Md. Code Regs. 10.09.34.01

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

Section 10.09.34.01 - Definitions

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

B. Terms Defined.

(1) "Behavioral plan" means an individualized written plan for therapeutic behavioral services which includes the components specified in Regulation .03B(1) of this chapter.

(2) "Department" means the Department of Health and Mental Hygiene, the single State agency designated to administer the Medical Assistance Program under Title XIX of the Social Security Act, 42 U.S.C. § 1396(a) -(v).

(3) "Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) provider" means any health care provider acting within the scope of the provider's practice who:

(a) Screens, evaluates, or identifies a condition; and

(b) Recommends treatment.

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

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

(b) Consistent with current accepted 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 consumer, family, or provider.

(5) "Participant" means an individual who is certified as eligible for and is receiving Medical Assistance benefits.

(6) "Preauthorization" means the approval required from the Department, or its designee, before services may be rendered.

(7) "Prescribed" means ordered in writing and signed by an EPSDT provider who has examined the participant and diagnosed the participant's medical condition.

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

(9) "Rehabilitative service" means a medical or remedial service prescribed by a licensed physician or authorized practitioner under Health Occupations Article, Annotated Code of Maryland, or the jurisdiction where services are rendered for:

(a) Maximum reduction of physical or mental disability; and

(b) Restoration of a participant's best possible functional level.

(10) "Therapeutic behavioral aide" means an individual who is:

(a) A health care professional or a nonprofessional who is supervised by an individual who is licensed, certified, or otherwise legally authorized to provide mental health services independently in the state where the service is rendered;

(b) Trained and supervised by a therapeutic behavioral service provider to implement a behavior plan; and

(c) Available on-site to provide one-to-one behavioral assistance and intervention to accomplish outcomes specified in the behavioral plan.

(11) "Therapeutic behavioral assessment" means a comprehensive assessment of a participant and, if applicable, a participant's family that:

(a) Is performed by a licensed or certified health care professional;

(b) Addresses the medical and behavioral needs for therapeutic behavioral services;

(c) Includes the risk of needing placement in a more restrictive living arrangement because of the behavior; and

(d) Includes development of a behavioral plan.

(12) "Therapeutic behavioral service" means an intensive, rehabilitative service that is documented in the written behavioral plan and is intended to:

(a) Provide the participant with behavioral management skills to effectively manage the behaviors or symptoms that place the participant at risk for a higher level of care; and

(b) Restore the participant's previously acquired behavior skills and enable the participant to develop appropriate behavior management skills.

(13) "Therapeutic behavioral service provider" means:

(a) A Developmental Disabilities Administration provider meeting criteria set forth in COMAR 10.22.02;

(b) An outpatient mental health clinic approved under COMAR 10.21.20;

(c) A mental health mobile treatment unit meeting criteria set forth in COMAR 10.09.59; or

(d) A psychiatric rehabilitation program approved under COMAR 10.21.29.

Md. Code Regs. 10.09.34.01

Regulation .01B amended effective May 2, 2011 (38:9 Md. R. 552); amended effective 49:25 Md. R.1041-1070, eff. 12/12/2022