reglab/statecodes huggingface dataset:
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.13 - Eligibility Requirements for the Institutionalized Categorically Needy and Medically Needy › Rule 37.82.1323 through 37.82.1329 - Reserved

Current through Register Vol. 13, July 5, 2024
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.13 - Eligibility Requirements for the Institutionalized Categorically Needy and Medically Needy › Rule 37.82.1330 - INSTITUTIONALIZED SPOUSE, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) The
				following definitions apply with respect to ARM
				37.82.1320,
				37.82.1321,
				37.82.1330,
				37.82.1331, and
				37.82.1336 through
				37.82.1338.
(a) "Community spouse" is the member of the
				married couple who continues to reside in the community after the
				institutionalization of the other spouse.
(b) "Community spouse resource allowance"
				means the amount of the couple's combined countable resources which are
				transferrable to the community spouse, as determined under ARM
				37.82.1336.
(c) "Continuous period
				of institutionalization" means at least 30 consecutive days of
				institutionalization without a break in care.
(d) "Countable resources" are those resources
				defined as countable in ARM
				37.82.903(2).
(e) "Dependent" means only minor or dependent
				children, dependent parents, or dependent siblings of the institutionalized or
				community spouse who are residing with the community spouse and are recognized
				as dependents for federal income tax purposes.
(f) "Institutionalization" means admission to
				a medical institution.
(g)
				"Institutionalized spouse" means an individual who:
(i) is in a medical institution or nursing
				facility;
(ii) is married to a
				spouse who is not in a medical institution or nursing facility; and
(iii) is likely to meet conditions (i) and
				(ii) of this definition for at least 30 consecutive days.
(h) "Medical institution" means an
				institution organized to provide medical care and includes, but is not limited
				to, hospitals and nursing facilities.
(i) "Shelter expenses" means the following
				expenses for the community spouse's principal residence:
(i) the monthly amount of rent or mortgage
				payment, including principal and interest;
(ii) real estate taxes on the community
				spouse's principal residence;
(iii)
				homeowners insurance on the community spouse's principal residence;
(iv) any required condominium or cooperative
				maintenance charge on the community spouse's principal residence; and
(v) a monthly standard utility allowance
				(SUA) available only to households which incur central heating or central
				cooling costs separate from rent or mortgage. The SUA shall be $225 and
				includes the cost of heating or cooling, water, sewerage, garbage and trash
				collections, cooking fuel, electricity not used to heat or cool the residence,
				and the basic service fee for a telephone.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.13 - Eligibility Requirements for the Institutionalized Categorically Needy and Medically Needy › Rule 37.82.1331 - INSTITUTIONALIZED SPOUSE, RESOURCE ASSESSMENTS

Current through Register Vol. 13, July 5, 2024
(1)
				A resource assessment is available to any married individual who:
(a) entered a medical institution on or after
				October 1, 1989;
(b) is likely to
				remain in the institution for at least 30 consecutive days; and
(c) has a spouse who continues to reside in
				the community.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.13 - Eligibility Requirements for the Institutionalized Categorically Needy and Medically Needy › Rule 37.82.1332 through 37.82.1335 - Reserved

Current through Register Vol. 13, July 5, 2024
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.13 - Eligibility Requirements for the Institutionalized Categorically Needy and Medically Needy › Rule 37.82.1336 - INSTITUTIONALIZED SPOUSE, RESOURCE ELIGIBILITY DETERMINATION

Current through Register Vol. 13, July 5, 2024
(1) The institutionalized spouse is resource
				eligible when the institutionalized spouse and community spouse's combined
				countable resources are less than or equal to the community spouse's resource
				allowance in (2) plus the supplemental security income (SSI) resource
				limitation for one person as defined in ARM
				37.82.1110.
(2) The community spouse resource allowance
				is the greatest of the following:
(a)
				one-half, but no more than $60,000, of the couple's combined countable
				resources. Effective January 1 of each calendar year after 1989, the $60,000
				limit shall increase by the same percentage increase in the consumer price
				index as adopted by the federal government for all urban consumers which
				occurred between September 1988 and the September before the calendar year
				involved;
(b) Montana's standard
				community spouse resource allowance of $12,000. Effective January 1 of each
				calendar year after 1989, the $12,000 limit shall increase by the same
				percentage increase in the consumer price index as adopted by the federal
				government for all urban consumers which occurred between September 1988 and
				the September before the calendar year involved;
(c) an amount established under a court
				order; or
(d) an amount designated
				by a department hearings officer.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.13 - Eligibility Requirements for the Institutionalized Categorically Needy and Medically Needy › Rule 37.82.1337 - INSTITUTIONALIZED SPOUSE, RECEIPT OF ADDITIONAL RESOURCES

