31.11.12.02

.02 Definitions.

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

B. Terms Defined.

(1) "Annual maximum" means the maximum amount the carrier is obligated to pay for all services of a covered person during the contract year.

(2) "Carrier" has the meaning stated in Insurance Article, §15-1201(c), Annotated Code of Maryland.

(3) "Case management" means a form of utilization review used with high cost cases to monitor and manage treatment and suggest appropriate medical services.

(4) "Chlamydia screening test" has the meaning stated in Insurance Article, §15-829, Annotated Code of Maryland.

(5) "Coinsurance percentage" or "coinsure" means the percentage of allowable charges allocated to the carrier and to the covered person.

(6) "Congenital or genetic birth defect" means a defect existing at or from birth, including a hereditary defect, which includes, but is not limited to, autism or an autism spectrum disorder and cerebral palsy.

(7) "Controlled clinical trial" means a treatment that is:

(a) Approved by an institutional review board;

(b) Conducted for the primary purpose of determining whether or not a particular treatment is safe and efficacious; and

(c) Approved by:

(i) An institute or center of the National Institutes of Health;

(ii) The Food and Drug Administration;

(iii) The Department of Veterans' Affairs; or

(iv) The Department of Defense.

(8) "Covered person" means an employee or a dependent of an employee covered by a carrier under the Limited Benefit Plan.

(9) "Copayment" means a specified charge that a covered person shall pay each time services of a particular type or in a designated setting are received.

(10) "Deductible" means the amount of allowable charges that must be incurred by an individual or a family per contract year before a carrier begins payment.

(11) "Delivery system" means the method that a carrier uses to provide the Limited Benefit Plan to covered persons.

(12) "Dependent" means a covered person's lawful spouse or dependent child.

(13) Dependent Child.

(a) "Dependent child" means an individual who is younger than 19 years old, or a full-time student younger than 23 years old, and is a:

(i) Biological child;

(ii) Stepchild;

(iii) Foster child;

(iv) Lawfully adopted child, or child in the process of being adopted from the date of placement;

(v) Child for whom the covered employee has been granted legal custody, including custody as a result of a guardianship, other than a temporary guardianship of less than 12 months duration, granted by a court or testamentary appointment; or

(vi) Child for whom the covered employee has the legal obligation to provide coverage pursuant to court order, court-approved agreement, or testamentary appointment.

(b) Notwithstanding the age limitation stated in §B(13)(a) of this regulation, "dependent child" includes an unmarried child who:

(i) Is chiefly dependent for support upon the covered employee; and

(ii) At the time of reaching the age limitation set forth in §B(13)(a) of this regulation, is incapable of self-support because of mental or physical incapacity that began before the dependent child's attaining the limiting age.

(14) "Domiciliary care" has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

(15) "Durable medical equipment" means equipment furnished by a supplier or a home health agency that:

(a) Can withstand repeated use;

(b) Is primarily and customarily used to serve a medical purpose;

(c) Generally is not useful to an individual in the absence of a disability, illness, or injury; and

(d) Is appropriate for use in the home.

(16) "Emergency services" has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.

(17) "Eligible employee" has the meaning stated in Insurance Article, §15-1201(e), Annotated Code of Maryland.

(18) Experimental Services.

(a) "Experimental services" means services that are not recognized as efficacious as that term is defined in the edition of the Institute of Medicine Report on Assessing Medical Technologies that is current when the care is rendered.

(b) "Experimental services" does not include controlled clinical trials as defined in §B(7) of this regulation.

(19) "Family" means:

(a) An individual and spouse;

(b) An individual and dependent minor or minors; or

(c) An individual, spouse, and dependent minor or minors.

(20) "Family planning services" means counseling, implanting or fitting birth control devices, and follow-up visits after a covered person selects a birth control method.

(21) "Federally qualified health maintenance organization" means a health maintenance organization which meets the requirements of Title XIII of the Public Health Service Act, 42 U.S.C. §3000e et seq.

(22) "Habilitative services" means services, including occupational therapy, physical therapy, and speech therapy, for the treatment of children with congenital and genetic birth defects to enhance the child's ability to function.

(23) "Health benefit plan" has the meaning stated in Insurance Article, §15-1201(f), Annotated Code of Maryland.

(24) "Health care facility" has the meaning stated in Health-General Article, §19-114, Annotated Code of Maryland.

(25) "Health care practitioner" has the meaning stated in Health-General Article, §19-132, Annotated Code of Maryland.

(26) "Health maintenance organization" has the meaning stated in Health-General Article, §19-701, Annotated Code of Maryland.

(27) "Home health care" means the continued care and treatment of a covered person in the home if:

(a) The institutionalization of the covered person in a hospital or related institution or skilled nursing facility would otherwise have been required if home health care were not provided; and

(b) The plan of treatment covering the home health care service is established and approved in writing by the health care practitioner.

