reglab/statecodes huggingface dataset:
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5020 - HEALTH MAINTENANCE ORGANIZATIONS: ACCESS TO SERVICES

Current through Register Vol. 13, July 5, 2024
(1) An enrollee must have the opportunity to
				choose a primary care provider to the extent possible and medically appropriate
				from any of the participating primary care providers in the enrollee's HMO. The
				HMO may assign an enrollee to a primary care provider when an enrollee fails to
				chose one after being notified to do so. The assignment must be appropriate to
				the enrollee's age, sex and residence. The HMO may limit an enrollee's ability
				to change primary care providers without cause.
(2) An HMO must have in effect the following
				arrangements which provide for adequate after hours call-in coverage by
				participating providers:
(a) An after hours
				call-in must include 24-hour-a-day phone coverage;
(b) If a medical provider is unavailable to
				answer the initial telephone call, there must be a written protocol specifying
				when the answering party must consult a medical provider;
(c) Calls requiring a medical decision must
				be forwarded to the on-call medical provider;
(d) A response to each call which requires a
				medical decision must be provided by the medical provider within 60
				minutes.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5025 - HEALTH MAINTENANCE ORGANIZATIONS: GRIEVANCE PROCEDURES

Current through Register Vol. 13, July 5, 2024
(1) An enrollee has the right of appeal as
				provided at ARM
				37.5.304,
				37.5.305,
				37.5.307,
				37.5.310,
				37.5.311,
				37.5.313,
				37.5.316,
				37.5.318,
				37.5.322,
				37.5.325,
				37.5.328,
				37.5.331,
				37.5.334 and
				37.5.337.
(2) An HMO must have a written procedure,
				approved in writing by the department prior to implementation, for resolution
				of grievances brought by enrollees either individually or as a class. Except as
				noted below, the HMO's grievance procedure must provide for resolution of a
				grievance within 45 days of receipt of the grievance. Resolution may be
				extended beyond 45 days only with the written approval of the department. In a
				situation requiring urgent care or emergency care, the department may require
				the HMO to expedite resolution.
(3)
				An enrollee must exhaust the HMO's grievance procedure before appeal of the
				matter may be made to the department under the provisions of ARM 37.5.304,
				37.5.305, 37.5.307, 37.5.310, 37.5.311, 37.5.313, 37.5.316, 37.5.318, 37.5.322,
				37.5.325, 37.5.328, 37.5.331, 37.5.334 and 37.5.337.
(4) For purposes of ARM
				37.5.307(1) (c),
				the 90 day appeal period starts on the day the enrollee files a grievance with
				the HMO.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-2-201,
					 53-6-101,
					 53-6-113
					 and
					 53-6-116,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5026 - HEALTH MAINTENANCE ORGANIZATIONS: RECORDS AND CONFIDENTIALITY

Current through Register Vol. 13, July 5, 2024
(1) An HMO must comply with the provisions of
				ARM 37.86.414 regarding maintenance and retention of medical and fiscal
				records.
(2) An HMO must submit
				reports and maintain records as required in the contract with the
				department.
(3) An HMO must have in
				effect arrangements to provide for an adequate medical record-keeping system
				which includes a complete medical record for each enrollee in accordance with
				provisions set forth in the contract. The complete medical record may be
				maintained by an HMO's participating provider.
(4) HMOS, participating providers, and the
				department are subject to the disclosure requirements of Title 50, chapter 16,
				MCA, and
				33-19-306,
				MCA.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-2-201,
					 53-6-101,
					 53-6-113
					 and
					 53-6-116,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5027 - HEALTH MAINTENANCE ORGANIZATIONS: RECIPIENT EDUCATION

Current through Register Vol. 13, July 5, 2024
(1) An HMO must have written instructions for
				enrollees in the use of all services provided. The policy must include, but is
				not limited to, written information on service restrictions and limitations
				regarding appropriate use of the referral system, grievance procedure, after
				hours call-in system, provisions for emergency treatment, how the enrollee may
				obtain services that are the responsibility of the HMO under ARM
				37.86.5007 and the contract
				between the HMO and the department but which are not available through the HMO
				due to religious objections and how to request a list of the HMO's
				participating providers.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-2-201,
					 53-6-101,
					 53-6-113
					 and
					 53-6-116,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5035 - HEALTH MAINTENANCE ORGANIZATIONS: QUALITY ASSURANCE

