Definitions.

For the purposes of sections 17b-262-573 to 17b-262-585, 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) “Billing provider” means a physician, physician group or other entity enrolled in Medicaid that bills the department for physicians’ services; (7) “Case rate payments” means provider-specific monthly payments that reimburse a subset of services included in the maternity episode and provided during the prenatal, labor and delivery, and postpartum periods; (8) “Certified doula” means a doula who is certified pursuant to section 20-86bb of the Connecticut General Statutes; (9) “Child” means a person who is under twenty-one years of age; (10) “Client” or “member” means a person eligible for goods or services under Medicaid; (11) “Commissioner” means the Commissioner of Social Services; (12) “Department” means the Department of Social Services or its agent; (13) “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; (14) “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; (15) “Essentially Normal” means a philosophic view of childbirth as a natural, normal process. Essentially normal means that if a client develops complications, the nurse-midwife either consults or collaborates with the physician in the management of care of the client or, depending on the severity of the complication, refers the client to the physician. This reflects again the team relationship with the physician, because normal is defined by the nurse-midwifes and physicians in a particular practice setting; (16) “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; (17) “Fees” means the payments for services, treatments, and drugs administered by nurse practitioners which the commissioner establishes and includes in the department’s fee schedules; (18) “Licensed Practitioner of the Healing Arts” means a professional person providing health care pursuant to a license issued by the Department of Public Health (DPH); (19) “Long-Term Care Facility” means a medical institution which provides, at a minimum, skilled nursing services or nursing supervision and assistance with personal care on a daily basis. Long-term care facilities include: (A) nursing facilities, (B) chronic disease hospitals—inpatient, and (C) intermediate care facilities for individuals with intellectual disabilities (ICF/IID); (20) “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; (21) “Maternity Cycle” means a period limited to: (A) pregnancy (B) labor, (C) birth, and (D) the postpartum period as defined by the Department; (22) “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; (23) “Medical necessity” or “medically necessary” have the same meaning as provided in section 17b-259b of the Connecticut General Statutes; (24) “Medical record” has the same meaning as provided in section 19a-14-40 of the Regulations of Connecticut State Agencies; (25) “Nurse-midwife” has the same meaning as provided in section 20-86a of the Connecticut General Statutes; (26) “Nurse-midwifery Services” means the services described in subdivision (1) of section 20-86a and section 20-86b of the Connecticut General Statutes; (27) “Performing provider” means the physician or AHP who actually performs the service; (28) “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; (29) “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; (30) “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; (31) “Provider” means a licensed nurse-midwife; (32) “Referral” means the nurse-midwife's request for a consultation and collaboration with the physician on a client which results in the physician providing the care for the client; and (33) “State Plan” means the document which contains the services covered by the Connecticut Medical Assistance Program in compliance with 42 CFR 430, Subpart B, as amended from time to time.