(28) "Hospice care" has the meaning stated in 42 U.S.C. §1395x(dd).

(29) "Insulin-using beneficiary" means a beneficiary who uses insulin as part of a treatment plan prescribed by the beneficiary's medical care provider.

(30) "Late enrollee" has the meaning stated in Insurance Article, §15-1201(h), Annotated Code of Maryland.

(31) "Limited Benefit Plan" has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.

(32) "Maintenance drug" has the meaning set forth in Insurance Article, §15-824(a)(3), Annotated Code of Maryland.

(33) "Managed care system" means a method that a carrier uses to review and preauthorize a treatment plan that a health care practitioner develops for a covered person using a variety of cost containment methods to control utilization, quality, and claims.

(34) "Mandated benefit" means:

(a) A health care service, benefit, coverage, or reimbursement for covered health care services that is required under the Insurance Article or the Health-General Article, Annotated Code of Maryland, to be provided or offered in a health benefit plan that is issued or delivered in the State by a carrier; or

(b) Reimbursement, required by statute, by a health benefit plan for a service if that service is performed by a care provider who is licensed under the Health Occupations Article and whose scope of practice includes that service.

(35) "Multiple risk factors" has the meaning stated in Insurance Article, §15-829, Annotated Code of Maryland.

(36) "Network" means providers who have entered into a provider service contract with a carrier to provide services on a preferential basis.

(37) "Nonpreferred brand name drug" means a drug that a carrier has not designated as a preferred drug.

(38) "Open formulary" means that prescription drugs to treat a covered service (brand and generic) are available to the insured or enrollee at specified levels of copayment.

(39) "Other nonfacility services" means services provided by non-physician health care practitioners and includes diagnostic and laboratory services.

(40) "Out-of-pocket limit" means the maximum amount of copayments, deductibles, and coinsurance that an individual or family is obligated to pay for covered services per contract year.

(41) "Outpatient rehabilitative services" means occupational therapy, speech therapy, and physical therapy, provided to covered persons not admitted to a hospital or related institution.

(42) "Part-time employee" has the meaning stated in Insurance Article, §15-1210, Annotated Code of Maryland.

(43) "Partial hospitalization" means the provision of medically directed intensive or intermediate short-term psychiatric treatment for a period of less than 24 hours but more than 4 hours in a day for an individual patient in a hospital, psychiatric day-care treatment center, or community mental health facility.

(44) "Personal care" has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

(45) "Preferred brand name drug" means a drug that a carrier has designated on its preferred drug list.

(46) "Preferred provider delivery system" means a delivery system that:

(a) Provides services to a covered person through a network; and

(b) Permits the covered person to select services outside the network.

(47) "Preexisting condition" has the meaning stated in Insurance Article, §15-1201(l), Annotated Code of Maryland.

(48) "Primary care" means services rendered by a health care practitioner in the following disciplines:

(a) General internal medicine;

(b) Family practice medicine;

(c) Pediatrics; or

(d) Obstetrics/gynecology.

(49) "Prominent carrier" has the meaning stated in Insurance Article, §15-1209, Annotated Code of Maryland.

(50) "Provider" means a health care practitioner or a health care facility licensed or otherwise authorized by law to provide health care services.

(51) "Related institution" has the meaning stated in Health-General Article, §19-301, Annotated Code of Maryland.

(52) "Religious organization" means an entity that:

(a) Is organized and operated exclusively for religious purposes; and

(b) Has obtained a tax exemption under 26 U.S.C. §501(c)(3) of the U.S. Internal Revenue Code.

(53) "Residential crisis services" means intensive mental health and support services that are:

(a) Provided to a child or an adult with a mental illness who is experiencing or is at risk of a psychiatric crisis that would impair the individual's ability to function in the community;

(b) Designed to prevent a psychiatric inpatient admission, provide an alternative to psychiatric inpatient admission, or shorten the length of inpatient stay;

(c) Provided out of the individual's residence on a short-term basis in a community-based residential setting; and

(d) Provided by entities that are licensed by the Maryland Department of Health to provide residential crisis services.

(54) "Service" means a health care diagnosis, procedure, treatment, or item.

(55) "Skilled nursing facility" means an institution, or a distinct part of an institution, licensed by the Maryland Department of Health, which is:

(a) Primarily engaged in providing:

(i) Skilled nursing care, and related services, for residents who require medical or nursing care; or

(ii) Rehabilitation services for injured, disabled, or sick persons; and

(b) Certified by the Medicare Program as a skilled nursing facility.

(56) "Small employer" has the meaning stated in Insurance Article, §15-1201(o), Annotated Code of Maryland.

(57) "Standard Plan" has the meaning stated in Insurance Article, §15-1201, Annotated Code of Maryland.