Current through Register Vol. 13, July 5, 2024
(1) When additional resources are received by
				an institutionalized spouse after the initial eligibility determination and
				receipt of such resources would cause ineligibility for the institutionalized
				spouse, the resources will be exempt as countable resources for 90 days from
				receipt if:
(a) the institutionalized spouse
				intends to transfer the new resources to the community spouse;
(b) receipt of the additional resources is
				reported within ten days of receipt; and
(c) a written statement of the intent to
				transfer the resources to the community spouse is made by the institutionalized
				spouse.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.13 - Eligibility Requirements for the Institutionalized Categorically Needy and Medically Needy › Rule 37.82.1338 - INSTITUTIONALIZED SPOUSE, TRANSFER OF RESOURCES TO COMMUNITY SPOUSE

Current through Register Vol. 13, July 5, 2024
(1) Within 90 days of the initial eligibility
				determination or court order, or within any time period specifically required
				under the court order, an institutionalized spouse must irrevocably transfer
				resources:
(a) to or for the sole benefit of
				the community spouse resources which constitute the community spouse's resource
				allowance; or
(b) to or for the
				sole benefit of the community spouse or a family member, if such transfer is
				pursuant to a court order.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.2 - Eligibility Requirements for Qualified Medicare Beneficiaries › Rule 37.83.201 - QUALIFIED MEDICARE BENEFICIARIES, APPLICATION AND ELIGIBILITY FOR MEDICAID

Current through Register Vol. 13, July 5, 2024
(1) A person is a
				qualified medicare beneficiary eligible for medicaid, as provided for in Title
				37, chapter 83, subchapter 8, if the person:
(a) is entitled to medicare Part A benefits
				as provided for in
				42 USC
				1395 c et seq.;
(b) meets the nonfinancial criteria in (3) of
				this rule;
(c) has countable
				resources not in excess of two times the resource limitation applicable to the
				federal supplemental security income (SSI) resource limitation at
				42 USC
				1382 a. The department hereby incorporates
				42 USC
				1382 a as amended through April 1, 1989,
				which sets forth the resource limitation applicable to the federal (SSI)
				program. Copies of
				42 USC
				1382 a, as amended through April 1, 1989, are
				available from the Department of Public Health and Human Services, Human and
				Community Services Division, 1400 Broadway, P.O. Box 202951, Helena, MT
				59620-2951; and
(d) has countable
				income as determined in accordance with this section;
(i) countable income may not exceed:
(A) 100% of the federal poverty income
				standard for state fiscal year 1991 and 1992;
(B) 110% of the federal poverty income
				standard for state fiscal year 1993 and 1994; and
(C) 120% of the federal poverty income
				standard for state fiscal year 1995 and years thereafter.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.2 - Eligibility Requirements for Qualified Medicare Beneficiaries › Rule 37.83.202 - QUALIFIED MEDICARE BENEFICIARIES, EFFECTIVE DATE OF ELIGIBILITY

Current through Register Vol. 13, July 5, 2024
(1) A person is eligible for the receipt of
				medicaid benefits at the beginning of the following month after the department
				determines that the person is a qualified medicare beneficiary.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-101
					 and
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.4 - Medicaid for Qualified Disabled Working Individuals › Rule 37.83.401 - QUALIFIED DISABLED WORKING INDIVIDUALS, APPLICATION AND ELIGIBILITY FOR MEDICAID

Current through Register Vol. 13, July 5, 2024
(1) A qualified
				disabled working individual (QDWI) is an individual:
(a) who is entitled to enroll in hospital
				insurance benefits (medicare Part A) under
				42
				USC 1395i-2a because he lost premium-free
				Part A medicare coverage due solely to excess earned income from substantial
				gainful activity;
(b) meets the
				non-financial criteria in (2) of this rule;
(c) whose income does not exceed 200% of the
				official federal poverty guideline as defined by the executive office of
				management and budget; and
(d)
				whose resources do not exceed twice the supplemental security income (SSI)
				resource limit set forth at
				42 USC
				1382 (a) (3) (A) and (B) (1990
				edition).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.4 - Medicaid for Qualified Disabled Working Individuals › Rule 37.83.402 - QUALIFIED DISABLED WORKING INDIVIDUALS, EFFECTIVE DATE OF ELIGIBILITY

Current through Register Vol. 13, July 5, 2024
(1) A person is eligible for QDWI benefits as
				of the date that all eligibility criteria set forth in ARM
				37.83.401 are met and he is
				enrolled in medicare Part A under
				42
				USC 1395i-2a.
(2) Retroactive coverage is available for up
				to 3 months prior to date of application.
Sec.
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-101
					 and
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.4 - Medicaid for Qualified Disabled Working Individuals › Rule 37.83.406 - QUALIFIED DISABLED WORKING INDIVIDUALS, MEDICAID BENEFITS

