37.89.103 MENTAL HEALTH SERVICES PLAN, DEFINITIONS

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

(1) "Adult" means an individual 18 years of age or older.

(2) "Applicant" means an individual for whom the process to determine member eligibility has been initiated but not completed.

(3) "Correctional or detention facility" means:

(a) the Montana State Prison, including any correctional facility located on the Warm Springs campus;

(b) the Montana Women's Prison;

(d) a city or county criminal detention facility; or

(e) any privately operated or out-of-state facility that the state of Montana may choose to utilize in place of one of the above facilities or categories of facilities. (4) "Covered diagnosis" means a diagnosis for which the Mental Health Services Plan provides covered services to members who have a severe disabling mental illness, as specified in ARM 37.86.3503.

(5) "Emergency" means a serious medical or behavioral condition resulting from mental illness which arises unexpectedly and manifests symptoms of sufficient severity to require immediate care to avoid jeopardy to the life or health of the member or harm to another person by the member.

(6) "Family" means a group of two or more persons related by birth, marriage, or adoption who live together. Family members are considered to live together even though a family member may reside temporarily in a residential treatment setting.

(7) "Federal poverty level" or "FPL" means the poverty guidelines for the 48 contiguous states and the District of Columbia as published under the "Annual Update of the HHS Poverty Guidelines" in the Federal Register each year on or about February 15.

(8) "Medically necessary service" is defined as provided in ARM 37.82.102.

(9) "Medicare Part D" means the prescription drug benefit available to Medicare beneficiaries through a Medicare prescription drug plan or a Medicare Advantage Plan.

(10) "Member" means, with respect to the plan, an individual (or, as the context allows, the parent or guardian of the individual) eligible, according to the requirements of ARM 37.89.106, for services and receiving or attempting to receive services under the plan.

(11) "Mental health professional" means one of the following practitioners:

(a) physician;

(b) licensed professional counselor;

(d) licensed clinical social worker; or

(e) advanced practice registered nurse, with a clinical specialty in psychiatric mental health nursing.

(12) "Mental Health Services Plan, (MHSP)" or "plan" means the Mental Health Services Program established in this subchapter.

(13) "Mental health services" means services covered as specified in ARM 37.89.114 when provided with respect to a covered diagnosis.

(14) "Provider" means a person or entity that has enrolled and entered into a provider agreement with the department in accordance with the requirements of ARM 37.89.115 to provide mental health services to members.

(15) "Provider agreement" means the written enrollment agreement entered into between the department and a person or entity to provide mental health services to recipients.

(16) "Severe disabling mental illness" is defined in ARM 37.86.3503.

(17) "Total family income" means the total annual gross cash receipts, as defined by the Bureau of the Census and cited in the "Annual Update of the HHS Poverty Guidelines" promulgated each year by the United States Office of Management and Budget, of all members of a family. Regular and continuing sources of income will be appropriately annualized for purposes of determining the annual income level. Extraordinary and nonrecurring income will be considered only for the 12 month period following receipt.

(a) Total family income does not include:

(i) money received as assets drawn down such as withdrawals from a bank or the sale of a house or a car; or

(ii) income tax refunds, gifts, loans, one-time insurance payments, except as beneficiary of a life insurance policy, or compensation for injury.

(18) The department adopts and incorporates by reference the ICD-10-CM diagnosis codes with meanings found in the ICD-10-CM Code Book (2015) published by the American Medical Association. A copy of the code book may be obtained at: http://www.ama-assn.org/ama. The department also adopts and incorporates by reference the DSM diagnosis codes with meanings found in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision (2013), published by the American Psychiatric Association of Washington, D.C. A copy of the DSM may be obtained at: http://www.medicalcodingbooks.com/. These systems of coding provide the codes and meanings of the diagnostic terms commonly used by treating professionals and are incorporated in order to provide common references for purposes of the provision of services through the Mental Health Services Plan.

History: 41-3-1103, 52-1-103, 53-2-201, 53-6-113, 53-6-131, 53-6-701, 53-21-703, MCA; IMP, 41-3-1103, 52-1-103, 53-1-601, 53-1-602, 53-1-603, 53-2-201, 53-6-101, 53-6-113, 53-6-116, 53-6-117, 53-6-131, 53-6-701, 53-6-705, 53-21-139, 53-21-201, 53-21-202, 53-21-701, 53-21-702, MCA; NEW, 1997 MAR p. 548, Eff. 3/25/97; AMD, 1998 MAR p. 3307, Eff. 12/18/98; AMD, 1999 MAR p. 308, Eff. 2/12/99; AMD, 1999 MAR p. 1806, Eff. 7/1/99; TRANS & AMD, from SRS, 2001 MAR p. 27, Eff. 1/12/01; AMD, 2001 MAR p. 989, Eff. 6/8/01; EMERG, AMD, 2002 MAR p. 3417, Eff. 12/1/02; AMD, 2003 MAR p. 653, Eff. 3/28/03; AMD, 2004 MAR p. 84, Eff. 1/1/04; AMD, 2006 MAR p. 1053, Eff. 4/21/06; AMD, 2007 MAR p. 1197, Eff. 8/24/07; AMD, 2008 MAR p. 1988, Eff. 9/12/08; AMD, 2011 MAR p. 322, Eff. 3/11/11; AMD, 2015 MAR p. 2283, Eff. 12/25/15.