Current through Register Vol. 13, July 5, 2024
(1) An HMO must have in effect an internal
				quality assurance system as specified in the contract.
(2) An internal quality assurance system must
				meet the requirements of 42 CFR 434.34. The department hereby adopts and
				incorporates by reference 42 CFR 434.34, dated October 1998.
(a) Copies of 42 CFR 434.34 may be obtained
				through the Department of Public Health and Human Services, Health Policy and
				Services 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 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5036 - HEALTH MAINTENANCE ORGANIZATIONS: THIRD PARTY

Current through Register Vol. 13, July 5, 2024
(1) The HMO is responsible for investigating
				third party resources and seeking payment from these sources.
(2) The HMO may retain all funds collected
				from third party resources.
(3) A
				complete record of all payments received from third party sources must be
				maintained and reported as required in the contract.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-2-201,
					 53-6-101,
					 53-6-113
					 and
					 53-6-116,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.51 - Passport to Health Program › Rule 37.86.5101 - PASSPORT TO HEALTH PROGRAM: AUTHORITY

Current through Register Vol. 13, July 5, 2024
(1)
				The department has been granted by the United States Department of Health and
				Human Services (HHS), as provided in
				42 U.S.C.
				1396 n(b), the authority to establish a
				primary care case management program for Medicaid members.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-6-116,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.51 - Passport to Health Program › Rule 37.86.5102 - PASSPORT TO HEALTH PROGRAM: DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1)
				"Case management" means directing and overseeing the delivery of certain
				services to an enrollee.
(2)
				"Clinic" means a federally qualified health center, a rural health clinic, an
				Indian health service clinic on a reservation, or any other clinic as defined
				in ARM
				37.86.1401
				which can meet the requirements of ARM
				37.86.5111.
(3) "Emergency service" means, as
				defined at ARM
				37.82.102(11),
				inpatient and outpatient services that are necessary to treat an emergency
				medical condition.
(4) "Emergency
				medical condition" means a medical condition manifesting itself by acute
				symptoms of sufficient severity (including severe pain) such that a prudent
				layperson, who possesses an average knowledge of health and medicine, could
				reasonably expect the absence of immediate medical attention to result in:
(a) placing the health of the individual (or,
				with respect to a pregnant woman, the health of the woman or her unborn child)
				in serious jeopardy;
(b) serious
				impairment to bodily functions; or
(c) serious dysfunction of any bodily organ
				or part.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.51 - Passport to Health Program › Rule 37.86.5103 - PASSPORT TO HEALTH PROGRAM: ELIGIBILITY

Current through Register Vol. 13, July 5, 2024
(1)
				The department may require a Medicaid member to enroll and participate in the
				Passport to Health Program, unless exempted from or ineligible for
				participation as defined by ARM
				37.86.5102(7) or
				(8).
(2) At the department's discretion, Medicaid
				members who are exempted from participation, as defined in ARM
				37.86.5102(7),
				may elect to enroll in the Passport to Health Program by choosing a primary
				care provider unless the member is ineligible.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-6-113,
					 53-6-116,
					 53-6-117,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.51 - Passport to Health Program › Rule 37.86.5104 - PASSPORT TO HEALTH PROGRAM: ENROLLMENT IN THE PROGRAM

