Terms Used In Illinois Compiled Statutes > 305 ILCS 5 > Article V-F - Medicare-Medicaid Alignment Initiative (MMAI) Nursing Home Residents' Managed Care Rights Law

• Appeal: A request made after a trial, asking another court (usually the court of appeals) to decide whether the trial was conducted properly. To make such a request is "to appeal" or "to take an appeal." One who appeals is called the appellant.
• Appeal: means any of the procedures that deal with the review of adverse organization determinations on the health care services the enrollee believes he or she is entitled to receive, including delay in providing, arranging for, or approving the health care services, such that a delay would adversely affect the health of the enrollee or on any amounts the enrollee must pay for a service, as defined under 42 C. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• Contract: A legal written agreement that becomes binding when signed.
• Demonstration Project: means the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• Department: means the Department of Healthcare and Family Services. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• Enrollee: means an individual who resides in a nursing home or is qualified to be admitted to a nursing home and is enrolled with a managed care organization participating in the Demonstration Project. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• Guardian: A person legally empowered and charged with the duty of taking care of and managing the property of another person who because of age, intellect, or health, is incapable of managing his (her) own affairs.
• Health care services: means the diagnosis, treatment, and prevention of disease and includes medication, primary care, nursing or medical care, mental health treatment, psychiatric rehabilitation, memory loss services, physical, occupational, and speech rehabilitation, enhanced care, medical supplies and equipment and the repair of such equipment, and assistance with activities of daily living. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• individual: shall include every infant member of the species homo sapiens who is born alive at any stage of development. See Illinois Compiled Statutes 5 ILCS 70/1.36
• MCO: means an entity that meets the definition of health maintenance organization as defined in the Health Maintenance Organization Act, is licensed, regulated and in good standing with the Department of Insurance, and is authorized to participate in the nursing home component of the Medicare-Medicaid Alignment Initiative Demonstration Project by a 3-way contract with the Department of Healthcare and Family Services and the Centers for Medicare and Medicaid Services. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• Medical professional: means a physician, physician assistant, or nurse practitioner. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• Medically necessary: means health care services that a medical professional, exercising prudent clinical judgment, would provide to a patient for the purpose of preventing, evaluating, diagnosing, or treating an illness, injury, or disease or its symptoms, and that are: (i) in accordance with the generally accepted standards of medical practice; (ii) clinically appropriate, in terms of type, frequency, extent, site, and duration, and considered effective for the patient's illness, injury, or disease; and (iii) not primarily for the convenience of the patient, a medical professional, other health care provider, caregiver, family member, or other interested party. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• Nurse practitioner: means an individual properly licensed as a nurse practitioner under the Nurse Practice Act. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• Nursing home: means a facility licensed under the Nursing Home Care Act. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• Physician: means an individual licensed to practice in all branches of medicine under the Medical Practice Act of 1987. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• Physician assistant: means an individual properly licensed under the Physician Assistant Practice Act of 1987. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• RAI Manual: means the most recent Resident Assessment Instrument Manual, published by the Centers for Medicare and Medicaid Services. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• Resident: means an enrollee who is receiving personal or medical care, including, but not limited to, mental health treatment, psychiatric rehabilitation, physical rehabilitation, and assistance with activities of daily living, from a nursing home. See Illinois Compiled Statutes 305 ILCS 5/5F-15
• State: when applied to different parts of the United States, may be construed to include the District of Columbia and the several territories, and the words "United States" may be construed to include the said district and territories. See Illinois Compiled Statutes 5 ILCS 70/1.14