reglab/statecodes huggingface dataset:
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 4. Home and Community-Based Long-Term Care Medicaid Services › 53-6-404. Use of waiver funding

53-6-404. Use of waiver funding.
(1) The department shall use money appropriated for home and community-based services waiver slots for the purpose of:
(a) creating waiver slots as authorized by the legislature; or
(b) addressing workforce shortages or other barriers to creating the number of waiver slots authorized by the legislature.
(2) Unencumbered funds appropriated for home and community-based services waiver slots for use by a particular division may not be transferred to another department division or program. The money must be used for the program for which it was appropriated or be reverted to the fund from which it was appropriated.
(3) The department shall report annually to the legislative finance committee in accordance with 5-11-210 on the status of appropriations for home and community-based services waiver slots.
History: En. Sec. 1, Ch. 176, L. 2021.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 4. Home and Community-Based Long-Term Care Medicaid Services › 53-6-405. Fraud prevention education -- department responsibilities

53-6-405. Fraud prevention education -- department responsibilities.
(1) In an effort to prevent and reduce fraud in the Montana medicaid program, a provider of personal assistance or attendant services or supports shall provide training and continuing education to consumers and employees if the personal assistance or attendant services or supports are funded:
(a) as a medicaid state plan service;
(b) through a medicaid state plan option available to the state under 42 U.S.C. 1396n(k); or
(c) under a medicaid home and community-based services waiver for the elderly and disabled that is operated through a division of the department that administers long-term care services for senior citizens and individuals with physical disabilities.
(2) (a) The training must be presented in person whenever the provider:
(i) hires a new employee; or
(ii) enrolls a consumer to receive services.
(b) The provider shall require its employees and the consumers who are receiving services to review fraud prevention materials on an annual basis after completing the initial training.
(c) Each employee and consumer shall sign a document attesting to the fact that the employee or consumer received the in-person training or received and reviewed the fraud prevention materials.
(d) When the training involves services provided using a self-directed service model, the consumer may provide the training.
(3) The training and continuing education must include but are not limited to information on:
(a) activities that constitute fraud;
(b) ways to prevent fraud; and
(c) when and how to report fraud, including how to contact the medicaid fraud hotline.
(4) (a) The department and the medicaid fraud control unit provided for in 53-6-156 shall, in consultation with home and community-based services consumers, providers, and advocates, develop the elements to be included in the training.
(b) A provider required to provide training under this section may:
(i) develop training materials that meet the requirements developed by the department and the medicaid fraud control unit; or
(ii) use training materials approved by the department by rule.
(5) The department may adopt rules requiring other providers of medicaid home and community-based services that are provided in a person's home to provide the training required under this section.
(6) The department shall:
(a) review and approve fraud education materials; and
(b) monitor compliance with training requirements.
History: En. Sec. 1, Ch. 324, L. 2015.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 4. Home and Community-Based Long-Term Care Medicaid Services › 53-6-406. Fiscal accountability for home and community-based services -- report to legislature

53-6-406. Fiscal accountability for home and community-based services -- report to legislature.
(1) (a) A provider of home and community-based services shall submit cost information to the department each year if personal assistance, community supports, private-duty nursing, or attendant services or supports are funded:
(i) as a state plan service;
(ii) through a medicaid state plan option available to the state under 42 U.S.C. 1396n(k); or
(iii) under a home and community-based services waiver that is operated through a division of the department that administers home and community-based services.
(b) The information provided to the department must reflect costs incurred during the provider's most recent fiscal year.
(2) The department shall develop a standardized format for the information that includes the recognized revenues and expenditures incurred by providers.
(3) The department shall analyze cost information submitted by providers to determine at a minimum:
(a) the reasonable cost of providing the home and community-based services detailed in the report;
(b) the percentage of a provider's cost represented by payment of wages and benefits for direct-care employees; and
(c) the level of profit or loss that each provider incurred in delivering the service. The profit or loss must be determined by comparing the recognized cost of providing the service with the medicaid reimbursement provided for the same service.
(4) The department shall establish protocols to protect provider-specific confidential data from public disclosure.
(5) By September 1 of the year preceding a regular legislative session, the department shall report to the children, families, health, and human services interim committee in accordance with 5-11-210 on all information in this section.
History: En. Sec. 2, Ch. 324, L. 2015; amd. Sec. 1, Ch. 59, L. 2023.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 4. Home and Community-Based Long-Term Care Medicaid Services › 53-6-407. Notification required before termination of waiver participation

