reglab/statecodes huggingface dataset:
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 10. Prescription Drug Plus Discount Program › 53-6-1012. Obligations of department

53-6-1012. Obligations of department.
The department shall establish simplified procedures for determining eligibility and issuing Montana prescription enrollment cards to qualified individuals under 53-6-1002 and shall undertake outreach efforts to build public awareness of the program and maximize enrollment of qualified individuals. The department may adjust the requirements and terms of the program to accommodate any new federally funded prescription drug programs.
History: En. Sec. 6, Ch. 551, L. 2003.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 10. Prescription Drug Plus Discount Program › 53-6-1013. Contracting

53-6-1013. Contracting.
The department may contract for the administration of any components of the program, including but not limited to outreach, eligibility, claims, administration, price and rebate negotiations, and drug rebate recovery and redistribution. Any contract to administer any program component must prohibit the contractor from receiving any compensation or other benefit from any drug manufacturer, labeler, or distributor participating in the medicaid or prescription drug plus discount programs.
History: En. Sec. 7, Ch. 551, L. 2003; amd. Sec. 8, Ch. 287, L. 2005.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 10. Prescription Drug Plus Discount Program › 53-6-1020. Contingency on expenditure

53-6-1020. Contingency on expenditure.
This part may not be construed to require implementation or ongoing operation of the program under 53-6-1201(3)(b) without a line item appropriation in the general appropriations bill included for that purpose.
History: En. Sec. 10, Ch. 287, L. 2005.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 11. Prevention and Stabilization Account › 53-6-1101. Prevention and stabilization account -- allocation of proceeds

53-6-1101. Prevention and stabilization account -- allocation of proceeds.
(1) There is a prevention and stabilization account in the state special revenue fund provided for in 17-2-102. Money in the account must be used by the department of public health and human services to finance, administer, and provide health and human services.
(2) (a) Funds in the prevention and stabilization account must be used for the following programs in order of priority:
(i) prescription drugs for adults with a serious and disabling mental illness eligible for programs initiated pursuant to 53-21-702(2) and (3);
(ii) child care for low-income families;
(iii) the Montana initiative for the abatement of mortality in infants administered pursuant to 50-19-301;
(iv) independent living;
(v) extended employment;
(vi) child support enforcement state matching funds;
(vii) stabilization of rates for medicaid mental health services;
(viii) medicaid hospice services;
(ix) home health therapy services;
(x) poison control; and
(xi) AIDS funds.
(b) Funds remaining after allocations to the priorities in subsection (2)(a) may be expended for other programs as directed in 17-6-606(1).
(c) Appropriations from the prevention and stabilization account for programs listed in subsection (2)(a) are restricted for the use specified and may not be transferred to other programs pursuant to 17-7-139.
History: (1)En. Sec. 14, Ch. 531, L. 2003; en. Sec. 2, Ch. 608, L. 2003.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1301. Short title

53-6-1301. (Temporary) Short title.
This part, along with Title 39, chapter 12, and 25-3-106, may be cited as the "Montana Health and Economic Livelihood Partnership (HELP) Act". (Terminates June 30, 2025--sec. 38, Ch. 415, L. 2019.)
History: En. Sec. 1, Ch. 368, L. 2015.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1303. Definitions

53-6-1303. (Temporary) Definitions.
As used in this part, the following definitions apply:
(1) "Community engagement" means participation in the activities specified in 53-6-1308 as a means to improve a program participant's well-being and opportunities for self-sufficiency.
(2) "Department" means the department of public health and human services provided for in 2-15-2201.
(3) "HELP Act" or "act" means the Montana Health and Economic Livelihood Partnership Act provided for in Title 39, chapter 12, and this part.
(4) "Member" means an individual enrolled in the Montana medicaid program pursuant to 53-6-131 or receiving medicaid-funded services pursuant to 53-6-1304.
(5) "Program participant" or "participant" means an individual enrolled in the Montana Health and Economic Livelihood Partnership Act program established in Title 39, chapter 12, and this part. (Terminates June 30, 2025--secs. 38, 48, Ch. 415, L. 2019.)
History: En. Sec. 3, Ch. 368, L. 2015; amd. Sec. 31, Ch. 415, L. 2019.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1304. Montana HELP Act program -- eligibility for coverage of health care services -- exceptions

