reglab/statecodes huggingface dataset:
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.1 - General Provisions › Rule 37.81.101 - BIG SKY RX PROGRAM

Current through Register Vol. 13, July 5, 2024
(1) The rules in
				this chapter implement the Pharmacy Access Prescription Drug Benefit program
				established in
				53-6-1004,
				MCA. This program is referred to in these rules as the Big Sky Rx
				program.
53-2-201,
					 53-6-1004,
					 MCA; IMP,
					 53-6-1001,
					 53-6-1004,
					 53-6-1005,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.301 - BIG SKY RX SCOPE AND PURPOSE

Current through Register Vol. 13, July 5, 2024
(1) On
				January 1, 2006, Medicare Prescription Drug Plans (PDPs) became available to
				people with Medicare. This is a voluntary federal program created by the
				Medicare Prescription Drug Improvement and Modernization Act of 2003 (MMA)
				42
				USC 1302,
				1395w-101
				through
				1395w-152,
				and
				1395
				hh. It is referred to as "Medicare Part D" in these rules and implemented in 42
				CFR part 423.
(2) An individual
				entitled to benefits under Medicare Part A or enrolled in Medicare Part B is
				eligible to enroll in a Medicare Part D PDP. An individual enrolled in a PDP is
				responsible for the premium and receives prescription drug coverage. There is
				also a federal premium subsidy called "Social Security Extra Help" for some
				individuals that assists in paying copayments, deductibles, and
				premiums.
(3) The purpose of
				Montana's Big Sky Rx Program is to pay a portion or all of the cost of the PDP
				premium for eligible Montana residents.
(4) The individual enrolled in Part D must
				choose and enroll in a federally approved PDP.
(5) The program does not provide assistance
				with selecting or enrolling in a PDP.
53-2-201,
					 53-6-1004,
					 MCA; IMP,
					 53-2-201,
					 53-6-1001,
					 53-6-1004,
					 53-6-1005,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.304 - AMOUNT OF THE BIG SKY RX BENEFIT

Current through Register Vol. 13, July 5, 2024
(1) An
				applicant eligible for the Big Sky Rx PDP premium assistance may receive a
				benefit not to exceed $38.90 per month. The benefit amount will not exceed
				$38.90 regardless of the cost of the premium for the PDP the individual
				chooses.
(a) If a portion of the applicant's
				PDP premium is paid through the Extra Help Program, the Big Sky Rx Program will
				pay the applicant's portion of the PDP premium up to $38.90 per
				month.
(b) Big Sky Rx does not pay
				for the cost of an enrollee's drugs or the cost of an enrollee's deductible,
				coinsurance, or copayments.
(c) All
				expenditures are contingent on legislative appropriation. The amount of the
				monthly benefit, $38.90, extends the Social Security Extra Help benefit amount
				to Montana residents with income up to 200% FPL. The department's total
				expenditure for the program will be based on appropriation and the number of
				enrolled applicants.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.307 - ELIGIBILITY FOR BIG SKY RX

Current through Register Vol. 13, July 5, 2024
(1) An applicant
				must be eligible and enrolled in the program to receive premium
				assistance.
(2) To qualify the
				applicant must:
(a) be a resident of the
				state of Montana; and
(b) have a
				family income at or below 200% FPL.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.310 - INCOME AND FAMILY SIZE CRITERIA FOR BIG SKY RX

Current through Register Vol. 13, July 5, 2024
(1) Family income must be at or below 200%
				FPL to qualify for the program. Assets are not considered. Family income is the
				total of the applicant's income and the spouse's income if married and living
				together. For purposes of determining Big Sky Rx eligibility, the income items
				listed in this rule are included in family income.
(2) Earned income includes gross wages, net
				earnings from self-employment, payment for services performed in a sheltered
				workshop or work activities center, royalties, and honoraria.
(3) Unearned income includes Social Security
				benefits, veterans benefits, railroad benefits, public and private pensions,
				annuities, workers' compensation, alimony, child support, unemployment, income
				from a trust, net rental income, dividends, interest, and
				inheritances.
(4) Income tax
				refunds, assistance based on need funded by a state or local government, and
				small amounts of income received infrequently or irregularly are not counted.
				The income listed in (2) and (3) may also be decreased based on the adjustments
				stated in 20 CFR 416 to calculate income for purposes of Social Security
				Supplemental Income (SSI).
(5) The
				result of adding (2) and (3) and making any disregards of income provided for
				in (4) equals countable income.
(6)
				Compare countable income with household size to figure FPL.
53-2-201,
					 53-6-1004,
					 MCA; IMP,
					 53-2-201,
					 53-6-1001,
					 53-6-1004,
					 53-6-1005,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.314 - MAXIMUM BIG SKY RX PROGRAM ENROLLMENT

