(1) "Authorization" means the approval by a primary care provider for the delivery to an enrollee by another provider of a service defined in ARM 37.86.5110. Authorization includes the provision of the primary care provider's medicaid number, unique physician identifying number (UPIN) , or the provider's passport number to the other treating provider. The primary care provider shall establish parameters of the authorization.

(2) "Case management" means directing and overseeing the delivery of certain services to an enrollee.

(3) "Clinic" means a federally-qualified health center, a rural health clinic, an Indian health service clinic on a reservation, or any other clinic as defined in ARM 37.86.1401 which can meet the requirements of ARM 37.86.5111.

(4) "Emergency service" means, as defined at ARM 37.82.102(11) , inpatient and outpatient services that are necessary to treat an emergency medical condition.

(5) "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.

(6) "Enroll" means to choose a primary care provider.

(7) "Enrollee" means a medicaid recipient participating in the program and who is enrolled with a primary care provider under the program.

(8) "Exempt" means medicaid recipients who are eligible for managed care but are able to establish it would be a hardship to participate in a managed care program. The department has the discretion to determine hardship and to place time limits on all exemptions on a case by case basis.

(9) "Ineligible" means a medicaid recipient who is not allowed to participate in a managed care program, such as the passport program, but is eligible for regular medicaid. The following categories of recipients are ineligible for the passport program:

(a) recipients with a spend down (medically needy) requirement;

(b) recipients living in a nursing home or institutional setting;

(c) recipients receiving medicaid for less than three months;

(d) recipients who have medicare;

(e) recipients who live in an area without medicaid managed care;

(f) recipients in the medicaid eligibility subgroup of subsidized adoption;

(g) recipients whose eligibility period is only retroactive;

(h) recipients who cannot find a primary care provider who is willing to provide case management;

(i) recipients who are receiving medicaid home and community services for persons who are aged or disabled; and

(j) recipients who reside in a county in which there are not enough primary care providers to serve the medicaid population required to participate in the program.

(10) "Medical care" means care provided to meet the medical and medically-related needs of a person.

(11) "Participate" means compliance with the requirements of the program.

(12) "Passport to health program" or "the program" means the primary care case management (PCCM) program for medicaid recipients.

(13) "Primary care" means medical care provided at a person's first point of contact with the health care system, except for emergencies. It includes treatment of illness and injury, health promotion and education, identification of persons at special risk, early detection of serious disease, promotion of preventive health care, and referral to specialists when appropriate.

(14) "Primary care case management" or "managed care" means promoting the access to, coordination of, quality of, and appropriate use of medical care, and containing the costs of medical care by having an enrollee obtain certain medical care from and through a primary care provider.

(15) "Team care" means a program for recipients identified as inappropriate utilizers of the medicaid program as set forth in ARM 37.86.5303. A medicaid recipient living in a nursing home or institutional setting and a recipient whose eligibility period is limited to a retroactive period only are ineligible for the team care program.

(16) "Primary care provider" means a physician, clinic, or mid-level practitioner other than a certified registered nurse anesthetist that is responsible by agreement with the department for providing primary care case management to enrollees in the passport to health program.