reglab/statecodes huggingface dataset:
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.15 - Home Infusion Therapy Services › Rule 37.86.1506 - HOME INFUSION THERAPY SERVICES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Subject to the requirements of these
				rules, the Montana Medicaid program will pay for home infusion therapy services
				on a fee basis, as specified in the department's home infusion therapy services
				fee schedule. The department adopts and incorporates by reference the Home
				Infusion Therapy Services Fee Schedule as provided in ARM
				37.85.105(3). A
				copy of the department's fee schedule is posted at the Montana Medicaid
				provider web site at http://medicaidprovider.hhs.mt.gov. A copy of the Home
				Infusion Therapy Services Fee Schedule may also be obtained from the Department
				of Public Health and Human Services, Health Resources Division, 1400 Broadway,
				P.O. Box 202951, Helena, MT 59620-2951. The specified fees are on a per day or
				a per dose basis as specified in the fee schedule. The fees are bundled fees
				which cover all home infusion therapy services as defined in ARM
				37.86.1501.
(2) For home infusion therapy services also
				reimbursed for the person by the Medicare program, Medicare payments will be
				considered to be third party payments and, if the Medicare payment is less than
				the Medicaid fee schedule amount, Medicaid will pay the difference between the
				Medicare payment and the Medicaid fee specified in the home infusion therapy
				fee schedule described in (1).
(3)
				Covered drugs prepared and administered as part of a person's home infusion
				therapy program are separately billable under the Montana Medicaid Outpatient
				Drug program as specified in ARM
				37.86.1102 and
				37.86.1105.
(4) Nursing services provided by licensed
				nurses employed by the home infusion therapy agency will be reimbursed to the
				agency as specified in the Home Infusion Therapy Fee Schedule. Home nursing
				services for infusion / specialty drug administration are not billable when the
				home infusion therapy program is provided in a nursing facility.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.17 - Family Planning Services › Rule 37.86.1701 - FAMILY PLANNING SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Family
				planning services may be provided by a physician in accordance with ARM
				37.86.101 through
				37.86.105, mid-level practitioner
				in accordance with ARM
				37.86.201 through
				37.86.205, or a local family
				planning program defined at ARM
				37.19.101. Family planning
				services include:
(a) comprehensive
				history;
(b) contraceptive supplies
				and procedures;
(c) initial,
				routine, and annual visits and examinations;
(d) laboratory services;
(e) medical counseling; and
(f) testing and treatment for sexually
				transmitted infections and testing for human immunodeficiency virus
				(HIV).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.17 - Family Planning Services › Rule 37.86.1705 - FAMILY PLANNING SERVICES, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) These requirements are in addition to
				those contained in ARM
				37.85.401,
				37.85.406,
				37.85.407,
				37.85.410, and
				37.85.414.
(a) Contraceptive clinic services are the
				services of a physician, a mid-level practitioner, or a local family planning
				program defined at ARM
				37.19.101.
(b) Laboratory services must be ordered by a
				physician or a mid-level practitioner.
(c) Contraceptive supplies must be prescribed
				by a physician or a mid-level practitioner with prescriptive
				authority.
(d) Eligible clients
				requesting family planning services must be free from coercion or mental
				pressure and free to choose the method of family planning to be used.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.17 - Family Planning Services › Rule 37.86.1706 - FAMILY PLANNING SERVICES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Reimbursement for family planning
				services is as follows:
(a) for physicians
				reimbursement is provided in accordance with the methodologies described in ARM
				37.85.212 and
				37.86.105;
(b) for mid-level practitioners reimbursement
				is provided in accordance with the methodologies described in ARM
				37.85.212 and
				37.86.205;
(c) for local family planning programs as
				defined at ARM
				37.19.101 reimbursement is
				provided in accordance with the methodologies described in ARM 37.85.212,
				37.86.105, and 37.86.205.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.18 - Prosthetic Devices, Durable Medical Equipment, and Medical Supplies › Rule 37.86.1801 - PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "Durable
				medical equipment and supplies" means the most economical equipment or supplies
				that are medically necessary to treat a health problem or a physical condition.
