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37.57.102    DEFINITIONS

Unless otherwise indicated, the following definitions apply throughout this subchapter:

(1) "Applicant" means a child or youth with special health care needs (CYSHCN) who has applied or whose parent or guardian has applied on the child's behalf to receive children's special health service (CSHS) financial assistance from the department.

(2) "Child or Youth with Special Health Care Needs" (CYSHCN) means a child or youth, under the age of 22, who has or is at increased risk for chronic physical, developmental, behavioral, or emotional condition and who also requires health and related services of a type or amount beyond that required by children generally.

(3) "Client" means a CYSHCN who is eligible to receive CSHS financial assistance as determined by the department under this subchapter.

(4) "CSHS" means the children's special health services program of the department, authorized by 50-1-202, MCA, that serves children and youth with special health care needs.

(5) "Department" means the Montana Department of Public Health and Human Services.

(6) "Disability" or "disabling condition" means a chronic physical, developmental, behavioral or emotional condition requiring health and related services of a type or amount beyond that required by children generally.

(7) "Disabled" means having any physical defect or characteristic, congenital or acquired, that prevents or restricts normal growth or capacity for activity.

(8) "Eligibility year" means the federal fiscal year in which a CYSHCN receives CSHS direct payment financial assistance.

(9) "Enabling services" means nonclinical services that enable individuals to access health care and improve health outcomes. Enabling services include, but are not limited to: case management, care coordination, referrals, home visiting, respite care, specialized daycare or preschool, translation/interpretation, transportation, eligibility assistance, health education for individuals or families, and outreach.

(10) "Family" means a group of related or non-related individuals who are living together as a single economic unit.

(11) "Federal fiscal year" means the period beginning October 1 and ending the following September 30.

(12) "Financial Assistance" means payment by the department for CSHS-authorized treatment and enabling services for a CYSHCN eligible for the CSHS program.

(13) "HMK" means Healthy Montana Kids (Children's Health Insurance Program or CHIP) insurance plan administered by the department.

(14) "HMK Plus" means Healthy Montana Kids Plus (children's Medicaid) plan administered by the department.

(15) "Initial diagnosis and evaluation" means taking a medical history and performing a physical examination, medical procedures, laboratory tests, hearing and other diagnostic tests, or other procedures necessary for the diagnosis of a condition.

(16) "Poverty income guidelines" means the poverty income guidelines published in 2018 in the Federal Register by the U.S. Department of Health and Human Services. The department adopts and incorporates by reference the federal poverty guidelines that establish income thresholds according to family unit size for purposes of determining eligibility for government assistance or services and that are published in the January 2018, Federal Register. A copy of the 2018 poverty guidelines may be obtained from the Department of Public Health and Human Services, Public Health and Safety Division, Children's Special Health Services Program, 1400 Broadway, Rm A-116, Helena, MT 59620, telephone (406) 444-3617.

(17) "Program" means the department's children's special health services program for a CYSHCN, authorized by 50-1-202, MCA.

(18) "Provider" means a supplier of medical care or services, enabling services, interventions, medical appliances, prescribed medications, formula or foods, and consultations.

(19) "Risk category" means any condition of a child or youth's life which qualifies them as being at an increased risk for chronic physical, development, behavioral, or emotional condition, further qualifying them as a CYSHCN. This may include but is not limited to: living in poverty, in the foster care or Child Protective Services system, having a parent with a disabling condition, multiple adverse childhood experiences, or homelessness.

(20) "Services" means enabling or treatment services covered by the rule.

(21) "Special Health Care Need" means a chronic condition that requires

health and related services of a type or amount beyond that generally required by children.

(22) "Third-party payer" means a public or private entity that is or may be liable to pay all or part of the medical costs for a client.

(23) "Treatment" means medical, corrective, and/or surgical intervention to alleviate a disabling condition or as recommended by a provider based on a CYSHCN's risk category, including for initial testing and diagnosis. This includes medications and medical equipment.


History: 50-1-202, MCA; IMP, 50-1-202, MCA; NEW, 1990 MAR p. 1256, Eff. 6/29/90; AMD, 1992 MAR p. 919, Eff. 5/1/92; TRANS, from DHES, 2001 MAR p. 398; AMD, 2003 MAR p. 1637, Eff. 8/1/03; AMD, 2012 MAR p. 1672, Eff. 8/24/12; AMD, 2013 MAR p. 1449, Eff. 8/9/13; AMD, 2014 MAR p. 977, Eff. 5/9/14; AMD, 2015 MAR p. 2148, Eff. 12/11/15; AMD, 2018 MAR p. 1733, Eff. 8/25/18.

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