Current through Register Vol. 13, July 5, 2024
(1) Medicaid benefits for a qualified
				disabled working individual are limited to payment of the monthly medicare
				hospital insurance (Part A) premium.
Sec.
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-101
					 and
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.5 - Specified Low Income Medicare Beneficiaries › Rule 37.83.501 - SPECIFIED LOW INCOME MEDICARE BENEFICIARIES, APPLICATION AND ELIGIBILITY FOR MEDICAID

Current through Register Vol. 13, July 5, 2024
(1) A person is a
				specified low income medicare beneficiary eligible for medicaid as provided in
				(7) of this rule if the person:
(a) is
				entitled to medicare Part A benefits as provided in
				42 USC
				1395 c et seq.;
(b) meets the nonfinancial criteria in (3) of
				this rule;
(c) has countable
				resources not in excess of two times the resource limitation applicable to the
				federal supplemental security income (SSI) resource limitation at
				42 USC
				1382 a; and
(d) has countable income as determined in
				accordance with this section;
(i) countable
				income may not be less than 100% of the federal poverty income standard nor
				more than:
(A) 110% of the federal poverty
				income standard for calendar year 1993; and
(B) 120% of the federal poverty income
				standard beginning January 1, 1994.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.801 - MEDICAID COVERAGE FOR QUALIFIED MEDICARE BENEFICIARIES

Current through Register Vol. 13, July 5, 2024
(1) ARM Title 37, chapter 83 implements
				medicaid coverage, as provided for in Section 301 of the Medicare Catastrophic
				Coverage Act of 1988 and House Bills 452 and 453 of the 51st Montana
				legislature for the costs of medicare Parts A and B insurance premiums,
				deductibles, and coinsurance for persons who are categorically entitled to
				medicaid and meet certain financial and other criteria.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-101
					 and
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.805 - QUALIFIED MEDICARE BENEFICIARIES, GENERAL REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) A qualified medicare beneficiary is
				subject to the requirements in the following rules:
(a) ARM
				37.86.5303 concerning prior
				approval and restrictions on provider; and
(b) ARM
				37.82.206 concerning the
				provisions of assistance.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.810 - QUALIFIED MEDICARE BENEFICIARIES, PAYMENT OF MEDICARE PREMIUMS

Current through Register Vol. 13, July 5, 2024
(1) Medicaid will cover the medicare Part B
				insurance premium for a qualified medicare beneficiary.
(2) Medicaid will cover the medicare Part A
				insurance premium for a qualified medicare beneficiary who is not eligible for
				premium-free medicare Part A insurance coverage.
(3) The department will enroll all qualified
				medicare beneficiaries in medicare Part B insurance. Persons who are not
				eligible for premium free medicare Part A insurance, will not be enrolled by
				the department in medicare Part A insurance. Those persons must enroll
				themselves through the United States social security administration.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-101
					 and
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.811 - QUALIFIED MEDICARE BENEFICIARIES, COVERAGE OF DEDUCTIBLES AND COINSURANCE FOR MEDICARE SERVICES ALSO COVERED BY FULL MEDICAID

Current through Register Vol. 13, July 5, 2024
(1) For a qualified medicare beneficiary,
				medicaid will participate in the deductibles and coinsurance for the following
				medicare services also covered by medicaid:
(a) inpatient hospital services;
(b) outpatient hospital services;
(c) home health services;
(d) skilled nursing home care;
(e) hospice care;
(f) outpatient physical therapy
				services;
(g) outpatient speech
				therapy services;
(h) outpatient
				occupational therapy services;
(i)
				prosthetic devices, durable medical equipment and medical supplies;
(j) physician services, including laboratory
				and x-ray services; and
(k) dental
				services which are oral surgery services.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.812 - QUALIFIED MEDICARE BENEFICIARIES, PAYMENT FOR CHIROPRACTIC SERVICES AS MEDICARE SERVICES NOT COVERED BY FULL MEDICAID (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.820 - QUALIFIED MEDICARE BENEFICIARIES, FREE CHOICE OF PROVIDERS

