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) "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.

(3) "Benefits" means the services an enrollee is eligible for as outlined in this subchapter. All benefits with the exception of dental and eyeglass services, are provided to an enrollee through the insurer.

(4) "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.

(5) "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.

(6) "Department" means the Montana department of public health and human services.

(7) "Earned income" means income received from employment, self-employment activity, profession, vocation or pastime and includes wages, salaries, tips, commissions, profits, farm or ranch income and honoraria.

(8) "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.

(9) "Enrollee" means an individual who is eligible to receive CHIP benefits as determined by the department under this subchapter and is enrolled with an insurer. 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.

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

(11) "Family" means a group of individuals who are residing together as a single economic unit. Members of the economic unit are considered to live together even though a member may reside temporarily in a residential treatment setting. For purposes of this subchapter, a minor living alone shall be considered an economic unit.

(12) "Family span" means the 12 month period of eligibility beginning the first day of the month after an applicant qualifies for CHIP benefits 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 for 2003 published in the Federal Register by the U.S. department of health and human services.

(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 adjusted gross earned income as defined by federal tax law and regulations plus unearned income of the family as defined in this rule. Regular, continuing and intermittent sources of income will be annualized for purposes of determining the annual income level. Family income does not include:

(a) earned income of individuals in the household who are under 19 years of age, unless they are of school age and are not attending school;

(b) money received from assets drawn down such as withdrawals from a savings account, an annuity or from the sale of a house or a car;

(c) gifts, loans, one-time insurance payments, or compensation for an injury;

(d) per capita income to enrolled members of Native American tribes;

(e) earned income which is excluded and dependent care expenses which are deducted from income under the state medicaid poverty programs for children; or

(f) income excluded under federal medicaid regulations.

(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) "Insurer" means an authorized insurer, health service corporation or health maintenance organization (HMO) with a valid certificate of authority issued by the Montana commissioner of insurance to transact business in the state of Montana.

(19) "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.

(20) "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.

(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) "Premium" means the amount of money the department pays monthly to an insurer for the provision of benefits for each enrollee. The premium is paid whether or not the enrollee received covered benefits during the month for which the premium is intended. All benefits outlined in this subchapter, except eyeglass and dental benefits, are covered through payment of this premium.

(25) "Primary care provider" means a participating health care professional designated by the insurer to supervise, coordinate or provide initial care or continuing care to a CHIP enrollee and who may be required by the insurer to initiate a referral for specialty care and to maintain supervision of health care services to the CHIP enrollee.

(26) "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.

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

(28) "Unearned income" means income that is not defined as earned under this subchapter and includes interest, dividends, distributions from trusts or estates, social security benefits, veteran's benefits or payments, workers' compensation and unemployment compensation benefits. Unearned income does not include income excluded under federal medicaid regulations.

(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 to pay their health care premiums.