Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 88 - Specialized Managed Care Programs › Rule 441-88.1 - Definitions

Current through Register Vol. 47, No. 3, July 24, 2024
"Capitation rate"
shall mean the fee the
				  department pays monthly to a PHP for each enrolled recipient for the provision
				  of covered medical services whether or not the enrolled recipient received
				  services during the month for which the fee is intended.
"Contract"
shall mean a contract between the
				  department and a PHP for the provision of medical services to enrolled Medicaid
				  recipients for whom the PHP assumes a risk as defined in the contract. These
				  contracts shall meet the requirements of the Code of Federal Regulations, Title
				  42, Part 434 as amended to December 31, 1996.
"Department"
shall mean the Iowa department
				  of human services.
"Emergency service"
shall mean those medical
				  services rendered under unforeseen conditions which require hospitalization for
				  the treatment of accidental injury and relief of acute pain, which, if not
				  immediately diagnosed and treated, would result in risk of permanent danger to
				  the patient's health.
"Enrollment area"
shall mean the county or
				  counties which the PHP has capability to serve and is defined in the contract
				  with the department. An enrollment area shall not be less than an entire
				  county.
"Grievance"
shall mean an incident,
				  complaint, or concern which cannot be resolved in a manner satisfactory to
				  enrolled recipients by the immediate response, verbal or otherwise, of the PHP
				  staff member receiving the complaint or any complaint received in
				  writing.
"Managed health care"
shall mean any one of
				  the alternative deliveries of regular, fee-for-service Medicaid such as defined
				  in subrules dealing with health maintenance organizations (HMOs), or prepaid
				  health plans (PHPs), or Medicaid Patient Access to Service System
				  (MediPASS).
"Managed health care review committee"
shall
				  mean a committee composed of representatives from the department. The committee
				  shall review and render a decision on all requests for disenrollment which are
				  not automatically approvable.
"Managed services"
shall mean all or part of
				  those medical services set forth in 441-Chapter 78 and covered in the contract
				  between the department and a PHP.
"Nonmanaged services"
shall mean medical
				  services covered under regular Medicaid, but which are not covered in the PHP's
				  contract with the department. Payment for nonmanaged services incurred by an
				  enrolled recipient shall be made under regular Medicaid procedures.
"Participating providers"
shall mean the
				  providers of covered medical services who subcontract with or who are employed
				  by the PHP.
"Prepaid health plan (PHP)"
shall mean an
				  entity defined in Section 1903(m)(2)(B)(iii) of the Social Security Act and
				  considered to be a PHP by the department based upon criteria set forth in the
				  Code of Federal Regulations at Title 42, Part 434.20(a)(3) as amended to March
				  31, 1991.
"Recipient"
shall mean any person determined
				  by the department to be eligible for Medicaid and for PHP enrollment. See
				  subrule 88.2(4) for a list of Medicaid eligibles who are not eligible for PHP
				  enrollment.
"Routine care"
shall mean medical care which
				  is not urgent or emergent in nature and can wait for a regularly scheduled
				  physician appointment without risk of permanent damage to the patient's life or
				  health status. The condition requiring routine care is not likely to
				  substantially worsen without immediate clinical intervention.
"Urgent, nonemergency need"
shall mean the
				  existence of conditions due to an illness or injury which are not life
				  threatening but which require expeditious treatment because of the prospect of
				  the condition worsening without immediate clinical
				  intervention.