				The equipment or supplies must be appropriate for use in any setting in which
				life activities take place, as defined at
				42 CFR
				440.70(c)(1) (2018).
				Equipment or supplies that are useful or convenient, but are not medically
				necessary to treat an illness or injury do not qualify for Medicaid
				coverage.
(2) "Prescription" means
				a prescription or order as provided in ARM
				37.86.1802.
(3) "Prior authorization" means the Medicaid
				program's review and approval of an item's medical necessity and coverage by
				Medicaid prior to the delivery of the item.
(4) "Prosthetic devices" means replacement,
				corrective, or supportive devices or appliances which artificially replace a
				missing portion of the body to:
(a) prevent
				or correct physical deformity or malfunction; or
(b) support a weak or deformed portion of the
				body.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.18 - Prosthetic Devices, Durable Medical Equipment, and Medical Supplies › Rule 37.86.1803 through 37.86.1805 - Reserved

Current through Register Vol. 13, July 5, 2024
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.18 - Prosthetic Devices, Durable Medical Equipment, and Medical Supplies › Rule 37.86.1806 - PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, REIMBURSEMENT REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) Requirements
				for the purchase or rental of prosthetic devices, durable medical equipment,
				medical supplies and related maintenance, repair, and services are as follows:
(a) Subject to the requirements of this rule,
				the department will pay the lowest of the following for prosthetic devices,
				durable medical equipment, medical supplies and related maintenance, repair,
				and services:
(i) the provider's usual and
				customary charge for the item; or
(ii) the department's fee schedule maintained
				in accordance with the methodology described in ARM
				37.86.1807.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.18 - Prosthetic Devices, Durable Medical Equipment, and Medical Supplies › Rule 37.86.1807 - PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, FEE SCHEDULE

Current through Register Vol. 13, July 5, 2024
(1) Providers must
				bill for prosthetic devices, durable medical equipment, medical supplies and
				related maintenance, repair and services using the procedure codes and
				modifiers set forth and according to the definitions contained in the Centers
				for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Coding
				System (HCPCS). Information regarding billing codes, modifiers and HCPCS is
				available upon request from the Department of Public Health and Human Services,
				Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT
				59620-2951.
(2) Prosthetic devices,
				durable medical equipment, and medical supplies will be reimbursed in
				accordance with the department's Durable Medical Equipment, Prosthetics,
				Orthotics, and Supplies (DMEPOS) Fee Schedule, as provided in ARM
				37.85.105(3),
				which is adopted and incorporated by reference.
(3) The department's DMEPOS Fee Schedule for
				items other than those billed under generic or miscellaneous codes as described
				in (1) will include fees set and maintained according to the following
				methodology:
(a) 100% of the Medicare region
				D allowable fee;
(b) 100% of the
				Medicaid allowable fee established by the department if there is no Medicare
				region D allowable fee established; or
(c) Except as provided in (4), for all items
				for which no Medicare or Medicaid allowable fee is available, the department's
				fee schedule amount will be 75% of the provider's usual and customary charge.
(i) For purposes of (3)(c) and (4), the
				amount of the provider's usual and customary charge may not exceed the
				reasonable charge usually and customarily charged by the provider to all
				payers.
(A) The charge will be considered
				reasonable if less than or equal to the manufacturer's suggested list price.
(B) For items without a
				manufacturer's suggested list price, the charge will be considered reasonable
				if the provider's acquisition cost from the manufacturer is at least 50% of the
				charge amount.
(C) For items that
				are custom fabricated at the place of service, the amount charged will be
				considered reasonable if it does not exceed the average charge of all Medicaid
				providers by more than 20%.
(D) For
				rental items, the reasonable monthly charge may not exceed a percentage of the
				reasonable purchase charge, as specified in ARM
				37.86.1806(3).
