Mont. Admin. r. 37.79.102 - DEFINITIONS
As used in this subchapter, unless expressly provided otherwise, the following definitions apply:
(1) "Advanced practice registered nurse
(APRN) " means a registered professional nurse who has completed educational
requirements related to the nurse's specific practice role, in addition to
basic nursing education, as specified by the Board of Nursing in ARM
24.159.1414.
(2) "Ambulance services " means all mileage,
services, procedures, and supplies provided by a licensed ambulance
provider.
(3) "Applicant " means an
individual under the age of 19 years who applied for the HMK Plan benefits or
whose parent or guardian applied for the HMK Plan benefits on the individual's
behalf.
(4) "Benefits " means the
services an enrollee is eligible to receive. The HMK coverage group benefits
are stated in its Evidence of Coverage. All benefits are provided to an
enrollee through the department .
(5) "Benefit year " means:
(a) for medical and mental health, the period
from October 1 through September 30 for those enrolled in the HMK coverage
group. If an individual is enrolled in the HMK coverage group after October 1,
the benefit year is the period from the date of enrollment through the
following September 30.
(b) for
dental, the period from July 1 through June 30 for those enrolled in the HMK
coverage group. If an individual is enrolled in the HMK coverage group after
July 1, the benefit year is the period from the date of enrollment through the
following June 30.
(6)
"Children's Health Insurance Program (CHIP) " means the Children's Health
Insurance Program described in this subchapter and administered by the
department under Title 53, chapter 4, part 10, MCA and Title XXI of the Social
Security Act.
(7) "Department "
means the Montana Department of Public Health and Human Services.
(8) "Earned income " means payments received
as compensation for work performed. Some examples are: bonus, wages, salaries,
tips, commission, self-employment, military pay, and severance pay.
(9) "Emergency medical condition " means a
medical condition manifesting itself by acute symptoms of sufficient severity,
including severe pain, such that a prudent layperson, with an average knowledge
of health and medicine, could reasonably expect the absence of immediate
medical attention to result in any of the following:
(a) serious jeopardy to the health of the
enrollee or the enrollee 's unborn child;
(b) serious impairment of bodily function;
or
(c) serious dysfunction of any
bodily organ or part.
(10) "Enrollee " means an individual who is
eligible and enrolled in the HMK coverage group. The term "enrollee " and
"member " are synonymous.
(11)
"Enrollment partner " means an organization or individual approved by the
department to assist in enrolling eligible children in the plan.
(12) "Eyeglasses " means corrective lens
and/or frames prescribed by an ophthalmologist or by an optometrist to aid and
improve vision.
(13) "Family span "
means the 12 month period beginning the first day of the month after the
department receives an application for HMK coverage group benefits and ending
the last day of the 12th month. Although qualified for the HMK coverage group
benefits , applicants placed on the waiting list may not be enrolled during the
entire family span .
(14) "Federal
poverty level (FPL) " means the poverty guidelines for 2013 for the 48
contiguous states and the District of Columbia as published under the "Annual
Update on the HHS Poverty Guidelines" 78 Federal Register 16, pp 5182-5183,
January 24, 2013.
(15) "Federally
qualified health center (FQHC) " means an entity that is a federally qualified
health center as defined in
42 USC
1396 d(l)(2)(B) (2009 Supp.).
(16) "Guardian " means the custodial parent or
a person granted legal guardianship of a child by court order, judgment, or
decree.
(17) "Health coverage "
means a program administered by the department or a disability insurance plan,
referred to in
33-1-207(1)(b),
MCA, that provides public health care coverage or private health insurance for
children.
(18) "Healthy Montana
Kids (HMK) Plan " means the two health care coverage groups, Healthy Montana
Kids (HMK) and Healthy Montana Kids Plus (HMK Plus), which pay for covered
health care services to qualified individuals until their 19th birthday. The
HMK coverage group was formerly referred to as CHIP and the provisions of Title
53, chapter 4, part 10, MCA apply. The HMK Plus coverage group is also referred
to as children's Medicaid and the provisions of Title 53, chapter 6, MCA
apply.
(19) "Incarcerated " means
living in a facility which would be termed a public institution under Medicaid
regulations at
42 CFR
435.1009.
(20) "Income " or "family income " means the
gross earned income , unearned income , and imputed income of the custodial
parent. Regular, continuing, and intermittent sources of income will be
annualized for purposes of determining the annual income level.
(21) "Initiative I-155 " means the initiative
passed by Montana voters in November, 2008, that enacted the HMK Plan
Act.
(22) "Institution for mental
disease (IMD) " means a facility which would be termed an institute for mental
disease under Medicaid regulations at
42 CFR
435.1009.
(23) "Medically necessary " or "medically
necessary covered services " means services and supplies which are necessary and
appropriate for the diagnosis, prevention, or treatment of physical or mental
conditions as described in this subchapter and that are not provided only as a
convenience.
(24) "Member " means an
individual who is eligible to receive HMK Plan benefits as determined by the
department under this rule. An individual is not a member while on a waiting
list or pending issuance of a hearing decision or during any period a hearing
officer determines the individual was not eligible for the HMK coverage group
benefits . The term "member " and "enrollee " are synonymous.
(25) "Mid-level practitioner" is defined at
ARM 37.86.202.
(26) "Montana resident " means a U.S. citizen
or qualified alien who declares himself or herself to be living in the state of
Montana, including a migrant or other seasonal worker.
(27) "Outpatient prospective payment system
(OPPS) " means the reimbursement method for federally qualified health centers
(FQHCs) and Rural Health Centers (RHCs).
(28) "Outreach " means efforts which promote
the Healthy Montana Kids Plan through a combination of traditional marketing
methods, and social marketing. The department will develop and maintain an
enrollment partner network to encourage, assist, and actively enroll children
in the program.
(29) "Participating
provider " means a health care professional or facility as defined at
33-36-103(19),
MCA.
(30) "Presumptive eligibility
(PE) " means a temporary period of HMK medical assistance not to exceed two
consecutive calendar months in a 12-month period for uninsured children through
the month of their 19th birthday, pending a decision of HMK Plan
eligibility.
(31) "Qualified alien "
means a person residing legally in the United States, as defined by federal
immigration laws and regulations and in ARM
37.78.220.
(32) "Qualified entity (QE) " means a health
care facility, individual, or other approved entity designated and trained by
HMK to make a presumptive eligibility determination for a child on behalf of
HMK.
(33) "Rural health clinic
(RHC) " means a clinic determined by the secretary of the U.S. Department of
Health and Human Service to meet the rural health clinic conditions of
certification specified in 42 CFR, part 491, subpart A.
(35) "State employee " means a person,
including the HMK applicant , employed on a permanent basis by the state of
Montana.
(36) "Third party
administrator (TPA) " means an entity with a certificate of registration to
conduct business in Montana in accordance with
33-17-603,
MCA, or an entity licensed as a health service corporation. The department may
contract for TPA services including but not limited to claims processing,
maintaining an adequate network of participating providers, coordination and
continuation of care, health education, notices, quality assurance, reporting,
case management services, and customer service.
(37) "Unearned income " means all payments
received other than earned income . Some examples are: adoption subsidies,
annuities, dividends, interest, social security benefits , disability, and
unemployment insurance payments.
(38) "Waiting list " means a list of
applicants who have been determined eligible for the HMK coverage group but who
are not enrolled because funds are not available.
Notes
53-4-1004, 53-4-1009, 53-4-1105, MCA; IMP, 53-4-1003, 53-4-1004, 53-4-1009, 53-4-1103, 53-4-1104, 53-4-1105, 53-4-1108, MCA;
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