53-6-1304. (Temporary) Montana HELP Act program -- eligibility for coverage of health care services -- exceptions.
(1) An individual is eligible for coverage of health care services provided pursuant to this part if the individual meets the requirements of 42 U.S.C. 1396a(a)(10)(A)(i)(VIII).
(2) The department may serve individuals who are eligible for medicaid-funded services pursuant to this part through the medical assistance program established in Title 53, chapter 6, part 1, if the individuals would be served more appropriately because the individuals:
(a) have exceptional health care needs, including but not limited to medical, mental health, or developmental conditions;
(b) live in a geographical area, including an Indian reservation, that would not be effectively or efficiently served through this part;
(c) need continuity of care that would not be available or cost-effective through this part;
(d) are exempt under the waiver implementing this part as of July 1, 2019; or
(e) are otherwise exempt under federal law. (Terminates June 30, 2025--secs. 38, 48, Ch. 415, L. 2019.)
History: En. Sec. 4, Ch. 368, L. 2015; amd. Sec. 32, Ch. 415, L. 2019.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1305. Montana HELP Act program -- delivery of health care services -- third-party administrator -- rulemaking

53-6-1305. (Temporary) Montana HELP Act program -- delivery of health care services -- third-party administrator -- rulemaking.
(1) The department may contract as provided in Title 18, chapter 4, with one or more third-party administrators to assist in administering the delivery of health care services to members eligible under 53-6-1304, including but not limited to:
(a) establishing networks of health care providers;
(b) paying claims submitted by health care providers;
(c) collecting the premiums provided for in 53-6-1307;
(d) coordinating care;
(e) helping to administer the program; and
(f) helping to administer the medicaid program reforms as specified in 53-6-1311.
(2) If the department decides to contract with a third-party administrator, the department shall determine the basic health care services to be provided through the arrangement with the third-party administrator.
(3) (a) The department may exempt certain individuals who are eligible for medicaid-funded services pursuant to 53-6-1304 from receiving health care services through an arrangement with a third-party administrator if the individuals would be served more appropriately through the medical assistance program established in Title 53, chapter 6, part 1.
(b) If the department contracts with a third-party administrator, the department shall:
(i) adopt rules establishing criteria for determining whether a member is exempt from receiving health care services through an arrangement with the third-party administrator;
(ii) provide coverage for exempted individuals through the medical assistance program established in Title 53, chapter 6, part 1; and
(iii) for members participating in the arrangement with a third-party administrator, directly cover any service required under federal or state law that is not available through the arrangement with the third-party administrator.
(4) The department may contract with a third-party administrator for the services allowed under subsections (1)(a) through (1)(f) only upon receipt of a federal waiver allowing a third-party administrator to provide services in accordance with this part. (Terminates June 30, 2025--secs. 38, 48, Ch. 415, L. 2019.)
History: En. Sec. 5, Ch. 368, L. 2015; amd. Sec. 33, Ch. 415, L. 2019.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1306. Prohibition on copayments

53-6-1306. (Temporary) Prohibition on copayments.
The department may not require a program participant to make a copayment, to pay a coinsurance amount, or to meet a deductible amount for any service covered under this part. (Terminates June 30, 2025--secs. 38, 48, Ch. 415, L. 2019.)
History: En. Sec. 6, Ch. 368, L. 2015; amd. Sec. 2, Ch. 21, L. 2019; amd. Sec. 34, Ch. 415, L. 2019.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1309. Community engagement -- reporting -- suspension -- audit

53-6-1309. (Temporary) Community engagement -- reporting -- suspension -- audit.
(1) The department shall adopt rules establishing:
(a) requirements for reporting community engagement requirements;
(b) requirements for obtaining an exemption from the community engagement requirements as allowed under 53-6-1308; and
(c) a program to audit information provided by program participants to the department to ensure compliance with the requirements of 53-6-1308.
(2) The department shall notify a program participant who is not in compliance with the community engagement requirements that:
(a) the participant has 180 days to come into compliance; and
(b) failure to comply within the 180-day period will be considered a voluntary suspension from the program unless the participant attests and the department confirms that the participant is exempt from the community engagement requirements as allowed under 53-6-1308.
(3) A participant who is suspended from the program for noncompliance may be reinstated 180 days after the date of suspension or upon a determination by the department that the program participant:
(a) is exempt from the community engagement requirements; or
(b) has been in compliance with the requirements for 30 days. A participant reinstated pursuant to this subsection (3)(b) must remain under heightened monitoring by the department during the remainder of the suspension period.
(4) (a) If suspensions for noncompliance with community engagement requirements reach a level exceeding 5% of program participants, the department shall notify the legislative audit committee. Upon consideration of recommendations by the legislative auditor, the legislative audit committee shall select an independent third-party auditor to conduct an audit of the participants who were subject to suspension using statistically valid methods.
(b) (i) The audit must be completed within 90 days and the report made available to the legislative audit committee.
(ii) If the audit is not completed within 90 days, the department shall immediately cease suspensions until the audit is complete and the legislative audit committee has received the audit report.
(c) If the audit finds that more than 10% of the participants in the audit sample were suspended erroneously, the department shall cease further suspensions until the conclusion of the next general legislative session.
(d) If the audit finds that 10% or fewer of the participants in the audit sample were suspended erroneously, the department shall continue to suspend the enrollment of program participants who fail to meet the community engagement requirements.
(e) The cost of any audit under this section performed at the direction of the legislative audit committee must be paid by the department. (Terminates June 30, 2025, on occurrence of contingency--sec. 48, Ch. 415, L. 2019.)
History: En. Sec. 2, Ch. 415, L. 2019.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1310. Health risk analysis