Current through Register Vol. 13, July 5, 2024
(1) The
				department will enroll the number of participants it determines can be served
				based on the amount of appropriation.
53-2-201,
					 53-6-1004,
					 MCA; IMP,
					 53-6-1001,
					 53-6-1004,
					 53-6-1005,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.318 - PROCESSING BIG SKY RX PARTICIPANT APPLICATIONS

Current through Register Vol. 13, July 5, 2024
(1) The department will process applications
				on a first in first served basis using the date the application is received by
				the department.
(a) The program will not
				enroll or pay benefits retroactively.
(b) Benefits will only be paid to eligible
				and enrolled individuals as of the first month following enrollment.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.322 - BIG SKY RX APPLICATION RENEWAL

Current through Register Vol. 13, July 5, 2024
(1) Sixty
				days prior to the end of the 12-month eligibility period, a prepopulated notice
				will automatically be generated and mailed to the client. This notice is
				generated based on the client's eligibility enrollment determination
				date.
(2) The client must review
				the information on the notice to ensure the information is accurate including,
				but not limited to, information about income, assets, dependent family members,
				and contact information.
(a) If the notice
				has incorrect information, the client must write the correct information on the
				notice and return the corrected notice to the department before the eligibility
				period ends.
(b) If the client has
				verified the information on the notice is correct, the client does not need to
				return it or take any other action.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.326 - MAINTENANCE OF A WAITING LIST FOR THOSE DETERMINED ELIGIBLE FOR BIG SKY RX

Current through Register Vol. 13, July 5, 2024
(1) The department will process applications
				and will notify eligible individuals in writing of their program
				status.
(2) If no available program
				slot exists, the eligible individuals will not be enrolled and will be
				maintained on a waiting list until a slot becomes available.
(3) When slots are available, individuals
				will be notified in writing prior to the month of enrollment.
(4) The 12-month eligibility stated in ARM
				37.81.307 applies.
53-2-201,
					 53-6-1004,
					 MCA; IMP,
					 53-6-1001,
					 53-6-1004,
					 53-6-1005,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.330 - BIG SKY RX GRIEVANCE AND APPEAL PROCEDURES

Current through Register Vol. 13, July 5, 2024
(1) All decisions of the department related
				to the administration of the Big Sky Pharmacy Rx program are reviewable using
				the procedures stated at ARM
				37.5.101,
				37.5.304,
				37.5.307,
				37.5.313,
				37.5.318,
				37.5.322,
				37.5.325,
				37.5.328,
				37.5.331, and
				37.5.334.
(2) An applicant contesting a denial, or an
				enrollee or guardian contesting a benefit or enrollment denial, benefit
				reduction, disenrollment, closure, or termination of Big Sky Rx may request a
				fair hearing.
(3) If a written
				request for hearing is not received by the department within 90 days of the
				mailing date of a notice of adverse action, the hearing officer may deny a
				hearing as provided in ARM 37.5.313.
53-2-201,
					 53-6-1004,
					 53-6-1011,
					 MCA; IMP,
					 53-2-606,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.334 - BIG SKY RX APPEAL PROCEDURES

Current through Register Vol. 13, July 5, 2024
(1)
				Hearings to contest adverse department actions under the Big Sky Rx program,
				Title 53, chapter 6, part 10, MCA, are available to the extent granted by
				statute or rule in accordance with ARM
				37.81.330.
53-2-201,
					 53-6-1004,
					 53-6-1011,
					 MCA; IMP,
					 53-2-606,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.338 - VERIFICATION OF ELIGIBILITY FOR BIG SKY RX

Current through Register Vol. 13, July 5, 2024
(1)
				A random sample of enrolled individuals will be required to participate in an
				eligibility verification review and provide documentation to verify the income
				as stated on the application.
(2)
				An individual will have 30 days from the date of the written request by the
				department to submit the required income documentation. The client will remain
				enrolled during the verification process.
(a)
				If the required documentation is not received by the department after 30 days,
				the enrolled individual will be disenrolled from the program the following
				month.
(b) An individual who
				provides income verification documentation after 30 will have the application
				reprocessed as if it is a new application.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.342 - BIG SKY RX PREMIUM PAYMENTS

