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) " means with respect to a youth between the ages of six and 17 years that the youth meets the following requirements of (15) (a) and either (15) (b) , or (15) (c) :

(a) The youth has been determined by a licensed mental health professional as having a mental disorder with a primary diagnosis falling within one of the following DSM-IV (or successor) classifications when applied to the youth's current presentation (current means within the past 12 calendar months unless otherwise specified in the DSM-IV) and the diagnosis has a severity specifier of moderate or severe:

(i) childhood schizophrenia (295.10, 295.20, 295.30, 295.60, 295.90) ;

(ii) oppositional defiant disorder (313.81) ;

(iii) autistic disorder (299.00) ;

(iv) pervasive developmental disorder not otherwise specified (299.80) ;

(v) Asperger's disorder (299.80) ;

(vi) separation anxiety disorder (309.21) ;

(vii) reactive attachment disorder of infancy or early childhood (313.89) ;

(viii) schizo affective disorder (295.70) ;

(ix) mood disorders (296.0x, 296.2x, 296.3x, 296.4x, 296.5x, 296.6x, 296.7, 296.80, 296.89) ;

(x) obsessive-compulsive disorder (300.3) ;

(xi) dysthymic disorder (300.4) ;

(xii) cyclothymic disorder (301.13) ;

(xiii) generalized anxiety disorder (overanxious disorder) (300.02) ;

(xiv) posttraumatic stress disorder (chronic) (309.81) ;

(xv) dissociative identity disorder (300.14) ;

(xvi) sexual and gender identity disorder (302.2, 302.3, 302.4, 302.6, 302.82, 302.83, 302.84, 302.85, 302.89) ;

(xvii) anorexia nervosa (severe) (307.1) ;

(xviii) bulimia nervosa (severe) (307.51) ;

(xix) intermittent explosive disorder (312.34) ; and

(xx) attention deficit/hyperactivity disorder (314.00, 314.01, 314.9) when accompanied by at least one of the diagnoses listed above.

(b) As a result of the youth's diagnosis determined in (15) (a) and for a period of at least six months, or for a predictable period over six months, the youth consistently and persistently demonstrates behavioral abnormality in two or more spheres, to a significant degree, well outside normative developmental expectations, that cannot be attributed to intellectual, sensory, or health factors:

(i) has failed to establish or maintain developmentally and culturally appropriate relationships with adult care givers or authority figures;

(ii) has failed to demonstrate or maintain developmentally and culturally appropriate peer relationships;

(iii) has failed to demonstrate a developmentally appropriate range and expression of emotion or mood;

(iv) has displayed disruptive behavior sufficient to lead to isolation in or from school, home, therapeutic or recreation settings;

(v) has displayed behavior that is seriously detrimental to the youth's growth, development, safety or welfare, or to the safety or welfare of others; or

(vi) has displayed behavior resulting in substantial documented disruption to the family including, but not limited to, adverse impact on the ability of family members to secure or maintain gainful employment.

(c) In addition to mental health services, the youth demonstrates a need for specialized services from at least one of the following human service systems during the previous six months:

(i) education services, due to the diagnosis determined in (15) (a) , as evidenced by identification as a child with a disability as defined in 20-7-401(4) , MCA with respect to which the youth is currently receiving special education services;

(ii) child protective services as evidenced by temporary investigative authority, or temporary or permanent legal custody;

(iii) the juvenile correctional system, due to the diagnosis determined in (15) (a) , as evidenced by a youth court consent adjustment or consent decree or youth court adjudication; or

(iv) current alcohol/drug abuse or addiction services as evidenced by participation in treatment though a state-approved program or with a certified chemical dependency counselor.

(d) Serious emotional disturbance (SED) with respect to a youth under six years of age means the youth exhibits a severe behavioral abnormality that cannot be attributed to intellectual, sensory, or health factors and that results in substantial impairment in functioning for a period of at least six months or is predicted to continue for a period of at least six months, as manifested by one or more of the following:

(i) atypical, disruptive or dangerous behavior which is aggressive or self-injurious;

(ii) atypical emotional responses which interfere with the child's functioning, such as an inability to communicate emotional needs and to tolerate normal frustrations;

(iii) atypical thinking patterns which, considering age and developmental expectations, are bizarre, violent, or hypersexual;

(iv) lack of positive interests in adults and peers or a failure to initiate or respond to most social interaction;

(v) indiscriminate sociability (e.g., excessive familiarity with strangers) that results in a risk of personal safety of the child; or

(vi) inappropriate and extreme fearfulness or other distress which does not respond to comfort by care givers.

(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 an individual who has not yet attained 18 years of age, except that for purposes of the definition of serious emotional disturbance, "youth" may include an individual who has not yet attained 21 years of age if the person is enrolled in a full-time special education program.

(19) The department adopts and incorporates by reference the ICD-9-CM diagnosis codes with meanings found in the St. Anthony's ICD-9-CM Code Book (1998) effective October 1, 1998 through September 30, 1999, published by St. Anthony Publishing. 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 (1994) , published by the American Psychiatric Association of Washington, DC. 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, 555 Fuller, P.O. Box 202905, Helena, MT 59620-2905.