service.

(20) "Evaluation" means a determination of the health status of a patient in a patient's home or any other appropriate setting by a licensed professional for the purpose of designing an individual plan of care, which incorporates the modalities of treatment that will promote optimal functional ability and recuperation.

(21) "Family member" means an adult who:

(a) Lives with or provides care to the participant; and

(b) Is not paid to provide the care under the REM program.

(22) "HealthChoice" means Maryland Medicaid’s Statewide mandatory managed care program as defined in COMAR 10.67.04.

(23) "Home" has the meaning stated in COMAR 10.09.53.01.

(24) "Home health agency" means an agency licensed by the Department in accordance with COMAR 10.07.10.

(25) "Home health aide (HHA)” means an individual who meets all the conditions of participation specified in:

(a) 42 CFR §484.36; and

(b) Health Occupations Article, Title 8, Annotated Code of Maryland.

(26) "Home health aide certified as a CMT (HHA-CMT)” means an individual who:

(a) Meets all the conditions of participation specified in 42 CFR §484.36 and Health Occupations Article, Title 8, Annotated Code of Maryland; and

(b) Completes a 20-hour course in medication administration approved by the Maryland Board of Nursing.

(27) "Hospital" means an institution licensed by and providing services in accordance with Health-General Article, §19-301, Annotated Code of Maryland.

(28) "Individualized education program (IEP)" means a written description of special education and related services developed by an IEP team to be implemented to meet the individual needs of a child.

(29) "Individualized family service plan (IFSP)" means a written plan for providing early intervention and other services to an eligible child and the child’s family developed by an IFSP team.

(30) "Interdisciplinary team" means the group comprised of the case manager and relevant service providers to develop the case management plan under the overall direction and coordination of the case manager, in consultation with the participant and, when applicable, the participant's family.

(31) "Intermediate care facility for individuals with intellectual disabilities or individuals with related conditions (ICF-IID)" means an institution licensed by the Department under COMAR 10.07.20 that provides health-related services or health rehabilitative services for individuals with intellectual disabilities or related conditions.

(32) "Licensed practical nurse (LPN)" means an individual licensed to practice licensed practical nursing as defined in Health Occupations Article, §8-301, Annotated Code of Maryland.

(33) "Managed care organization (MCO)" has the meaning stated in Health-General Article, §15-101, Annotated Code of Maryland.

(34) "Medical Assistance" means the program administered by the State under Title XIX of the Social Security Act which provides comprehensive medical and other health-related care for categorically eligible and medically needy individuals.

(35) "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 participant, the participant’s family, or the provider.

(36) "Medicare" means the federal program that provides benefits to the aged and disabled under Title XVIII of the Social Security Act, 42 U.S.C. §1395 et seq.

(37) "Nurse" means an individual who is licensed to practice as a registered nurse (RN) or a licensed practical nurse (LPN) in the jurisdiction in which services are provided.

(38) "Nurse practitioner" means an individual who is licensed and certified to practice as a nurse practitioner in the jurisdiction in which services are provided.

(39) "Nursing facility" has the meaning stated in COMAR 10.09.10.01B.

(40) "Nutritional counseling" means the assessment of the participant’s nutritional status and education about improving their nutritional status provided by a licensed dietitian-nutritionist.

(41) "Nutritional supplements" means enteral feeding which is medically indicated as either the sole source of nutrition or a supplement that enhances the physical well-being of the participant.

(42) "Occupational therapist" means an individual licensed by the Maryland State Board of Occupational Therapy Practice to practice occupational therapy in Maryland.

(43) "Participant" means an eligible individual who is enrolled in the Program.

(44) "Physician" means an individual who is licensed or otherwise legally authorized to practice in the jurisdiction in which the services are rendered.

(45) "Physician assistant" means an individual who is licensed to practice medicine with physician supervision as stated in the Health Occupations Article, §§15-301(d) and (e) and 15-302, Annotated Code of Maryland.

(46) "Plan of care" means the document which governs a participant's care management which includes the:

(a) Case management assessment report;

(b) Interdisciplinary plan of care; and

(c) Case management plan.

(47) "Preauthorization" means the approval required from the Department or its designee before specific services may be rendered.

(48) "Primary care provider (PCP)" means a physician, physician assistant, or nurse practitioner who is the primary coordinator of care for the participant, and whose responsibility it is to provide accessible, continuous, comprehensive, and coordinated health care services covering the full range of benefits required by the Maryland Medicaid Managed Care Program, as specified in COMAR 10.67.06.

(49) "Private duty nursing" means skilled nursing services for participants, who require more individual and continuous care than is available under the home health program, which are provided by a registered nurse (RN) or a licensed practical nurse (LPN), in a participant’s home or another setting when normal life activities take the participant outside his or her home.

(50) "Program", unless the context indicates otherwise, has the meaning stated in COMAR 10.09.36.01B.

(51) "Progress note" means a signed and dated written notation by the RN, LPN, CNA, CNA-CMT, HHA, or HHA-CMT, which:

(a) Summarizes facts about the care given and the participant's response during a given period of time;

(b) Specifically addresses the established goals of treatment;

(c) Is consistent with the participant's plan of care; and

(d) Is written during the course of care.

(52) "Provider" means an individual, agency, or facility, which is enrolled in the Program through an agreement with the Department, and has been identified as a Program provider by the issuance of a provider number.

(53) "Rare and expensive case management (REM)" means a Maryland Medical Assistance program that provides case management services and optional services to eligible individuals with specific rare and expensive conditions.

(54) "Rare and expensive condition" means a medical diagnosis or condition identified in Regulation .16 of this chapter.

(55) "Registered nurse (RN)" means an individual licensed to practice registered nursing as defined in Health Occupations Article, §8-301, Annotated Code of Maryland.

(56) "REM optional services" means the services listed in Regulations .09 and .10 of this chapter, which meet the general requirements under Regulation .08 of this chapter.

(57) "Residential service agency" means an agency licensed by the Department in accordance with COMAR 10.07.05.

(58) "Residential treatment center" means any institution which falls within the jurisdiction of Health-General Article, §19-308, Annotated Code of Maryland, and is licensed as required by COMAR 10.07.04 or other applicable standards established by the state in which the service is provided.

(59) "Social worker" means an individual who is licensed by the Maryland State Board of Social Work Examiners to practice social work in Maryland.

(60) "Speech-language pathologist" means an individual who is licensed by the Maryland Board of Examiners for Audiologists, Hearing Aid Dispensers, and Speech-Language Pathologists to practice speech-language pathology in Maryland.