Current through Register Vol. 13, July 5, 2024
(1) Monthly
				premium payments will be made:
(a) to an
				insurer that has contracted with the department;
(b) directly to clients if:
(i) their monthly premium is deducted from
				their Social Security check;
(ii)
				they enroll in a PDP provided by an insurer that does not contract with the
				department; or
(iii) the client
				chooses to be paid directly.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.3 - Big Sky Rx Program › Rule 37.81.346 - BIG SKY RX PDP MEMORANDUM OF UNDERSTANDING (MOU) AND BUSINESS ASSOCIATES AGREEMENT (BAA)

Current through Register Vol. 13, July 5, 2024
(1) An insurer
				receiving direct payment of all or part of a PDP premium from the state on
				behalf of an enrollee must enter into a Memorandum of Understanding (MOU) or
				Business Associates Agreement (BAA) with the department.
53-2-201,
					 53-6-1004,
					 MCA; IMP,
					 53-2-201,
					 53-6-1001,
					 53-6-1004,
					 53-6-1005,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.10 - Montana PharmAssist Program › Rule 37.81.1001 - MONTANA PHARMASSIST PROGRAM

Current through Register Vol. 13, July 5, 2024
(1) The
				rules in this chapter implement the Prescription Drug Consumer Information and
				Technical Assistance Program established in
				53-6-1006,
				MCA. This program is referred to in these rules as the Montana PharmAssist
				Program.
53-2-201,
					 53-6-1006,
					 MCA; IMP,
					 53-2-201,
					 53-6-1006,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.10 - Montana PharmAssist Program › Rule 37.81.1002 - RULE DEFINITIONS

Current through Register Vol. 13, July 5, 2024
In addition to the definitions in
				  53-6-1001,
				  MCA, the following definitions apply to this chapter:
(1) "Application" means the form developed by
				the department to provide the program with client specific
				information.
(2) "Authorized
				client" means an applicant has met all the Montana PharmAssist authorization
				criteria stated in ARM
				37.81.1009.
(3) "Chronic disease" means a condition or
				disease of long duration and generally slow progression that requires long term
				drug treatment such as cardiovascular disease, chronic respiratory disease,
				diabetes mellitus, arthritis, epilepsy, cancer, osteoporosis, depression,
				anxiety, bipolar disorder, or schizophrenia.
(4) "Client inventory form" means a form
				developed by the department to include pertinent client and health
				information.
(5) "Credentialed
				pharmacist" means a Montana licensed pharmacist in good standing who has
				completed the required initial training for the PharmAssist Program and has a
				current personal service contract with the department.
(6) "Department" means the Department of
				Public Health and Human Services.
(7) "Eligible client" means an applicant has
				met all the Montana PharmAssist eligibility criteria stated in ARM
				37.81.1009.
(8) "First in first
				served" means completed applications will be processed and eligible applicants
				will be referred to a pharmacist for services based upon the date
				received.
(9) "Personal service
				contract" means the contract between the department and the credentialed
				pharmacist.
(10) "PharmAssist
				patient packet" means an application, a signed Acknowledgement of Receipt of
				Notice of Privacy Practices, and a Client Inventory Form.
(11) "Qualified" means an applicant has met
				all the Montana PharmAssist qualification criteria stated in ARM
				37.81.1009.
(12) "Residing" means
				living in Montana voluntarily with the intention of making a home in the state
				and not for a temporary purpose.
53-2-201,
					 53-6-1006,
					 MCA; IMP,
					 53-2-201,
					 53-6-1006,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.10 - Montana PharmAssist Program › Rule 37.81.1005 - MONTANA PHARMASSIST SCOPE AND PURPOSE