53-6-1310. (Temporary) Health risk analysis.
(1) Within 1 year of a program participant's enrollment in the program, the department shall use available claims data and other information collected directly from the participant to assess whether the participant would be better served in a coordinated care or other treatment model approved by the department.
(2) Coordinated care models may include but are not limited to a:
(a) medicaid health home;
(b) patient-centered or advanced primary care medical home;
(c) substance use disorder or mental health treatment or other treatment or prevention programs;
(d) care coordination program;
(e) tribal health improvement program; or
(f) primary care case management arrangement.
(3) The department is not required to complete a separate analysis for a participant who:
(a) is already being served through a coordinated care model listed in subsection (2); or
(b) has received primary care or preventative care services within the last 12 months. (Terminates June 30, 2025, on occurrence of contingency--sec. 48, Ch. 415, L. 2019.)
History: En. Sec. 3, Ch. 415, L. 2019.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1311. Medicaid program reforms

53-6-1311. (Temporary) Medicaid program reforms.
(1) To ensure that the Montana medicaid program is administered efficiently and effectively, the department shall strengthen existing programs that manage the way members obtain approval for medical services and shall establish additional programs designed to reduce costs and improve medical outcomes. The efforts may include but are not limited to:
(a) establishing by rule requirements designed to strengthen the relationship between physicians and members enrolled in existing primary care case management programs;
(b) strengthening data-sharing arrangements with providers to reduce inappropriate use of emergency room services and overuse of other services;
(c) expanding to additional members any existing programs in which case managers and providers work with members with high-risk medical conditions to provide preventive care and advice and to make referrals for medical services;
(d) establishing, within existing funds, one or more pilot programs to improve the health of members, including but not limited to efforts to increase pain management, decrease emergency department overuse, and prevent drug or alcohol addiction or abuse;
(e) reviewing existing primary care case management programs to evaluate and improve their effectiveness; and
(f) engaging members with chronic or other medical or behavioral health conditions in coordinated care models that more closely monitor and manage a member's health to reduce costs or improve medical outcomes. These coordinated care models may include but are not limited to:
(i) patient-centered medical homes;
(ii) accountable care organizations;
(iii) managed care organizations as defined in 42 CFR 438.2;
(iv) health improvement programs;
(v) health homes for behavioral health or other chronic conditions; and
(vi) changes to current service delivery methods.
(2) The department shall work to reduce fraud, waste, and abuse in the medicaid program before, during, and after enrollment by enhancing technology system support to provide knowledge-based authentication for verifying the identity and financial status of individuals seeking benefits, including the use of public records to confirm identity and flag changes in demographics.
(3) The department may ask a third-party administrator under contract with the department to assist in efforts undertaken pursuant to subsections (1) and (2) when the activity can appropriately be handled by a third-party administrator.
(4) A care coordination entity used to deliver medicaid services shall meet all state standards for operation, including but not limited to solvency, consumer protection, nondiscrimination, network adequacy, care model design, and fraud and abuse standards. (Terminates June 30, 2025--secs. 38, 48, Ch. 415, L. 2019.)
History: En. Sec. 8, Ch. 368, L. 2015; amd. Sec. 36, Ch. 415, L. 2019.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1312. Health care services payment schedules

53-6-1312. Health care services payment schedules.
(1) The department of corrections and the department of public health and human services shall reimburse health care service for individuals identified in subsection (2) at the rates adopted by the department for the medicaid program under Title 53, chapter 6, part 1, if the health care services are not otherwise covered by medicaid, medicare, a health insurer, or another private or governmental program that pays for health care costs.
(2) This section applies to individuals:
(a) in the custody of the department of corrections; or
(b) who are residents, by commitment or otherwise, of the Montana state hospital, the Montana mental health nursing care center, the Montana chemical dependency center, the state facility at Galen, or the Montana developmental center.
History: En. Sec. 9, Ch. 368, L. 2015; amd. Sec. 15, Ch. 456, L. 2019.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1313. Reduction in federal medical assistance percentage