53-6-407. Notification required before termination of waiver participation.
(1) The department shall notify a person participating in a medicaid home and community-based services waiver at least 30 days before terminating the person's participation in the waiver. The department shall:
(a) notify the person of the planned termination from the program by mail; and
(b) allow the person to provide the department with information demonstrating the person's continued need for waiver services. The information must be provided within 30 days of the date the notification was mailed.
(2) (a) The department may terminate the person's participation in the waiver at the end of the 30-day period provided for in subsection (1) if:
(i) the person has not responded to the notification; or
(ii) after reviewing information provided by the person, the department has determined the person is no longer eligible to participate in the waiver.
(b) If the department determines that the person is no longer eligible to participate in the waiver, the department must notify the person by mail before the expiration of the 30-day notification period.
(3) The termination notice provided for in subsection (2) must state that:
(a) the decision may be appealed in accordance with 53-2-606;
(b) the person may request continued services during the period of the appeal; and
(c) the department will not seek reimbursement of services provided during the period of appeal unless the department finds evidence of fraud or other similar circumstances indicating waiver services were not warranted.
(4) An appeal must be filed within 90 days of the mailing date of the termination notice provided for in subsection (2).
History: En. Sec. 1, Ch. 257, L. 2021.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 4. Home and Community-Based Long-Term Care Medicaid Services › 53-6-413. Substantive changes to waiver provisions -- rulemaking requirements -- definition

53-6-413. Substantive changes to waiver provisions -- rulemaking requirements -- definition.
(1) The department may not make a substantive change to the services offered under an approved waiver or to the eligibility requirements or process for waiver participants unless the department:
(a) adopts rules to implement the changes; and
(b) if necessary, submits a waiver amendment to the centers for medicare and medicaid services and receives approval for the change.
(2) (a) For the purposes of this section, "substantive change" means a change that:
(i) reduces, limits, or otherwise establishes caps on the amount or duration of a service; or
(ii) limits a person's ability to access waiver services.
(b) The term includes but is not limited to changes requiring:
(i) preauthorization before a service is provided;
(ii) preauthorization before an individual is placed on the waiting list for services; or
(iii) that services be used within a specific, shorter time period than previously allowed.
History: En. Sec. 1, Ch. 258, L. 2021.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 5. Traumatic Brain Injury -- Services › 53-6-501. Traumatic brain injury defined

53-6-501. Traumatic brain injury defined.
(1) (a) As used in 53-6-502 and this section, "traumatic brain injury" means:
(i) an injury to the brain caused by an external physical force, including but not limited to a motor vehicle accident, a fall, an assault, a sports injury, or a recreational or work-related accident; or
(ii) brain damage caused by an internal occurrence including but not limited to:
(A) disease, such as a benign or malignant tumor, meningitis, or encephalitis; or
(B) a cerebrovascular accident, such as stroke, atherosclerosis, aneurysm, or arteriovenous malformation; or
(C) anoxia, including but not limited to anoxia caused by near drowning, drug overdose, kidney or heart failure, chemical exposure, or electrical shock.
(b) The term "traumatic brain injury" does not include injuries of a degenerative or congenital nature.
(2) Traumatic brain injury as defined in this section may produce a diminished or altered state of consciousness that results in a temporary or permanent impairment of cognitive or mental abilities, physical functioning, or behavioral or emotional functioning.
History: En. Sec. 1, Ch. 591, L. 1993.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 5. Traumatic Brain Injury -- Services › 53-6-502. Traumatic brain injury trust fund established -- source of funds -- uses

53-6-502. Traumatic brain injury trust fund established -- source of funds -- uses.
(1) There is an account in the state special revenue fund to be used to establish a traumatic brain injury trust fund.
(2) The trust fund consists of donations or grants received for the purpose of providing services for persons suffering from traumatic brain injury.
(3) The money in this account must be used solely for planning, coordinating, and providing services to persons suffering from traumatic brain injury.
History: En. Sec. 2, Ch. 591, L. 1993.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 6. Long-Term Care Reform › 53-6-602. Purpose -- policy