(ii) Items having no product retail list
				price, such as items customized by the provider, will be reimbursed at 75% of
				the provider's usual and customary charge as defined in (3)(b)(i).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.20 - Optometric Services › Rule 37.86.2001 - OPTOMETRIC SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1)
				"Optometric services" means services provided by a licensed optometrist that
				are within the scope of practice. Optometric services include visual
				training.
53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.20 - Optometric Services › Rule 37.86.2002 - OPTOMETRIC SERVICES, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1)
				These requirements are in addition to the rule provisions generally applicable
				to Medicaid providers.
(2) The
				department hereby adopts and incorporates by reference the definitions found in
				the introduction of Physicians Current Procedural Terminology, fourth edition
				(CPT 4), published by the American Medical Association of Chicago, Illinois.
				These materials set forth meanings of terms commonly used by the Montana
				Medicaid program in implementation of the program's optometric schedule. A copy
				of the definitions herein incorporated may be obtained through the Department
				of Public Health and Human Services, Health Resources Division, P.O. Box
				202951, 1400 Broadway, Helena, MT 59620-2951. Providers must bill for services
				using the procedure codes, and modifiers set forth, and according to the
				definitions contained in the Health Care Financing Administration's Common
				Procedure Coding System (HCPCS). Information regarding billing codes, modifiers
				and HCPCS is available upon request from the Health Resources Division at the
				address stated above.
(3) A
				Medicaid member under 21 years of age is limited to one eye examination for
				determination of refractive state per 365-day period. A Medicaid member 21
				years of age or older is limited to one eye examination for determination of
				refractive state per 730-day period unless one of the following circumstances
				exist:
(a) following cataract surgery more
				than one examination during the 365-day period is necessary; or
(b) the provider determines by screening that
				a loss of one line acuity has occurred with present glasses.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.20 - Optometric Services › Rule 37.86.2005 - OPTOMETRIC SERVICES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1)
				Subject to the requirements of this rule, the department will pay the lowest of
				the following for optometric services:
(a)
				the provider's usual and customary charge for the service or item;
(b) the reimbursement provided in accordance
				with the methodologies described in ARM
				37.85.212;
				or
(c) the amount specified for
				the particular service or item in the department's fee schedule.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.21 - Eyeglass Services › Rule 37.86.2101 - EYEGLASSES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) Eyeglasses mean
				corrective lens and/or frames prescribed by an ophthalmologist or by an
				optometrist, to aid and improve vision.
(a)
				Corrective lenses also include contact lenses.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.21 - Eyeglass Services › Rule 37.86.2102 - EYEGLASSES, SERVICES, REQUIREMENTS AND RESTRICTIONS

Current through Register Vol. 13, July 5, 2024
(1) These requirements are in addition to the
				rule provisions generally applicable to Medicaid providers.
(2) The dispensing service may be provided by
				an ophthalmologist, an optometrist, an optician, or their employees within the
				scope of their professional practice allowed by law.
(3) Ophthalmologists, optometrists,
				opticians, or their employees dispensing eyeglasses and ophthalmologists or
				optometrists, or their employees dispensing contact lenses must bill for
				services using the procedure codes and modifiers set forth, and according to
				the definitions contained, in the Health Care Financing Administration's Common
				Procedure Coding System (HCPCS). Information regarding billing codes, modifiers
				and HCPCS is available upon request from the Department of Public Health and
				Human Services, Health Services Division, 1400 Broadway, P.O. Box 202951,
				Helena, MT 59620-2951.
(4) A member
				under 21 years of age is limited to one pair of eyeglasses per 365-day period
				and a member 21 years of age or older is limited to one pair of eyeglasses
				every 730-day period.
