reglab/statecodes huggingface dataset:
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.311 - RATE ADJUSTMENT FOR COUNTY FUNDED RURAL NURSING FACILITIES

Current through Register Vol. 13, July 5, 2024
(1) For each state fiscal year, the
				department will provide a mechanism for a one time, lump sum payment to
				nonstate government owned or operated facilities for Medicaid services
				according to the methodology specified in this rule. These payments will be for
				the purpose of maintaining access and viability for a class of "at risk" county
				affiliated facilities who are predominately rural and are the only nursing
				facility in their community or county or who provide a significant share of
				nursing facility services in their community or county.
(2) A nursing facility is eligible to
				participate in this lump sum payment distribution if it is a nonstate
				government owned or operated facility that has provided Medicaid services in
				the current state fiscal year.
(a) The
				department will calculate the amount of lump sum distribution that will be
				allowed for each county affiliated provider so that the total per day amount
				does not exceed the computed Medicare upper payment limit for these providers.
				Distribution of these lump sum payments will be based on the Medicaid
				utilization at each participating facility for the period July 1 of the
				previous year through June 30 of the current year.
(b) In order to qualify for this lump sum
				adjustment, each county on behalf of its non-state government owned or operated
				facility must enter into a written agreement to transfer local county funds to
				be used as matching funds by the department. This transfer option is voluntary,
				but those counties that agree to participate must abide by the terms of the
				written agreement.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.313 - OPERATING COST COMPONENT (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.314 - DIRECT NURSING PERSONNEL COST COMPONENT (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.315 - STAFFING AND REPORTING REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) Providers must
				provide staffing at levels which are adequate to meet federal law, regulations,
				and requirements.
(a) Each provider must
				submit to the department within ten days following the end of each calendar
				month a complete and accurate DPHHS-SLTC-015, "Monthly Nursing Home Staffing
				Report" prepared in accordance with all applicable department rules and
				instructions.
(b) If a complete
				and accurate DPHHS-SLTC-015 is not received by the department within ten days
				following the end of each calendar month, the department may withhold all
				payments for nursing facility services until the provider complies with the
				reporting requirements in (1)(a).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.321 - CORRECTION OF ERRONEOUS OR MISSING DATA

Current through Register Vol. 13, July 5, 2024
(1)
				The department will prepare and distribute resident listings to facilities by
				the 15th day of the third month of each quarter (cut off date). The listings
				will identify current assessments for residents in the nursing facility on the
				first day of the second month of each quarter as reflected in the database
				maintained by the department. The listings will identify resident social
				security numbers, names, assessment reference date, the calculated RUG-III
				category and the payor source. Resident listings shall be signed and returned
				to the department by the 15th day of the first month of the following calendar
				quarter. Facilities who do not return this corrected resident listing by the
				due date will use the database information on file in their case mix
				calculation.
(2) If data reported
				on the resident listings is in error or if there is missing data, facilities
				will have until the 15th day of the first month of each calendar quarter to
				correct data submissions.
(a) Errors or
				missing data on the resident listings due to untimely submissions to the CMS
				database maintained by the Department of Public Health and Human Services
				(DPHHS) are corrected by transmitting the appropriate assessments or tracking
				documents to DPHHS in accordance with CMS requirements.
(b) Errors in key field items are corrected
				following the CMS key field specifications through DPHHS.
(c) Errors on the current payor source should
				be noted on the resident listings prior to signing and returning to
				DPHHS.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.322 - OBRA NURSE AIDE TESTING AND TRAINING COST REPORTING