Current through Register Vol. 13, July 5, 2024
(1) Beginning July 15, 2007, Montana
				residents may request applications for referral to a credentialed pharmacist
				for review of their medication regimens to address medication cost and the
				proper and prudent use of their medications. Clients who have applied and whose
				personal circumstances warrant a referral will be referred to a pharmacist for
				a drug regimen review and face-to-face interactions to identify therapeutic
				duplications and possible cost saving alternatives. The pharmacist will
				schedule and perform a face-to-face consultation and provide recommendations
				for the client to discuss with their prescriber. Upon completion, the client,
				their prescribers, and department representatives will receive a letter
				prepared by the pharmacist outlining the face-to-face discussion. The letter
				will include the pharmacist's recommendations for the possible alternatives
				available for the client. Clients are encouraged to discuss the pharmacist's
				recommendations with their prescribers prior to making any changes.
53-2-201,
					 53-6-1006,
					 MCA; IMP,
					 53-2-201,
					 53-6-1006,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.10 - Montana PharmAssist Program › Rule 37.81.1008 - AMOUNT OF PHARMASSIST BENEFIT

Current through Register Vol. 13, July 5, 2024
(1) If
				eligible for Montana PharmAssist, a client may receive up to $200 of pharmacist
				services per 12 month period as outlined in the pharmacist's Personal Service
				Contract. Services will include an initial face-to-face consultation and may
				include follow-up services if warranted and approved by the department or its
				designee. All expenditures are contingent on available
				appropriations.
53-2-201,
					 53-6-1006,
					 MCA; IMP,
					 53-2-201,
					 53-6-1006,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.10 - Montana PharmAssist Program › Rule 37.81.1009 - ELIGIBILITY FOR MONTANA PHARMASSIST

Current through Register Vol. 13, July 5, 2024
(1) An
				applicant must be qualified, eligible, and authorized to receive pharmacist
				services.
(2) To qualify, an
				applicant must have a chronic disease and either:
(a) take four or more medications;
				or
(b) have a condition or health
				issue determined by the screening pharmacist that provides an opportunity for
				benefit.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.10 - Montana PharmAssist Program › Rule 37.81.1012 - PROCESSING MONTANA PHARMASSIST APPLICATIONS

Current through Register Vol. 13, July 5, 2024
(1) The department or its designee will
				process PharmAssist Patient Packets on a first in first served basis using the
				date the complete package is received.
(2) Authorized clients will be referred to a
				pharmacist for services.
(3)
				Applicants failing to meet criteria defined in ARM
				37.81.1009 will be notified in
				writing.
53-2-201,
					 53-6-1006,
					 MCA; IMP,
					 53-2-201,
					 53-6-1006,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.10 - Montana PharmAssist Program › Rule 37.81.1013 - MAINTENANCE OF A WAITING LIST FOR THOSE DETERMINED ELIGIBLE FOR MONTANA PHARMASSIST

Current through Register Vol. 13, July 5, 2024
(1) The department
				will process PharmAssist Patient Packets and notify eligible individuals in
				writing if no available program slot exists, either due to lack of
				appropriations or credentialed pharmacists in their region.
(2) Eligible individuals will have their
				names maintained on a waiting list until program slots become
				available.
(3) When program slots
				become available, clients will be referred to a credentialed pharmacist for
				services on a first in first served basis.
53-2-201,
					 53-6-1006,
					 MCA; IMP,
					 53-2-201,
					 53-6-1006,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.10 - Montana PharmAssist Program › Rule 37.81.1018 - MONTANA PHARMASSIST

Current through Register Vol. 13, July 5, 2024
(1) To participate
				in the PharmAssist Program a pharmacist must be licensed by the state of
				Montana and complete initial training, which consists of a self-guided
				educational packet prepared by the department.
53-2-201,
					 53-6-1006,
					 MCA; IMP,
					 53-2-201,
					 53-6-1006,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.10 - Montana PharmAssist Program › Rule 37.81.1020 - MONTANA PHARMASSIST GRIEVANCE AND APPEAL PROCEDURES