Current through Register Vol. 13, July 5, 2024
(1) Any qualified medicare beneficiary may
				obtain services from any institution, agency, pharmacy, or practitioner
				licensed and qualified to perform such services and participating under the
				medicaid program, unless the department restricts the person's access to
				services as provided for in ARM
				37.86.5303.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-101,
					 53-6-113,
					 53-6-116
					 and
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.821 - QUALIFIED MEDICARE BENEFICIARIES, PROVIDER REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) As a condition of participation in the
				Montana medicaid program, including the qualified medicare beneficiary program,
				all providers of service shall abide by all applicable state and federal
				statutes and regulations, including but not limited to federal regulations and
				statutes found in Title 42 of the United States Code and the Code of Federal
				Regulations governing the medicaid program, and all pertinent Montana statutes
				and rules governing licensure and certification.
(2) In addition to the requirements provided
				in these rules, a provider of services to a medicaid qualified medicare
				beneficiary must comply with the requirements in the following rules:
(a) ARM
				37.85.402 concerning provider
				requirements, participation and service delivery;
(b) ARM
				37.85.406(1) 
				concerning billing requirements;
(c) ARM
				37.85.406(2) 
				concerning prompt payment of claims and prompt recovery of all payments
				erroneously or improperly made to a provider;
(d) ARM
				37.85.406(3) and
				(4) concerning reimbursement requirements,
				payment in full and retroactive payment increases;
(e) ARM
				37.85.406(5), (6) and
				(7) concerning direct provider payments,
				payment rates for out of state providers and governmental billing of
				medicaid;
(f) ARM
				37.85.407 concerning third party
				liability;
(g) ARM
				37.85.414 concerning record
				keeping, record disclosure and audits; and
(h) ARM
				37.85.501 concerning
				sanctions.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.822 - QUALIFIED MEDICARE BENEFICIARIES, PROVIDER CHOICE OF PARTICIPATION AND OTHER RIGHTS

Current through Register Vol. 13, July 5, 2024
(1) A provider may
				choose to provide services to a person either as a private pay client or as a
				medicaid client. A medicaid client is a person who is medicaid eligible either
				as a qualified medicare beneficiary or as a qualified medicare beneficiary who
				is also eligible under another medicaid category.
(2) A provider has the rights set forth in
				ARM 37.85.411, concerning the exercise
				of professional judgment, management of business affairs and a provider's right
				to appeal an administrative decision.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-101
					 and
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.825 - QUALIFIED MEDICARE BENEFICIARIES, PAYMENTS TO PROVIDERS

Current through Register Vol. 13, July 5, 2024
(1) Payments for services provided to
				medicaid qualified medicare beneficiaries may only be made to a provider. A
				provider in order to receive payments must be enrolled in the medicaid program.
(a) Medicaid payment will be made to the
				provider even when the provider for medicare purposes has not accepted
				assignment.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.826 - QUALIFIED MEDICARE BENEFICIARIES, COPAYMENTS

Current through Register Vol. 13, July 5, 2024
(1) A qualified medicare beneficiary is
				responsible for copayments to the same extent as a medicaid recipient under the
				provisions of ARM
				37.85.204.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-101
					 and
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.830 - QUALIFIED MEDICARE BENEFICIARIES, BILLING

Current through Register Vol. 13, July 5, 2024
(1) The requirements for billing medicaid are
				as follows:
(a) Claims for qualified medicare
				beneficiaries must be submitted to medicare first.
(i) Claims for medicare Part A insurance
				services must be submitted to the medicare Part A insurance intermediary for
				medicare payment and then submitted to medicaid on the appropriate claim form
				with the medicare explanation of medical benefits (EOMB) attached for payment
				of the deductibles and coinsurance.
(ii) Claims for medicare Part B insurance
				services must be submitted to the medicare Part B insurance carrier for
				medicare payment and then submitted to medicaid on the appropriate claim form
				with the medicare explanation of medical benefits (EOMB) attached for payment
				of the deductibles and coinsurance. The Part B carrier may, under an agreement
				with the department, submit the claims by electronic media to medicaid for
				payment of the deductibles and coinsurance.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.83 - MEDICAID FOR CERTAIN MEDICARE BENEFICIARIES AND OTHERS › Subchapter 37.83.8 - Requirements for Qualified Medicare Beneficiaries › Rule 37.83.831 - QUALIFIED MEDICARE BENEFICIARIES, DETERMINATION OF MEDICAL NECESSITY

Current through Register Vol. 13, July 5, 2024
(1) For services to qualified medicare
				beneficiaries, medicaid may accept medicare's determination of medical
				necessity for services which require approval prior to service delivery or
				review prior to payment. Medicaid may also accept medicare's determination of
				whether a medical procedure is experimental or not.
(2) The department will only pay for
				medically necessary, non-experimental services, as established in ARM
				37.82.102(2) and
				ARM 37.85.410.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-6-101
					 and
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.84 - MEDICAID EXPANSION › Subchapter 37.84.1 - Montana Health and Economic Livelihood Partnership (HELP) Program › Rule 37.84.101 - HELP ACT: PURPOSE