Current through Register Vol. 13, July 5, 2024
(1) Omnibus Budget Reconciliation Act of 1987
				(OBRA) costs will be reimbursed under the per diem rate determined under ARM
				37.40.307. No further
				reimbursement will be provided outside the per diem rate.
(2) Each provider must document and submit to
				the department on a quarterly basis information on the nurse aide certification
				training and competency evaluation (testing) costs, including but not limited
				to the costs of training for nurse aides and the costs of actual testing
				required for nurse aides, incurred at the facility and, in the case of
				competency evaluation (testing) costs for providers that are not testing
				entities, incurred in payment of a qualified testing entity's fee for
				competency evaluation (testing). The required information must be submitted
				quarterly on the nurse aide certification/training and competency evaluation
				(testing) survey reporting form provided by the department and must include the
				total dollars incurred in each of the categories of facility personnel,
				supplies and equipment, subcontracted services and testing fees. The reporting
				form must include a brief description of the items included in each of the four
				categories.
(a) Acceptable documentation will
				be any documentation that adequately supports the costs claimed on the
				reporting form and includes all records and documentation as defined in ARM
				37.40.346, such as invoices,
				contracts, canceled checks and time cards. This documentation is subject to
				desk review and audit in accordance with ARM 37.40.346. This documentation must
				be maintained by the facility for six years, three months from the date the
				form is filed with the department or until any dispute or litigation regarding
				the costs supported by such documentation is finally resolved, whichever is
				later.
(b) If a provider fails to
				submit the quarterly reporting form within 30 calendar days following the end
				of the quarter, the department may withhold reimbursement payments in
				accordance with ARM
				37.40.346(4) (c).
				All amounts so withheld will be payable to the provider upon submission of a
				complete and accurate nurse aide certification/training survey reporting
				form.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.323 - CALCULATED PROPERTY COST COMPONENT (REPEALED)

Current through Register Vol. 13, July 5, 2024
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 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.324 - GRANDFATHERED PROPERTY COST COMPONENT (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.325 - CHANGE IN PROVIDER DEFINED

Current through Register Vol. 13, July 5, 2024
(1) Except as
				provided in (2), a change in provider will be deemed to have occurred if the
				events described in any one of the following (1) (a) through (d) occurs:
(a) For sole proprietorship providers, a
				change in provider occurs where the entire sole proprietorship is sold to an
				unrelated party and a selling proprietor does not retain a right of control
				over the business.
(b) For
				partnership providers, a change in provider occurs where:
(i) a new partner acquires an interest in the
				partnership greater than 50%;
(ii)
				the new partner is not a related party to either a current partner or a former
				partner from whom the new partner acquired all or any portion of the new
				partner's interest; and
(iii) the
				current or former partners from whom the new partner acquires an interest do
				not retain a right of control over the partnership arising from the transferred
				interest.
(c) For
				corporation providers, a change in provider occurs where stock and the
				associated stockholder rights representing an interest of more than 50% in the
				provider's corporation is acquired by an unrelated party.
(d) For all providers, a change in provider
				occurs where an unrelated party acquires:
(i)
				the provider's title or interest in the nursing facility or a leasehold
				interest in the nursing facility; and
(ii) the right to control and manage the
				business of the nursing facility.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.326 - INTERIM PER DIEM RATES FOR NEWLY CONSTRUCTED FACILITIES AND NEW PROVIDERS

Current through Register Vol. 13, July 5, 2024
(1) This rule specifies the methodology the
				department will use to determine the interim per diem rate for in-state
				providers, other than ICF/IID providers, which as of July 1 of the rate year
				have not filed with the department a cost report covering a period of at least
				six months participation in the Medicaid program in a newly constructed
				facility or following a change in provider as defined in ARM
				37.40.325.
(a) Effective July 1, 2001, and thereafter,
				the rate paid to new providers that acquire or otherwise assume the operations
				of an existing nursing facility, that was participating in the Medicaid program
				prior to the transaction, will be paid the price-based reimbursement rate in
				effect for the prior owner/operator of the facility before the transaction as
				if no change in provider had occurred. These rates will be adjusted at the
				start of each state fiscal year in accordance with (1)(b).
(b) Effective July 1 2020, and thereafter,
				the rate paid to newly constructed facilities or to facilities participating in
				the Medicaid program for the first time will be the flat rate component
				specified under ARM
				37.40.307(2)(a)
				combined with the quality component specified under ARM
				37.40.307(2)(b).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.331 - ITEMS BILLABLE TO RESIDENTS

