Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.09 - MEDICAID BASIC PLAN BENEFITS › Section 16.03.09.011 - DEFINITIONS: I THROUGH O

Current through August 31, 2023
01.
Intermediate Care Facility for Individuals with Intellectual Disabilities
			 (ICF/IID)
. An entity licensed as an ICF/IID and federally certified to
			 provide care to Medicaid and Medicare participants with developmental
			 disabilities. (7-1-23)T
02.
Idaho Behavioral Health Plan (IBHP)
. A prepaid ambulatory health
			 plan (PAHP) that provides outpatient behavioral health coverage for
			 Medicaid-eligible children and adults. Outpatient behavioral health services
			 include mental health and substance use disorder treatment and case management
			 services. The coordination and provision of behavioral health services as
			 authorized through the IBHP contract are provided to qualified, enrolled
			 participants by a statewide network of professionally licensed and certified
			 behavioral health providers. (7-1-23)T
03.
Idaho Infant Toddler Program
			 (ITP)
. Serves children from birth through the end of their 36th month of
			 age who meet the requirements and provisions of the Individuals with
			 Disabilities Education Act (IDEA), Part C. (7-1-23)T
04.
In-Patient Hospital
			 Services
. Services that are ordinarily furnished in a hospital for the
			 care and treatment of an in-patient under the direction of a physician or
			 dentist except for those services provided in mental hospitals.
			 (3-17-22)
05.
Intermediary
. Any organization that administers Title XIX or Title XXI;
			 in this case the Department of Health and Welfare. (3-17-22)
06.
Intermediate Care Facility
			 Services
. Services furnished in an intermediate care facility as defined
			 in 42 CFR
			 440.150, but excluding services provided in a
			 Christian Science Sanatorium. (7-1-23)T
07.
Legal Representative
. A
			 parent with custody of a minor child, one who holds a legally-executed and
			 effective power of attorney for health decisions, or a court-appointed guardian
			 whose powers include the power to make health care decisions.
			 (3-17-22)
08.
Legend
			 Drug
. A drug that requires, by federal regulation or state rule, the
			 order of a licensed medical practitioner before dispensing or administration to
			 the patient. (3-17-22)
09.
Level of Care
. The classification in which a participant is
			 placed, based on severity of need for institutional care. (3-17-22)
10.
Licensed, Qualified
			 Professionals
. Individuals licensed, registered, or certified by
			 national certification standards in their respective discipline, or otherwise
			 qualified within the state of Idaho. (3-17-22)
11.
Licensed Practitioner of the
			 Healing Arts
. The term includes the following practitioner types:
			 certified registered nurse anesthetists (CRNA), nurse practitioners (NP), nurse
			 midwives (NM), clinical nurse specialists (CNS), and physician assistants (PA),
			 as defined in these rules. (7-1-23)T
12.
Lock-In Program
. An
			 administrative sanction, required of a participant found to have misused the
			 services provided by the Medical Assistance Program. The participant is
			 required to select one (1) provider in the identified area(s) of misuse to
			 serve as the primary provider. (3-17-22)
13.
Locum Tenens/Reciprocal
			 Billing
. The practice of a physician to retain a substitute physician
			 when the regular physician is absent for reasons such as illness, pregnancy,
			 vacation, or continuing medical education. The substitute physician is called
			 the "Locum Tenens'' physician. Reimbursement to a Locum Tenens physician will
			 be limited to a period of ninety (90) continuous days. Reciprocal billing
			 occurs when a substitute physician covers the regular physician during an
			 absence or on an on-call basis a period of fourteen (14) continuous days or
			 less. (3-17-22)
14.
Medical
			 Assistance
. Payments for part or all of the cost of services funded by
			 Titles XIX or XXI of the federal Social Security Act. (7-1-23)T
15.
Medicaid
. Idaho's Medical
			 Assistance Program. (3-17-22)
16.
Medicaid-Related Ancillary Costs
. Services considered to be
			 ancillary by Medicare cost reporting principles. Medicaid-related ancillary
			 costs will be determined by apportioning direct and indirect costs associated
			 with each ancillary service to Medicaid participants by dividing Medicaid
			 charges into total charges for that service. The resulting percentage, when
			 multiplied by the ancillary service cost, will be considered Medicaid-related
			 ancillaries. (7-1-23)T
17.
Medical Necessity (Medically Necessary)
. A service is medically
			 necessary if: (3-17-22)
a. It is reasonably
			 calculated to prevent, diagnose, or treat conditions in the participant that
			 endanger life, cause pain, or cause functionally significant deformity or
			 malfunction; and (3-17-22)
b. There
			 is no other equally effective course of treatment available or suitable for the
			 participant requesting the service that is more conservative or substantially
			 less costly. (3-17-22)
c. Medical
			 services must be: (3-17-22)
i. Of a quality
			 that meets professionally-recognized standards of health care; and
			 (3-17-22)
ii. Substantiated by
			 records including evidence of such medical necessity and quality. Those records
			 must be made available to the Department upon request.
			 (3-17-22)