Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › COVERED SERVICES › SUB AREA: PRIMARY CARE CASE MANAGEMENT › Section 16.03.09.560 - HEALTHY CONNECTIONS: DEFINITIONS

Current through August 31, 2023
Healthy Connections is a primary care case management
					 program in which a primary care provider or team provides comprehensive medical
					 care for participants with the goal of improving health outcomes. For purposes
					 of this Sub Area that includes Sections
					 560 through
					 566 of these rules, the following
					 terms and definitions apply: (3-17-22)
01.
Capitated Payments
. Payments
				  to a primary care provider made on a per assigned participant per month basis
				  for patient services. Capitated payments will vary to reflect the level of
				  responsibility for services the provider elects to provide as described in
				  Section 564 of these
				  rules. Capitated payments may include payment for all provider services at a
				  set rate per participant per month when that type of full-risk reimbursement is
				  agreed to by the provider and the Department. (3-17-22)
02.
Clinic
. Two (2) or more
				  qualified medical professionals who provide services jointly through an
				  organization for which an individual is given authority to act on its behalf.
				  It also includes Federally Qualified Health Centers (FQHCs), Certified Rural
				  Health Clinics, and Indian Health Clinics. (3-17-22)
03.
Grievance
. The formal
				  process by which problems and complaints related to Healthy Connections are
				  addressed and resolved. Grievance decisions may be appealed as provided herein.
				  (3-17-22)
04.
Patient-Centered Medical Home
. A model of primary care that is
				  patient-centered, comprehensive, team-based, coordinated, accessible, and
				  focused on quality and safety. This results in primary care being delivered at
				  the right place, at the right time, and in the manner that best suits a
				  patient's needs. (3-17-22)
05.
Preventive Care
. Medical care that focuses on disease prevention
				  and health maintenance. (3-17-22)
06.
Primary Care Case
				  Management
. A model of care in which primary care providers and their
				  primary care team are responsible for direct care of a participant, and for
				  coordinating access to services that improve the health of the participant.
				  (3-17-22)
07.
Primary Care
				  Provider (PCP)
. A physician, physician assistant, or advanced practice
				  registered nurse as defined in IDAPA 24.34.01,"Rules of the Idaho Board of
				  Nursing," who contracts with Medicaid to coordinate and manage the care of
				  participants enrolled in the Healthy Connections program. (3-17-22)
08.
Primary Care Team
. A
				  multidisciplinary team of health care providers who work together to meet the
				  physical, emotional, and psychological needs of their patients using a
				  patient-centered and coordinated approach. (3-17-22)
09.
Referral
. A documented
				  communication from a participant's primary care provider (PCP) to another
				  Medicaid provider authorizing specific covered services subject to primary care
				  case management that are not provided by the participant's PCP.
				  (3-17-22)
10.
Transitional
				  Care
. A set of actions designed to ensure the coordination and
				  continuity of health care as patients transfer between different locations or
				  different levels of care within the same location. (3-17-22)