Current through Register Vol. 13, July 5, 2024
(1) The purpose of
				this subchapter is to implement the Montana Health and Economic Livelihood
				Partnership Act (HELP Act) enacted by the 64th Montana Legislature, Ch. 368, L.
				2015 MT.
AUTH:
					 53-2-215,
					 53-6-113,
					 53-6-1305,
					 53-6-1318,
					 MCA; IMP:
					 53-2-215,
					 53-6-101,
					 53-6-113,
					 53-6-131,
					 53-6-1302,
					 53-6-1303,
					 53-6-1304,
					 53-6-1305,
					 53-6-1306,
					 53-6-1307,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.84 - MEDICAID EXPANSION › Subchapter 37.84.1 - Montana Health and Economic Livelihood Partnership (HELP) Program › Rule 37.84.102 - HELP ACT: DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "Advanced
				practice registered nurse (APRN)" means a registered professional nurse who has
				completed educational requirements related to the nurse's specific practice
				role, in addition to basic nursing education, as specified by the Board of
				Nursing in ARM
				24.159.1414.
(2) "Medicaid Benefit Plan" means a service
				plan available to Medicaid and HELP members that is equivalent to the Medicaid
				services described in ARM Title 37.
(3) "American Indian and Alaska Native" means
				an American Indian, Alaska Native, or other individual who is eligible for
				health services through the Indian Health Service, tribes and tribal
				organizations, or urban Indian organizations.
(4) "Benefit year" means the state fiscal
				year from July 1 through June 30.
(5) "Benefits" means the services a person is
				eligible to receive. The HELP Program benefits are stated in the Medicaid
				Benefit Plan.
(6) "Copayment" means
				a predetermined portion of the cost for a health care service or item that is
				owed by the member directly to a provider for a covered health care
				service.
(7) "Cost Share" means the
				total of premium and copayment costs in relation to the delivery of health care
				services to the participant that are the responsibility of the participant to
				pay.
(8) "Department" means the
				Montana Department of Public Health and Human Services.
(9) "Emergency medical condition" means a
				medical condition manifesting itself with acute symptoms of sufficient
				severity, including severe pain, such that a prudent layperson could reasonably
				expect the absence of immediate medical attention to result in any of the
				following:
(a) serious jeopardy to the health
				of the member or the member's unborn child;
(b) serious impairment of bodily function; or
(c) serious dysfunction of any
				bodily organ or part.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.84 - MEDICAID EXPANSION › Subchapter 37.84.1 - Montana Health and Economic Livelihood Partnership (HELP) Program › Rule 37.84.103 - HELP ACT: ELIGIBILITY FOR COVERAGE

Current through Register Vol. 13, July 5, 2024
(1) An individual
				qualifies for Medicaid coverage under the HELP Program if the person is a
				Montana resident who meets the eligibility criteria for Medicaid expansion
				coverage as authorized at
				42 U.S.C.
				1396 a(a)(10)(A)(i)(VIII) (2015).
(2) HELP Program coverage, as specified in
				(1), is inclusive of a person who is 19 through 64 years of age, has a modified
				adjusted gross income at or below 138% of FPL as appropriate to the household
				size, and is not:
(a) pregnant at the time of
				enrollment;
(b) entitled to or
				enrolled in Medicare;
(c) disabled
				as determined for purposes of social security; or
(d) in one of the other categories for
				Medicaid coverage that are excluded from Medicaid expansion coverage by the
				language of the applicable federal authority .
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.84 - MEDICAID EXPANSION › Subchapter 37.84.1 - Montana Health and Economic Livelihood Partnership (HELP) Program › Rule 37.84.106 - HELP ACT: BENEFITS

Current through Register Vol. 13, July 5, 2024
(1) Coverage for a
				person in the HELP Program is provided through the Medicaid Benefit
				Plan.
AUTH:
					 53-2-215,
					 53-6-113,
					 53-6-1305,
					 53-6-1318,
					 MCA; IMP:
					 53-2-215,
					 53-6-101,
					 53-6-1305,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.84 - MEDICAID EXPANSION › Subchapter 37.84.1 - Montana Health and Economic Livelihood Partnership (HELP) Program › Rule 37.84.107 - HELP ACT: PREMIUMS

Current through Register Vol. 13, July 5, 2024
(1) A HELP
				participant must pay a premium equal to two percent of the prorated share of
				the participant's annual household income. The premium will be billed in twelve
				equal monthly amounts.
(2) A
				participant, except as provided in (4) and (5), for whom an overdue premium is
				owed, will be disenrolled from coverage as provided in (3).
(3) The process for collection of overdue
				premiums is as follows:
(a) Within 30 days of
				the date a participant's premium payment was due, the department must notify
				the participant that the payment is overdue and that all overdue premiums must
				be paid within 90 days of the date the notification was sent.
(b) If payment for overdue premiums is not
				received, the department will notify the Department of Revenue of the sum owed.
(c) Unless the participant states
				the intent not to reenroll, the department may reenroll the person in the HELP
				Plan when the Department of Revenue assesses the unpaid premium through the
				participant's income tax.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.84 - MEDICAID EXPANSION › Subchapter 37.84.1 - Montana Health and Economic Livelihood Partnership (HELP) Program › Rule 37.84.108 - HELP ACT: HELP PLAN COPAYMENTS. (Repealed)

