Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5001 - HEALTH MAINTENANCE ORGANIZATIONS: DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "Administrative contractor for managed
				care" means the entity the department contracts with to perform certain
				administrative functions of the managed health care programs.
(2) "Basic medicaid" means the program of
				medicaid services for adults receiving medical assistance through the FAIM
				program who are 21 years and older and not pregnant. Basic medicaid excludes
				coverage for dental services, most durable medical equipment and supplies, eye
				examinations, eyeglasses, hearing aids, audiology services, and personal care
				services.
(3) "Capitation rate"
				means the fee the department pays monthly to an HMO for the provision of
				covered medical and health services to each enrolled recipient. The fee is
				reimbursed whether or not the enrolled recipient received services during the
				month for which the fee is intended. The fee may vary by age, eligibility
				category and region.
(4)
				"Community-based organizations" means local governmental and nonprofit
				organizations providing programs of preventive and other health related
				services. Community-based organizations include but are not limited to: local
				family planning services; local women, infants and children (WIC) projects;
				local projects of Montana initiative for the abatement of mortality of infants
				(MIAMI) ; HIV testing, partner notification and early intervention; childhood
				lead poisoning prevention services; cherish our Indian children; follow me
				programs for special needs children.
(5) "Complaint" means an informal, verbal
				communication which an enrollee or their authorized representative presents
				regarding what the enrollee or their authorized representative perceives to be
				an inappropriate or lack of appropriate action by the HMO or any of its
				providers.
(6) "Contract" means a
				contract between the department and an HMO for the provision of medical and
				health services to medicaid recipients.
(7) "County office" means the location people
				go to apply for medicaid benefits that is either the department's local office
				of human services or the human services or welfare office of a
				county.
(8) "Covered services"
				means all or a part of the medical and health services set forth in ARM
				37.86.5007 that an HMO is
				responsible for delivering to enrolled recipients under a contract with the
				department.
(9) "Day" means
				calendar days, except where the term working days or business days is expressly
				used.
(10) "Department" means the
				Montana department of public health and human services.
(11) "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.