Current through Register Vol. 13, July 5, 2024
(1) The department
				will not pay a provider for any of the following items or services provided by
				a nursing facility to a resident. The provider may charge these items or
				services to the nursing facility resident:
(a) gifts purchased by residents;
(b) social events and entertainment outside
				the scope of the provider's activities program;
(c) cosmetics and grooming items and services
				in excess of those for which payment is made by Medicare or Medicaid;
(d) personal comfort items, including tobacco
				products and accessories, notions, novelties, and confections;
(e) personal dry cleaning;
(f) beauty shop services;
(g) television, radio and private telephone
				rental;
(h) less-than-effective
				drugs (exclusive of stock items) ;
(i) vitamins, multivitamins, vitamin
				supplements and calcium supplements;
(j) personal reading materials;
(k) personal clothing;
(l) flowers and plants;
(m) privately hired nurses or
				aides;
(n) specially prepared or
				alternative food requested instead of food generally prepared by facility;
				and
(o) the difference between the
				cost of items usually reimbursed under the per diem rate and the cost of
				specific items or brands requested by the resident which are different from
				that which the facility routinely stocks or provides (e.g., special lotion,
				powder, diapers) ;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.336 - REIMBURSEMENT FOR INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES

Current through Register Vol. 13, July 5, 2024
(1) For
				intermediate care facility services for individuals with intellectual
				disabilities provided in facilities located in the state of Montana, the
				Montana Medicaid program will pay a provider a per diem rate equal to the
				actual allowable cost incurred by the provider during the fiscal year,
				determined retrospectively in accordance with ARM
				37.40.345 and
				37.40.346, divided by the total
				patient days of service during the rate year, minus the amount of the Medicaid
				recipient's patient contribution, subject to the limits specified in (2)(a) and
				(b).
(2) Payments under (1) may not
				exceed the following limits:
(a) Final per
				diem payment rates for base years shall be as specified in (1) , without
				application of any further limit. Base years are even-numbered state fiscal
				years, i.e., state fiscal years 1994, 1996, and subsequent even-numbered years.
(b) Final per diem rates in
				non-base years are limited to the final per diem rate for the immediately
				preceding base year indexed from June 30 of the base year to June 30 of the
				rate year. The index is the final Medicare market basket index applicable to
				the non-base year. Non-base years are odd-numbered state fiscal years, i.e.,
				state fiscal years 1993, 1995 and subsequent odd-numbered years.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.337 - REIMBURSEMENT TO OUT-OF-STATE FACILITIES

Current through Register Vol. 13, July 5, 2024
(1)
				The department will reimburse nursing facilities located outside the state of
				Montana for nursing facility services and any other reimbursable services or
				supplies provided to eligible Montana Medicaid individuals at the Medicaid rate
				and upon the basis established by the Medicaid agency in the state in which the
				facility is located.
(2) The
				Montana Medicaid program will pay for nursing facility services or related
				supplies provided to eligible Montana Medicaid individuals in nursing
				facilities located outside the state of Montana only when one of the following
				conditions is met:
(a) because of a
				documented medical emergency, the resident's health would be endangered if he
				or she was to return to Montana for medical services;
(b) the services required are not provided in
				Montana;
(c) the required services
				and all related expenses are less costly than if the required services were
				provided in Montana;
(d) the
				recipient is a child in another state for whom Montana makes adoption
				assistance or foster care assistance payments; or
(e) the department determines that it is
				general practice for recipients in the resident's particular locality to use
				medical resources located in another state.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.338 - BED HOLD PAYMENTS

Current through Register Vol. 13, July 5, 2024
(1) Except as
				provided in (6) through (9) for therapeutic home visits, payment will be made
				to a provider for holding a bed for a resident only if:
(a) the provider's facility is full and has a
				current waiting list of potential residents during each such bed day claimed
				for reimbursement;
(b) the resident
				for whom the bed is held is temporarily receiving medical services outside the
				facility, except in another nursing facility, and is expected to return to the
				provider;
(c) the cost of holding
				the bed will evidently be less costly than the possible cost of extending the
				hospital stay until an appropriate long term care bed would otherwise become
				available; and
(d) the provider has
				received written approval from the department's senior and long term care
				division as provided in (4).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.339 - MEDICARE HOSPICE BENEFIT - REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) In accordance with section 9435(b) of the
				Omnibus Budget Reconciliation Act of 1986, Public Law 99-509, the department
				may not pay a nursing facility provider for services provided to an eligible
				Medicaid/Medicare individual who has elected the Medicare hospice benefit.
(a) This rule applies where the hospice
				provider and the nursing facility provider have made a written agreement under
				which the hospice provider agrees to provide professional management of the
				individual's hospice care and the nursing facility provider agrees to provide
				room and board to the individual.
(b) When this rule applies, the department
				will pay the hospice provider in accordance with the department's rules
				governing Medicaid reimbursement to hospice providers.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.345 - ALLOWABLE COSTS