Current through Register Vol. 13, July 5, 2024
AUTH:
					 53-2-215,
					 53-6-113,
					 53-6-1305,
					 53-6-1318,
					 MCA IMP:
					 53-2-215,
					 53-6-101,
					 53-6-1306,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.84 - MEDICAID EXPANSION › Subchapter 37.84.1 - Montana Health and Economic Livelihood Partnership (HELP) Program › Rule 37.84.109 - HELP ACT: HELP PLAN REIMBURSEMENT. (Repealed)

Current through Register Vol. 13, July 5, 2024
AUTH:
					 53-2-215,
					 53-6-113,
					 53-6-1305,
					 53-6-1318,
					 MCA IMP:
					 53-2-215,
					 53-6-101,
					 53-6-1305,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.84 - MEDICAID EXPANSION › Subchapter 37.84.1 - Montana Health and Economic Livelihood Partnership (HELP) Program › Rule 37.84.112 - HELP ACT: HELP PLAN PROVIDER QUALIFICATIONS (Repealed)

Current through Register Vol. 13, July 5, 2024
AUTH:
					 53-2-215,
					 53-6-113,
					 53-6-1305,
					 53-6-1318,
					 MCA IMP:
					 53-2-215,
					 53-6-101,
					 53-6-113,
					 53-6-1305,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.84 - MEDICAID EXPANSION › Subchapter 37.84.1 - Montana Health and Economic Livelihood Partnership (HELP) Program › Rule 37.84.115 - HELP ACT: HELP PLAN GRIEVANCE AND APPEAL PROCESS (Repealed)

Current through Register Vol. 13, July 5, 2024
AUTH:
					 53-2-215,
					 53-6-113,
					 53-6-1305,
					 53-6-1318,
					 MCA; IMP:
					 53-2-215,
					 53-6-101,
					 53-6-113,
					 53-6-1305,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.1 - Montana Medicaid Provider Fee Schedules › Rule 37.85.104 - EFFECTIVE DATES OF PROVIDER FEE SCHEDULES FOR MONTANA NON-MEDICAID SERVICES

Current through Register Vol. 13, July 5, 2024
(1) The department
				adopts and incorporates by reference the fee schedule for the following
				programs within the Behavioral Health and Developmental Disabilities Division
				on the dates stated:
(a) Mental health crisis
				services, as provided in ARM
				37.88.101, is effective July 1,
				2023.
(b) Goal 189, as provided in
				ARM 37.89.201, is effective October 1,
				2022.
(c) Youth respite care
				services, as provided in ARM
				37.87.2203, is effective July 1,
				2023.
(d) Substance use disorder
				services provider reimbursement, as provided in ARM
				37.27.905, is effective July 1,
				2023.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.1 - Montana Medicaid Provider Fee Schedules › Rule 37.85.106 - MEDICAID BEHAVIORAL HEALTH TARGETED CASE MANAGEMENT FEE SCHEDULE

Current through Register Vol. 13, July 5, 2024
(1) The Montana Medicaid Program establishes
				provider reimbursement rates for medically necessary, covered services based on
				the estimated demand for services and the legislative appropriation and federal
				matching funds.
(2) The Department
				of Public Health and Human Services (department) adopts and incorporates by
				reference the Medicaid Behavioral Health Targeted Case Management Fee Schedule
				effective July 1, 2023, for the following programs within the Behavioral Health
				and Developmental Disabilities Division:
(a)
				Targeted Case Management Services (TCM) for Youth with Serious Emotional
				Disturbance (SED), as provided in ARM
				37.87.901;
(b) Targeted Case Management Services for
				Substance Use Disorders (SUD), as provided in ARM
				37.27.905; and
(c) Targeted Case Management Services for
				Adults with Severe Disabling Mental Illness (SDMI), as provided in ARM
				37.86.3515.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.2 - Miscellaneous › Rule 37.85.201 - SELECTION OF PROVIDER

Current through Register Vol. 13, July 5, 2024
(1) Except as
				otherwise provided in ARM Title 37, chapters 40, 80, 82, 83, 85, 86, 88 any
				individual eligible for medical assistance may obtain the services available
				from any institution, agency, pharmacy, or practitioner, qualified to perform
				such services and participating under the program, including an organization
				which provides these services or arranges for their availability on a
				prepayment basis.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-6-116,
					 53-6-132,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.2 - Miscellaneous › Rule 37.85.204 - MEMBER REQUIREMENTS, COST SHARING