Current through Register Vol. 13, July 5, 2024
(1) All decisions of the department related
				to the administration of the Montana PharmAssist are reviewable using the
				procedures in ARM
				37.5.101,
				37.5.304,
				37.5.307,
				37.5.313,
				37.5.318,
				37.5.322,
				37.5.325,
				37.5.328,
				37.5.331, and
				37.5.334.
(2) An aggrieved applicant may request a fair
				hearing in writing within 90 days. The request must be mailed to the Department
				of Public Health and Human Services, Quality Assurance Division, Office of Fair
				Hearings, P.O. Box 202953, Helena, MT 59620-2953.
(3) If a written request for hearing is
				received by the department more than 90 days after the mailing date of a notice
				of denial, the hearing officer must deny a hearing as provided in ARM
				37.5.313.
53-2-201,
					 53-6-1006,
					 MCA; IMP,
					 53-2-201,
					 53-6-1006,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.90 - Medicare Part D Low Income Subsidies › Rule 37.81.9004 - APPLICATION FOR MEDICARE PART D LOW INCOME PREMIUM AND COST SHARING SUBSIDIES (LIS) (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 MCA; IMP,
					 53-2-201,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.90 - Medicare Part D Low Income Subsidies › Rule 37.81.9005 - PROCESSING OF APPLICATIONS FOR LIS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 MCA; IMP,
					 53-2-201,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.90 - Medicare Part D Low Income Subsidies › Rule 37.81.9006 - EFFECTIVE DATE OF ELIGIBILITY FOR LIS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 MCA; IMP,
					 53-2-201,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.90 - Medicare Part D Low Income Subsidies › Rule 37.81.9009 - REDETERMINATIONS OF ELIGIBILITY FOR LIS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 MCA; IMP,
					 53-2-201,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.81 - PHARMACY ACCESS PRESCRIPTION DRUG BENEFIT PROGRAM › Subchapter 37.81.90 - Medicare Part D Low Income Subsidies › Rule 37.81.9010 - APPEAL PROCESS FOR LIS APPLICATIONS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-2-201,
					 MCA; IMP,
					 53-2-201,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.1 - Medical Assistance › Rule 37.82.101 - MEDICAL ASSISTANCE, PURPOSE, AND INCORPORATION OF POLICY MANUALS

Current through Register Vol. 13, July 5, 2024
(1) Subject to applicable state and federal
				laws, regulations and rules, the Montana Medicaid program pays for covered
				medically necessary services for persons determined eligible by the department
				or its agents.
(2) The department
				adopts and incorporates by reference the state policy manuals, namely the
				Family Medicaid Manual, dated January 1, 2010, and the Aged Blind Disabled
				(ABD) Medicaid Manual governing the administration of the Medicaid program
				dated July 1, 2011. The Family Medicaid Manual, the ABD Medicaid Manual, and
				the proposed manual updates are available for public viewing at each local
				Office of Public Assistance or at the Department of Public Health and Human
				Services, Human and Community Services Division, 111 N. Jackson Street, Fifth
				Floor, P.O. Box 202925, Helena, MT 59601-2925. The proposed manual updates are
				also available on the department's web site at
				www.dphhs.mt.gov/legalresources/proposedmanualchange.shtml.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-6-101,
					 53-6-131,
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.1 - Medical Assistance › Rule 37.82.102 - MEDICAL ASSISTANCE DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1)
				"AABD" means aid to the aged, blind, and disabled under Title XVI of the Social
				Security Act.
(2) "AB" means Aid to
				the Blind under Title X of the Social Security Act.
(3) "AFDC" means Aid to Families with
				Dependent Children under Title IV-A of the Social Security Act.
(4) "Affiliates" means persons having an
				overt or covert relationship such that any one of them directly or indirectly
				controls or has the power to control another.
(5) "APTD" means aid to the permanently and
				totally disabled under Title XIV of the Social Security Act.
(6) "Categorically needy" means aged, blind
				or disabled individuals or families and children:
(a) who are otherwise eligible for Medicaid
				and who meet the financial eligibility requirements of section 1951 of the
				Social Security Act, SSI, or an optional state supplement; or
(b) whose categorical eligibility is
				otherwise provided for in ARM Title 37, chapter 82, subchapters 7, 9, 11, and
				13.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.2 - Application, Determination and Redetermination of Eligibility and Furnishing Assistance › Rule 37.82.201 - APPLICATION

Current through Register Vol. 13, July 5, 2024
(1) Opportunity to apply:
(a) Any individual wishing to do so will be
				afforded the opportunity to apply for medicaid without delay.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.2 - Application, Determination and Redetermination of Eligibility and Furnishing Assistance › Rule 37.82.204 - DETERMINATION OF ELIGIBILITY

Current through Register Vol. 13, July 5, 2024
(1) Timely
				determination of eligibility:
(a) Aid will be
				furnished in a timely manner to eligible persons and will conform to the
				following time standards:
(i) 90 days for
				applicants on the basis of disability; and
(ii) 45 days for all other
				applicants.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.2 - Application, Determination and Redetermination of Eligibility and Furnishing Assistance › Rule 37.82.205 - REDETERMINATION OF ELIGIBILITY