Current through Register Vol. 13, July 5, 2024
(1) The department will notify a Medicaid
				member required by ARM
				37.86.5103 to enroll in the
				program that the member must enroll in the program.
(2) The member required to enroll in the
				program must select a primary care provider within 45 days of being notified of
				the enrollment requirement. For Team Care Program members, enrollment with a
				provider will be as required at ARM
				37.86.5303.
(3) If the member does not choose a provider
				within 45 days of the notification, the department will designate a primary
				care provider for the member. For Team Care Program members, enrollment with a
				provider will be as required in ARM 37.86.5303.
(4) An enrollee may choose a new primary care
				provider up to once per month. For Team Care Program members, a change of
				provider may be made in accordance with ARM 37.86.5303. The frequency of a
				member's request to change providers will be monitored by the
				department.
(5) Each enrollee in a
				household may choose a different primary care provider.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-6-113,
					 53-6-116,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.51 - Passport to Health Program › Rule 37.86.5111 - PASSPORT TO HEALTH PROGRAM: PRIMARY CARE PROVIDERS REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) A primary care provider must meet the
				following requirements:
(a) enroll as a
				Medicaid provider;
(b) provide
				primary care;
(c) sign a Passport
				agreement for primary care case management; and
(d) keep a paper or electronic log,
				spreadsheet, or other record of all Passport referrals given and
				received.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.51 - Passport to Health Program › Rule 37.86.5112 - PASSPORT TO HEALTH PROGRAM: REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Reimbursement for primary care case
				management services is as follows:
(a) $3.00
				per enrollee per month for individuals categorically eligible for Aged, Blind,
				Disabled and Medically Frail Medicaid; or
(b) $1.00 per enrollee per month for all
				others who are members of Passport eligible populations.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.51 - Passport to Health Program › Rule 37.86.5120 - PASSPORT TO HEALTH PROGRAM: FAIR HEARING

Current through Register Vol. 13, July 5, 2024
(1)
				An enrollee or a provider has the right to appeal an adverse action in
				accordance with ARM
				37.5.304,
				37.5.305,
				37.5.307,
				37.5.310,
				37.5.311,
				37.5.313,
				37.5.316,
				37.5.318,
				37.5.322,
				37.5.325,
				37.5.328,
				37.5.331,
				37.5.334 and
				37.5.337.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-116,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.52 - Health Improvement Program › Rule 37.86.5201 - HEALTH IMPROVEMENT PROGRAM: DEFINITIONS (Repealed)

Current through Register Vol. 13, July 5, 2024
AUTH:
					 53-6-101,
					 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 37.86.52 - Health Improvement Program › Rule 37.86.5202 - HEALTH IMPROVEMENT PROGRAM: GENERAL (Repealed)

Current through Register Vol. 13, July 5, 2024
AUTH:
					 53-6-101,
					 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 37.86.52 - Health Improvement Program › Rule 37.86.5204 - CRITERIA FOR DETERMINING MEDICAID AND HEALTHY MONTANA KIDS PLUS (HMK PLUS) ELIGIBLE INDIVIDUALS MANAGED UNDER THE HEALTH IMPROVEMENT PROGRAM

Current through Register Vol. 13, July 5, 2024
AUTH:
					 53-6-101,
					 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 37.86.52 - Health Improvement Program › Rule 37.86.5205 - HEALTH IMPROVEMENT PROGRAM: CLIENT ELIGIBILITY AND ASSIGNMENT (Repealed)

Current through Register Vol. 13, July 5, 2024
AUTH:
					 53-6-101,
					 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 37.86.52 - Health Improvement Program › Rule 37.86.5206 - HEALTH IMPROVEMENT PROGRAM: SCOPE OF SERVICES AND REIMBURSEMENT (Repealed)

Current through Register Vol. 13, July 5, 2024
AUTH:
					 53-6-101,
					 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 37.86.53 - Passport to Health Team Care Program › Rule 37.86.5303 - PASSPORT TO HEALTH'S TEAM CARE PROGRAM

