Mont. Admin. R. 37.83.802 - QUALIFIED MEDICARE BENEFICIARIES, DEFINITIONS
(1) "Assignment" means an agreement between
the medicare carrier and a medicare provider under which the carrier makes
payment to the provider rather than the recipient, and the provider agrees to
accept the medicare allowable rate as payment in full.
(2) "Carrier" means the private insurance
company contracted with by the United States health care financing
administration to process medicare Part B claims and issue payments to
physicians and other providers or to recipients.
(3) "Chiropractic services" means the
manipulation of the spine by a licensed chiropractor to correct a subluxation.
Chiropractic services do not include x-rays or other diagnostic or therapeutic
services provided by a licensed chiropractor.
(4) "Coinsurance" means an amount of medical
and other costs incurred by an eligible person that are the financial
responsibility of that person rather than of the medicare Parts A or B
insurance. The amount of coinsurance is the difference between the medicare
allowable rate and the actual medicare payment.
(5) "Copayment" means a cost sharing fee
imposed upon a qualified medicare beneficiary recipient for a medical service
paid for by medicaid.
(6)
"Customary charge" means the charge most frequently used by the provider for
the service or item.
(7)
"Deductible" means a set amount of medical and other costs designated by
medicare as the person's financial responsibility. Medicare coverage begins
with costs in excess of the deductibles.
(8) "Department" means the department of
public health and human services as provided for at
2-15-2201,
MCA.
(9) "Full medicaid" means
medicaid coverage other than that provided to qualified medicare
beneficiaries.
(10) "Hospice care"
are those services providing pain relief, symptom management, respite care, and
support services to terminally ill persons.
(11) "Intermediary" means the private
insurance company contracted with by the United States health care financing
administration to make coverage and payment decisions on services covered by
medicare Part A insurance in hospitals, skilled nursing facilities, home health
agencies and hospices.
(12)
"Medicare allowable rate" means the reasonable charge for the medical service
reimbursable under medicare Part B.
(13) "Medicare" means the health insurance
programs under Title XVIII of the Social Security Act.
(14) "Medicare Part A insurance" means the
insurance program under medicare that covers inpatient hospital care, inpatient
care in a skilled nursing facility, home health care, and hospice
care.
(15) "Medicare Part B
insurance" means the insurance program under medicare that covers outpatient
hospital services, physician services, home health care services, and other
medical services not covered by medicare Part A insurance.
(16) "Premiums" means the monthly amounts
that are charged for a person to receive medicare Part B insurance coverage and
that may be charged for a person to receive medicare Part A coverage when the
person is not eligible for premium-free coverage.
(17) "Prevailing charge" means a level equal
to at least three-fourths of the average of all the charges for the same
service billed by all the physicians or suppliers in the state.
(18) "Qualified medicare beneficiary" means a
person eligible for the program provided for in Title 37, chapter 83.
(19) "Respite care" is a short term inpatient
hospital stay necessary to temporarily relieve the person who regularly
provides hospice care to a person.
Notes
Sec. 53-2-201 and 53-6-113, MCA; IMP, Sec. 53-6-101 and 53-6-131, MCA;
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