Current through Register Vol. 13, July 5, 2024
(1) Periodic
				redetermination of eligibility:
(a) where an
				individual has been determined eligible, eligibility will be reconsidered or
				redetermined:
(i) at the time required when
				the department has information obtained previously about anticipated changes in
				the individual's situation which might affect eligibility;
(ii) within 30 days after a report is
				obtained which indicates that changes in the individual's circumstances may
				affect the individual's eligibility; and
(iii) at least every six months if the client
				is categorically eligible related to FAIM financial assistance; or
(iv) at least every 12 months if the client
				is categorically eligible related to SSI.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.2 - Application, Determination and Redetermination of Eligibility and Furnishing Assistance › Rule 37.82.206 - FURNISHING ASSISTANCE

Current through Register Vol. 13, July 5, 2024
(1) The department
				will:
(a) furnish medicaid in a timely manner
				to recipients, as required by ARM
				37.82.204(1) (a),
				without any delay caused by the agency's administrative procedures;
(b) continue to furnish medicaid regularly to
				all eligible individuals;
(c) make
				arrangements to assist applicants and recipients to get emergency medical care
				whenever needed.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.2 - Application, Determination and Redetermination of Eligibility and Furnishing Assistance › Rule 37.82.207 - RECIPIENT OVERPAYMENTS

Current through Register Vol. 13, July 5, 2024
(1) The department
				shall take reasonable and appropriate actions to recover each recipient
				overpayment, as defined in ARM
				37.82.102, of medicaid benefits
				when the recipient overpayment is the result of the recipient's intentional or
				unintentional act or omission. The department shall also take reasonable and
				appropriate actions to recover overpayments that result from continued benefits
				which were paid pending the outcome of a fair hearing that is ultimately
				decided, at least in part, in the department's favor.
(2) The department shall not seek to recover
				a recipient overpayment, as defined in ARM 37.82.102, of medicaid benefits when
				the entire recipient overpayment is the result of an error made by the
				department.
(3) A recipient
				overpayment shall be calculated to include:
(a) the total amount of medicaid benefits
				paid to or on behalf of an ineligible recipient; or
(b) the difference between the amount of an
				accurately calculated monthly incurment and the amount of monthly incurment the
				recipient paid toward an incorrectly calculated incurment.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.3 - Modified Adjusted Gross Income (MAGI) › Rule 37.82.301 - MAGI AS THE MEASURE OF INCOME

Current through Register Vol. 13, July 5, 2024
(1) Effective
				January 1, 2014, except for members receiving aged, blind, or disabled benefits
				or benefits based on participation in a Medicaid home and community-based
				services waiver, a person's income must be determined in accordance with
				42 U.S.C.
				1396 a(e)(14) (2015), which establishes
				modified adjusted gross income (MAGI) as the required measure of
				income.
(2) To create uniformity
				among the states for income disregards, federal regulation
				42 CFR
				435.603 (d)(4) (2015) requires a state to
				subtract an amount equal to five percentage points of the current FPL to
				determine an individual's eligibility. This is implemented by increasing the
				maximum income to qualify for Medicaid from 133% to 138% of the current
				FPL.
AUTH:
					 53-6-113,
					 MCA; IMP:
					 53-6-131,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.401 - CITIZENSHIP AND ALIENAGE

Current through Register Vol. 13, July 5, 2024
(1) As a condition
				of eligibility for Medicaid, an otherwise eligible individual must be either:
(a) a citizen of the United States;
				or
(b) a qualified alien as defined
				in ARM 37.78.220 lawfully admitted for
				permanent residence or who entered the U.S. after August 22, 1996, otherwise
				permanently residing in the United States, including any alien who is lawfully
				present in the United States under authority of sections 203(a)(7) or 212(d)(5)
				of the Immigration and Nationality Act.
(c) a noncitizen legal alien living in the
				U.S. prior to August 23, 1996.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.402 - RESIDENCY

