Definitions: P Through Z

01. Participant. A person eligible for and enrolled in Medicaid. (7-1-26) 02. Patient Driven Payment Model (PDPM). Process to group residents according to the clinical and functional status identified by responses to key elements of the MDS and used for rate setting and determining NF level of care. (7-1-26) 03. Personal Assistance Agency (PAA). An entity that recruits, hires, fires, trains, supervises, schedules, oversees quality of work, takes responsibility for services provided, provides payroll and benefits for personal assistants working for them, and is the employer of record as well as the actual employer. (7-1-26) 04. Plan Developer. A service coordinator identified by the participant responsible for developing a service plan and subsequent addenda covering all services and supports, based on a person-centered planning process. A plan developer may be paid, unpaid or the unpaid participant themselves. (7-1-26) 05. Plan Monitor. A person who oversees service delivery on a paid or non-paid basis. For DD services, the plan monitor is a service coordinator. (7-1-26) 06. Plan of Care. A written description of medical, remedial, habilitative, or rehabilitative services to provide to a participant, developed by or under the direction and written approval of a provider. Medications, services, and treatments shall be identified specifically by amount, type, and duration of service. (7-1-26) 07. Primary Care Provider (PCP). A healthcare professional acting within the scope of their practice, who is the first point of contact for routine medical concerns. (7-1-26) 08. Prior Authorization (PA). PA means a written, faxed, or electronic approval from the Department that permits payment or coverage of a medical item or service that is covered only by such authorization. (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 007 Page 20 09. Property Rental Rate. Rate paid per Medicaid patient day to free-standing nursing facilities in lieu of payment for property costs other than property taxes, insurance, and, for ICF/IID providers, costs of major movable equipment. (7-1-26) 10. Prosthetic Device. Replacement, corrective, or supportive devices to: (7-1-26) a. Artificially replace a missing portion of the body; (7-1-26) b. Prevent or correct physical deformities or malfunctions; or (7-1-26) c. Support a weak or deformed portion of the body. (7-1-26) d. Computerized communication devices are not included in this definition. (7-1-26) 11. Provider. Any individual acting under Section 020 including, but not limited to certified registered nurse anesthetists, nurse practitioners, nurse midwives, clinical nurse specialists, pharmacists, physician assistants, and physicians. Alternatively, a partnership, association, corporation, or organization that furnishes medical goods or services in compliance with these rules. (7-1-26) 12. Provider Status Review. Written documentation identifying a participant's progress toward goals defined in their service plan. (7-1-26) 13. Qualified Intellectual Disabilities Professional (QIDP). As described in 42 CFR 483.430(a). (7-1-26) 14. Quality Improvement Organization (QIO). An organization that performs utilization and quality control review of health care furnished to Medicare and Medicaid participants. (7-1-26) 15. Recoupment. As detailed in IDAPA 16.05.07. (7-1-26) 16. Recreational Services. Activities and goods that are generally perceived as recreation such as, but not limited to, fishing, hunting, camping, attendance or participation in sporting events or practices, attendance at concerts, fairs or rodeos, skiing, sightseeing, boating, bowling, swimming, and special day parties. (7-1-26) 17. Readiness Review. A review conducted by the Department to ensure that each FEA is prepared to enter into and comply with the requirements of the provider agreement and this chapter of rules. (7-1-26) 18. Referral. A documented recommendation from a healthcare professional to see another Medicaid provider for a specific service. (7-1-26) 19. Related Entity. An organization associated or affiliated to a significant extent, or has control of, or is controlled by, that furnishes the services, facilities, or supplies for the provider. (7-1-26) 20. Restrictive Intervention. Any intervention used to restrict rights or freedom of movement and includes chemical, mechanical, and physical restraints, or seclusion. (7-1-26) 21. Retrospective Review. A review of an item or service after it has been provided. The review determines medical necessity and conformity to Medicaid requirements. Claims that have already received payment may be subject to recoupment. (7-1-26) 22. Rural Hospital-Based Behavioral Care Unit. A Rural Hospital-Based Provider that qualifies as a behavioral care unit. (7-1-26) 23. Service Coordination. Case management activity to assist participants with gaining and coordinating access to necessary care and services appropriate to their needs. (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 010 Page 21 24. Service Plan. An initial or annual plan that identifies all services and supports based on a person- centered planning process and authorized by the Department. (7-1-26) 25. Skilled Nursing Care. Level of care for patients requiring twenty-four (24) hour skilled nursing services. (7-1-26) 26. Supervision. Procedural guidance by a qualified person and initial direction and periodic inspection of the actual act, at the site of service delivery. (7-1-26) 27. Support and Spending Plan (SSP). A document that functions as a participant’s plan of care when the participant is eligible for and has chosen a CDCS option. This document identifies the goods, services, and supports selected by a participant, including those available outside of Medicaid-funded services that can help the participant meet desired goals, and the cost of each one. The participant uses this document to manage their individualized budget. (7-1-26) 28. Support Broker (SB). An individual who advocates on behalf of the participant and who is hired by the participant to provide SB services. (7-1-26) 29. Supports. Services provided for a participant, or a person who provides a support service. A support service may be a paid service provided by a CSW, or an unpaid service provided by a natural support, such as a family member, a friend, neighbor, or other volunteer. (7-1-26) 30. Third Party. Includes a person, institution, corporation, or public or private agency that is liable to pay all or part of the medical cost of injury, disease, or disability of a participant. (7-1-26) 31. Traditional Adult DD Waiver Services. A program option for participants eligible for the Adult DD Waiver consisting of specific Medicaid Enhanced Plan Benefits. (7-1-26) 32. Traditional Children's HCBS State Plan Option Services. A program option for children eligible for the Children's HCBS State Plan Option consisting of specific Medicaid Enhanced Plan Benefits. (7-1-26) 33. Utilization Control (UC). Program of prepayment screening and annual review by the Department determining the appropriateness of and the need for continued medical entitlement of applicants or participants in a NF. (7-1-26) 34. Utilization Control Team (UCT). Team of Regional nurse reviewers that conducts on-site reviews of the care and services in NFs approved by the Department as Medicaid providers. (7-1-26) 35. Vocational Services. Services directly related to the preparation for paid or unpaid employment. Vocational services are provided with the expectation a participant will participate in a work services program or the general workforce within a year. (7-1-26) 008. – 009. (RESERVED) GENERAL PARTICIPANT PROVISIONS (Sections 010-019)