10.09.76.01

.01 Definitions.

A. The following terms have the meanings indicated.

B. Terms Defined.

(1) “Department” means the Maryland Department of Health, the State agency designated to administer the Maryland Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. §1396 et seq.

(2) “Early and periodic screening, diagnosis and treatment (EPSDT)” means the provision of preventive health care, including medical and dental services under 42 CFR §441.50 et seq., in order to assess growth and development and to detect and treat health problems in Medical Assistance eligible individuals younger than 21 years old.

(3) “Federally qualified health center (FQHC)” means an entity that has entered into an agreement with the Centers for Medicare and Medicaid Services (CMS) to meet Medicare requirements under 42 CFR §405.2464 and in accordance with 42 CFR §405.2401(b).

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

(5) “Medically necessary” means that the service or benefit is:

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

(b) Consistent with currently accepted standards of good medical practice, dental practice, or both;

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

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

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

(7) “Participant” means an individual who is certified as eligible for, and who is receiving, Medical Assistance benefits.

(8) “Primary care provider (PCP)” means a 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 Medical Assistance Program.

(9) “Primary health services” means a basic level of health care, including diagnostic, treatment, consultative, referral, and preventive health services, generally rendered by:

(a) General practitioners;

(b) Family practitioners;

(c) Internists;

(d) Obstetricians;

(e) Gynecologists;

(f) Pediatricians;

(g) Physician assistants; and

(h) Nurse practitioners.

(10) “Program” means the Maryland Medical Assistance Program.

(11) “Provider” means a school-based health center which has been approved by the Department.

(12) “School-based health center (SBHC)” means a health center that:

(a) Is located on school grounds;

(b) Provides on-site primary and preventive health care, referrals, and follow-up services;

(c) Could provide on-site dental care or behavioral health care, referrals, and follow-up services; and

(d) Has been approved by the Maryland State Department of Education (MSDE).

(13) “Specialty behavioral health” means services specified in COMAR 10.09.59.06 and 10.09.80.05.