53-6-1313. (Temporary) Reduction in federal medical assistance percentage.
If the federal medical assistance percentage for medical services provided to individuals eligible for medicaid-funded services pursuant to 53-6-1304 is set below the levels established in 42 U.S.C. 1396d(y)(1) on the effective date of this section, the continuation of coverage under this part is contingent on:
(1) the appropriation of additional state general fund or other action by the legislature;
(2) the ability of the department to increase premiums assessed under 53-6-1307 to pay the difference; or
(3) a combination of legislative action and premium increases as necessary to provide for the increased state match obligation. (Terminates June 30, 2025--sec. 38, Ch. 415, L. 2019.)
History: En. Sec. 10, Ch. 368, L. 2015.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1314. Disenrollment for failure to report change in circumstances

53-6-1314. (Temporary) Disenrollment for failure to report change in circumstances.
(1) (a) A program participant shall report to the department a permanent increase in income that would affect the participant's eligibility for the program. The change must be reported within 30 days of the change in income.
(b) A short-term increase in income that is caused by overtime pay or other nonregular payments and that will not be sustained over time does not qualify as a permanent increase in income for the purposes of this section.
(2) Disenrollment may occur only after the state conducts an administrative review and determines the participant is ineligible for medicaid coverage under any eligibility category. (Terminates June 30, 2025, on occurrence of contingency--sec. 48, Ch. 415, L. 2019.)
History: En. Sec. 4, Ch. 415, L. 2019.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1315. Montana HELP Act special revenue account

53-6-1315. (Temporary) Montana HELP Act special revenue account.
(1) There is a Montana HELP Act account in the state special revenue fund to the credit of the department.
(2) Money from the following sources must be deposited in the account:
(a) the taxpayer integrity fees provided for in 15-30-2660;
(b) the outpatient hospital utilization fee provided for in 15-66-102(3)(b);
(c) the health service corporation fee provided for in 33-2-714; and
(d) premiums paid by members pursuant to 53-6-1307.
(3) Money in the account must be used to pay for:
(a) the state share of costs, including benefits and administrative costs, of providing health care services under this part; and
(b) grants made under the HELP Act employer grant program provided for in 39-12-106.
(4) Money from the account must be used for the benefits and administrative costs of providing health care services under this part before any general fund is expended on the costs. (Terminates June 30, 2025, on occurrence of contingency--sec. 48, Ch. 415, L. 2019.)
History: En. Sec. 5, Ch. 415, L. 2019.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1316. Repealed

53-6-1316. Repealed.
Sec. 3, Ch. 21, L. 2019; sec. 39, Ch. 415, L. 2019.
History: En. Sec. 11, Ch. 368, L. 2015.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1317. Repealed

53-6-1317. Repealed.
Sec. 3, Ch. 21, L. 2019.
History: En. Sec. 12, Ch. 368, L. 2015.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1318. Rulemaking authority

53-6-1318. (Temporary) Rulemaking authority.
(1) The department may adopt rules as necessary to carry out this part.
(2) The department and the department of labor and industry may, in coordination, adopt rules as necessary for the implementation of the employment and reemployment assessments and workforce development activities provided for in Title 39, chapter 12. (Terminates June 30, 2025--sec. 38, Ch. 415, L. 2019.)
History: En. Sec. 13, Ch. 368, L. 2015.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 13. Montana Health and Economic Livelihood Partnership (HELP) Act › 53-6-1325. Report to legislature

53-6-1325. (Temporary) Report to legislature.
(1) The department shall report the following information to the legislative finance committee and the children, families, health, and human services interim committee quarterly:
(a) the number of individuals who were determined eligible for medicaid-funded services pursuant to 53-6-1304;
(b) demographic information on program participants;
(c) the average length of time that participants remained eligible for medical assistance;
(d) the number of participants subject to the fees provided for in 15-30-2660 and the total amount of fees collected;
(e) the amount of money deposited in the Montana HELP Act special revenue account, by source of funding;
(f) the level of participant engagement in wellness activities or incentives offered under this part;
(g) the number of participants who took part in community engagement activities, the number whose program participation was suspended for failure to take part in community engagement activities, and the number who were disenrolled from the program for failure to report a change in circumstances;
(h) the number of participants who reduced their dependency on the HELP Act program, either voluntarily or because of increased income levels; and
(i) the total cost of providing services under this part, including related administrative costs.
(2) A compilation of reports received during the interim must be provided to the legislature in accordance with 5-11-210.(Terminates June 30, 2025, on occurrence of contingency--sec. 48, Ch. 415, L. 2019.)
History: En. Sec. 37, Ch. 415, L. 2019; amd. Sec. 91, Ch. 261, L. 2021.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 14. Medicaid Overpayment Audits › 53-6-1402. Overpayment audit procedures -- provider records -- limitations on record requests and reviews -- onsite audits