Current through Register Vol. 13, July 5, 2024
(1) This rule
				applies for purposes of determining allowable costs for cost reporting periods
				beginning on or after July 1, 1991. Allowable costs for cost reporting periods
				beginning prior to July 1, 1991 will be determined in accordance with rules for
				allowable costs then in effect.
(2) For purposes of reporting and determining
				allowable costs, the department hereby adopts and incorporates herein by
				reference the Provider Reimbursement Manual (PRM-15) , published by the United
				States Department of Health and Human Services, Social Security Administration,
				which provides guidelines and policies to implement Medicare regulations and
				principles for determining the reasonable cost of provider services furnished
				under the Health Insurance for Aged Act of 1965, as amended. A copy of the
				PRM-15 may be obtained through the Department of Public Health and Human
				Services, Senior and Long Term Care Division, P.O. Box 4210, 111 N. Sanders,
				Helena, MT 59604-4210. Applicability of the PRM-15 is subject to the exceptions
				and limitations specified in this rule.
(a)
				The term "allowable costs" means costs which are allowable under the provisions
				of this subchapter and which are considered in determining the costs of
				providing Medicaid nursing facility services. The determination that a cost is
				an allowable cost does not require the department to reimburse the provider for
				that cost. Providers will be reimbursed only as specifically provided in these
				rules.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.346 - COST REPORTING, DESK REVIEW AND AUDIT

Current through Register Vol. 13, July 5, 2024
(1)
				Providers must use generally accepted accounting principles to record and
				report costs. The provider must, in preparing the cost report required under
				this rule, adjust such costs in accordance with ARM
				37.40.345 to determine allowable
				costs.
(2) Providers must use the
				accrual method of accounting, except that, for governmental institutions that
				operate on a cash method or a modified accrual method, such methods of
				accounting will be acceptable.
(3)
				Cost finding means the process of allocating and prorating the data derived
				from the accounts ordinarily kept by a provider to ascertain the provider's
				costs of the various services provided. In preparing cost reports, all
				providers must use the methods of cost finding described at
				42 CFR
				413.24 (1997), which the department hereby
				adopts and incorporates herein by reference.
				42 CFR
				413.24 is a federal regulation setting forth
				methods for allocating costs. A copy of the regulation may be obtained from the
				Department of Public Health and Human Services, Senior and Long Term Care
				Division, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210. Notwithstanding
				the above, distinctions between skilled nursing and nursing facility care need
				not be made in cost finding.
(4)
				All providers must report allowable costs based upon the provider's fiscal year
				and using the financial and statistical report forms designated and/or provided
				by the department. Reports must be complete and accurate. Incomplete reports or
				reports containing inconsistent data will be returned to the provider for
				correction.
(a) A provider must file its cost
				report:
(i) within 150 days after the end of
				its designated fiscal year;
(ii)
				within 150 days after the effective date of a change in provider as defined in
				ARM 37.40.325; or
(iii) for changes in providers occurring on
				or after July 1, 1993, within 150 days after six months participation in the
				Medicaid program for providers with an interim rate established under ARM
				37.40.326. Subsequent cost reports
				are to be filed in accordance with (4) (a) (i) above and subsequent cost
				reports shall not duplicate previous cost reporting periods.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.347 - COST SETTLEMENT PROCEDURES

