As used in this subchapter, unless expressly provided otherwise, the following definitions apply:

(1) "Advanced practice registered nurse (APRN)" means a registered professional nurse who has completed educational requirements related to the nurse's specific practice role, in addition to basic nursing education, as specified by the Board of Nursing in ARM 24.159.1414.

(2) "Ambulance services" means all mileage, services, procedures, and supplies provided by a licensed ambulance provider.

(3) "Applicant" means an individual under the age of 19 years who applied for the HMK Plan benefits or whose parent or guardian applied for the HMK Plan benefits on the individual's behalf.

(4) "Benefits" means the services an enrollee is eligible to receive. The HMK coverage group benefits are stated in its Evidence of Coverage. All benefits are provided to an enrollee through the department.

(5) "Benefit year" means:

(a) for medical and mental health, the period from October 1 through September 30 for those enrolled in the HMK coverage group. If an individual is enrolled in the HMK coverage group after October 1, the benefit year is the period from the date of enrollment through the following September 30.

(b) for dental, the period from July 1 through June 30 for those enrolled in the HMK coverage group. If an individual is enrolled in the HMK coverage group after July 1, the benefit year is the period from the date of enrollment through the following June 30.

(6) "Children's Health Insurance Program (CHIP)" means the Children's Health Insurance Program described in this subchapter and administered by the department under Title 53, chapter 4, part 10, MCA and Title XXI of the Social Security Act.

(7) "Department" means the Montana Department of Public Health and Human Services.

(8) "Earned income" means payments received as compensation for work performed. Some examples are: bonus, wages, salaries, tips, commission, self-employment, military pay, and severance pay.

(9) "Emergency medical condition" means a medical condition manifesting itself by acute symptoms of sufficient severity, including severe pain, such that a prudent layperson, with an average knowledge of health and medicine, could reasonably expect the absence of immediate medical attention to result in any of the following:

(a) serious jeopardy to the health of the enrollee or the enrollee's unborn child;

(b) serious impairment of bodily function; or

(c) serious dysfunction of any bodily organ or part.

(10) "Enrollee" means an individual who is eligible and enrolled in the HMK coverage group. The term "enrollee" and "member" are synonymous.

(11) "Enrollment partner" means an organization or individual approved by the department to assist in enrolling eligible children in the plan.

(12) "Eyeglasses" means corrective lens and/or frames prescribed by an ophthalmologist or by an optometrist to aid and improve vision.

(13) "Family span" means the 12 month period beginning the first day of the month after the department receives an application for HMK coverage group benefits and ending the last day of the 12th month. Although qualified for the HMK coverage group benefits, applicants placed on the waiting list may not be enrolled during the entire family span.

(14) "Federal poverty level (FPL)" means the poverty guidelines for 2013 for the 48 contiguous states and the District of Columbia as published under the "Annual Update on the HHS Poverty Guidelines" 78 Federal Register 16, pp 5182-5183, January 24, 2013.

(15) "Federally qualified health center (FQHC)" means an entity that is a federally qualified health center as defined in 42 USC 1396d(l)(2)(B) (2009 Supp.).

(16) "Guardian" means the custodial parent or a person granted legal guardianship of a child by court order, judgment, or decree.

(17) "Health coverage" means a program administered by the department or a disability insurance plan, referred to in 33-1-207(1)(b), MCA, that provides public health care coverage or private health insurance for children.

(18) "Healthy Montana Kids (HMK) Plan" means the two health care coverage groups, Healthy Montana Kids (HMK) and Healthy Montana Kids Plus (HMK Plus), which pay for covered health care services to qualified individuals until their 19th birthday. The HMK coverage group was formerly referred to as CHIP and the provisions of Title 53, chapter 4, part 10, MCA apply. The HMK Plus coverage group is also referred to as children's Medicaid and the provisions of Title 53, chapter 6, MCA apply.

(19) "Incarcerated" means living in a facility which would be termed a public institution under Medicaid regulations at 42 CFR 435.1009.

(20) "Income" or "family income" means the gross earned income, unearned income, and imputed income of the custodial parent. Regular, continuing, and intermittent sources of income will be annualized for purposes of determining the annual income level.

(21) "Initiative I-155" means the initiative passed by Montana voters in November, 2008, that enacted the HMK Plan Act.

(22) "Institution for mental disease (IMD)" means a facility which would be termed an institute for mental disease under Medicaid regulations at 42 CFR 435.1009.

(23) "Medically necessary" or "medically necessary covered services" means services and supplies which are necessary and appropriate for the diagnosis, prevention, or treatment of physical or mental conditions as described in this subchapter and that are not provided only as a convenience.

(24) "Member" means an individual who is eligible to receive HMK Plan benefits as determined by the department under this rule. An individual is not a member while on a waiting list or pending issuance of a hearing decision or during any period a hearing officer determines the individual was not eligible for the HMK coverage group benefits. The term "member" and "enrollee" are synonymous.

(25) "Mid-level practitioner" is defined at ARM 37.86.202.

(26) "Montana resident" means a U.S. citizen or qualified alien who declares himself or herself to be living in the state of Montana, including a migrant or other seasonal worker.

(27) "Outpatient prospective payment system (OPPS)" means the reimbursement method for federally qualified health centers (FQHCs) and Rural Health Centers (RHCs).

(28) "Outreach" means efforts which promote the Healthy Montana Kids Plan through a combination of traditional marketing methods, and social marketing. The department will develop and maintain an enrollment partner network to encourage, assist, and actively enroll children in the program.

(29) "Participating provider" means a health care professional or facility as defined at 33-36-103(19), MCA.

(30) "Presumptive eligibility (PE)" means a temporary period of HMK medical assistance not to exceed two consecutive calendar months in a 12-month period for uninsured children through the month of their 19th birthday, pending a decision of HMK Plan eligibility.

(31) "Qualified alien" means a person residing legally in the United States, as defined by federal immigration laws and regulations and in ARM 37.78.220.

(32) "Qualified entity (QE)" means a health care facility, individual, or other approved entity designated and trained by HMK to make a presumptive eligibility determination for a child on behalf of HMK.

(33) "Rural health clinic (RHC)" means a clinic determined by the secretary of the U.S. Department of Health and Human Service to meet the rural health clinic conditions of certification specified in 42 CFR, part 491, subpart A.

(34) "Serious emotional disturbance (SED)" means the criteria stated in ARM 37.87.303.

(35) "State employee" means a person, including the HMK applicant, employed on a permanent basis by the state of Montana.

(36) "Third party administrator (TPA)" means an entity with a certificate of registration to conduct business in Montana in accordance with 33-17-603, MCA, or an entity licensed as a health service corporation. The department may contract for TPA services including but not limited to claims processing, maintaining an adequate network of participating providers, coordination and continuation of care, health education, notices, quality assurance, reporting, case management services, and customer service.

(37) "Unearned income" means all payments received other than earned income. Some examples are: adoption subsidies, annuities, dividends, interest, social security benefits, disability, and unemployment insurance payments.

(38) "Waiting list" means a list of applicants who have been determined eligible for the HMK coverage group but who are not enrolled because funds are not available.