(5) A member
				may receive additional lenses in the following circumstances:
(a) cataract surgery;
(b) .50 diopter change in correction in
				sphere;
(c) .75 diopter change in
				cylinder;
(d) .5 prism diopter
				change in vertical prism;
(e) .50
				diopter change in the near reading power;
(f) a minimum of a 5 degree change in axis of
				any cylinder less than or equal to 3.00 diopters;
(g) a minimum of a 3 degree change in axis of
				any cylinder greater than 3.00 diopters; or
(h) any 1 prism diopter or more change in
				lateral prism.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.21 - Eyeglass Services › Rule 37.86.2105 - EYEGLASSES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Eyeglasses are
				paid by the department through a single volume purchase contract.
(2) Reimbursement for contact lenses or
				dispensing fees is as follows:
(a) The
				department pays the lower of the following:
(i) the provider's usual and customary charge
				for the service; or
(ii) the
				amount specified for the particular service or item in the department's
				Eyeglasses Fee Schedule.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2201 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , PURPOSE, ELIGIBILITY, AND SCOPE

Current through Register Vol. 13, July 5, 2024
(1) The
				early and periodic screening, diagnostic and treatment services (EPSDT) are
				preventive health screenings, diagnostic services, and medically necessary
				treatment services as specified in these rules.
(2) Services provided for EPSDT purposes are
				only available to Medicaid eligible persons up to and including 20 years of
				age.
(3) Limitations on the amount,
				scope or duration for particular services, funded with Medicaid monies, do not
				apply to such services when provided to EPSDT recipients unless otherwise
				provided in these rules.
(4)
				Criteria, requirements, and limitations applicable to eligibility for and the
				receipt of home and community services provided under a Medicaid waiver, govern
				the provision of waiver and EPSDT services to persons who are eligible for both
				EPSDT and waiver services.
(5)
				Criteria, requirements and limitations generally applicable to Medicaid
				services, recipients, or providers, including but not limited to medical
				necessity requirements, experimental or cosmetic service exclusions, prior
				authorization, prescreening, certification or utilization review requirements,
				provider participation, billing or reimbursement requirements, recipient
				eligibility or copayment requirements, or other similar requirements or
				restrictions apply to EPSDT recipients, EPSDT services, and providers of
				services to EPSDT recipients.
(6)
				An EPSDT service may only be provided by a provider that is appropriate and
				qualified to deliver the service in accordance with the relevant and applicable
				educational, professional and licensing standards and requirements.
(7) An EPSDT service must be delivered in
				accordance with those standards and requirements applicable to the provision of
				the service.
(8) School based
				health related services may only be provided in public school districts,
				full-service education cooperatives and joint boards described in ARM
				37.86.2231.
(9) A service, item or provider category is
				not available as an EPSDT service unless made available in accordance with
				these rules.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2202 through 37.86.2204 - Reserved

Current through Register Vol. 13, July 5, 2024
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2205 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), REQUIRED SCREENING AND PREVENTIVE SERVICES

Current through Register Vol. 13, July 5, 2024
(1) EPSDT screening
				and preventive services are available in accordance with this rule.
(2) The number and timing of comprehensive
				health, vision, hearing and dental screenings should follow the American
				Academy of Pediatrics (AAP) Bright Futures schedule.
(a) Screening and preventive services must
				include assessments, exams, immunizations, tests, and appropriate health
				education.
(b) Caregiver depression
				screenings are covered for caregivers of children under one year of age.
				Appropriate evidence-based screening tools should be administered to caregivers
				as needed. Positive screenings must be appropriately referred for follow-up
				care.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2206 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , MEDICAL AND OTHER SERVICES

Current through Register Vol. 13, July 5, 2024
(1) EPSDT
				eligible persons may receive any services otherwise available to persons
				eligible for Medicaid funded services.