Current through Register Vol. 13, July 5, 2024
(1) For purposes of this rule, a person is
				considered incapable of indicating intent if:
(a) his I.Q. is 49 or less or he has a mental
				age of seven or less, based on standardized tests;
(b) he has been judged legally incompetent;
				or
(c) documentation acceptable to
				the department supports a finding that he is incapable of indicating intent.
				Acceptable documentation includes but is not limited to medical, psychological
				or psychiatric reports prepared by a qualified professional person.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.403 through 37.82.405 - 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 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.406 - APPLICANT'S CHOICE OF CATEGORY

Current through Register Vol. 13, July 5, 2024
(1) A
				person who is eligible for more than one category of Medicaid eligibility will
				have eligibility determined for the category the person selects.
(2) A person who is eligible for Medicaid as
				a qualified Medicare beneficiary and under another Medicaid eligibility
				category may have eligibility determined under all categories for which the
				person may qualify.
(3) "Category"
				as used in this rule means aged, blind, disabled, families, and children or
				qualified Medicare beneficiary.
53-6-113,
					 MCA; IMP,
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.407 - LIMITATION ON THE FINANCIAL RESPONSIBILITY OF RELATIVES

Current through Register Vol. 13, July 5, 2024
(1) The income and resources of the following
				relatives are considered available to an individual in determining the
				individual's eligibility for Aged Blind Disabled (ABD) Medicaid:
(a) the spouse of the individual, except as
				provided in (3); and
(b) the
				biological or adoptive parent or parents or stepparent of the individual with
				whom the individual resides, if the individual is under the age of
				18.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.408 through 37.82.414 - 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 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.415 - APPLICATION FOR OTHER BENEFITS

Current through Register Vol. 13, July 5, 2024
(1) As a
				condition of eligibility, applicants and recipients must make every effort to
				obtain any benefits to which they are entitled, unless they can show good cause
				for not doing so. These benefits include, but are not limited to, veteran's
				compensation and pensions, OASDI benefits, railroad retirement benefits, and
				unemployment compensation.
53-6-113,
					 MCA; IMP,
					 53-6-131,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.416 - ASSIGNMENT OF RIGHTS TO BENEFITS, COOPERATION WITH CHILD SUPPORT SERVICES REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) As a condition
				of eligibility for Medicaid, each legally able applicant and recipient must
				assign his rights to medical support or other third party payments to the
				department and must cooperate with the department in obtaining medical support
				or payments, except as provided in (4)(a) through (4)(e).
(2) Assignment method and rights assigned:
(a) Under
				53-2-612,
				MCA, the department has a lien upon all money paid by a third party or his
				insurer in satisfaction of a judgment or settlement arising from a recipient's
				claim for damages or compensation for personal injury, disease, illness, or
				disability. Under
				53-2-613,
				MCA, by signing the department-prescribed application form for Medicaid, an
				applicant for or recipient of Medicaid assigns to the department:
(i) his own rights to any medical care
				support under an order of a court or an administrative agency, and any third
				party payments for medical care; and
(ii) the rights of any other eligible
				individual in the family for whom he can legally make an assignment.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.417 - TRANSFER OF RESOURCES

Current through Register Vol. 13, July 5, 2024
(1) The following
				definitions apply to this subchapter:
(a)
				"Fair market value" means the amount of compensation at which property would
				change hands between a willing buyer and an unrelated seller, neither being
				under compulsion to buy or sell and both having reasonable knowledge of the
				relevant facts.
(b) "Compensation"
				means money, food, shelter, support, maintenance, services, or other valuable
				real or personal property, as further specified in (5), received by an
				individual in exchange for the transferred property.
(c) "Uncompensated value" means the
				difference between the property's fair market value at the time of the transfer
				less any outstanding encumbrances on the property and the fair market value of
				compensation received in exchange for the property.
(d) "Transfer of property" means any transfer
				or renunciation of a client's property. Transfers to joint tenancy or to
				tenancy in common are included in this definition. Transfers of or restrictions
				upon a client's right of access to or legal ability to dispose of property are
				also included in this definition, except as provided in (8)(b)(iv).
(e) "Incurred medical expenses" are those
				actually incurred medical expenses which are not subject to payment by a third
				party.
(f) "Undue hardship" means
				any one of the conditions specified in (8)(b)(i) through (8)(b)(v).
(g) "Client" means applicant for or recipient
				of Medicaid services or such a person at any time prior to application and,
				where the context allows, includes any person whose resources are considered by
				the department in determining eligibility of the applicant or
				recipient.
(h) "Property" means any
				full or proportionate right, title or interest in or to any real or personal
				property or property right.
(i)
				"Institutionalization" means admission to a nursing facility, admission to a
				medical institution at a level of care equivalent to nursing facility services,
				or commencement of services to the applicant or recipient under the Home and
				Community Based Waiver program.
(j)
				"Home" means the client's principal place of residence, including adjoining
				land and outbuildings;
(k)
				"Principal place of residence" means the property on which the individual, the
				individual's spouse, or a dependent child of the individual (including a
				dependent adult child) currently resides or has resided within the previous six
				months and the individual, the individual's spouse, or a dependent child of the
				individual intends to return to the property to reside within six months of
				absence in the event of a temporary absence. Only one property may qualify as
				an individual's principal place of residence.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.418 - BONA FIDE EFFORT TO SELL NON-HOME REAL PROPERTY (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-6-113,
					 MCA; IMP,
					 53-6-131,
					 53-6-141,
					 53-6-142,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.419 through 37.82.421 - 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 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.422 - CONDITIONAL MEDICAL ASSISTANCE, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) Definitions for the purposes of
				conditional medical assistance include:
(a)
				"Nonliquid resource" is personal property which is not cash and which cannot be
				converted to cash within 20 workdays.
(b) "Liquid resource" is property which is
				cash or can be converted to cash within 20 workdays.
(c) "Net proceeds" is the current market
				value of the resource less sale costs and encumbrances.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.423 - CONDITIONAL MEDICAL ASSISTANCE, ELIGIBILITY