Current through Register Vol. 13, July 5, 2024
(1)
				A recipient may be subject to restrictions on, or prior approval for, physician
				related services, pharmacy services or any other services covered by the
				medicaid program if the department determines that the recipient's utilization
				of service is excessive, inappropriate, or fraudulent with respect to medical
				need.
(2) The restrictions
				described in (1) may be imposed if any of the following events occur:
(a) the recipient seeks medical services that
				are not medically necessary;
(b)
				there is multiple provider usage that results in the receipt of unnecessary
				services;
(c) there is repeated use
				of emergency rooms for routine medical services;
(d) there is unwarranted multiple pharmacy
				usage, indicated by the use of more than three pharmacies, that results in the
				receipt of unnecessary prescriptions;
(e) there is admission of or conviction for
				forgery of medicaid drug prescriptions by the recipient; or
(f) the recipient utilizes a medicaid card in
				any unlawful or fraudulent manner.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.53 - Passport to Health Team Care Program › Rule 37.86.5306 - TEAM CARE PROGRAM: REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1)
				Reimbursement for team care case management services is $6.00 a month for each
				enrollee.
(2) A provider may be
				reimbursed for team care case management for an enrollee for a month during
				which case management or medical care was not provided to the enrollee if the
				primary care provider is otherwise in compliance with the agreement with the
				program.
(3) Medicaid services
				authorized or provided by a primary care provider are reimbursed as provided in
				ARM Title 37, chapters 40, 82, 83, 85, 86 and 88.
(4) Services listed in ARM
				37.86.5110(1) 
				provided to enrollees are not reimbursable unless provided or authorized by an
				enrollee's primary care provider in accordance with these rules.
Sec.
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-104
					 and
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.54 - Preventive Services › Rule 37.86.5401 - PURPOSE

Current through Register Vol. 13, July 5, 2024
(1) The rules in this chapter implement
				Montana Medicaid diabetes and cardiovascular disease prevention services.
				Diabetes and cardiovascular disease prevention services are evidence-based to
				assist in preventing Medicaid eligible individuals from developing diabetes and
				cardiovascular disease.
53-2-201,
					 53-6-101,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.54 - Preventive Services › Rule 37.86.5402 - DEFINITIONS

Current through Register Vol. 13, July 5, 2024
For purposes of Montana Medicaid diabetes and cardiovascular
				  disease prevention services, the following definitions apply:
(1) "After core program" means six
				consecutive monthly sessions.
(2)
				"Core program" means 16 consecutive weekly sessions.
(3) "Eligible client" means Medicaid eligible
				individuals at high risk for developing diabetes or cardiovascular
				disease.
(4) "Eligible provider"
				means Medicaid providers with licensed and trained health care professionals on
				staff delivering standardized curriculum and reporting data to the Public
				Health and Safety Division of the Department of Public Health and Human
				Services.
(5) "Evidence-based
				intervention" means the group-based National Institutes of Health's Diabetes
				Prevention Program as adapted by the Public Health and Safety Division of the
				Department of Public Health and Human Services.
53-2-201,
					 53-6-101,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.54 - Preventive Services › Rule 37.86.5403 - DIABETES AND CARDIOVASCULAR DISEASE PREVENTION SERVICES GENERAL

Current through Register Vol. 13, July 5, 2024
(1) Diabetes and cardiovascular disease
				prevention services include the following evidence-based intervention services:
(a) Group nutrition counseling to prevent
				diabetes and cardiovascular disease; and
(b) Physical activity coaching to prevent
				diabetes and cardiovascular disease.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.54 - Preventive Services › Rule 37.86.5404 - DIABETES AND CARDIOVASCULAR DISEASE PREVENTION SERVICES REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Reimbursement for diabetes and
				cardiovascular disease prevention services to eligible providers is in
				accordance with fee-for-service fee schedules for appropriate provider types
				posted on the department's web site at www.mtmedicaid.org [File Link Not
				Available].
53-2-201,
					 53-6-101,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.1 - Definitions › Rule 37.87.102 - MENTAL HEALTH SERVICES (MHS) FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE (SED), DEFINITIONS

Current through Register Vol. 13, July 5, 2024
As used in this chapter, the following terms apply:
(1) "Licensed mental health center" means a
				mental health center licensed in accordance with ARM
				37.106.1906
				through
				37.106.1965.
(2) "Medically necessary service"
				for Medicaid is defined in ARM
				37.82.102.
(3) "Mental health professional" means one of
				the following practitioners:
(a)
				physician;
(b) licensed
				professional counselor;
(c)
				licensed psychologist;
(d) licensed
				clinical social worker;
(e)
				licensed marriage and family therapist; or
(f) advanced practice registered nurse, with
				a clinical specialty in psychiatric mental health nursing.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.3 - Serious Emotional Disturbance Criteria › Rule 37.87.303 - YOUTH MENTAL HEALTH SERVICES, SERIOUS EMOTIONAL DISTURBANCE CRITERIA (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 53-21-703,
					 MCA; IMP,
					 53-1-601,
					 53-1-602,
					 53-1-603,
					 53-2-201,
					 53-21-201,
					 53-21-202,
					 53-21-701,
					 53-21-702,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.7 - Mental Health Center Services for Youth With Serious Emotional Disturbance (SED) › Rule 37.87.701 - COMMUNITY-BASED PSYCHIATRIC REHABILITATION SUPPORT SERVICES (Repealed)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.7 - Mental Health Center Services for Youth With Serious Emotional Disturbance (SED) › Rule 37.87.702 - MENTAL HEALTH CENTER SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE (SED), DEFINITIONS