(2) In addition to the services generally
				available to Medicaid persons, the following services are available to EPSDT
				eligible persons:
(a) nutrition services as
				provided in ARM
				37.86.2209;
(b) chiropractic services as provided in ARM
				37.86.2211;
(c) outpatient chemical dependency treatment
				as provided in ARM
				37.86.2213;
(d) private duty nursing as provided in ARM
				37.86.2217;
(e) mental health services for youth as
				provided in ARM Title 37, chapter 87;
(f) school-based health related services as
				provided in ARM
				37.86.2230; and
(g) orientation and mobility specialist
				services as provided in ARM
				37.86.2235.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2207 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1)
				Reimbursement for an EPSDT service, except as otherwise provided in this rule,
				is the lowest of the following:
(a) the
				provider's usual and customary charge for the service;
(b) the reimbursement determined in
				accordance with the methodologies provided in ARM
				37.85.212 and
				37.86.105;
(c) the department's Medicaid Mental Health
				Fee Schedule as provided in ARM
				37.85.105(6);
				or
(d) for public agencies, cost
				based reimbursement as determined in accordance with OMB Circular A-87, Cost
				Principles for State, Local and Indian Tribal Governments as established and
				approved by the department. The department adopts and incorporates by reference
				the OMB Circular A-87, Cost Principles for State, Local and Indian Tribal
				Governments, as further amended May 14, 2004. A copy of OMB Circular A-87 may
				be obtained from the Department of Public Health and Human Services, Health
				Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT
				59620-2951.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2209 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , NUTRITION SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Nutrition
				services may include:
(a) nutrition
				counseling for counseling directly with a child, or with a responsible care
				giver, to explain the nutrition assessment and to implement a plan of nutrition
				care;
(b) nutrition assessment for
				evaluation of a child's nutritional problems, and design of a plan to prevent,
				improve or resolve identified nutritional problems, based upon the health
				objectives, resources and capacity of the child;
(c) nutrition consultation for consultation
				with or for health professionals, researching or resolving special nutrition
				problems or referring a child to other services, pertaining to the nutritional
				needs of a child; or
(d) nutrition
				education for routine education for normal nutritional needs.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2211 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), CHIROPRACTIC SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Chiropractic
				services are limited to evaluation and management office visits, manual
				manipulation of the spine, and x-rays to support the diagnosis of subluxation
				of the spine
(2) There must be
				documented medical necessity for chiropractic services by the child's primary
				care provider and the treatment must be directly related to a neuromuscular
				diagnosis of the spine.
AUTH:
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2213 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , OUTPATIENT CHEMICAL DEPENDENCY TREATMENT SERVICES (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2214 through 37.86.2216 - Reserved

Current through Register Vol. 13, July 5, 2024
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2217 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), PRIVATE DUTY NURSING SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Private
				duty nursing services are limited to:
(a)
				skilled nursing services provided directly to a child; and
(b) patient-specific training provided to a
				registered nurse or licensed practical nurse when a child is new to the nursing
				agency, when a change in the condition of a child requires additional training
				for the current nurse, or when a change in nursing personnel requires a new
				nurse to be trained to care for a child.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2219 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , THERAPEUTIC YOUTH GROUP HOME SERVICES (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2221 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , THERAPEUTIC FAMILY CARE TREATMENT SERVICES (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2222 and 37.86.2223 - Reserved

Current through Register Vol. 13, July 5, 2024
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2224 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT SERVICE (EPSDT), COMPREHENSIVE SCHOOL AND COMMUNITY TREATMENT (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2225 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), CSCT PROGRAM BILLING (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 50-5-103,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2226 through 37.86.2229 - Reserved

Current through Register Vol. 13, July 5, 2024
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2230 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), SCHOOL-BASED HEALTH RELATED SERVICES

Current through Register Vol. 13, July 5, 2024
(1)
				School-based services for the purposes of Medicaid are defined as medically
				necessary services provided through a public school district, joint board, or
				cooperative. The public school district or cooperative must receive funds from
				the state general fund for the purpose of providing special
				education.
(2) School-based health
				related services may include:
(a) physical
				therapy;
(b) speech-language
				pathology and audiology;
(c)
				occupational therapy;
(d) private
				duty nursing;
(e) personal care
				paraprofessional services;
(f)
				licensed psychologist services;
(g)
				school psychologist services;
(h)
				licensed clinical social worker services;
(i) licensed professional counselor
				services;
(j) comprehensive school
				and community treatment;
(k)
				specialized transportation; and
(l)
				orientation and mobility specialist services.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2231 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , ELIGIBILITY AND SCOPE OF SCHOOL BASED HEALTH RELATED SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Only public school districts,
				full-service education cooperatives (established under
				20-3-351,
				MCA) and joint boards are eligible for enrollment and participation in the
				school based Montana Medicaid program.