53-6-1402. Overpayment audit procedures -- provider records -- limitations on record requests and reviews -- onsite audits.
(1) When conducting an overpayment audit, the department or an auditor shall:
(a) allow the provider at least 30 days to comply with a request to provide records;
(b) include in a request for records adequate information to allow the provider to identify the particular records sought;
(c) allow providers to submit the requested records in an electronic format; and
(d) allow reasonable extensions of the 30-day compliance period for good cause.
(2) If an auditor is conducting an overpayment audit and requires the provider to provide records in a nonelectronic format, the auditor shall reimburse the provider for the cost of providing the records.
(3) (a) For an initial overpayment audit, the department or an auditor may request up to 6 months of records from a provider for claims paid by the medicaid program up to 3 years before the request was made.
(b) If the department or an auditor demonstrates a significant error rate, the department or the auditor with the department's approval may request additional records related to the issue under review for purposes of a followup audit.
(c) The 3-year limitation in subsection (3)(a) does not apply to a record request by the department or auditor for purposes of a followup audit but does apply to such a request by a recovery audit contractor.
(4) The department or an auditor may not request records or perform an overpayment audit regarding services that were provided outside the period of time for which providers are required by applicable law to retain records for purposes of the medicaid program.
(5) Except in cases of suspected fraud or criminal conduct, the department or an auditor may not schedule an onsite overpayment audit without first providing written notice at least 10 days in advance of the onsite audit. The department or auditor shall make a good faith effort to establish a mutually agreed-upon date and time for the onsite audit.
History: En. Sec. 2, Ch. 82, L. 2017.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 14. Medicaid Overpayment Audits › 53-6-1403. Extrapolation and statistical sampling prohibited -- exceptions

53-6-1403. Extrapolation and statistical sampling prohibited -- exceptions.
(1) Except as provided in subsection (2):
(a) in conducting an initial overpayment audit, the department or an auditor may not use statistical sampling extrapolation for automated reviews and may not rely on extrapolation to determine or support the amount of an overpayment determination; and
(b) an overpayment determination must be based on and supported by evidence of an overpayment for each claim.
(2) In an overpayment audit of a high-risk provider or a followup audit of any provider, the department or an auditor may use statistical sampling extrapolation for an automated review or may rely on extrapolation to determine or support the amount of an overpayment determination.
(3) The department or an auditor may use data analysis techniques to identify claims that are most likely to contain overpayments for purposes of selecting providers or claims for overpayment audits.
History: En. Sec. 3, Ch. 82, L. 2017.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 14. Medicaid Overpayment Audits › 53-6-1404. Peer review of overpayment findings

53-6-1404. Peer review of overpayment findings.
(1) (a) A provider's request for an administrative review of an overpayment determination may include a request for peer review of any clinical or professional judgment upon which the overpayment determination relies. A clinical or professional judgment includes but is not limited to any clinical or professional judgment upon which the provider's evaluation, treatment, records, coding, or billing is based.
(b) The provider's peer review request must identify each clinical or professional judgment to be reviewed and include a statement of the provider's opinion regarding the identified clinical or professional judgment.
(2) If a provider requests peer review, the department shall obtain and consider as part of its administrative review a peer review of each clinical or professional judgment upon which the overpayment determination relied. The department shall mail a copy of the peer review to the provider within 10 days of receipt. The department may not issue its administrative review determination or demand or collect repayment of the alleged overpayment until the department has obtained and considered the peer review.
(3) If at any time during an administrative review, appeal, or other legal proceedings regarding an overpayment determination the department relies on a clinical or professional judgment not identified in the initial notice of overpayment determination and for which a peer review was not previously requested, obtained, or considered, the provider may request in writing that peer review be conducted in accordance with this section. The proceedings must be suspended or stayed until the department has obtained, considered, and responded in writing to the peer review.
History: En. Sec. 4, Ch. 82, L. 2017.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 14. Medicaid Overpayment Audits › 53-6-1405. Audit completion -- notice of overpayment determination -- opportunity to resubmit claim

