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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 that is not a youth as defined in this rule.

(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 the Warm Springs correctional facilities;

(b) the Montana women's correctional center;

(c) the Pine Hills youth correctional facility;

(d) the Riverside youth correctional facility;

(e) a department of corrections boot camp;

(f) a juvenile detention center;

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

(h) 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, as specified in ARM 37.89.114.

(a) A "covered diagnosis" means one of the ICD-9-CM diagnosis codes numbered 290, 293, 293.0 through 302, 302.2, 302.4, 302.6, 302.84 through 302.89, 306, 306.0 through 307, 307.1 through 307.3, 307.46, 307.5 through 307.80, 307.82 through 312.30, 312.32 through 314.9 and 316.

(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 2000 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 on February 15, 2000 and subsequent annual updates.

(8) "Medically necessary" 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 services plan" or "plan" means the Mental Health Services Program established in this subchapter.

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

(13) "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.

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

(15) "Serious emotional disturbance (SED)" is defined in ARM 37.86.3702(2).

(16) "Severe disabling mental illness" means with respect to a person who is 18 or more years of age that the person meets the requirements of (16)(a), (b), or (c). The person must also meet the requirements of (16)(d). The person:

(a) has been involuntarily hospitalized at least 30 consecutive days because of a mental disorder at Montana State Hospital (Warm Springs campus) at least once;

(b) has a DSM-IV diagnosis with a severity specifier of moderate or severe of:

(i) schizophrenic disorder (295);

(ii) other psychotic disorder (295.40, 295.70, 297.1, 297.3, 298.9, 293.81, 293.82);

(iii) mood disorder (293.83, 296.2x, 296.3x, 296.40, 296.4x, 296.5x, 296.6x, 296.7, 296.80, 296.89);

(iv) amnestic disorder (294.0, 294.8);

(v) disorder due to a general medical condition (310.1);

(vi) pervasive developmental disorder not otherwise specified (299.80) when not accompanied by mental retardation;

(vii) anxiety disorder (300.01, 300.21, 300.3); or

(c) has a DSM-IV diagnosis with a severity specifier of moderate or severe of personality disorder (301.00, 301.20, 301.22, 301.4, 301.50, 301.6, 301.81, 301.82, 301.83, or 301.90) which causes the person to be unable to work competitively on a full-time basis or to be unable to maintain a residence without assistance and support by family or a public agency for a period of at least six months or for an obviously predictable period over six months; and

(d) has ongoing functioning difficulties because of the mental illness for a period of at least six months or for an obviously predictable period over six months, as indicated by at least two of the following:

(i) a medical professional with prescriptive authority has determined that medication is necessary to control the symptoms of mental illness;

(ii) the person is unable to work in a full-time competitive situation because of mental illness;

(iii) the person has been determined to be disabled due to mental illness by the Social Security Administration;

(iv) the person maintains a living arrangement only with ongoing supervision, is homeless or is at imminent risk of homelessness due to mental illness; or

(v) the person has had or will predictably have repeated episodes of decompensation. An episode of decompensation includes increased symptoms of psychosis, self-injury, suicidal or homicidal intent or psychiatric hospitalization.

(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) "Youth" means a person 17 years of age and younger or a person who is under 20 years of age and is enrolled in secondary school.

(19) The department adopts and incorporates by reference the ICD-9-CM diagnosis codes with meanings found in the Ingenix ICD-9-CM Code Book (2006) valid October 1, 2006 through September 30, 2007, published by Ingenix. The department also adopts and incorporates by reference the DSM-IV diagnosis codes with meanings found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition Text Revision (2000), published by the American Psychiatric Association of Washington, D.C. These systems of coding provide the codes and meanings of the diagnostic terms commonly used by treating professionals and are incorporated herein in order to provide common references for purposes of the provision of services through the mental health services plan. Copies of applicable portions of the ICD-9-CM and the DSM-IV may be obtained from the Department of Public Health and Human Services, Addictive and Mental Disorders Division, Mental Health Services Bureau, 555 Fuller, P.O. Box 202905, Helena, MT 59620-2905 (for adult services) or the Health Resource Division, Children's Mental Health Bureau, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951 (for youth services).

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, 53-2-201, 53-6-101, 53-6-113, 53-6-116, 53-6-117, 53-6-131, 53-6-701, 53-6-705, 53-21-139, 53-21-202, 53-21-701, 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.

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