Current through Register Vol. 13, July 5, 2024
For purposes of this subchapter, the following definitions
				  apply:
(1) "Community-based
				psychiatric rehabilitation and support (CBPRS)" means rehabilitation services
				provided in home, school, and community settings for youth with serious
				emotional disturbance (SED) who are at risk of out of home or residential
				placement, or risk removal from current setting for youth under six years of
				age. CBPRS services are provided for a short period of time, generally 90 days
				or less, to improve or restore the youth's functioning in one or more of the
				impaired areas identified in the SED definition in ARM
				37.87.102.
				Services are provided by trained mental health personnel under the supervision
				of a licensed mental health professional and according to rehabilitation
				goals.
(2) "Comprehensive school
				and community treatment" is defined in the manual adopted and incorporated by
				reference in ARM
				37.87.903.
(3) "In-training mental health
				professional services" are services provided under the supervision of a
				licensed mental health professional by an individual who has completed all
				academic requirements for licensure as a psychologist, clinical social worker,
				licensed professional counselor, or licensed marriage and family therapist and
				is in the process of completing the supervised experience requirement for
				licensure, in accordance with ARM Title 24, chapters 189 and 219.
(4) "Licensed mental health center" is
				defined in ARM 37.87.102. For purposes of this subchapter the following
				provisions also apply:
(a) For a mental
				health center to be licensed, there are specific services that must be provided
				to its clients in accordance with ARM
				37.106.1906.
(b) A mental health center may
				provide other appropriate services with an endorsement by the department in
				accordance with ARM 37.106.1906.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.7 - Mental Health Center Services for Youth With Serious Emotional Disturbance (SED) › Rule 37.87.703 - MENTAL HEALTH CENTER SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE (SED), COVERED SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Mental health
				center services for youth with SED include:
(a) Community-Based Psychiatric
				Rehabilitation and Support (CBPRS) services as defined in ARM
				37.87.702.
(b) Comprehensive school and community
				treatment in accordance with ARM Title 37, chapter 87, subchapter 18.
(c) Youth day treatment services as defined
				in ARM 37.87.702.
(d) In-training
				mental health professional services as defined in ARM 37.87.702. Services are
				subject to the same requirements that apply to licensed mental health
				professionals.
(e) Outpatient
				therapy services provided according to an individualized treatment plan and
				such services must include:
(i) psychotherapy
				services provided in accordance with the current edition of the American
				Medical Association's Current Procedural Terminology, Professional Edition, and
				codes approved by the department. The department adopts and incorporates by
				reference this manual;
(ii) family
				therapy, provided with or without the youth present, directed at the eligible
				youth's mental health needs and their impact on the family dynamics;
				and
(iii) individual and family
				therapy are targeted at reducing or eliminating symptoms or behaviors related
				to a youth's mental health diagnosis as specified in the treatment
				plan.
(f) Targeted case
				management (TCM) services as defined in the manual adopted and incorporated by
				reference in ARM
				37.87.903.
(g) Mental health professional services,
				which include the professional component of physician or psychiatrist services
				covered in ARM
				37.86.101,
				37.86.104, and
				37.86.105. Mental health
				professional services are subject to the following limitations:
(i) To the extent otherwise permitted by
				applicable Medicaid rules, such mental health professional services may be
				billed either by the mental health center as mental health center services or
				by the mental health professional under the applicable Medicaid category of
				service, but may not be billed as both mental health center services and mental
				health professional services.
(ii)
				Mental health professional services may be covered and reimbursed by Medicaid
				only if the mental health professional is enrolled as a provider and the
				services are provided according to the Medicaid rules and requirements
				applicable to the mental health professional's category of service.
(h) Home support services (HSS)
				and therapeutic foster care (TFC) as defined in the manual adopted and
				incorporated by reference in ARM 37.87.903.
(i) Mental health intensive outpatient
				therapy (IOP) as defined in the manual adopted and incorporated by reference in
				ARM 37.87.903.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.7 - Mental Health Center Services for Youth With Serious Emotional Disturbance (SED) › Rule 37.87.705 - MENTAL HEALTH CENTER SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, NONCOVERED SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Mental health
				professional services, provided in a hospital on an inpatient basis, that are
				covered by Medicaid as part of the diagnosis related group (DRG) payment under
				ARM 37.86.2907 are not reimbursable as
				mental health center services. These noncovered services include:
(a) mental health professional services
				provided by mental health professionals who are staff members of a mental
				health center which has a contract with a hospital involving
				consideration;
(b) services
				provided for purposes of discharge planning as required by 42 CFR part 482.43;
				and
(c) services including but not
				limited to group therapy that are required as a part of hospital licensure or
				certification.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.7 - Mental Health Center Services for Youth With Serious Emotional Disturbance (SED) › Rule 37.87.723