53-6-1405. Audit completion -- notice of overpayment determination -- opportunity to resubmit claim.
(1) The department or an auditor shall conclude an overpayment audit and notify the provider in writing of the audit results, including any overpayment determination, within 90 days of:
(a) the receipt of all records requested in the department's or the auditor's initial record request;
(b) a determination regarding fraud in cases in which the department investigates a credible allegation of fraud; or
(c) the conclusion of an investigation and any related enforcement proceedings if a government agency or entity other than the department is conducting a civil fraud or criminal investigation of the provider and the government agency or entity conducting the investigation determines and notifies the department in writing that providing earlier notification would interfere with or jeopardize the investigation, recovery of a fraudulent overpayment, or criminal prosecution.
(2) A notice of overpayment determination, including any notice of audit results under subsection (1) that includes a notice of overpayment determination, must include a detailed explanation of the overpayment determination, including at a minimum:
(a) a description of the overpayment;
(b) the dollar value of the overpayment;
(c) the specific reason for the overpayment determination;
(d) the specific medical criteria and any clinical and professional judgment upon which the determination is based;
(e) in cases in which an overpayment resulted from incorrect billing rather than a lack of medical necessity or failure to provide the services or items in accordance with applicable requirements, a statement that the provider may submit a new claim or claim adjustment as provided in 53-6-111;
(f) the action to be taken by the department;
(g) an explanation of any action required of the provider; and
(h) an explanation of the provider's right to appeal.
History: En. Sec. 5, Ch. 82, L. 2017.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 14. Medicaid Overpayment Audits › 53-6-1406. Publication of audit results

53-6-1406. Publication of audit results.
At least once a year the department shall publish and make accessible on its website the following information regarding all medicaid overpayment audits:
(1) the number and type of issues reviewed;
(2) the number of medical and other records requested from providers;
(3) the number of audits conducted by provider type;
(4) the number and aggregate dollar amounts of:
(a) overpayments identified;
(b) overpayments collected; and
(c) underpayments identified;
(5) the duration of audits from initiation to completion;
(6) the number of overpayment determinations and the reversal rates of those determinations at each stage of the informal and formal appeal process;
(7) the number of informal and formal appeals filed by providers, categorized by disposition status; and
(8) the auditor's compensation structure and total dollar amount of compensation for underpayments and overpayments.
History: En. Sec. 6, Ch. 82, L. 2017.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 14. Medicaid Overpayment Audits › 53-6-1407. Audit education and training

53-6-1407. Audit education and training.
In order to carry out the requirements of 53-6-160(6) and to reduce claims errors, the department shall provide:
(1) educational and training programs for providers at least twice a year to discuss a summary of audit results, common issues and problems, mistakes identified through audits, and opportunities for improvement in provider performance related to claims billings and documentation; and
(2) information on the department's website regarding recurring audit issues, including at a minimum a description of each recurring audit issue, the types of providers affected, the review period in which the audit issues occurred, and any applicable department policy or rule related to the issue.
History: En. Sec. 7, Ch. 82, L. 2017.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 14. Medicaid Overpayment Audits › 53-6-1408. Applicability to auditor -- scope

53-6-1408. Applicability to auditor -- scope.
(1) An auditor performing or participating in an overpayment audit, overpayment determination, or related activity is subject to the same laws and regulations that would apply to the department in carrying out the same functions.
(2) This part does not apply to the medicaid fraud control unit provided for in 53-6-156 but apply to an overpayment audit, overpayment determination, or related activity by the department or an auditor that is based on or arises out of a medicaid fraud control unit investigation or referral.
History: En. Sec. 8, Ch. 82, L. 2017.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 14. Medicaid Overpayment Audits › 53-6-1409. Auditor evaluation hearings -- adoption of rules

53-6-1409. Auditor evaluation hearings -- adoption of rules.
At least once a year, the department shall conduct auditor evaluation hearings to identify issues, recommend or require corrective actions, and provide for ongoing and future evaluation of auditor performance. With input from providers, including comments gathered at the auditor evaluation hearings, the department shall adopt rules for:
(1) appropriate and inappropriate conduct and determinations by auditors; and
(2) penalties and sanctions for inappropriate conduct and determinations.
History: En. Sec. 9, Ch. 82, L. 2017.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 14. Medicaid Overpayment Audits › 53-6-1410. Absorption of costs

53-6-1410. Absorption of costs.
Any cost incurred by the department of public health and human services in implementing 53-6-111 and this part must be absorbed into the department's existing budget.
History: En. Sec. 10, Ch. 82, L. 2017.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 21. Children's Mental Health Services Pilot Project -- Youth Outcome Improvement (Terminated) › 53-6-2101. Terminated

53-6-2101. Terminated.
Sec. 7, Ch. 265, L. 2015.
History: En. Sec. 1, Ch. 265, L. 2015.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 21. Children's Mental Health Services Pilot Project -- Youth Outcome Improvement (Terminated) › 53-6-2102. Terminated

53-6-2102. Terminated.
Sec. 7, Ch. 265, L. 2015.
History: En. Sec. 2, Ch. 265, L. 2015.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 21. Children's Mental Health Services Pilot Project -- Youth Outcome Improvement (Terminated) › 53-6-2103. Terminated