Current through Register Vol. 13, July 5, 2024
(1)
				Effective for claims paid on or after January 1, 2020, members covered under
				Medicaid or Medicaid Expansion will not be assessed a copayment, as defined in
				ARM 37.84.102, for any covered
				service.
(2) The total of Medicaid
				or Medicaid Expansion cost share, as defined in ARM 37.84.102, incurred by a
				Medicaid or Medicaid Expansion household may not exceed an aggregate limit of
				five percent of the family's income applied quarterly. There may not be further
				cost sharing applied to the household members in a quarter once a household has
				met the quarterly aggregate cap.
(3) Providers may directly charge members
				only for the following services if the member signs an Advanced Beneficiary
				Notice for the specific service prior to the service being provided:
(a) noncovered services;
(b) experimental services;
(c) unproven services;
(d) services performed in an inappropriate
				setting;
(e) services that are not
				medically necessary;
(f)
				investigational services; or
(g)
				dental treatment expenses that exceed the annual dental treatment cap.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.2 - Miscellaneous › Rule 37.85.205 - RECIPIENT RESTRICTION OF ACCESS TO MEDICAL SERVICES (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-6-113,
					 MCA; IMP,
					 53-6-104,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.2 - Miscellaneous › Rule 37.85.206 - SERVICES PROVIDED

Current through Register Vol. 13, July 5, 2024
(1) Except as
				otherwise provided in this rule, the following medical or remedial care and
				services are available to all persons who are eligible for Medicaid benefits
				under this chapter including deceased persons, categorically related, who would
				have been eligible had death not prevented them from applying.
(a) inpatient hospital services;
(b) outpatient hospital services;
(c) non-hospital laboratory and x-ray
				services;
(d) nursing facility
				services;
(e) early and periodic
				screening, diagnosis and treatment services;
(f) physician's services;
(g) podiatry services;
(h) outpatient physical therapy services;
(i) speech therapy, audiology and
				hearing aid services;
(j)
				outpatient occupational therapy services;
(k) home health care services;
(l) personal care services in a member's
				home;
(m) home dialysis services;
(n) private duty nursing services;
(o) clinic services;
(p) dental services;
(q) outpatient drugs;
(r) durable medical equipment, prosthetic
				devices, and medical supplies;
(s)
				eyeglasses and optometric services;
(t) transportation and per diem;
(u) ambulance services;
(v) specialized nonemergency transportation;
(w) family planning services;
(x) home and community
				services;
(y) mid-level
				practitioner services;
(z) hospice
				services;
(aa) licensed
				psychologist services;
(ab)
				licensed clinical social worker services;
(ac) licensed professional counselor
				services;
(ad) inpatient
				psychiatric services;
(ae) mental
				health center services;
(af) case
				management services;
(ag)
				institutions for mental diseases for persons age 65 and over;
(ah) payment of premiums, co-insurance,
				deductibles, and other cost sharing obligations under an individual or group
				health plan in accordance with the provisions of ARM
				37.82.424;
(ai) diabetes and cardiovascular disease
				prevention services;
(aj)
				habilitative services; and
(ak)
				rehabilitative services.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.2 - Miscellaneous › Rule 37.85.207 - SERVICES NOT PROVIDED BY THE MEDICAID PROGRAM

Current through Register Vol. 13, July 5, 2024
(1) Items or medical services not
				specifically included within these rules as covered benefits of the Montana
				Medicaid program are not reimbursable.
(2) The following medical and nonmedical
				services are explicitly excluded from the Montana Medicaid program, except for
				those services specifically available, as listed in ARM
				37.40.1406,
				37.90.402, and Title 37, chapter
				34, subchapter 9 to persons eligible for home and community-based services; and
				except for those Medicare covered services, as listed in ARM
				37.83.812 to qualified Medicare
				beneficiaries for whom the Montana Medicaid program pays the Medicare premiums,
				deductible, and coinsurance:
(a) chiropractic
				services;
(b) acupuncture
				services;
(c) naturopathic
				services;
(d) dietician
				services;
(e) physical therapy aide
				services, except as provided in ARM
				37.86.601,
				37.86.605,
				37.86.606, and
				37.86.610;
(f) surgical technicians who are not
				physicians or mid-level practitioners;
(g) nutritional services;
(h) masseur or masseuse services;
(i) dietary supplements;
(j) homemaker services;
(k) telephone service in home, remodeling of
				home, plumbing service, car repair, and/or modification of
				automobile;
(l) delivery services
				not provided in a licensed health care facility or nationally accredited
				birthing center unless as an emergency service. Delivery services means
				services necessary to protect the health and safety of the woman and fetus from
				the onset of labor through delivery. Emergency service is defined in ARM
				37.82.102;
(m) treatment services for infertility,
				including sterilization reversals;
(n) experimental services;
(o) all invasive medical procedures
				undertaken for the purpose of weight reduction such as gastric bypass, gastric
				banding, or bariatric surgery, including all revisions; and
(p) circumcisions not authorized by the
				department as medically necessary.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.2 - Miscellaneous › Rule 37.85.220 - INDEPENDENT DIAGNOSTIC TESTING FACILITIES