(2) To qualify, the district, cooperative or
				joint board must receive special education funding from the state's general
				fund for the purpose of providing public education.
(3) School districts include only elementary,
				high school, and K-12 districts organized to provide public educational
				services under the jurisdiction of a board of trustees as provided in Title 20,
				MCA.
(4) Full-service education
				cooperatives and joint boards include only those cooperatives and joint boards
				eligible to receive direct state aid payments from the superintendent of public
				instruction for the purpose of providing special education services consistent
				with the provisions of Title 20, MCA.
(5) Cooperatives, joint boards and nonpublic
				schools that do not receive state general funds for special education do not
				meet the criteria for Medicaid enrollment and cannot participate in the
				Medicaid program as a school-based provider.
53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2232 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , SCHOOL BASED PERSONAL CARE PARAPROFESSIONAL SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Personal care paraprofessional services
				are medically necessary in-school services provided to Medicaid clients whose
				health conditions cause them to be functionally limited in performing
				activities of daily living.
(2)
				Personal care includes assistance with activities of daily living which
				include:
(a) grooming;
(b) transferring;
(c) mobility;
(d) eating;
(e) dressing;
(f) toileting; and
(g) bus escort for children with functional
				limitations.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2233 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , SCHOOL PSYCHOLOGIST SERVICES

Current through Register Vol. 13, July 5, 2024
(1)
				School psychologist services are those services provided by an individual with
				a class 6 specialist license with a school psychologist endorsement, as
				required by ARM
				10.57.434.
(2) School psychologists may perform
				medically necessary evaluation and counseling services. Counseling services may
				be provided to individuals or groups.
(3) Group counseling and therapy services
				provided by a school psychologist must have no more than eight individuals
				participating in the group.
(4)
				When an eligible child receives school psychologist services and the
				psychologist consults with the parent as part of the child's treatment, time
				spent with the parent may be billed to Medicaid under the child's name. The
				provider shall indicate on the claim that the child is the patient and state
				the child's diagnosis.
(5) Services
				considered educational are not a covered benefit under Medicaid.
53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2234 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT) , SCHOOL-BASED SPECIALIZED TRANSPORTATION SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Coverage of specialized transportation is
				limited to school-based transportation of clients with disabilities for the
				purpose of obtaining nonemergency medical services covered by the Medicaid
				program.
(a) The client must be in need of
				specialized transportation due to the client either being wheelchair-bound or
				subject to transport by stretcher.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.22 - Early and Periodic Screening, Diagnostic and Treatment Services (EPSDT) › Rule 37.86.2235 - EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), ORIENTATION AND MOBILITY SPECIALIST SERVICES

Current through Register Vol. 13, July 5, 2024
(1)
				Orientation and Mobility Specialist Services are those services provided by an
				individual with:
(a) a certification from the
				Academy for Certification of Vision Rehabilitation and Education Professionals
				(ACVREP); or
(b) a National
				Orientation and Mobility Certification (NOMC) offered by the National Blindness
				Professional Certification Board (NBPCB) to Medicaid clients with a diagnosis
				of a visual impairment.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.24 - Transportation Services › Rule 37.86.2401 - TRANSPORTATION AND PER DIEM, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1)
				"Per diem" means financial assistance with expenses for a Medicaid recipient's
				meals and lodging enroute to and from, and while receiving medically necessary
				medical care.
(2) "Prior
				authorization" means the department or its designee's review and approval of
				the medical necessity and coverage of a service prior to delivery of the
				service.
(3) "Transportation
				service" means travel furnished by common carrier or private vehicle.
