Md. Code Regs. 10.09.44.01

Current through Register Vol. 51, No. 22, November 1, 2024

Section 10.09.44.01 - Definitions

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

B. Terms Defined.

(1) "Amount that would otherwise have been paid (AWOP)" means the amount the Program expects to have paid for services for a PACE participant under the State Plan had the participant not enrolled under the PACE program.

(2) "Community spouse" means an individual who:

(a) Lives in the community outside a long-term care facility;

(b) Is not determined to meet the criteria for participation for:

(i) PACE under this chapter; or

(ii) A waiver under § 1915(c) of the Social Security Act; and

(c) Is married to an institutionalized spouse.

(3) "Continuous period of institutionalization" means at least 30 consecutive days of institutional care in a long-term care facility.

(4) "Contract" means a written agreement between a PACE provider and a third party under which the third party agrees to perform one or more of the PACE provider's obligations under this chapter or the PACE agreement.

(5) "Capitation payment" means the sum of money paid in advance on a monthly per capita basis to a PACE provider by the Department on a participant's behalf for the PACE provider benefit package specified in the PACE program agreement.

(6) "Centers for Medicare and Medicaid Services (CMS)" means the federal administering agency for the Medicare and Medicaid program benefits in PACE.

(7) "Contractor" means an entity with which the PACE provider has a contract agreement.

(8) "Contract year" means the term of a PACE Program Agreement, which is a calendar year, except that a PACE provider's initial contract year may be from 12 to 23 months, as determined by CMS.

(9) "Department" means the Maryland Department of Health and Mental Hygiene, as defined in COMAR 10.09.36.01B, or its authorized agents acting on its behalf.

(10) "Eligible person" means any person who meets the eligibility requirements for enrollment in the PACE program as specified in the PACE program agreement and Regulation .05 of this chapter.

(11) "Emergency medical condition" means a medical condition characterized by sudden onset and symptoms of sufficient severity, including severe pain, that the absence of immediate attention could reasonably be expected by a prudent lay person, who possesses an average knowledge of health and medicine, to result in:

(a) Placing the individual's health in serious jeopardy;

(b) Serious impairment to bodily functions; or

(c) Serious dysfunction of any bodily organ or part.

(12) "Emergency services" means health care services that are:

(a) Covered under the PACE provider benefit package;

(b) Provided to a participant with an emergency medical condition;

(c) Rendered by entities who are not employees or agents of the PACE provider and with whom the PACE provider does not have a contract; and

(d) Provided in a hospital emergency facility.

(13) "Insolvency" means that the entity's net tangible equity or fund balance is negative and results from total program expenditures exceeding total program revenues to date.

(14) "Institutionalized spouse" means an individual who is married to a community spouse and who is:

(a) An inpatient in a long-term care facility with a length of stay exceeding 30 days; or

(b) Determined to meet the criteria for participation for:

(i) PACE under this chapter; or

(ii) A waiver under § 1915(c) of Title XIX of the Social Security Act.

(15) "Long-term care facility" means a nursing facility, intermediate care facility for individuals with intellectual disabilities or persons with related conditions (ICF/IID), chronic hospital, tuberculosis hospital, or psychiatric hospital.

(16) "Medical Assistance Program" means the Maryland Medical Assistance Program, as defined in COMAR 10.09.36.01B.

(17) "Medically necessary" means directly related to diagnostic, preventive, curative, palliative, or rehabilitative treatment.

(18) "Medicare" means the federal program that provides benefits to aged or disabled individuals under Title XVIII of the Social Security Act.

(19) "PACE enrollment limit" means the maximum number of Medicaid participants permitted to the PACE provider as declared in the State Certification Page of the CMS PACE provider application.

(20) "PACE benefit package" means a prepaid, comprehensive package of all the health care services to which a PACE provider's participants are entitled under the State Plan when the services are medically necessary and appropriate.

(21) "PACE center" means a facility operated by a PACE provider where primary care is furnished to participants.

(22) "PACE provider" means an entity that is approved by the Department and CMS to provide the PACE benefit package covered under this chapter to Medical Assistance participants.

(23) "PACE program agreement" means a written, signed agreement between the Department, CMS, and the PACE provider, which specifies the terms of the relationship between the Department and the PACE provider.

(24) "Participant" means an eligible person who voluntarily enrolls and enters into an agreement with a PACE provider or an eligible person who is enrolled by a legal representative.

(25) "Primary care" means health care services that address an individual's general health needs, including the coordination of the individual's health care, with the responsibility for the prevention of disease, promotion and maintenance of health, treatment of illness, maintenance of the individual's health records, and referral for medically necessary and appropriate specialty care.

(26) "Primary care provider" means a practitioner who provides a participant's primary care services and is the primary coordinator of all other health care services for the participant, responsible for providing or assuring access to continuous, comprehensive, and coordinated health care services covered in the PACE benefit package.

(27) "Professional standards" means professional requirements set forth in the Annotated Code of Maryland or by the national accrediting body for a practitioner's profession.

(28) "Program" means the Medical Assistance Program, as defined in COMAR 10.09.36.

(29) "Programs of All-Inclusive Care for the Elderly (PACE)" means a jointly administered capitated Medicare/Medicaid program providing medical and long term care services to nursing home eligible, frail, elderly recipients.

(30) "Provider" means a PACE provider.

(31) "Provider agreement" is the agreement between the PACE provider and the Department.

(32) "Quality Assurance and Performance Improvement Plan (QAPI)" means a document or series of documents that set forth a PACE provider's strategy for systematically monitoring, evaluating, and improving all facets of operations including, but not limited to, clinical health care delivery, participant assistance and outreach services, and administrative services.

(33) "Recipient" means an individual who is certified by the Department as eligible to receive Medical Assistance Program benefits, as stated in COMAR 10.09.36.

(34) "Secretary" means the Secretary of Health and Mental Hygiene.

(35) "Service area" means a defined geographic area selected by the PACE provider and approved by the Department in the PACE program agreement, in which the complete PACE benefit package is available to all the PACE provider's participants, and beyond which the PACE provider is restricted from directly marketing its services.

(36) "Services" includes both items and services.

(37) "State Plan" means the plan for the Medical Assistance Program as submitted by the Department and approved by the Secretary of the U.S. Department of Health and Human Services pursuant to Title XIX of the Social Security Act, as modified or amended.

(38) "Trial period" means the first 3 contract years in which a PACE organization operates under a PACE program agreement, including any contract year during which the entity operated under a PACE demonstration waiver program.

(39) "Urgent care" means health care services for a medical condition that manifests itself by symptoms of sufficient severity that the absence of medical attention within 48 hours could reasonably be expected, by a prudent layperson who possesses an average knowledge of health and medicine, to result in an emergency medical condition.

Md. Code Regs. 10.09.44.01

Regulations.01 adopted as an emergency provision effective November 1, 2002 (29:25 Md. R. 1979); adopted permanently effective April 28, 2003 (30:8 Md. R. 540)
Regulation .01B amended effective 40:20 Md. R. 1652, eff.10/14/2013 ; amended effective 51:16 Md. R. 742, eff. 8/19/2024.