53-6-2103. Terminated.
Sec. 7, Ch. 265, L. 2015.
History: En. Sec. 3, Ch. 265, L. 2015.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 7. Vocational Rehabilitation › Part 1. General Vocational Rehabilitation › 53-7-102. Powers and duties of department

53-7-102. Powers and duties of department.
The department:
(1) shall adopt rules necessary for the administration of this part. Rules adopted may include but are not limited to the provision of services, individual service plans, eligibility for services, application, service goals and design, quality of services, provider relationships, program standards, program staffing, staff training, provider accounting procedures, confidential information, recipient grievance procedures, hearings, and definitions necessary to carry out this part.
(2) may take any other action that it determines necessary or appropriate to carry out the purposes of this part;
(3) may cooperate with other departments and agencies and institutions, both public and private, in providing for vocational rehabilitation of persons with disabilities, in studying the problems involved in vocational rehabilitation, and in establishing, developing, and providing programs, facilities, and services;
(4) may conduct research and compile statistics relating to the vocational rehabilitation of persons with disabilities; and
(5) may accept and use gifts to carry out this part.
History: En. Sec. 3, Ch. 74, L. 1947; amd. Sec. 3, Ch. 53, L. 1961; amd. Sec. 12, Ch. 93, L. 1969; Sec. 41-803, R.C.M. 1947; amd. and redes. 71-1802 by Sec. 11, Ch. 121, L. 1974; R.C.M. 1947, 71-2102; amd. Sec. 2, Ch. 396, L. 1989; amd. Sec. 54, Ch. 472, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 7. Vocational Rehabilitation › Part 1. General Vocational Rehabilitation › 53-7-103. Department to cooperate with federal government

53-7-103. Department to cooperate with federal government.
The department shall cooperate, pursuant to agreements with the federal government, in carrying out the purposes of the federal Rehabilitation Act of 1973 (29 U.S.C. 701, et seq.), as may be amended, and may adopt methods of administration as required by the federal government for state participation in programs funded under the federal act.
History: En. Sec. 5, Ch. 74, L. 1947; amd. Sec. 2, Ch. 218, L. 1959; amd. Sec. 5, Ch. 53, L. 1961; Sec. 41-805, R.C.M. 1947; amd. and redes. 71-1803 by Sec. 12, Ch. 121, L. 1974; R.C.M. 1947, 71-2103; amd. Sec. 3, Ch. 396, L. 1989.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 7. Vocational Rehabilitation › Part 1. General Vocational Rehabilitation › 53-7-104. Repealed

53-7-104. Repealed.
Sec. 16, Ch. 396, L. 1989.
History: En. Sec. 6, Ch. 74, L. 1947; amd. Sec. 3, Ch. 218, L. 1959; Sec. 41-806, R.C.M. 1947; amd. and redes. 71-1804 by Sec. 13, Ch. 121, L. 1974; R.C.M. 1947, 71-2104.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 7. Vocational Rehabilitation › Part 1. General Vocational Rehabilitation › 53-7-105. Eligibility

53-7-105. Eligibility.
A person with a disability is eligible for vocational rehabilitation services if the department, after full investigation, determines that the person may become employable or achieve accepted vocational objectives through the provision of vocational rehabilitation services that are made available as provided for in 53-7-108.
History: En. Sec. 8, Ch. 74, L. 1947; amd. Sec. 3, Ch. 192, L. 1971; Sec. 41-808, R.C.M. 1947; amd. and redes. 71-1805 by Sec. 14, Ch. 121, L. 1974; R.C.M. 1947, 71-2105; amd. Sec. 1, Ch. 55, L. 1981; amd. Sec. 4, Ch. 396, L. 1989; amd. Sec. 55, Ch. 472, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 7. Vocational Rehabilitation › Part 1. General Vocational Rehabilitation › 53-7-106. Hearings

53-7-106. Hearings.
A person applying for or receiving vocational rehabilitation services who is aggrieved by any action or inaction of the department is entitled to a fair hearing in accordance with the rules adopted by the department.
History: En. Sec. 10, Ch. 74, L. 1947; amd. Sec. 4, Ch. 192, L. 1971; Sec. 41-810, R.C.M. 1947; amd. and redes. 71-1806 by Sec. 15, Ch. 121, L. 1974; R.C.M. 1947, 71-2106; amd. Sec. 5, Ch. 396, L. 1989.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 7. Vocational Rehabilitation › Part 1. General Vocational Rehabilitation › 53-7-107. Repealed