(a) Transportation service does not include
				ambulance services or specialized nonemergency medical transportation services
				for persons with disabilities.
(b)
				A motor carrier operated by the Indian Health Service or by a federally
				recognized Indian Tribe which meets all applicable standards for a class B
				public service commission license need not obtain such a license to be enrolled
				as a Medicaid provider under (3).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.24 - Transportation Services › Rule 37.86.2402 - TRANSPORTATION AND PER DIEM, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) These
				requirements are in addition to those rule provisions generally applicable to
				Medicaid providers.
(2) Coverage
				of transportation and per diem is limited to transportation and per diem
				necessary to obtain necessary medical services covered by the Medicaid
				program.
(3) Coverage for
				transportation and per diem is only available for transportation and per diem
				to the site of medical services at the provider closest to the locality of the
				recipient unless:
(a) The closest provider is
				determined based on equivalent licensure or certification from the appropriate
				national or state licensing board without consideration of continuing education
				credits or units.
(b) The closest
				provider is determined using providers who are currently accepting Medicaid
				recipients regardless of any individual client's:
(i) noncompliance with medical treatment
				plans;
(ii) financial or legal
				actions pending or filed against the provider; or
(iii) behavior (including but not limited to
				aggressive, inappropriate communication, failure to keep appointments or to
				arrive for appointments on time) that may have caused an individual not to be
				accepted as a patient in a particular practice.
(c) Transportation and per diem to a site,
				other than the one nearest to the locality of the recipient, is available if
				the combined total cost to the Medicaid program of medical services and
				transportation and per diem at the more distant site is less than the total
				cost to the Medicaid program for the provision of the services in the closest
				location, or to a Center of Excellence, as defined in ARM
				37.86.2901, if prior authorization
				requirements have been met.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.24 - Transportation Services › Rule 37.86.2405 - TRANSPORTATION AND PER DIEM, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1)
				The department pays the lower of the following reimbursement rates for
				transportation services:
(a) the provider's
				actual submitted charge; or
(b) the
				department's Personal and Commercial Transportation Fee Schedule adopted in
				this rule.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.25 - Specialized Nonemergency Medical Transportation › Rule 37.86.2501 - SPECIALIZED NONEMERGENCY MEDICAL TRANSPORTATION, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) Specialized nonemergency transportation
				means transportation service by a provider with a class B public service
				commission license allowing the provider to transport physically disabled
				individuals.
(a) A motor carrier operated by
				the Indian Health Service or by a federally recognized Indian Tribe which meets
				all applicable standards for a class B public service commission license need
				not obtain such a license to be enrolled as a Medicaid provider under
				(1).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.25 - Specialized Nonemergency Medical Transportation › Rule 37.86.2502 - SPECIALIZED NONEMERGENCY MEDICAL TRANSPORTATION, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) These requirements are in addition to
				those rule provisions generally applicable to Medicaid providers.
(2) Coverage of specialized nonemergency
				medical transportation is limited to transportation of persons with
				disabilities for the purpose of obtaining nonemergency medical services covered
				by the Medicaid program.
(a) The person must
				be in need of specialized transportation due to the person either being
				wheelchair-bound or subject to transport by stretcher.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.25 - Specialized Nonemergency Medical Transportation › Rule 37.86.2505 - SPECIALIZED NONEMERGENCY MEDICAL TRANSPORTATION, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) The department pays the lower of the
				following for specialized nonemergency medical transportation services:
(a) the provider's usual and customary
				charge; or
(b) the department's fee
				schedule.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.26 - Ambulance Services › Rule 37.86.2601 - AMBULANCE SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "Air
				ambulance services" means ambulance services provided by aircraft. There are
				two categories of air ambulance services, namely, fixed wing (airplane) and
				rotary wing (helicopter) aircraft.
