(1) "Case management" means directing and overseeing the delivery of certain services to an enrollee.
(2) "Clinic" means a federally qualified health center, a rural health clinic, an Indian health service clinic on a reservation, or any other clinic as defined in ARM 37.86.1401 which can meet the requirements of ARM 37.86.5111.
(3) "Emergency service" means, as defined at ARM 37.82.102(11), inpatient and outpatient services that are necessary to treat an emergency medical condition.
(4) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a prudent layperson, who possesses an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in:
(a) placing the health of the individual (or, with respect to a pregnant woman, the health of the woman or her unborn child) in serious jeopardy;
(b) serious impairment to bodily functions; or
(c) serious dysfunction of any bodily organ or part.
(5) "Enroll" means to choose a primary care provider.
(6) "Enrollee" means a Medicaid member participating in the program and who is enrolled with a primary care provider under the program.
(7) "Exempt" means a Medicaid member who is:
(a) eligible for managed care but able to establish that participating would be a hardship;
(b) enrolled in a health maintenance organization that provides case management services;
(c) unable to find a primary care provider willing to provide case management; or
(d) residing in a county in which there are not enough primary care providers to serve the Medicaid population required to participate in the program. The department has the discretion to determine hardship and to place time limits on all exemptions described in (a) through (d) on a case-by-case basis.
(8) "Ineligible" means a Medicaid member who is not eligible to participate in a managed care program, such as the Passport Program, but is eligible for regular Medicaid. The following categories of members are ineligible for the Passport Program:
(a) eligible for Medicaid with a spend down (medically needy);
(b) living in a nursing home or institutional setting;
(c) receiving Medicaid for less than three months;
(d) eligible for Medicare;
(e) eligible for Medicaid adoption assistance or guardianship;
(f) eligible for pregnancy Medicaid;
(g) retroactive Medicaid eligibility;
(h) receiving Medicaid home and community-based services for persons who are aged or disabled;
(i) eligible for Plan First;
(j) receiving Medicaid under a presumptive eligibility program; and
(k) eligible for the Breast and Cervical Cancer program.
(9) "Medical care" means care provided to meet the medical and medically related needs of a person.
(10) "Participate" means compliance with the requirements of the program.
(11) "Passport to Health Program" or "the program" means the primary care case management (PCCM) program for Medicaid members.
(12) "Primary care" means medical care provided at a person's first point of contact with the health care system, except for emergencies. It includes treatment of illness and injury, health promotion and education, identification of persons at special risk, early detection of serious disease, promotion of preventive health care, and referral to specialists when appropriate.
(13) "Primary care case management" or "managed care" means promoting the access to, coordination of, quality of, and appropriate use of medical care, and containing the costs of medical care by having an enrollee obtain certain medical care from and through a primary care provider.
(14) "Primary care provider" means a physician, clinic, or midlevel practitioner other than a certified registered nurse anesthetist that is responsible by agreement with the department for providing primary care case management to enrollees in the Passport to Health Program.
(15) "Referral" means the approval by the Passport enrollee's primary care provider for the delivery by another provider of a service(s) that requires Passport referral. Referral is the provision of the primary care provider's Passport referral number to the other provider. The primary care provider shall establish the parameters of the referral.
(16) "Team Care" means a program for members identified as excessive or inappropriate utilizers of the Medicaid program as set forth in ARM 37.86.5303.