53-6-602. Purpose -- policy.
(1) The legislature finds that in keeping with the traditional concept of the inherent dignity of the individual in a democratic society, the elderly or persons with disabilities should be able to live as independently as possible.
(2) The legislature further finds that:
(a) the ability to continue to live in a person's own residence or in the least restrictive setting best serves the health and dignity of the elderly or persons with disabilities;
(b) state programs of assistance for the elderly or persons with disabilities should be coordinated in a manner that best serves the interests of the recipients;
(c) state programs of assistance for the elderly or persons with disabilities should encourage the development of services that support the maintenance of lives as independently as possible;
(d) state programs of assistance for the elderly or persons with disabilities should encourage the development of affordable services for persons seeking services, whether financed through private means or public means;
(e) the elderly or persons with disabilities should be able to obtain insurance and other means of private financing for services that are affordable and readily available; and
(f) state agencies are required to carry out their various responsibilities for the provision of assistance, the protection of the elderly and persons with disabilities, and the licensing of facilities and professions in accordance with this part.
(3) The legislature declares that the policy of this state is to:
(a) respect the dignity of persons in the provision of state-sponsored and state-funded services for the elderly and persons with disabilities by seeking to maintain the maximum level of independence possible for those persons receiving services;
(b) foster the development of community services that allow a person to choose to remain in a person's own residence or in the least restrictive setting;
(c) foster coordination of services for the elderly or persons with disabilities among the various public and private programs; and
(d) foster the development of private means of financing services for the elderly or persons with disabilities.
History: En. Sec. 2, Ch. 384, L. 1995.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 6. Long-Term Care Reform › 53-6-603. Long-term care service development -- coordination -- delivery

53-6-603. Long-term care service development -- coordination -- delivery.
(1) The department of public health and human services shall cooperate in the development, implementation, and coordination of state programs of assistance for the elderly or persons with disabilities.
(2) The planning and delivery systems that provide state programs of assistance for the elderly and persons with disabilities must be jointly coordinated to foster:
(a) efficient and cost-effective financing, service delivery, intake, eligibility, assessment, and other measures, as appropriate; and
(b) general development of service systems that may serve persons with either private means or public means of financing services at a reasonable cost.
(3) State programs of assistance for the elderly or for persons with disabilities should be made available in the most appropriate, most cost-effective, and least restrictive residential setting integrated into a community.
(4) State programs of assistance that provide services or oversight in order to maintain or to protect a person's health and social life should recognize the person's dignity and independence.
History: En. Sec. 3, Ch. 384, L. 1995.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 7. Medicaid Managed Care › 53-6-701. Policy of medicaid managed care -- system for integrated health care services

53-6-701. Policy of medicaid managed care -- system for integrated health care services.
It is the public policy of the state of Montana to adopt, to the extent practicable, a health care system that encourages the integration of health care services and that manages the health care of enrollees to improve their health while preserving reasonable choice within a competitive and cost-efficient environment. In furtherance of this public policy, the department shall develop and implement integrated health care programs consistent with the provisions of this part. The provisions of this part apply only to programs created under this part. The department shall by rule identify persons eligible for enrollment in a program. The department shall inform enrollees of their choice, if any, among health care delivery systems. Persons enrolled in a program may also be offered cost-effective indemnity insurance plans, subject to availability.
History: En. Sec. 1, Ch. 502, L. 1995; amd. Sec. 4, Ch. 466, L. 2001.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 7. Medicaid Managed Care › 53-6-702. Definitions

53-6-702. Definitions.
As used in this part, the following definitions apply:
(1) "Department" means the department of public health and human services.
(2) "Health maintenance organization" means a health maintenance organization as defined in 33-31-102.
(3) (a) "Managed health care entity" or "entity" means a health maintenance organization or an insurer regulated under Title 33 that:
(i) contracts for an estimated annual value of $1 million or more of state and federal medicaid funds; or
(ii) operates statewide or covers 20% or more of the medicaid population.
(b) The term does not include:
(i) a provider of health care services under a contract with the department on a fee-for-service basis;
(ii) a medicaid primary care case management service within the meaning of 42 CFR 438; or
(iii) a PACE organization as defined in 42 CFR 460.6 or an accountable care organization as defined in 33-31-102 that has received a waiver under 33-31-201.
(4) "Program" means an element of the integrated health care system created by this part.
History: En. Sec. 2, Ch. 502, L. 1995; amd. Sec. 5, Ch. 466, L. 2001; amd. Sec. 3, Ch. 401, L. 2003; amd. Sec. 4, Ch. 403, L. 2003; amd. Sec. 3, Ch. 195, L. 2009; amd. Sec. 4, Ch. 346, L. 2011.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 7. Medicaid Managed Care › 53-6-703. Repealed

53-6-703. Repealed.
Sec. 11, Ch. 351, L. 2011.
History: En. Sec. 3, Ch. 502, L. 1995; amd. Sec. 9, Ch. 577, L. 1999; amd. Sec. 6, Ch. 466, L. 2001; amd. Sec. 64, Ch. 130, L. 2005; amd. Sec. 10, Ch. 426, L. 2009.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 7. Medicaid Managed Care › 53-6-704. Different benefit packages

