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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 pursuant to 37-8-202(5)(a), MCA.

(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 CHIP benefits or whose parent or guardian applied for CHIP benefits on the individual's behalf.

(4) "Benefits" means the services an enrollee is eligible for as outlined in this subchapter. All benefits are provided to an enrollee through the department.

(5) "Benefit year" means the period from October 1st through September 30th of a calendar year. If an individual is enrolled in CHIP after October 1st, the benefit year is the period from the date of enrollment through September 30th of the calendar year.

(6) "Children's Health Insurance Plan (CHIP)" means the Children's Health Insurance Plan described in this subchapter and administered by the department under 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 to receive CHIP benefits as determined by the department under this subchapter and is enrolled in the CHIP program. An individual is not an enrollee 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 CHIP benefits. The term "enrollee" and "member" are synonymous.

(11) "Eyeglasses" means corrective lens and/or frames prescribed by an ophthalmologist or by an optometrist to aid and improve vision.

(12) "Family span" means the 12 month period beginning the first day of the month after an eligibility determination for CHIP benefits is completed and ending the last day of the 12th month. Although qualified for CHIP benefits, applicants placed on the waiting list may not be enrolled during the entire family span.

(13) "Federal poverty level (FPL)" means the poverty income guidelines published in the Federal Register by the U.S. Department of Health and Human Services for 2007.

(14) "Guardian" means the custodial parent or a person granted legal guardianship of a child by court order, judgment, or decree.

(15) "Incarcerated" means living in a facility which would be termed a public institution under Medicaid regulations at 42 CFR 435.1009.

(16) "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.

(17) "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.

(18) "Medicaid screening" means a determination by the department of an individual's potential eligibility to receive Medicaid benefits applying the criteria set forth in ARM Title 37, chapter 82 and certain Medicaid rules which disregard income.

(19) "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.

(20) "Member" means an individual who is eligible to receive CHIP benefits as determined by the department under this and is enrolled in the CHIP program. 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 CHIP benefits. The term "member" and "enrollee" are synonymous.

(21) "Mid-level practitioner" is defined at ARM 37.86.202.

(22) "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.

(23) "Participating provider" means a health care professional or facility as defined at 33-36-103(19), MCA.

(24) "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.

(25) "Serious emotional disturbance (SED)" means a designation determined by qualified department staff and based on social history and clinical information in the form of a psychological assessment with DSM-IV diagnosis, completed by a licensed psychologist, social worker, or professional counselor, that a youth is seriously emotionally disturbed according to the definition set forth in ARM 37.86.3702(2).

(26) "State employee" means a person, including the CHIP applicant, employed on a permanent basis by the state of Montana.

(27) "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 CHIP program 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.

(28) "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.

(29) "Waiting list" means a list of applicants who have been determined eligible for CHIP but who are not enrolled because funds are not available.

History: 53-4-1009, MCA; IMP, 53-4-1003, MCA; NEW, 2000 MAR p. 1221, Eff. 5/12/00; AMD, 2004 MAR p. 1027, Eff. 2/13/04; AMD, 2008 MAR p. 49, Eff. 1/18/08.

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