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(1) "Advance Benefit Notice (ABN)" means a notice that providers give to the participant when they have determined that a service or item is a noncovered benefit of the HELP Plan. The ABN provides notice to the participant that the participant is responsible for the full payment of the particular service.

(2) "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.

(3) "Aligned Medicaid Alternative Benefit Plan" means a service plan available to HELP members that is equivalent to the Medicaid services described in ARM Title 37, chapters 86 and 88.

(4) "American Indian and Alaska Native" means an American Indian, Alaska Native, or other individual who is eligible for health services through the Indian Health Service, tribes and tribal organizations, or urban Indian organizations.

(5) "Benefit year" means the state fiscal year from July 1 through June 30.

(6) "Benefits" means the services a person is eligible to receive. The HELP Program benefits are stated in the Evidence of Coverage or the Aligned Medicaid Alternative Benefit Plan as applicable.

(7) "Copayment" means a predetermined portion of the cost for a health care service or item that is owed by the participant directly to a provider for a covered health care service.

(8) "Cost Share" means the total of premium and copayment costs in relation to the delivery of health care services to the participant that are the responsibility of the participant to pay.

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

(10) "Emergency medical condition" means a medical condition manifesting itself with acute symptoms of sufficient severity, including severe pain, such that a prudent layperson could reasonably expect the absence of immediate medical attention to result in any of the following:

(a) serious jeopardy to the health of the participant or the participant's unborn child;

(b) serious impairment of bodily function; or

(c) serious dysfunction of any bodily organ or part.

(11) "Evidence of Coverage (EOC)" means a document that explains covered services, defines the HELP Plan's obligations, and explains the rights and responsibilities of the HELP Plan participant.

(12) "Experimental, investigational, and unproven" means any drug, device, treatment, or procedure that meets any of the following criteria:

(a) prescription drugs not approved by the Food and Drug Administration (FDA) to be lawfully marketed for the proposed use, and it is not identified in the American Hospital Formulary Service, the AMA Drug Evaluation, or the Pharmacopoeia as an appropriate use;

(b) it is subject to review or approval by an institutional review board (meaning that a hospital considered it experimental and put it under review to meet federal regulations, or review is required and defined by federal regulations, particularly those of the FDA or U.S. Department of Health and Human Services);

(c) it is the subject of an ongoing clinical trial that meets the definition of a Phase 1, 2, or 3 clinical trial set forth in FDA regulations, regardless of whether it is an FDA trial;

(d) it has not been demonstrated through prevailing, peer-reviewed medical literature to be safe and effective for treating or diagnosing the condition or illness for which its use is proposed;

(e) the predominant opinion among experts as expressed in the published authoritative literature is that further research is necessary in order to define safety, toxicity, and effectiveness (or effectiveness compared with conventional alternatives), or that usage should be substantially confined to research settings;

(f) it is not a covered benefit under Medicare, as determined by the Centers for Medicare and Medicaid Services (CMS), because it is considered experimental, investigational, or unproven;

(g) it is experimental, investigational, unproven, or not a generally acceptable medical practice in the predominant opinion of independent experts utilized by the administrator of each plan; or

(h) it is not experimental or investigational in itself pursuant to the above and would not be medically necessary, but it is being provided in conjunction with the provision of a treatment, procedure, device, or drug that is experimental, investigational, or unproven.

(13) "Eyeglasses" mean corrective lens, frames, or both prescribed by an ophthalmologist or by an optometrist to improve vision.

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

(15) "Federally Qualified Health Center (FQHC)" means an entity as defined in 42 USC 1396d(l)(2)(B) (2015) and 42 CFR, part 491, subpart A (2015).

(16) "Health and economic livelihood partnership (HELP) plan" means the participant's benefits as described in the evidence of coverage, the network of providers, the coordination of care, and the claims processing that is administered by the third-party administrator pursuant to the HELP Act.