53-6-704. Different benefit packages.
(1) The department may by rule provide for different benefit packages for different categories of persons enrolled in the program. Alcohol and substance abuse services, services for mental disorders, services related to children with chronic or acute conditions requiring longer-term treatment and followup, and rehabilitation care provided by a freestanding rehabilitation hospital or a rehabilitation unit may be excluded from a benefit package and those services may be made available through a separate delivery system. If a service is excluded from the program but made available in a separate delivery system by a managed health care entity, that managed health care entity is subject to this part. An exclusion does not prohibit the department from developing and implementing demonstration projects for categories of persons or services. Benefit packages for persons eligible for medical assistance under Title 53, chapter 6, parts 1 and 4, may be based on the requirements of those parts and must be consistent with the Title XIX of the Social Security Act. This part applies only to services purchased by the department.
(2) The program established by this part may be implemented by the department in various contracting areas at various times. The health care delivery systems and providers available under the program may vary throughout the state. Except as otherwise provided in a contract for mental health services and subject to the public comment and review provisions of 53-6-710 and 53-6-711, a licensed managed health care entity must be permitted to contract in any geographic area for which it has a sufficient provider network and that otherwise meets the requirements of the state contract.
History: En. Sec. 4, Ch. 502, L. 1995; amd. Sec. 10, Ch. 577, L. 1999; amd. Sec. 7, Ch. 351, L. 2011.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 7. Medicaid Managed Care › 53-6-706. Requirements relating to enrollees

53-6-706. Requirements relating to enrollees.
(1) All individuals enrolled in the program must be provided with a full written explanation of all fee-for-service and managed health care plan options as provided by rule. The department shall provide to enrollees, upon enrollment in the program and at least annually, notice of the process for requesting an appeal under the department's administrative appeal procedures. The department shall maintain a toll-free telephone number for program enrollees' use in reporting problems with managed health care entities.
(2) If an individual becomes eligible for participation in the program while the individual is hospitalized, the department may, but is not required to, enroll the individual in the program prior to the individual's discharge from the hospital. This subsection does not apply to a newborn infant whose mother is enrolled in the program.
(3) The department shall, by rule, establish rates for managed health care entities that:
(a) are in accordance with federal requirements and with the department's current payment system;
(b) take into account any difference of cost to provide health care to different populations based on age and eligibility category. The rates for managed health care entities must be determined on a capitated basis.
(c) are based on treatment settings reasonably available to enrollees.
History: En. Sec. 6, Ch. 502, L. 1995; amd. Sec. 11, Ch. 577, L. 1999.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 7. Medicaid Managed Care › 53-6-707. Payment reductions and adjustments -- freedom to contract

53-6-707. Payment reductions and adjustments -- freedom to contract.
(1) The department shall by rule establish a method to reduce its payments to managed health care entities to take the following into consideration:
(a) any adjustment payments paid to health care facilities under subsection (2)(b) to the extent that those payments or any part of those payments have been taken into account in establishing capitated rates under 53-6-705; and
(b) the implementation of methodologies to limit financial liability for managed health care entities under 53-6-705.
(2) For key services provided by a hospital or nursing facility that contracts with an entity, adjustment payments that are not included in capitated rates must be paid directly to the hospital or nursing facility by the department. Adjustment payments include but are not limited to:
(a) adjustment payments to disproportionate share hospitals as defined by department rule;
(b) perinatal center payments;
(c) payments for direct medical education, indirect medical education, and certified registered nurse anesthetists;
(d) supplemental medicaid payments to hospitals made pursuant to 53-6-149; and
(e) supplemental medicaid payments to nursing facilities made pursuant to 15-60-211.
(3) For any hospital or nursing facility eligible for the adjustment payments described in this section, the department shall maintain, through the period ending June 30, 1996, reimbursement levels in accordance with statutes and rules in effect at the time the payments are made.
(4) The department may not assign an existing agreement with a medicaid provider to a managed health care entity. The managed health care entity shall enter into a new agreement with a provider in order for the provider to be considered a part of the managed health care entity's network of providers.
(5) This part does not limit or otherwise impair the authority of the department to enter into a contract, negotiated pursuant to this part, with a managed health care entity, including a health maintenance organization, that provides for termination or nonrenewal of the contract without cause upon notice as provided in the contract and without a hearing. If available funds are not sufficient to provide medical assistance for all eligible persons, the department may set priorities to limit, reduce, or otherwise curtail the amount, scope, or duration of the medical services made available under the Montana medicaid program and managed care.
History: En. Sec. 7, Ch. 502, L. 1995; amd. Sec. 9, Ch. 351, L. 2011.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 7. Medicaid Managed Care › 53-6-708. Waiver