Current through Register Vol. 13, July 5, 2024
AUTH:
					 53-2-201,
					 53-6-101,
					 53-6-113,
					 MCA; IMP:
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.7 - Mental Health Center Services for Youth With Serious Emotional Disturbance (SED) › Rule 37.87.733 - MENTAL HEALTH CENTER SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE (SED), REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Medicaid
				reimbursement for mental health center services shall be the lesser of:
(a) the provider's actual (submitted) charge
				for the service; or
(b) the rate
				established in the department's Medicaid fee schedule, as adopted in ARM
				37.85.105.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.8 - Targeted Case Management Services for Youth With Serious Emotional Disturbance › Rule 37.87.802 - TARGETED CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
As used in this chapter, the following terms apply:
(1) "Department" means the Department of
				Public Health and Human Services.
(2) "Natural supports" means relationships
				and supports that occur within the community in everyday life including but not
				limited to relationships with family members, friends, neighbors, and community
				acquaintances.
(3) "Targeted case
				management services (TCM)" means case management as defined in the manual
				adopted and incorporated by reference in ARM
				37.87.903.
(4) The definitions in ARM
				37.86.3301
				also apply when not inconsistent with this subchapter.
AUTH:
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 53-1-601,
					 53-1-602,
					 53-1-603,
					 53-2-201,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.8 - Targeted Case Management Services for Youth With Serious Emotional Disturbance › Rule 37.87.805 - TARGETED CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, ELIGIBILITY