(17) "Health and economic livelihood partnership (HELP) program" means a Medicaid coverage program for persons as authorized at Title 53, chapter 6, part 13, MCA, and as implemented in accordance with that part, 53-2-215, MCA, 42 U.S.C. 1315 (2015), 42 U.S.C. 1396d(y) (2015), and other applicable state and federal authorities for those persons who are eligible for the HELP Program as authorized under 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) (2015).

(18) "Healthy behavior plan" means a program implemented to improve the health of participants by providing services focused on the promotion or maintenance of good health.

(19) "Indian Health Service (IHS)" means an agency within the U.S. Department of Health and Human Services that is responsible for providing federal health services to American Indians and Alaska Natives.

(20) "Inpatient hospital services" means services or supplies provided to the participant who has been admitted to a hospital as a registered bed patient and who is receiving services under the direction of a participating provider with staff privileges at that hospital, including a critical access hospital. The facility must:

(a) be licensed or formally approved as an acute care or critical access hospital by the officially designated authority in the state where the institution is located; and

(b) except as otherwise permitted by federal law, meet the requirements for participation in Medicare as a hospital and have in effect a utilization review plan that meets the requirements of 42 CFR 482.30 (2015).

(21) "Medically frail" means individuals defined in 42 CFR 440.315(f) (2015).

(22) "Medically necessary" or "medically necessary covered services" means services and supplies that are necessary and appropriate for the diagnosis, prevention, or treatment of physical or mental conditions as specified in the HELP Plan Evidence of Coverage provided in ARM 37.84.106.

(23) "Member" means an individual enrolled in the Montana Medicaid Program under 53-6-131, MCA, or receiving Medicaid-funded services under 53-6-1304, MCA.

(24) "Modified adjusted gross income (MAGI)" means income determined in accordance with 42 U.S.C. 1396a(e)(14) (2015) and 42 CFR 435.603(d)(4) (2015).

(25) "Outpatient facility services" means preventive, diagnostic, therapeutic, rehabilitative, or palliative services provided to an outpatient by or under the direction of a physician, dentist, or other practitioner as permitted by federal law. The facility must:

(a) be licensed or formally approved as an acute care or critical access hospital by the officially designated authority in the state where the institution is located; and

(b) except as otherwise permitted by federal law, meet the requirements for participation in Medicare as a hospital.

(26) "Participant" means an individual enrolled in the HELP Program established in Title 53, chapter 6, part 13, MCA, and Title 39, chapter 12, MCA. A participant is eligible for and enrolled with the HELP Program and receiving benefits through the HELP Plan.

(27) "Participating provider" means a health care professional or facility that is participating in either the HELP Plan network or the Medicaid program.

(28) "Physician assistant (PA)" means a mid-level practitioner as defined in ARM 37.86.202.

(29) "Premium" means a fee owed by an individual as a participant in the HELP Plan.

(30) "Preventative health care services" means routine health care that includes screenings, checkups, and patient counseling to prevent illnesses, disease, or other health problems, including secondary and tertiary preventive care.

(31) "Rural health clinic (RHC)" means a clinic determined by the U.S. Department of Health and Human Services to meet the rural health clinic conditions of certification specified in 42 U.S.C. 1396d(l)(1) (2015) and 42 CFR, part 491, subpart A (2015).

(32) "Third party administrator (TPA)" means an entity appropriately authorized, as may be required by Montana law, to provide administrative services including, but not limited to, claims processing, maintaining an adequate network of participating providers, coordination of care, health education, notices, quality assurance, reporting, case management services, and customer service.

(33) "Tribal health services" means a service provided by a federally recognized American Indian Tribe or tribal organization under a P.L. 93-638 agreement.

(34) "Workforce program" means a program developed and administered by the Department of Labor and Industry that includes employment assessment and workforce development opportunities to participants.

History: 53-2-215, 53-6-113, 53-6-1305, 53-6-1318, MCA; IMP, 53-2-215, 53-6-101, 53-6-113, 53-6-131, 53-6-1304, 53-6-1305, 53-6-1306, 53-6-1307, MCA; NEW, 2015 MAR p. 2294, Eff. 1/1/16.

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