53-6-708. Waiver.
The department may seek and obtain any necessary authorization provided under federal law to implement the program, including the waiver of any federal statutes or regulations. The department may not expand eligibility requirements unless authorized by the legislature. The department may seek a waiver of the federal requirement that the combined membership of medicare and medicaid enrollees in a managed health care entity may not exceed 75% of the managed health care entity's total enrollment. The department may not seek a waiver of the inpatient hospital reimbursement methodology in 42 U.S.C. 1396a(a)(13) even if the federal agency responsible for administering Title XIX determines that 42 U.S.C. 1396a(a)(13) applies to managed health care systems.
History: En. Sec. 8, Ch. 502, L. 1995; amd. Sec. 239, Ch. 42, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 7. Medicaid Managed Care › 53-6-709. Legislative auditor -- oversight

53-6-709. Legislative auditor -- oversight.
(1) In order to prevent, detect, and eliminate fraud, waste, abuse, mismanagement, and misconduct and to determine that the program is administered fairly and effectively, the legislative auditor shall oversee the managed care covered by this part.
(2) A medical provider may not be compelled to provide individual medical records of patients unless the records are provided in accordance with the provisions of the Government Health Care Information Act. State and local governmental agencies shall provide the requested information, assistance, or cooperation.
(3) All activities conducted by the legislative auditor must be conducted in a manner that ensures the preservation of evidence for use in criminal prosecutions. The legislative auditor may present for prosecution the findings of any activity to the office of the attorney general or to United States attorneys in Montana.
(4) The legislative auditor shall report all convictions, terminations, and suspensions taken against vendors, contractors, and health care providers to the department and to any agency responsible for licensing or regulating those persons or entities.
(5) The legislative auditor shall make periodic reports, findings, and recommendations regarding its oversight activities authorized by this section.
(6) This part does not limit investigations by the department that may otherwise be required by law or that may be necessary in the department's capacity as the central administrative authority responsible for administration of public aid programs in this state.
History: En. Sec. 9, Ch. 502, L. 1995; amd. Sec. 12, Ch. 577, L. 1999.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 7. Medicaid Managed Care › 53-6-710. Advisory council -- duties

53-6-710. Advisory council -- duties.
(1) There is an advisory council to review requests for proposals issued and contracts proposed to be awarded under this part.
(2) The advisory council consists of seven members appointed as follows:
(a) two members appointed by the speaker of the house of representatives, at least one of whom must be a health care provider;
(b) two members appointed by the president of the senate, at least one of whom must be a health care provider; and
(c) three members appointed by the governor, at least one of whom must be a health care provider.
(3) Members shall serve staggered, 3-year terms.
(4) When the department proposes to seek a medicaid waiver for managed care, the council shall conduct the following activities before the department issues a request for proposal and after it has selected a vendor but before a contract is awarded:
(a) hold a public hearing in the geographic area that would be affected by the program or contract in order to:
(i) educate medicaid recipients, health care providers, and the public residing in the area about the provisions of the proposed program or contract and the consumer's options; and
(ii) accept public comment about the proposed program or contract;
(b) submit a report if managed care is in place of its findings related to the public comment process to the children, families, health, and human services interim committee in accordance with 5-11-210, the legislative auditor's office, and the department.
(5) The council shall meet according to a schedule adopted by a majority vote of the council.
(6) The council is attached to the department for administrative purposes only, and members are entitled to reimbursement for travel expenses as provided in 2-18-501 through 2-18-503.
History: En. Sec. 1, Ch. 351, L. 2011; amd. Sec. 90, Ch. 261, L. 2021.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 7. Medicaid Managed Care › 53-6-711. Requests for proposals and contracts -- review requirements -- public notice and comment