Current through Register Vol. 13, July 5, 2024
(1) The department
				will notify the provider of any overpayment discovered. The provider may
				contact the department to seek an agreement providing for repayment of the full
				overpayment within 60 days of mailing of the overpayment notice.
(2) Unless, within 30 days of mailing of
				overpayment notice to the provider, the provider enters into an agreement with
				the department which provides for full repayment within 60 days of mailing of
				the overpayment notice, the department will immediately commence offsetting
				from rate payments so as to complete full recovery as soon as
				possible.
(3) The department may
				recover the full overpayment amount regardless of whether the provider disputes
				the department's determination of the overpayment in whole or in part. A
				request for administrative review or fair hearing does not entitle a provider
				to delay repayment of any overpayment determined by the department.
(4) The department will notify the provider
				of any underpayment discovered. In the event an underpayment has occurred, the
				department will reimburse the provider promptly following the department's
				determination of the amount of the underpayment.
(5) Court or administrative proceedings for
				collection of overpayment or underpayment must be commenced within five years
				following the due date of the original cost report or the date of receipt of a
				complete cost report whichever is later. In the case of a reimbursement or
				payment based on fraudulent information, recovery of overpayment may be
				undertaken at any time.
(6) The
				amount of any overpayment constitutes a debt due the department as of the date
				the department mails notice of overpayment to the provider. The department may
				recover the overpayment from any person, party, transferee, or fiduciary who
				has benefited from either the payment or from a transfer of assets.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.351 - THIRD PARTY PAYMENTS AND PAYMENT IN FULL

Current through Register Vol. 13, July 5, 2024
(1)
				Regardless of any other provision of these rules, a provider may not bill the
				Medicaid program for any patient day, item, service or other amount which could
				have been or could be paid by any other payer, including but not limited to a
				private or governmental insurer, or Medicare, regardless of whether the
				facility participates in such coverage or program. If the department finds that
				Medicaid has made payments in such an instance, retroactive collections may be
				made from the provider in accordance with ARM
				37.40.347.
(a) This rule does not apply to payment
				sources which by law are made secondary to Medicaid.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.352 - UTILIZATION REVIEW AND QUALITY OF CARE