Current through Register Vol. 13, July 5, 2024
(1) If otherwise
				eligible for Medicaid services, youth with SED may receive medically necessary
				targeted case management services in the community setting or when
				transitioning to a community setting as provided in this subchapter.
AUTH:
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 53-1-601,
					 53-1-602,
					 53-1-603,
					 53-2-201,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.8 - Targeted Case Management Services for Youth With Serious Emotional Disturbance › Rule 37.87.807 - TARGETED CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, COVERED SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Targeted case
				management services include:
(a) comprehensive
				assessment and periodic reassessment of an eligible youth and the youth's
				family or caregivers to determine the need for any medical, educational,
				social, or other services.
The assessment activities include the following:
(i) taking youth and the youth's family or
				caregivers history;
(ii)
				identifying the needs of the youth and the youth's family or caregivers, and
				completing related documentation; and
(iii) gathering necessary information from
				other sources, such as family members, medical providers, social workers, and
				educators to make a complete assessment of the eligible youth.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.8 - Targeted Case Management Services for Youth With Serious Emotional Disturbance › Rule 37.87.808 - TARGETED CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, AUTHORIZATION REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) Targeted case
				management services for youth with SED do not require prior authorization to be
				reimbursed.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-1-601,
					 53-1-602,
					 53-1-603,
					 53-2-201,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.8 - Targeted Case Management Services for Youth With Serious Emotional Disturbance › Rule 37.87.809 - TARGETED CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Targeted case
				management (TCM) services for youth with SED will be reimbursed on a fee per
				unit of service basis. For purposes of this rule, a unit of service is based on
				a 15-minute unit increment:
(a) one unit of
				service is equal to 8 minutes but less than 23 minutes;
(b) two units of service are greater than or
				equal to 23 minutes but less than 38 minutes;
(c) three units of service are greater than
				or equal to 38 minutes but less than 53 minutes;
(d) four units of service are greater than or
				equal to 53 minutes but less than 68 minutes;
(e) five units of service are greater than or
				equal to 68 minutes but less than 83 minutes;
(f) six units of service are greater than or
				equal to 83 minutes but less than 98 minutes;
(g) seven units of service are greater than
				or equal to 98 minutes but less than 113 minutes; and
(h) eight units of service are greater than
				or equal to 113 minutes but less than 128 minutes.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.8 - Targeted Case Management Services for Youth With Serious Emotional Disturbance › Rule 37.87.823 - TARGETED CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, PROVIDER REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) The
				requirements in this subchapter are in addition to those contained in
				provisions generally applicable to Medicaid providers.
(2) Targeted case management services for
				youth with SED must be provided by a licensed mental health center as defined
				in ARM
				37.87.102.
				A mental health center must:
(a) have a
				current license endorsement permitting the mental health center to provide
				targeted case management services; and
(b) be enrolled in the Montana Medicaid
				program as a targeted case management services provider.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.9 - Medicaid Mental Health Services for Youth › Rule 37.87.901 - MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Medicaid
				reimbursement for mental health services will be the lowest of:
(a) the provider's actual (submitted) charge
				for the service; or
(b) the rate
				established in the department's fee schedule. Reimbursement fees are as
				provided in ARM
				37.85.105(6).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.9 - Medicaid Mental Health Services for Youth › Rule 37.87.903 - MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, AUTHORIZATION REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) The department will not reimburse
				providers for two services that duplicate one another on the same
				day.
(2) The department will
				reimburse providers of Medicaid mental health youth services if they meet the
				prior authorization or continued stay review requirements specified in the
				Children's Mental Health Medicaid Services Provider Manual, referenced in
				(7).
(3) Youth are not required to
				have a serious emotional disturbance to receive the following outpatient
				therapy services:
(a) the first 24 sessions
				of individual, family, or both outpatient therapies per state fiscal year.
				Group outpatient therapy is not included in the 24-session limit; and
(b) group outpatient therapy.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.10 - Therapeutic Group Home › Rule 37.87.1011 - THERAPEUTIC GROUP HOME (TGH), PROVIDER REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) The requirements in this subchapter are
				in addition to those requirements contained in rules generally applicable to
				Medicaid providers.
(2) Therapeutic
				group home (TGH) services may be provided by an in-state facility which is
				licensed as a TGH by the department in accordance with the provisions of Title
				52, chapter 2, part 6, MCA, and found in ARM
				37.87.1011,
				37.87.1017, and the manual adopted
				and incorporated by reference in ARM
				37.87.903, or by an out-of-state
				facility similarly licensed in the state in which it operates.
(3) TGH services must be provided to a youth
				in accordance with an individualized treatment plan developed and maintained as
				specified by licensure requirements and this subchapter.
(4) In addition to the clinical records
				required by TGH licensure rules, the provider must maintain the records
				required by ARM
				37.85.414.
AUTH:
					 53-2-201,
					 53-6-113, MCA; IMP:
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.10 - Therapeutic Group Home › Rule 37.87.1013 - THERAPEUTIC GROUP HOME (TGH), REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) For the purpose of this subchapter, the
				following definitions apply:
(a) "Patient
				day" means a whole 24-hour period that a youth is present and receiving TGH
				services. Even though a youth may not be present for a whole 24-hour period,
				the day of admission is a patient day. The day of discharge is not a patient
				day.
(b) "Therapeutic intervention"
				is defined in ARM
				37.97.102(23).
(c) "Therapy" is defined in ARM
				37.97.102(26).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.10 - Therapeutic Group Home › Rule 37.87.1015 - THERAPEUTIC GROUP HOME (TGH), AUTHORIZATION REQUIREMENTS (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,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.10 - Therapeutic Group Home › Rule 37.87.1017 - THERAPEUTIC GROUP HOME (TGH), EXTRAORDINARY NEEDS AIDE (ENA) SERVICES, AND AUTHORIZATION REQUIREMENTS (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,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.10 - Therapeutic Group Home › Rule 37.87.1021 - THERAPEUTIC FAMILY CARE (TFC) AND THERAPEUTIC FOSTER CARE (TFOC) SERVICES REIMBURSEMENT (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,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.10 - Therapeutic Group Home › Rule 37.87.1023 - THERAPEUTIC FAMILY CARE (TFC) AND THERAPEUTIC FOSTER CARE (TFOC) SERVICES, AUTHORIZATION REQUIREMENTS AND COVERED 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,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.10 - Therapeutic Group Home › Rule 37.87.1025 - THERAPEUTIC FAMILY CARE (TFC) AND THERAPEUTIC FOSTER CARE (TFOC) SERVICES, DEFINITION OF PERMANENCY TFOC TREATAMENT (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,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.12 - Psychiatric Residential Treatment Facility Services › Rule 37.87.1201 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, PURPOSE

