Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.802 - QUALIFIED MEDICARE BENEFICIARIES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "Assignment" means an agreement between
				the medicare carrier and a medicare provider under which the carrier makes
				payment to the provider rather than the recipient, and the provider agrees to
				accept the medicare allowable rate as payment in full.
(2) "Carrier" means the private insurance
				company contracted with by the United States health care financing
				administration to process medicare Part B claims and issue payments to
				physicians and other providers or to recipients.
(3) "Chiropractic services" means the
				manipulation of the spine by a licensed chiropractor to correct a subluxation.
				Chiropractic services do not include x-rays or other diagnostic or therapeutic
				services provided by a licensed chiropractor.
(4) "Coinsurance" means an amount of medical
				and other costs incurred by an eligible person that are the financial
				responsibility of that person rather than of the medicare Parts A or B
				insurance. The amount of coinsurance is the difference between the medicare
				allowable rate and the actual medicare payment.
(5) "Copayment" means a cost sharing fee
				imposed upon a qualified medicare beneficiary recipient for a medical service
				paid for by medicaid.
(6)
				"Customary charge" means the charge most frequently used by the provider for
				the service or item.
(7)
				"Deductible" means a set amount of medical and other costs designated by
				medicare as the person's financial responsibility. Medicare coverage begins
				with costs in excess of the deductibles.
(8) "Department" means the department of
				public health and human services as provided for at
				2-15-2201,
				MCA.
(9) "Full medicaid" means
				medicaid coverage other than that provided to qualified medicare
				beneficiaries.
(10) "Hospice care"
				are those services providing pain relief, symptom management, respite care, and
				support services to terminally ill persons.
(11) "Intermediary" means the private
				insurance company contracted with by the United States health care financing
				administration to make coverage and payment decisions on services covered by
				medicare Part A insurance in hospitals, skilled nursing facilities, home health
				agencies and hospices.
(12)
				"Medicare allowable rate" means the reasonable charge for the medical service
				reimbursable under medicare Part B.
(13) "Medicare" means the health insurance
				programs under Title XVIII of the Social Security Act.
(14) "Medicare Part A insurance" means the
				insurance program under medicare that covers inpatient hospital care, inpatient
				care in a skilled nursing facility, home health care, and hospice
				care.
(15) "Medicare Part B
				insurance" means the insurance program under medicare that covers outpatient
				hospital services, physician services, home health care services, and other
				medical services not covered by medicare Part A insurance.
(16) "Premiums" means the monthly amounts
				that are charged for a person to receive medicare Part B insurance coverage and
				that may be charged for a person to receive medicare Part A coverage when the
				person is not eligible for premium-free coverage.
(17) "Prevailing charge" means a level equal
				to at least three-fourths of the average of all the charges for the same
				service billed by all the physicians or suppliers in the state.
(18) "Qualified medicare beneficiary" means a
				person eligible for the program provided for in Title 37, chapter 83.
(19) "Respite care" is a short term inpatient
				hospital stay necessary to temporarily relieve the person who regularly
				provides hospice care to a person.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-101
					 and
					 53-6-131,
					 MCA;