Current through Register Vol. 13, July 5, 2024
(1) Upon admission
				and as frequently thereafter as the department may deem necessary, the
				department or its agents, in accordance with 42 CFR 456 subpart F (1997), may
				evaluate the necessity of nursing facility care for each Medicaid resident in
				an intermediate care facility for individuals with intellectual disabilities.
				42 CFR 456 subpart F contains federal regulations which specify utilization
				review criteria for intermediate care facilities. The department adopts and
				incorporates by reference 42 CFR 456(1997). A copy of these regulations may be
				obtained from the Department of Public Health and Human Services, Senior and
				Long Term Care Division, 111 N. Sanders, P.O. Box 4210, Helena, MT
				59604-4210.
AUTH:
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 53-6-142,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.3 - Reimbursement for Skilled Nursing and Intermediate Care Services › Rule 37.40.360 - LIEN AND ESTATE RECOVERY FUNDS FOR ONE-TIME EXPENDITURES (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 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.4 - Swing-beds › Rule 37.40.401 - SWING-BED HOSPITALS, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) A
				swing-bed hospital is a licensed hospital, critical access hospital (CAH) with
				swing-bed approval or licensed medical assistance facility which is
				medicare-certified to provide posthospital SNF care as defined in
				42 CFR
				409.20.
(2) Swing-bed hospital services are services
				provided in accordance with these rules by a swing-bed hospital which meets the
				swing-bed hospital participation requirements specified in these
				rules.
(3) "Swing-bed" means a bed
				approved pursuant to
				42 USC
				1395 tt to be used to provide either acute
				care or extended skilled nursing care to a patient.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113
					 and
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.4 - Swing-beds › Rule 37.40.405 - SWING-BED HOSPITALS, SPECIAL SERVICE REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) Before admitting a Medicaid recipient to
				a swing-bed, the swing-bed hospital must meet all of the following
				requirements:
(a) the hospital must obtain a
				preadmission screening to determine the level of care required by the patient's
				medical condition. Medicaid will not reimburse a provider for swing-bed
				hospital services provided to a Medicaid recipient admitted to a swing-bed
				unless the recipient meets the nursing facility level of care requirements
				specified in ARM
				37.40.202 and
				37.40.205. The swing-bed hospital
				must ensure that form DPHHS-SLTC-61, "screening notification", is completed by
				the department preadmission screening team to document the level of care
				determination.
(b) Except when a
				waiver is obtained under (4), the hospital must determine that no appropriate
				nursing facility bed is available to the Medicaid patient within a 25 mile
				radius of the swing-bed hospital. The hospital is required to maintain written
				documentation of inquiries to nursing facilities about the availability of a
				nursing facility bed and indicating that if a bed is not available, the
				hospital will provide swing-bed services to the patient. The swing-bed hospital
				is encouraged to enter into availability agreements with Medicaid-participating
				nursing facilities in its geographic region that require the nursing facility
				to notify the hospital of the availability of nursing facility beds and dates
				when beds will be available.
(i) For purposes
				of this rule, an "appropriate" nursing facility bed is a bed in a
				Medicaid-participating nursing facility which provides the level of care
				required by the recipient's medical condition.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.4 - Swing-beds › Rule 37.40.406 - SWING-BED HOSPITALS, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Montana
				medicaid will reimburse swing-bed hospitals as provided in this rule for
				swing-bed hospital services provided in accordance with all applicable
				swing-bed hospital service requirements specified in ARM
				37.40.401,
				37.40.402,
				37.40.405 and this rule and
				subject to all other applicable laws and regulations.
(2) For swing-bed hospital services, the
				Montana medicaid program will pay a provider a per diem rate as specified in
				(2) (a) for each medicaid patient day, plus additional reimbursement for
				separately billable items as provided in (2) (b) .
(a) The swing-bed hospital services per diem
				rate is the average medicaid per diem rate paid to nursing facilities under ARM
				37.40.307 for routine services
				furnished during the calendar year immediately previous to the year in which
				the swing-bed hospital services are provided. Nursing facility routine services
				are those services included in the definition of "nursing facility services"
				specified at ARM
				37.40.302.
(b) Separately billable items are those items
				specified in ARM
				37.40.330. Swing-bed hospital
				service providers will be reimbursed for separately billable items at the rates
				specified in ARM
				37.40.330 and subject to the
				requirements of ARM 37.40.330.
(c)
				The Montana medicaid program will not reimburse swing-bed hospital service
				providers for items billable to residents as specified in ARM
				37.40.331.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.4 - Swing-beds › Rule 37.40.408 - FACILITY POLICY REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) The facility
				must develop and implement written policies and procedures that prohibit
				mistreatment, neglect, and abuse of residents and misappropriation of resident
				property.
(2) The policies must
				provide that the facility will:
(a) not use
				verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary
				seclusion;
(b) not employ
				individuals who have been found guilty of abusing, neglecting, or mistreating
				residents by a court of law, or have had a finding entered into the nurse aide
				registry concerning abuse, neglect, mistreatment of residents or
				misappropriation of their property;
(c) report any knowledge it has of actions by
				a court of law against an employee, which would indicate unfitness for service
				as a nurse aide or other facility staff to the nurse aide registry maintained
				by the department of public health and human services;
(d) ensure that all alleged violations
				involving mistreatment, neglect, or abuse, including injuries of unknown
				source, and misappropriation of resident property are reported immediately to
				the administrator of the facility, the long term care ombudsman, and the
				department of public health and human services in accordance with
				52-3-811,
				MCA;
(e) have evidence that all
				alleged violations are thoroughly investigated, and must prevent further
				potential abuse while the investigation is in progress;
(f) ensure that the results of all
				investigations must be reported to the administrator of the facility and to the
				department of public health and human services in accordance with
				52-3-811, MCA,
				within five working days of the incident; and
(g) if the alleged violation is verified,
				take appropriate corrective action.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.4 - Swing-beds › Rule 37.40.409 - SPECIALIZED REHABILITATIVE SERVICES

Current through Register Vol. 13, July 5, 2024
(1) If
				specialized rehabilitative services such as but not limited to physical
				therapy, speech-language pathology, occupational therapy, and mental health
				rehabilitative services for mental illness and mental retardation are required
				in the resident's comprehensive plan of care, the facility must provide the
				required services, or obtain the required services from an outside resource
				from a provider of specialized rehabilitative services.
(a) Specialized rehabilitative services must
				be provided under the written order of a physician by qualified
				personnel.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.4 - Swing-beds › Rule 37.40.412 - RESIDENT ACTIVITIES PROGRAM