Current through Register Vol. 13, July 5, 2024
(1) The purpose of
				ARM Title 37, chapter 87, subchapter 12 is to specify provider participation
				and program requirements and to define the basis and procedure the department
				will use to pay for psychiatric residential treatment facility (PRTF)
				services.
(2) Facilities in which
				these services are available are referred to as providers.
AUTH:
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.12 - Psychiatric Residential Treatment Facility Services › Rule 37.87.1202 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
As used in this subchapter, the following definitions
				  apply:
(1) "Continuity of care payment"
				means an annual payment made to qualifying hospital-based psychiatric
				residential treatment facilities (PRTF) according to the eligibility criteria
				and payment calculation methodology in ARM
				37.87.1224.
(2) "Devoted to the provision of
				inpatient psychiatric care for persons under the age of 21" means an inpatient
				psychiatric hospital facility or residential treatment facility whose goals,
				purpose, and care are designed for and devoted exclusively to persons under the
				age of 21.
(3) "Hospital-based
				psychiatric residential treatment facility" means a residential treatment
				facility that meets the requirements of ARM
				37.87.1207.
(4) "Inpatient psychiatric
				services" means psychiatric residential treatment facility services, or
				hospital-based psychiatric residential treatment facility services.
(5) "Patient day" means a whole 24-hour
				period in which a person is present and receiving inpatient psychiatric
				services. Even though a person may not be present for a whole 24-hour period,
				the day of admission and, subject to the limitations and requirements of ARM
				37.87.1223,
				therapeutic home leave days are patient days. The day of discharge is not a
				patient day for purposes of reimbursement.
(6) "Psychiatric residential treatment
				facility (PRTF)" is defined in the Children's Mental Health Bureau Medicaid
				Services Provider Manual, adopted and incorporated by reference in ARM
				37.87.903.
(7) "Therapeutic Home Visit (THV)" is defined
				in the Children's Mental Health Bureau Medicaid Services Provider Manual,
				adopted and incorporated by reference in ARM 37.87.903.
AUTH:
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.87 - CHILDREN'S MENTAL HEALTH SERVICES › Subchapter 37.87.12 - Psychiatric Residential Treatment Facility Services › Rule 37.87.1203 - PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES

Current through Register Vol. 13, July 5, 2024
(1) Inpatient
				psychiatric services are services that comply with the requirements of this
				subchapter and the applicable federal regulations and are provided in a
				psychiatric residential treatment facility (PRTF) that is devoted to the
				provision of inpatient psychiatric care for persons under the age of
				21.
(2)
									42 CFR
				440.160 and Title 42 CFR, part 441, subpart D
				provide federal definitions and federal PRTF program requirements. The
				department adopts and incorporates by reference
				42 CFR
				440.160(2010) and Title 42
				CFR, part 441, subpart D (2010). A copy of the regulations may be obtained
				through the Department of Public Health and Human Services, Developmental
				Services Division, 111 N. Sanders, P.O. Box 4210, Helena, MT 59620- 4210.
AUTH:
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 MCA