Current through Register Vol. 13, July 5, 2024
(1) Any facility that is enrolled in the
				federal Medicare program as an independent diagnostic testing facility (IDTF)
				may also enroll in the Montana Medicaid program as an IDTF.
(2) IDTFs enrolled in the Montana Medicaid
				program shall be governed by
				42
				CFR 410.32 and
				410.33.
				The department hereby adopts and incorporates by reference
				42
				CFR 410.32 and
				410.33
				(2001). Copies of
				42
				CFR 410.32 and
				410.33
				(2001) are available upon request from the Department of Public Health and
				Human Services, Health Policy and Services Division, 1400 Broadway, P.O. Box
				202951, Helena, MT 59620-2951.
(3)
				In addition to
				42
				CFR 410.32 and
				410.33,
				IDTFs enrolled in the Montana Medicaid program shall comply with all rules
				generally applicable to Medicaid providers.
(4) An IDTF shall be reimbursed for
				diagnostic services performed pursuant to this rule in accordance with ARM
				37.85.406 and
				37.86.105.
(5) The definitions found in the introduction
				to Physicians Current Procedural Terminology, fourth edition (CPT4), published
				by the American Medical Association of Chicago, Illinois and adopted at ARM
				37.86.101 set forth meanings of
				terms commonly used by the Montana Medicaid program in implementation of the
				program's IDTF fee schedule.
(6)
				The Physician-Related Services Manual governing the administration of the IDTF
				program adopted at ARM
				37.86.101 applies to independent
				diagnostic testing facilities.
53-6-113,
					 MCA; IMP,
					 53-6-111,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.2 - Miscellaneous › Rule 37.85.221 - MEDICAID OVERPAYMENT AUDITOR EVALUATION HEARINGS ; RECOVERY AUDIT CONTRACTOR (RAC) PROGRAM

Current through Register Vol. 13, July 5, 2024
(1) Within one year
				after the establishment of the contract auditor, and each subsequent year, the
				department will announce auditor evaluation hearing meetings via the
				department's website at www.dphhs.mt.gov and the State of Montana's public
				calendaring system. The meetings will provide an opportunity for the Medicaid
				provider community and the department to discuss appropriate conduct and
				determinations by contract auditors. The evaluation meetings' information will
				be published no less than 30 calendar days in advance of any annual
				meeting.
AUTH:
					 53-6-1409,
					 MCA; IMP:
					 53-6-111,
					 53-6-1409,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.4 - Provider Requirements › Rule 37.85.401 - PROVIDER PARTICIPATION

Current through Register Vol. 13, July 5, 2024
(1) As a
				condition of participation in the Montana Medicaid program all providers must
				comply with all applicable state and federal statutes, rules and regulations,
				including but not limited to federal regulations and statutes found in Title 42
				of the Code of Federal Regulations and the United States Code governing the
				Medicaid Program and all applicable Montana statutes and rules governing
				licensure and certification.
53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.85 - GENERAL MEDICAID SERVICES › Subchapter 37.85.4 - Provider Requirements › Rule 37.85.402 - PROVIDER ENROLLMENT AND AGREEMENTS

Current through Register Vol. 13, July 5, 2024
(1)
				Providers must enroll in the Montana Medicaid program for each category of
				services to be provided. As a condition of granting enrollment approval or of
				allowing continuing enrollment, the department may require the provider to:
(a) complete and submit an enrollment
				application or form;
(b) complete
				and submit agreements or other forms applicable to the provider's category of
				service;
(c) provide information
				and documentation regarding ownership and control of the provider entity and
				regarding the provider's ownership interest or control rights in other
				providers that bill Medicaid;
(d)
				provide information and documentation regarding:
(i) any sanctions, suspensions, exclusions or
				civil monetary penalties imposed by the Medicare program, any state Medicaid
				program or other federal program against the provider, a person or entity with
				an ownership or control interest in the provider or an agent or managing
				employee of the provider; and
(ii)
				any criminal charges brought against and any criminal convictions of the
				provider, a person or entity with an ownership or control interest in the
				provider or an agent or managing employee of the provider related to that
				person's or entity's involvement in Medicare, Medicaid, or the Title XX
				Services program; and
(e) submit documentation and information
				demonstrating compliance with participation requirements applicable to the
				provider's category of service.