Section 16.03.09.560 - HEALTHY CONNECTIONS: DEFINITIONSHealthy Connections is a primary care case management program in which a primary care provider or team provides comprehensive medical care for participants with the goal of improving health outcomes. For purposes of this Sub Area that includes Sections 560 through 566 of these rules, the following terms and definitions apply:
01.Capitated Payments. Payments to a primary care provider made on a per assigned participant per month basis for patient services. Capitated payments will vary to reflect the level of responsibility for services the provider elects to provide as described in Section 564 of these rules. Capitated payments may include payment for all provider services at a set rate per participant per month when that type of full-risk reimbursement is agreed to by the provider and the Department.02.Clinic. Two (2) or more qualified medical professionals who provide services jointly through an organization for which an individual is given authority to act on its behalf. It also includes Federally Qualified Health Centers (FQHCs), Certified Rural Health Clinics, and Indian Health Clinics.03.Grievance. The formal process by which problems and complaints related to Healthy Connections are addressed and resolved. Grievance decisions may be appealed as provided herein.04.Patient-Centered Medical Home. A model of primary care that is patient-centered, comprehensive, team-based, coordinated, accessible, and focused on quality and safety. This results in primary care being delivered at the right place, at the right time, and in the manner that best suits a patient's needs.05.Preventive Care. Medical care that focuses on disease prevention and health maintenance.06.Primary Care Case Management. A model of care in which primary care providers and their primary care team are responsible for direct care of a participant, and for coordinating access to services that improve the health of the participant.07.Primary Care Provider (PCP). A physician, physician assistant, or advanced practice registered nurse as defined in IDAPA 24.34.01, "Rules of the Idaho Board of Nursing," who contracts with Medicaid to coordinate and manage the care of participants enrolled in the Healthy Connections program.08.Primary Care Team. A multidisciplinary team of health care providers who work together to meet the physical, emotional, and psychological needs of their patients using a patient-centered and coordinated approach.09.Referral. A documented communication from a participant's primary care provider (PCP) to another Medicaid provider authorizing specific covered services subject to primary care case management that are not provided by the participant's PCP.10.Transitional Care. A set of actions designed to ensure the coordination and continuity of health care as patients transfer between different locations or different levels of care within the same location.Idaho Admin. Code r. 16.03.09.560