Current through Register Vol. 13, July 5, 2024
(1) The
				facility must provide for an ongoing program of activities designed to meet the
				interests and the physical, mental, and psychosocial well being of each
				resident.
(2) The activities
				program must be directed by a qualified professional who:
(a) is a qualified therapeutic recreation
				specialist or an activities professional who is licensed or registered and is
				eligible for certification as a therapeutic recreation specialist or as an
				activities professional by a recognized accrediting body on or after October 1,
				1990;
(b) has two years of
				experience in a social or recreational program within the last five years, one
				of which was full-time in a patient activities program in a health care
				setting;
(c) is a qualified
				occupational therapist or occupational therapy assistant; or
(d) has completed a training course approved
				by the state.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.4 - Swing-beds › Rule 37.40.416 - RESIDENT RIGHTS

Current through Register Vol. 13, July 5, 2024
(1) The swing-bed
				hospital must be in substantial compliance with the requirements set forth in
				this rule pertaining to resident rights.
(2) A provider must protect and promote the
				rights of each resident, including each of the following rights:
(a) The resident has a right to a dignified
				existence, self-determination, and communication with and access to persons and
				services inside and outside the provider's facility.
(b) The resident has the right to be fully
				informed of the resident's total health status, including but not limited to
				medical condition, in language that the resident can understand.
(c) The resident has the right to refuse
				treatment, to refuse to participate in experimental research, and to formulate
				an advance directive as specified in
				42 CFR 483.10 (b)
				(8). The department adopts and incorporates by reference
				42 CFR 483.10 (b)
				(8). A copy of
				42 CFR 483.10 (b)
				(8) may be obtained from the Department of Public Health and Human Services,
				Senior and Long Term Care Division, 111 N. Sanders, PO Box 4210, Helena, MT
				59604-4210.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.4 - Swing-beds › Rule 37.40.420 - RESIDENT TRANSFER AND DISCHARGE RIGHTS

Current through Register Vol. 13, July 5, 2024
(1) The resident
				has the following transfer and discharge rights. Transfer and discharge
				includes movement of a resident to a bed outside of the swing-bed hospital
				facility whether or not that bed is in the same physical plant. Transfer and
				discharge does not refer to movement of a resident to a bed within the same
				certified facility.
(2) The
				facility must permit each resident to remain in the facility and may not
				transfer or discharge the resident from the facility unless any one or more of
				the following apply:
(a) the transfer or
				discharge is necessary for the resident's welfare and the resident's needs
				cannot be met in the facility;
(b)
				the transfer or discharge is appropriate because the resident's health has
				improved sufficiently so the resident no longer needs the services provided by
				the facility;
(c) the safety of
				individuals in the facility is endangered;
(d) the health of individuals in the facility
				would otherwise be endangered;
(e)
				the resident has failed, after reasonable and appropriate notice, to pay for
				(or to have paid under medicare or medicaid) a stay at the facility. For a
				resident who becomes eligible for medicaid after admission to a facility, the
				facility may charge a resident only allowable charges under medicaid;
(f) the facility ceases to
				operate; or
(g) an appropriate
				nursing facility bed is available within a 25 mile radius of the swing-bed
				hospital, as provided in ARM
				37.40.405.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.4 - Swing-beds › Rule 37.40.421 - RESIDENT POST DISCHARGE RIGHTS