53-6-711. Requests for proposals and contracts -- review requirements -- public notice and comment.
(1) Before the department issues a request for proposals or awards a contract for the provision of services through a managed health care entity:
(a) the department shall meet the public notice, legislative presentation, and public comment requirements of 53-2-215;
(b) the legislative auditor's office and the state auditor's office, in consultation with the department, shall analyze the request for proposal and the proposed contract for:
(i) actuarial soundness;
(ii) network adequacy as provided for in Title 33, chapter 36, part 2; and
(iii) consumer choice; and
(c) within 60 days of receipt of the request for proposal and proposed contract, the legislative auditor's office and state auditor's office shall complete their analyses and publish the findings of their analyses.
(2) (a) Before the department may award a contract, it shall seek an independent analysis to verify that the potential vendor is able to comply with the goals of the proposed managed care program.
(b) The vendor shall pay the costs of the analysis.
History: En. Sec. 2, Ch. 351, L. 2011.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 8. Long-Term Care Insurance Partnerships › 53-6-801. Purpose

53-6-801. Purpose.
The purpose of this part and the long-term care insurance partnerships authorized by this part is to encourage individuals to purchase long-term care insurance policies or certificates that will provide for their potential long-term care needs, thereby reducing the amount of money spent by the state of Montana for long-term care under the Montana medicaid program. The purpose of this part is also to provide an incentive for the purchase of the policies or certificates by providing individuals some protection from the requirement that they spend down their resources in order to qualify for medical assistance benefits in the form of payment for long-term care.
History: En. Sec. 2, Ch. 195, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 8. Long-Term Care Insurance Partnerships › 53-6-802. Definitions

53-6-802. Definitions.
As used in this part, unless the context indicates otherwise, the following definitions apply:
(1) "Certificate" means a certificate as defined in 33-22-1107.
(2) "Commissioner" means the commissioner of insurance provided for in 2-15-1903.
(3) "Department" means the department of public health and human services provided for in 2-15-2201.
(4) "Dollar-for-dollar model" means a program in which the amount of resources that is disregarded in determining medical assistance eligibility for an individual is increased by $1 for each dollar paid by an insurer to an insured under the insured's long-term care insurance policy or certificate.
(5) "Long-term care insurance" means an insurance policy or certificate that provides coverage for medically necessary services in a long-term care facility, as defined in 50-5-101, or in the insured's home.
(6) "Long-term care insurance partnership" or "partnership" means a program of collaboration between the commissioner, the department, insurers, and their insureds to create an incentive, through the issuance of insurance policies or certificates certified by the commissioner and the department, for individuals to purchase long-term care insurance.
(7) "Policy" means a policy as defined in 33-22-1107.
History: En. Sec. 1, Ch. 195, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 8. Long-Term Care Insurance Partnerships › 53-6-803. Long-term care insurance partnerships authorized

53-6-803. Long-term care insurance partnerships authorized.
(1) The commissioner and the department may in their discretion establish long-term care insurance partnerships as provided for in federal law under 42 U.S.C. 1396p or if allowed by a waiver of federal law under section 1115 of Title XI of the Social Security Act, 42 U.S.C. 1315.
(2) The department may in its discretion collaborate with private insurers to implement long-term care insurance partnerships that will allow individuals who have resources in excess of the resource limit for receipt of medical assistance under the Montana medicaid program to receive medical assistance benefits if those individuals are eligible for or require the level of care provided by a long-term care facility and meet the other program requirements in accordance with federal law or an approved waiver in order to facilitate the enrollment of persons into long-term care insurance plans.
(3) Under partnerships created pursuant to this section, individuals may qualify for special treatment of their resources if they purchase a long-term care insurance policy or certificate certified by the commissioner and the department as provided in 53-6-804 prior to becoming eligible for medical assistance benefits. The department may modify eligibility and other medicaid requirements by administrative rule as provided in 53-6-805 and as allowed by state and federal law to encourage individuals to maintain long-term care insurance.
(4) The long-term care insurance partnerships may in the department's discretion be based on a dollar-for-dollar model or any other model that is cost-neutral.
History: En. Sec. 3, Ch. 195, L. 1997; amd. Sec. 1, Ch. 406, L. 2005.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 8. Long-Term Care Insurance Partnerships › 53-6-804. Rulemaking and certification of policies by commissioner and department

53-6-804. Rulemaking and certification of policies by commissioner and department.
(1) The commissioner and the department may by rule adopt requirements for certification of long-term care insurance policies and certificates. These requirements may include but are not limited to:
(a) minimum levels and durations of benefits;
(b) mandatory inflation protection;
(c) mandatory home and community care coverage;
(d) case management; and
(e) procedures for the insured to appeal a denial of benefits.
(2) The commissioner and the department shall review long-term care insurance policies and certificates to determine whether policies and certificates meet the requirements for certification pursuant to this section.
History: En. Sec. 4, Ch. 195, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 8. Long-Term Care Insurance Partnerships › 53-6-805. Department to make rules