53-7-107. Repealed.
Sec. 1, Ch. 32, L. 1987.
History: En. Sec. 12, Ch. 74, L. 1947; Sec. 41-812, R.C.M. 1947; amd. and redes. 71-1807 by Sec. 16, Ch. 121, L. 1974; R.C.M. 1947, 71-2107.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 7. Vocational Rehabilitation › Part 1. General Vocational Rehabilitation › 53-7-108. Provision of services -- financial responsibility for services

53-7-108. Provision of services -- financial responsibility for services.
(1) The department, in accord with this part and the federal Rehabilitation Act of 1973 (29 U.S.C. 701, et seq.), as may be amended, may provide to persons determined eligible under 53-7-105 any vocational rehabilitation services listed in 53-7-101 that are determined by the department to be appropriate and necessary for the person's vocational rehabilitation.
(2) The following vocational rehabilitation services are available without cost to an eligible person:
(a) counseling and guidance;
(b) diagnostic evaluation; and
(c) placement.
(3) In addition to the services listed in subsection (2), the department may pay the cost of other vocational rehabilitation services for an eligible person to the extent that the department determines that the person is without sufficient financial resources to pay the cost of such services.
(4) The department may in its discretion provide maintenance payments to a recipient of vocational rehabilitation services if the department determines that the recipient is without sufficient financial resources to:
(a) obtain basic necessities at a level the department determines is appropriate; and
(b) pay the cost of vocational rehabilitation services to be provided to the person.
History: En. Sec. 6, Ch. 396, L. 1989.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 7. Vocational Rehabilitation › Part 1. General Vocational Rehabilitation › 53-7-109. Administration of vocational rehabilitation programs -- applicability

53-7-109. Administration of vocational rehabilitation programs -- applicability.
(1) Those divisions of the department that have programs for the provision of vocational rehabilitation services may share administrative personnel, operations, and policies in order to ensure uniform administration necessary under the federal Rehabilitation Act of 1973, 29 U.S.C. 701, et seq., as may be amended.
(2) This section applies to all programs and services in Title 53, chapter 7, administered by the department with funds provided under the federal Rehabilitation Act of 1973, 29 U.S.C. 701, et seq., as may be amended.
History: En. Sec. 14, Ch. 396, L. 1989; amd. Sec. 65, Ch. 130, L. 2005.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 7. Vocational Rehabilitation › Part 2. Sheltered Workshops › 53-7-201. Legislative findings and purpose

53-7-201. Legislative findings and purpose.
(1) The purpose of this part is to encourage the development and improvement of supervised work programs and support services for persons with severe disabilities.
(2) Supervised work programs and support services should be available to provide persons with severe disabilities the skills and means by which they may lead socially and vocationally productive lives so they can be integrated into society.
(3) The state may encourage the establishment of and provide funding for supervised work programs and support services for persons with severe disabilities.
History: En. Sec. 1, Ch. 322, L. 1973; R.C.M. 1947, 41-816; amd. Sec. 1, Ch. 267, L. 1989.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 7. Vocational Rehabilitation › Part 2. Sheltered Workshops › 53-7-202. Definitions

53-7-202. Definitions.
(1) "Department" means the department of public health and human services.
(2) "Severe disability" means a severe physical or mental impairment that seriously limits a person's functional capacities in respect to obtaining employment.
(3) "Sheltered employment" means a recognized program of rehabilitation, remunerative employment, or other occupational rehabilitating activity of an educational or therapeutic nature provided by a nonprofit sheltered workshop provider. Sheltered employment includes job skills and social skills training and remunerative employment.
(4) "Supervised work program" means a program providing guidance in learning and achieving the requirements of job performance through work activity, sheltered employment, and supported employment.
(5) "Support services" means continuous or periodic job skills training provided to a person at a worksite to enable the person to perform work. Support services also include services away from the worksite that are necessary to allow a person with a severe disability to participate in a supervised work program, such as transportation, direction and assistance in functional skills, and counseling for family members.
(6) "Supported employment" means competitive work in an integrated work setting for a person with a severe disability who is in need of assistance in order to become employed or remain employed. Supported employment includes assessment, preplacement preparation, job development, job placement, job skills training, and support services.
(7) "Work activity" means therapeutic work-related activities provided by a nonprofit work activity center provider to persons whose physical or mental impairment is so severe as to make their productive capacity inconsequential. Therapeutic work-related activities include training in basic skills of living and any purposeful activity so long as work or production is not the main purpose.
History: En. Sec. 2, Ch. 322, L. 1973; amd. Sec. 1, Ch. 333, L. 1974; amd. Sec. 10, Ch. 37, L. 1977; R.C.M. 1947, 41-817; amd. Sec. 2, Ch. 267, L. 1989; amd. Sec. 460, Ch. 546, L. 1995.