Definitions.

For the purposes of sections 17b-262-337 to 17b-262-349, inclusive, of the Regulations of Connecticut State Agencies, the following definitions apply: (1) “Accountable provider” means the maternity billing provider entity delivering services under the physicians’ services benefit category; (2) “Acute” means having rapid onset, severe symptoms, and a short course; (3) “Admission” means the formal acceptance by a hospital of a client who is to receive health care services while lodged in an area of the hospital reserved for continuous nursing services; (4) “Advanced practice registered nurse” means a person licensed pursuant to section 20-94a of the Connecticut General Statutes; (5) “Allied Health Professional” or “AHP” means a qualified individual other than a physician who: (A) Is qualified by special training, education, skills and experience in health care and treatment, (B) is certified or licensed by the Department of Public Health as one or more of the following: Psychologist, licensed clinical social worker, advanced practice registered nurse, nurse-midwife, physician assistant, licensed professional counselor, licensed marital and family therapist, licensed alcohol and drug counselor, physical therapist, occupational therapist, speech pathologist, audiologist, optician, optometrist, respiratory care practitioner, certified doula or such other category of licensed health care professional that the department permits to enroll individually as a Medicaid provider or meets other applicable qualifications approved in writing by the department and incorporated into the Medicaid State Plan or other applicable federally authorized state Medicaid document, (C) acts within the AHP’s scope of practice under state law and (D) complies with all requirements in 42 CFR 440, as amended from time to time, applicable to the AHP; (6) “Audiologist” means a person licensed to practice audiology pursuant to section 20-395c of the Connecticut General Statutes; (7) “Billing provider” means a physician, physician group or other entity enrolled in Medicaid that bills the department for physicians’ services; (8) “Border provider” means a provider that is (A) located in a state bordering Connecticut in an area that allows the provider to generally serve Connecticut residents, (B) enrolled as and treated as a Medicaid provider, (C) certified, accredited or licensed by the applicable agency in their state and (D) deemed a border provider by the department on a case-by-case basis; (9) “Case rate payments” means provider-specific monthly payments that reimburse a subset of services included in the maternity bundle episode and provided during the prenatal, labor and delivery, and postpartum periods; (10) “Certified doula” means a doula who is certified pursuant to section 20-86bb of the Connecticut General Statutes; (11) “Child” means a person who is under twenty-one years of age; (12) “Chronic disease hospital” has the same meaning as provided in section 19a-490 of the Connecticut General Statutes; (13) “Client” or “member” means a person eligible for goods or services under Medicaid; (14) “Commissioner” means the Commissioner of Social Services; (15) “Consultation” means those services rendered by a physician whose opinion or advice is requested by the client’s physician or agency in the evaluation or treatment of the client’s illness; (16) “Department” means the Department of Social Services or its agent; (17) “Early and Periodic Screening, Diagnostic and Treatment services” or “EPSDT services” means the services provided in accordance with section 1905(r) of the Social Security Act, as amended from time to time; (18) “Emergency” means a medical condition, including labor and delivery, manifesting itself by acute symptoms of sufficient severity, including severe pain, such that the absence of immediate medical attention could reasonably be expected to result in placing the client’s health in serious jeopardy, serious impairment to bodily functions or serious dysfunction of any bodily organ or part; (19) “Family planning services” means any medically approved diagnostic procedure, treatment, counseling, drug, supply or device that a provider prescribes or furnishes to individuals of childbearing age for the purpose of enabling such individuals to freely plan the number and spacing of their children; (20) “Fees” means the payments for services, treatments and drugs administered by physicians which the commissioner establishes and includes in the department’s fee schedules; (21) “General hospital” has the same meaning as provided in section 17-134d-80 of the Regulations of Connecticut State Agencies; (22) “Home” means the client’s place of residence, which includes a boarding home, community living arrangement or residential care home. “Home” does not include facilities such as hospitals, chronic disease hospitals, nursing facilities, intermediate care facilities for individuals with intellectual disabilities or other facilities that are paid an all-inclusive rate directly by Medicaid for the care of the client; (23) “Hysterectomy” has the same meaning as provided in 42 CFR 441.251, as amended from time to time; (24) “Informed consent” has the same meaning as provided in 42 CFR 441.257, as amended from time to time; (25) “Intermediate care facility for individuals with intellectual disabilities” or “ICF/IID” means a residential facility for individuals with intellectual disabilities licensed pursuant to section 17a-227 of the Connecticut General Statutes and certified to participate in Medicaid as an intermediate care facility for individuals with intellectual disabilities pursuant to 42 CFR 442.101, as amended from time to time; (26) “ICD” means the International Classification of Diseases established by the World Health Organization or such other disease classification system that the department currently requires providers to use when submitting Medicaid claims; (27) “Institutionalized