53-6-805. Department to make rules.
The department shall adopt rules necessary for the administration of the partnerships, including but not limited to rules concerning:
(1) the populations and age groups eligible to have resources disregarded for the purposes of qualification for medical assistance benefits under the Montana medicaid program;
(2) the level of care that an individual requires in order to have resources disregarded in determining eligibility for medical assistance benefits;
(3) the amount and type of resources of an individual that will be disregarded in determining eligibility for medical assistance benefits;
(4) requirements for the disregard of resources of an individual in determining eligibility for medical assistance benefits; and
(5) the exemption of protected resources from a lien provided in 53-6-171 through 53-6-189 for the recovery of medical assistance benefits paid by the state.
History: En. Sec. 5, Ch. 195, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 9. Medicaid Medical Savings Account Pilot Project (Terminated) › 53-6-901. Terminated

53-6-901. Terminated.
Sec. 1, Ch. 28, L. 1999.
History: En. Sec. 1, Ch. 380, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 9. Medicaid Medical Savings Account Pilot Project (Terminated) › 53-6-902. Terminated

53-6-902. Terminated.
Sec. 1, Ch. 28, L. 1999.
History: En. Sec. 2, Ch. 380, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 9. Medicaid Medical Savings Account Pilot Project (Terminated) › 53-6-903. Terminated

53-6-903. Terminated.
Sec. 1, Ch. 28, L. 1999.
History: En. Sec. 3, Ch. 380, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 9. Medicaid Medical Savings Account Pilot Project (Terminated) › 53-6-904. Terminated

53-6-904. Terminated.
Sec. 1, Ch. 28, L. 1999.
History: En. Sec. 4, Ch. 380, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 9. Medicaid Medical Savings Account Pilot Project (Terminated) › 53-6-905. Terminated

53-6-905. Terminated.
Sec. 1, Ch. 28, L. 1999.
History: En. Sec. 5, Ch. 380, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 9. Medicaid Medical Savings Account Pilot Project (Terminated) › 53-6-906. Terminated

53-6-906. Terminated.
Sec. 1, Ch. 28, L. 1999.
History: En. Sec. 6, Ch. 380, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 9. Medicaid Medical Savings Account Pilot Project (Terminated) › 53-6-907. Terminated

53-6-907. Terminated.
Sec. 1, Ch. 28, L. 1999.
History: En. Sec. 7, Ch. 380, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 9. Medicaid Medical Savings Account Pilot Project (Terminated) › 53-6-908. Terminated

53-6-908. Terminated.
Sec. 1, Ch. 28, L. 1999.
History: En. Sec. 8, Ch. 380, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 9. Medicaid Medical Savings Account Pilot Project (Terminated) › 53-6-909. Terminated

53-6-909. Terminated.
Sec. 1, Ch. 28, L. 1999.
History: En. Sec. 9, Ch. 380, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 9. Medicaid Medical Savings Account Pilot Project (Terminated) › 53-6-910. Terminated

53-6-910. Terminated.
Sec. 1, Ch. 28, L. 1999.
History: En. Sec. 10, Ch. 380, L. 1997.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 10. Prescription Drug Plus Discount Program › 53-6-1001. Definitions

53-6-1001. Definitions.
As used in this part, unless the context requires otherwise, the following definitions apply:
(1) "Department" means the department of public health and human services provided for in Title 2, chapter 15, part 22.
(2) "Discounted price" means a price set by the department by rule pursuant to 53-6-1002.
(3) "Manufacturer" means a manufacturer of prescription drugs and includes a subsidiary or affiliate of a manufacturer.
(4) "Participating retail pharmacy" means a retail pharmacy located in this state or another business licensed to dispense prescription drugs in this state that is medicaid-approved.
(5) "Program" means the prescription drug plus discount program provided for in 53-6-1002.
(6) "Secondary discounted price" means the discounted price less any further discounts funded by manufacturer rebates for medication purchased by participants in the program.
History: En. Sec. 1, Ch. 551, L. 2003; amd. Sec. 4, Ch. 287, L. 2005; amd. Sec. 30, Ch. 19, L. 2011.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 10. Prescription Drug Plus Discount Program › 53-6-1003. Eligibility -- income determination

53-6-1003. Eligibility -- income determination.
To be eligible for the program, an individual must:
(1) reside in a household with an income level less than or equal to 250% of the federal poverty guidelines as adopted by the U.S. department of health and human services; and
(2) lack prescription drug coverage or shall provide documentation that the individual has exceeded the coverage of the individual's prescription drug benefits.
History: En. Sec. 3, Ch. 551, L. 2003; amd. Sec. 6, 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 › 53-6-1004. State pharmacy access program

