37.83.802    QUALIFIED MEDICARE BENEFICIARIES, DEFINITIONS

(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.

History: Sec. 53-2-201 and 53-6-113, MCA; IMP, Sec. 53-6-101 and 53-6-131, MCA; NEW, 1989 MAR p. 835, Eff. 6/30/89; TRANS, from SRS, 2000 MAR p. 197; AMD, 2001 MAR p. 1476, Eff. 8/10/01; AMD, 2001 MAR p. 2156, Eff. 10/26/01.