individual” has the same meaning as provided in 42 CFR 441.251, as amended from time to time; (28) “Legend Device” has the same meaning as provided in section 20-571 of the Connecticut General Statutes; (29) “Legend Drug” has the same meaning as provided in section 20-571 of the Connecticut General Statutes; (30) “Licensed alcohol and drug counselor” means an individual licensed pursuant to section 20-74s of the Connecticut General Statutes; (31) “Licensed clinical social worker” means an individual licensed pursuant to section 20-195n of the Connecticut General Statutes; (32) “Licensed marital and family therapist” means an individual licensed pursuant to section 20-195c of the Connecticut General Statutes; (33) “Licensed professional counselor” means an individual licensed pursuant to sections 20-195cc and 20-195dd of the Connecticut General Statutes; (34) “Maternity bundle episode” or “bundle” or “episode” means a defined group of maternity-related Medicaid covered services provided to a specific patient over a specific period of time; (35) “Medicaid” means the program operated by the department pursuant to section 17b-260 of the Connecticut General Statutes and authorized by Title XIX of the Social Security Act, as amended from time to time; (36) “Medical necessity” or “medically necessary” has the same meaning as provided in section 17b-259b of the Connecticut General Statutes; (37) “Medical record” has the same meaning as provided in section 19a-14-40 of the Regulations of Connecticut State Agencies; (38) “Mentally incompetent individual” has the same meaning as provided in 42 CFR 441.251, as amended from time to time; (39) “Nurse-midwife” has the same meaning as provided in section 20-86a of the Connecticut General Statutes; (40) “Nursing facility” has the same meaning as provided in 42 USC 1396r(a), as amended from time to time; (41) “Occupational therapist” means an individual licensed pursuant to section 20-74b or section 20-74c of the Connecticut General Statutes; (42) “Optician” means a person licensed pursuant to section 20-146 of the Connecticut General Statutes; (43) “Optometrist” means a person licensed pursuant to section 20-130 of the Connecticut General Statutes; (44) “Out-of-state provider” means a provider that is located outside Connecticut and is not a border provider; (45) “Panel or Profile Tests” means specified groups of tests performed on a single specimen or material derived from the human body that are related to a condition, disorder or family of disorders, and when combined mathematically or otherwise, comprise a finished identifiable laboratory study or studies; (46) “Performing provider” means the physician or AHP who actually performs the service; (47) “Performance year” means the specific time period during which the accountable provider’s performance is measured to determine financial incentives or penalties or both, and the first Performance Year (PY1) is defined as January 1, 2025 to December 31, 2025; (48) “Physical therapist” means an individual licensed pursuant to 20-70 or 20-71 of the Connecticut General Statutes; (49) “Physician” means a person who is: (A) Licensed pursuant to section 20-13 of the Connecticut General Statutes and (B) acting within the physician’s scope of practice under state law; (50) “Physician assistant” means an individual licensed pursuant to section 20-12b of the Connecticut General Statutes; (51) “Physicians’ services” or “physicians’ services benefit category” means services that are billed by the billing provider and are provided: (A) By an individual physician who is also the billing provider; (B) by a physician who is employed by or affiliated with the billing provider; or (C) by an AHP working under the personal supervision of a physician who is employed by or affiliated with the billing provider; (52) “Prior authorization” means approval for the provision of a service or the delivery of goods from the department before the provider actually provides the service or delivers the goods; (53) “Provider” means (A) a physician or a physician group enrolled in Medicaid or (B) an AHP who is providing physicians’ services; (54) “Psychologist” means a person licensed pursuant to sections 20-188 or 20-190 of the Connecticut General Statutes; (55) “Quality of care” means the evaluation of medical care to determine if it meets the professionally recognized standards of acceptable medical care for the client’s condition; (56) “Quality performance criteria” means a provider’s achievement of Medicaid’s quality standards based upon quality measure performance results; (57) “Respiratory care practitioner” means an individual licensed pursuant to section 20-162o of the Connecticut General Statutes; (58) “Speech pathologist” means an individual licensed pursuant to section 20-411 of the Connecticut General Statutes; (59) “Sterilization” has the same meaning as provided in 42 CFR 441.251, as amended from time to time; (60) “Under the personal supervision” means the administrative and clinical responsibility personally assumed by the physician for the AHP’s services within the AHP’s scope of practice; (61) “Under-service” means actions taken by or on behalf of a participating entity that have the result of limiting, excluding or discouraging one or more members from seeking or receiving medically necessary Medicaid covered services; (62) “Usual and customary charge” means the amount that the provider charges for the service or procedure in the majority of non-Medicaid cases, except, if the provider varies the charges so that no one amount is charged in the majority of cases, “usual and customary charge” means the median amount that the provider charges for such service or procedure. “Usual and customary charge” does not include token charges for charity patients and other exceptional charges; and (63) “Utilization review” has the same meaning as provided in section 17-134d-80 of the Regulations of Connecticut State Agencies.