53-6-1004. State pharmacy access program.
(1) The department shall administer a pharmacy access prescription drug benefit program that contributes to the cost of the premium and, optionally, to the cost of the deductible for the Part D medicare prescription drug benefit as established in Title I of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003.
(2) An individual is eligible for the pharmacy access program if the individual:
(a) has a family income, as adopted by rule, of up to 200% of the federal poverty guidelines set annually by the U.S. department of health and human services and is not eligible for federal low-income assistance under Part D;
(b) submits proof of enrollment in a prescription drug plan for the Part D medicare benefit.
(3) The department shall establish by rule eligibility based upon the applicant's family income within the range provided in subsection (2). The department may adopt rules defining income. In establishing eligibility based upon income, the department shall take into account the amount of funding available for the program.
(4) The department shall set an amount of benefit for the premium and may optionally set a portion of the deductible by rule based on the numbers enrolled and the appropriation.
(5) The department shall open the enrollment of the pharmacy access program at the same time as enrollment commences for the medicare Part D program.
(6) If the department determines that there are excess funds for the pharmacy access program, it may use the funds for the program provided for in 53-6-1002.
History: En. Sec. 1, 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 › 53-6-1005. Department administration -- pharmacy access

53-6-1005. Department administration -- pharmacy access.
The department shall administer the pharmacy access program. The department shall provide for outreach and enrollment in the pharmacy access program. The department shall integrate the enrollment and outreach procedures with other services provided to individuals and families eligible for other related programs.
History: En. Sec. 2, Ch. 287, L. 2005; amd. Sec. 7, Ch. 81, L. 2017.
2023 Montana Code Annotated › Title 53. Social Services and Institutions › Chapter 6. Health Care Services › Part 10. Prescription Drug Plus Discount Program › 53-6-1006. Prescription drug consumer information and technical assistance program -- education outreach for consumers and professionals

53-6-1006. Prescription drug consumer information and technical assistance program -- education outreach for consumers and professionals.
(1) There is a prescription drug consumer information and technical assistance program in the department to provide Montana residents with advice on the prudent use of prescription drugs and how to access government and private prescription drug programs and discounts. The program must include consultation by licensed pharmacists with individuals on how to avoid dangerous drug interactions and provide for substitution of more cost-effective drugs with approval by the prescribing health care professional.
(2) The department shall create educational resources, including a website, concerning the costs and benefits of various drugs to inform consumers and medical practitioners on clinically effective and cost-conscious prescription drugs.
History: En. Sec. 3, 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 › 53-6-1010. Specifications for administration of program

53-6-1010. Specifications for administration of program.
(1) The department shall adopt specifications for the administration and management of the program. Specifications may include but are not limited to program objectives, accounting and handling practices, supervisory authority, and an evaluation methodology.
(2) Information disclosed by manufacturers during negotiations and all terms and conditions negotiated between the director and manufacturers and all information requested or required under the program are public information, except for information that the department determines is proprietary information.
(3) The department may use a formulary or other committee to determine preferred drug lists for department programs. The department shall include a representative of consumers on any formulary committee or committee to determine preferred drug lists for purchase by the department or reimbursement of costs. Any formulary or preferred drug list must be based on objective clinical data on safety and effectiveness. If two or more drugs are found to be equally effective and safe for the treatment of the same medical condition, the drug available at the lowest net price, inclusive of discounts and rebates, must be placed on the list. Other drugs for treating the same medical condition may be added to the list if they are therapeutically equivalent and the department determines them to be cost-effective.
(4) The department may negotiate rebates from the prescription drug manufacturers for drugs that will be on any preferred drug list. The department may negotiate price discounts with prescription drug manufacturers for any state-purchased health care programs, including medicaid, the state children's health insurance program, and the program provided for in 53-6-1002.
(5) The department may use the access restrictions and a preferred drug list to negotiate for the most favorable discount prices and rebates for the program.
(6) The department may participate in multistate purchasing pool initiatives for the benefit of the program.
History: En. Sec. 4, Ch. 551, L. 2003; amd. Sec. 7, 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 › 53-6-1011. Appeals

53-6-1011. Appeals.
An eligibility determination made by the department based on information provided by the department of revenue is final, subject to appeal in accordance with the appeal process established in the medicaid program.
History: En. Sec. 5, Ch. 551, L. 2003.