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<section article="ghg" article_name="Health - General" number="15-101" title_number="15" title_name="Assistance Programs" subtitle_number="1" subtitle_name="Medical and Pharmacy Assistance Programs">
  <level label="a">
    <text>In this title the following words have the meanings indicated.</text>
  </level>
  <level label="a–1">
    <text>“Dental managed care organization” means a pre–paid dental plan that receives fees to manage dental services.</text>
  </level>
  <level label="a–2">
    <text>“Dental services” means diagnostic, emergency, preventive, and therapeutic services for oral diseases.</text>
  </level>
  <level label="b">
    <text>“Enrollee” means a program recipient who is enrolled in a managed care organization.</text>
  </level>
  <level label="b–1">
    <text>“Expedited eligibility” means a streamlined eligibility process, conducted by the local health departments, for medical assistance for children and pregnant women under which an eligibility determination is made promptly, but not later than 10 working days after the date of application.</text>
  </level>
  <level label="c">
    <text>“Facility” means a hospital or nursing facility including an intermediate care facility, skilled nursing facility, comprehensive care facility, or extended care facility.</text>
  </level>
  <level label="d">
    <text>“Former foster care adolescent” means an individual:</text>
    <level label="1">
      <text>Who is under 26 years of age; and</text>
    </level>
    <level label="2">
      <text>Who, on the individual’s 18th birthday, was in foster care under the responsibility of the State, any other state, or the District of Columbia.</text>
    </level>
  </level>
  <level label="d–1">
    <level label="1">
      <text>“Historic provider” means a health care provider, as defined in § 19–132 of this article, or a residential service agency licensed under Title 19, Subtitle 4A of this article, that, on or before June 30, 1995, had a demonstrated history of providing services to program recipients, as defined by the Department in regulations.</text>
    </level>
    <level label="2">
      <text>“Historic provider”, to the extent the provider meets the requirements in paragraph (1) of this subsection, shall include:</text>
      <level label="i">
        <text>A federal or State qualified community health center;</text>
      </level>
      <level label="ii">
        <text>A provider with a program for the training of health care professionals, including an academic medical center;</text>
      </level>
      <level label="iii">
        <text>A hospital outpatient program, physician, or advanced practice nurse that is a Maryland Access to Care (MAC) provider;</text>
      </level>
      <level label="iv">
        <text>A local health department;</text>
      </level>
      <level label="v">
        <text>A hospice, as defined in Title 19, Subtitle 9 of this article;</text>
      </level>
      <level label="vi">
        <text>A pharmacy; and</text>
      </level>
      <level label="vii">
        <text>Any other historic provider designated in accordance with regulations adopted by the Department.</text>
      </level>
    </level>
  </level>
  <level label="e">
    <text>“Managed care organization” means:</text>
    <level label="1">
      <text>A certified health maintenance organization that is authorized to receive medical assistance prepaid capitation payments; or</text>
    </level>
    <level label="2">
      <text>A corporation that:</text>
      <level label="i">
        <text>Is a managed care system that is authorized to receive medical assistance prepaid capitation payments;</text>
      </level>
      <level label="ii">
        <text>Enrolls only program recipients or individuals or families served under the Maryland Children’s Health Program; and</text>
      </level>
      <level label="iii">
        <text>Is subject to the requirements of § 15–102.4 of this subtitle.</text>
      </level>
    </level>
  </level>
  <level label="f">
    <text>“Ombudsman program” means a program that assists enrollees in resolving disputes with managed care organizations in a timely manner and that is responsible, at a minimum, for the following functions:</text>
    <level label="1">
      <text>Investigating disputes between enrollees and managed care organizations referred by the enrollee hotline;</text>
    </level>
    <level label="2">
      <text>Reporting to the Department:</text>
      <level label="i">
        <text>The resolution of all disputes;</text>
      </level>
      <level label="ii">
        <text>A managed care organization’s failure to meet the Department’s requirements; and</text>
      </level>
      <level label="iii">
        <text>Any other information specified by the Department;</text>
      </level>
    </level>
    <level label="3">
      <text>Educating enrollees about:</text>
      <level label="i">
        <text>The services provided by the enrollee’s managed care organization; and</text>
      </level>
      <level label="ii">
        <text>The enrollee’s rights and responsibilities in receiving services from the managed care organization; and</text>
      </level>
    </level>
    <level label="4">
      <text>Advocating on behalf of the enrollee before the managed care organization, including assisting the enrollee in using the managed care organization’s grievance process.</text>
    </level>
  </level>
  <level label="g">
    <text>“Primary mental health services” means the clinical evaluation and assessment of services needed by an individual and the provision of services or referral for additional services as deemed medically appropriate by a primary care provider.</text>
  </level>
  <level label="h">
    <text>“Program” means the Maryland Medical Assistance Program.</text>
  </level>
  <level label="i">
    <text>“Program recipient” means an individual who receives benefits under the Program.</text>
  </level>
  <level label="j">
    <text>“Self–measured blood pressure monitoring” means the regular measurement of blood pressure by the patient outside the clinical setting, either at home or elsewhere, requiring the use of a home blood pressure measurement device by the patient.</text>
  </level>
  <level label="k">
    <text>“Special pediatric hospital” means a facility in the State that provides nonacute medical, rehabilitation, therapy, and palliative services to individuals:</text>
    <level label="1">
      <text>Under the age of 22 years; or</text>
    </level>
    <level label="2">
      <text>Who are at least 2 years old and under the age of 23 years and have co–occurring physical and behavioral health conditions.</text>
    </level>
  </level>
  <level label="l">
    <text>“Specialty mental health services” means any mental health services other than primary mental health services.</text>
  </level>
  <level label="m">
    <text>“Validated home blood pressure monitor” means a blood pressure measurement device that has been validated for accuracy and is listed in the U.S. Blood Pressure Validated Device Listing.</text>
  </level>
</section>