(a) Fixed
				wing air ambulance services are furnished when the recipient's medical
				condition is such that transport by ground ambulance, in whole or in part, is
				not appropriate. Generally, transport by fixed wing air ambulance may be
				necessary because the recipient's condition requires rapid transport to a
				treatment facility, and either great distances or other obstacles, for example,
				heavy traffic, preclude such rapid delivery. Transport by fixed wing air
				ambulance may also be necessary because the recipient is inaccessible by land
				or water ambulance vehicle.
(b)
				Rotary wing air ambulance services are furnished when the recipient's medical
				condition is such that transport by ground ambulance, in whole or in part, is
				not appropriate. Generally, transport by rotary wing air ambulance may be
				necessary because the recipient's condition requires rapid transport to a
				treatment facility, and either great distances or other obstacles, for example,
				heavy traffic, preclude such rapid delivery. Transport by rotary wing air
				ambulance may also be necessary because the recipient is inaccessible by land
				or water ambulance vehicle.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.26 - Ambulance Services › Rule 37.86.2602 - AMBULANCE SERVICES, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) These
				requirements are in addition to those rule provisions generally applicable to
				Medicaid providers.
(2) Ambulance
				services must be provided by a licensed ambulance provider.
(3) Coverage of ambulance services is limited
				to transportation necessary to obtain medically necessary services from the
				nearest appropriate facility.
(4)
				Coverage for ambulance services is not available where transportation by a mode
				other than the ambulance could be utilized without endangering the patient's
				health, whether or not such other transportation is actually
				available.
(5) Ground ambulance
				service is covered when the patient's medical condition requires transportation
				by ambulance. The following are examples of circumstances which may be
				considered in determining the medical need for ground ambulance service.
				However, the presence or absence of any one or more of the following does not
				necessarily establish the medical need for the service:
(a) the patient is transported in an
				emergency situation, e.g., as a result of an accident or injury;
(b) the patient is unconscious or in
				shock;
(c) the patient requires
				oxygen as an emergency rather than a maintenance measure or requires other
				emergency treatment on the way to the destination;
(d) the patient has to remain immobile
				because of a fracture that has not been set or the possibility of a
				fracture;
(e) the patient sustains
				an acute stroke or myocardial infarction; or
(f) the patient is hemorrhaging.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.26 - Ambulance Services › Rule 37.86.2604 - AMBULANCE SERVICES, COVERAGE AND BILLABLE SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Except as provided in (2), the base
				charge specified in the department's fee schedule referred to in ARM
				37.86.2605 for both basic life
				support (BLS) and advanced life support (ALS) ambulance services includes
				charges for all personnel, reusable supplies and capital equipment. This
				includes:
(a) The driver and attendants,
				including extra attendants;
(b)
				Nurse, physician, or nonambulance personnel in ambulance;
(c) All services provided by the personnel
				such as:
(i) CPR and
				defibrillation;
(ii) monitoring of
				pulse oximeter;
(iii) monitoring of
				vital signs;
(iv) EKG
				monitoring;
(v) IV and drug
				therapy;
(vi) intubation;
				and
(vii) glucometer
				check.
(d) ALS
				director;
(e) Reusable supplies,
				including but not limited to:
(i) ambu bag
				(bag valve mask);
(ii) anti-shock
				trousers (mast pants/suits);
(iii)
				cervical collar (neck immobilization item), nondisposable;
(iv) CPR board;
(v) CPR pocket mask, nondisposable;
				and
(vi) splints,
				nondisposable.
(f)
				Capital equipment, including but not limited to:
(i) heart monitor;
(ii) defibrillator;
(iii) aspirator (see suction);
(iv) back board;
(v) pulse oximeter;
(vi) IV pumps;
(vii) special stretchers such as:
(A) scoop stretcher;
(B) plastic stretcher;
(C) spine board; and
(D) flat cot;
(viii) suction and suction
				equipment;
(ix)
				glucometer;
(x) compressor;
				and
(xi) nebulizer.
(g) Billing charges;
(h) Decontamination of ambulance;
(i) Emergency charge;
(j) Night charge;
(k) Transporting of portable EKG to facility
				or location; and
(l) Waiting
				time.