Current through Register Vol. 13, July 5, 2024
(1) When the
				facility anticipates discharge, a resident must have a discharge summary that
				includes:
(a) a recapitulation of the
				resident's stay;
(b) a final
				summary of the resident's status which includes:
(i) medically defined conditions and prior
				medical history;
(ii) medical
				status measurement;
(iii) physical
				and mental functional status;
(iv)
				sensory and physical impairments;
(v) nutritional status and
				requirements;
(vi) special
				treatments or procedures;
(vii)
				mental and psychosocial status;
(viii) discharge potential;
(ix) dental condition;
(x) activities potential;
(xi) cognitive status;
(xii) drug therapy; and
(c) a post discharge plan of care that is
				developed with the participation of the resident and family, which will assist
				the resident to adjust to the new living environment.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.7 - Home Health Services › Rule 37.40.701 - HOME HEALTH SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1)
				"Home health agency" means an entity licensed by the Montana Department of
				Public Health and Human Services, certified by Medicare, and enrolled as a
				Medicaid provider.
(2) "Home health
				aide services" means services of an appropriately trained individual to assist
				with routine care not requiring specialized nursing skills and supervised by a
				licensed registered nurse .
(3)
				"Home health services" means services provided by a home health agency to a
				member, on a part-time or intermittent basis for the purposes of postponing or
				preventing institutionalization.
(a) Home
				health services include:
(i) skilled nursing
				services;
(ii) home health aide
				services;
(iii) physical therapy
				services;
(iv) occupational therapy
				services
(v) speech therapy
				services;
(vi) disposable medical
				supplies for the purposes of the visit; and
(vii) medical supplies , equipment, and
				appliances suitable for use in any setting in which normal life activities take
				place and as provided in ARM
				37.86.1801.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.7 - Home Health Services › Rule 37.40.702 - HOME HEALTH 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) A home health agency must be:
(a) licensed by the Montana department of
				public health and human services;
(b) medicare certified; and
(c) an enrolled medicaid provider.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.7 - Home Health Services › Rule 37.40.705 - HOME HEALTH SERVICES, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1)
				Reimbursement fees for home health services are as referenced in ARM
				37.85.105(4).
(2) Home health services reimbursement
				includes the following services:
(a) nursing
				or therapy service;
(b) home
				health aide visit; and
(c) medical
				supplies, equipment, and appliances suitable for use in any setting in which
				normal life activities take place .
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.8 - Hospice › Rule 37.40.801 - HOSPICE, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "Department"
				means the Montana Department of Public Health and Human Services.
(2) Except for the definition of "physician,"
				the definitions of terms defined under
				42
				CFR 418.3 apply for purposes of this
				subchapter.
(3) "Physician" means
				an individual licensed under the state medical practice act to practice
				medicine or osteopathy.
AUTH:
					 53-6-113,
					 MCA; IMP:
					 53-6-101,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.8 - Hospice › Rule 37.40.802 - ADOPTION AND INCORPORATION BY REFERENCE

Current through Register Vol. 13, July 5, 2024
(1)
				For purposes of this subchapter, the department adopts and incorporates by
				reference the following sections of the Code of Federal Regulations (CFR) that
				are in effect as of October 1, 2022:
(a)
										42 CFR
				418.3, which sets forth definitions of
				terms.
(b)
										42 CFR
				418.20 through
				418.30, which set forth Medicare
				hospice care eligibility, election, and duration of benefits.
(c)
										42 CFR
				418.52 through
				418.116, which set forth Medicare
				conditions of participation for hospice programs.
(d)
										42 CFR
				418.200 through
				418.205, which set forth Medicare
				coverage of hospice services.
(e)
										42 CFR
				418.301 through
				418.312, which set forth Medicare
				hospice care payment procedures.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.40 - SENIOR AND LONG TERM CARE SERVICES › Subchapter 37.40.8 - Hospice › Rule 37.40.805 - HOSPICE, CONDITIONS OF PARTICIPATION

Current through Register Vol. 13, July 5, 2024
(1)
				The hospice must be licensed under state law and must meet Medicare's
				conditions of participation for hospice programs and have a valid provider
				agreement with Medicare as conditions of enrollment in Medicaid. Medicare
				conditions of participation for hospice programs are set forth under
				42 CFR
				418.52 through
				418.116.
(2) The above requirements are in addition to
				those contained in ARM
				37.82.102,
				37.85.401,
				37.85.402,
				37.85.406,
				37.85.407,
				37.85.410,
				and
				37.85.414.
(3) The hospice must submit a physician
				listing with their provider application and update changes in the listing of
				the physicians who are hospice employees, including physician
				volunteers.
(4) The designated
				hospice must notify the department when the designated attending physician of a
				beneficiary in their care is not a hospice employee.
AUTH:
					 53-6-113,
					 MCA; IMP:
					 53-6-101,
					 MCA