Md. Code Regs. 10.09.93.01

Current through Register Vol. 51, No. 25, December 13, 2024

Section 10.09.93.01 - Definitions

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

B. Terms Defined.

(1) "Acute hospital" means an institution that provides active, short-term medical diagnosis, treatment, and care.

(2) "Administrative day" means a day of medical services delivered to a participant who no longer requires the level of care that the provider is licensed to deliver.

(3) "Admission" means the formal acceptance by a hospital of a participant who is to be provided with room, board, and medically necessary services in an area of the hospital where individuals stay at least overnight.

(4) "Ancillary services" means diagnostic and therapeutic services including but not limited to radiology, laboratory tests, pharmacy, and physical therapy services, provided exclusive of room and board.

(5) "Appropriate facility" means:

(a) A facility located within a 25-mile radius of the participant's residence; or

(b) If acceptable to the participant, a more distant facility, which is licensed and certified to render the participant's required level of care, except when the only facility or facilities that provide the level of care and specialized services required by the participant exceed that distance.

(6) "Brain injury" means an injury or insult to the brain that occurs after birth and is not related to congenital or degenerative disease, which results in cognitive, physical, behavioral, or emotional disability that is documented in the medical record.

(7) "Brain injury community integration program" means a program located on the campus of a licensed chronic hospital and approved by the Department to treat individuals with primary diagnoses of brain injury resulting in functional limitations and disability, who need services designed to transition to home or a community-based program of services and supports.

(8) Chronic Hospital.

(a) "Chronic hospital" means an institution licensed by the Department of Health and Mental Hygiene in accordance with COMAR 10.07.01.03B, which provides services to patients with complex medical needs who do not require hospitalization in an acute hospital, but whose treatment needs exceed the capabilities of a nursing facility.

(b) "Chronic hospital" does not mean a:

(i) Long-term care hospital, as defined at 42 CFR § 412.23(e); or

(ii) Long-term care facility, as defined at 42 CFR § 483.5(a).

(9) "Concurrent review" means a periodic reauthorization of continued medical eligibility for the level of services provided by a chronic hospital which allows for close monitoring of the participant's progress, treatment goals, and objectives, performed during an inpatient hospitalization.

(10) "Date of service" means:

(a) For inpatient hospitalizations, the date of admission into a chronic hospital up to, but not including, the date of discharge; or

(b) For outpatient services, the date services are rendered in the outpatient department of the hospital.

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

(12) "Designee" means any entity designated to act on behalf of the Department.

(13) "Electronic signature" means a secure electronic identification of an individual who authorizes an electronic record or transaction.

(14) "Health Services Cost Review Commission (HSCRC)" means the independent organization within the Department of Health and Mental Hygiene which is responsible for reviewing and approving rates for hospitals pursuant to Health-General Article, Title 19, Subtitle 2, Annotated Code of Maryland.

(15) "Interdisciplinary team" means a physician-led multidisciplinary clinical team consisting of, at a minimum:

(a) The participant or an individual of the participant's choice;

(b) A physician;

(c) A registered nurse;

(d) A social worker;

(e) The participant's case manager; and

(f) Any other clinical professional indicated by an individual's specific needs, including but not limited to:

(i) A psychologist;

(ii) A behavioral analyst;

(iii) A dietitian or nutritionist; and

(iv) Licensed therapists in other disciplines.

(16) "Medical Assistance Program" means the program of comprehensive medical and other health-related care for indigent and medically indigent persons.

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

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

(b) Consistent with 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, family, or provider.

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

(19) "Neuro-behavioral" means the discipline within medical rehabilitation that focuses on behavioral impairments seen in association with brain injury resulting from trauma, hypoxia, or ischemia.

(20) "Out-of-State hospital" means any hospital outside of Maryland, except for hospitals located in the District of Columbia.

(21) "Outpatient services" means services provided to the participant on the hospital campus that do not require hospital admission.

(22) "Participant" means an individual who is enrolled with the Department to receive Medical Assistance services.

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

(24) "Provider" means a chronic hospital which, through agreement with the Department, has been identified as a Program provider by the issuance of a provider number.

Md. Code Regs. 10.09.93.01

Regulation .01 adopted effective 44:7 Md. R. 354, eff. 4/10/2017; amended effective 46:10 Md. R. 485, eff. 5/20/2019