Current through Register Vol. 13, July 5, 2024
(1) Medicaid applicants may qualify for
				assistance conditioned on the sale, at current market value, of excess
				nonliquid resources.
(2) To be
				eligible for conditional assistance an applicant must:
(a) be categorically eligible by reason of
				being:
(i) age 65 or older;
(ii) blind; or
(iii) disabled;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.424 - HEALTH PLAN PREMIUM PAYMENTS

Current through Register Vol. 13, July 5, 2024
(1) "Group
				health plan" means any plan of an employer or any plan to which an employer
				contributes including a self-insured plan to provide health care, directly or
				otherwise, to the employer's employees, former employees, or the families of
				such employees, or former employees.
(2) "Individual health plan" means any plan
				to provide health care to an individual and/or his family which is not a plan
				of the individuals's employer or to which the individual's employer
				contributes.
(3) "Cost effective"
				means the amount paid for premiums, coinsurance, deductibles, and other cost
				sharing obligations under an individual or group health plan plus the
				additional departmental administrative costs is likely to be less than the
				department would pay out for Medicaid services for a Medicaid recipient,
				determined on an actuarial basis.
(a) Cost
				effective criteria may include assessment of medical diagnoses and health risk
				assessment.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.82 - MEDICAID ELIGIBILITY › Subchapter 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.425 through 37.82.429 - 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 37.82.4 - General Non-Financial And Financial Eligibility Requirements for the Categorically Needy and the Medically Needy › Rule 37.82.430 - COBRA CONTINUATION BENEFICIARIES, APPLICATION, AND ELIGIBILITY FOR MEDICAID

Current through Register Vol. 13, July 5, 2024
(1) A person is a
				COBRA continuation beneficiary eligible for Medicaid, if:
(a) the person meets the nonfinancial
				criteria in (2) of this rule;
(b)
				the person has countable resources which do not exceed twice the federal
				supplemental security income (SSI) resource limitation set forth at
				42 USC
				1382 (a)(3)(A) and (B). The department hereby
				incorporates
				42 USC
				1382 (a)(3)(A) and (B) as amended through
				April 1, 1991. Copies of
				42 USC
				1382 (a)(3)(A) and (B), as amended through
				April 1, 1991, are available from the Department of Public Health and Human
				Services, Human and Community Services Division, Cogswell Building, 1400
				Broadway, P.O. Box 202952, Helena, MT 59620-2952;
(c) the person has countable income not in
				excess of 100% of the federal poverty income standard as defined by the
				Executive Office of Management and Budget (EOMB) and revised
				annually;
(d) the person is
				eligible for coverage under a group health plan provided by an employer with at
				least 75 employees pursuant to Title XXII of the Public Health Service Act,
				subsection 4980B of the Internal Revenue Code of 1986, or Title VI of the
				Employee Retirement Income Security Act (ERISA) of 1974 due to a qualifying
				event;
(i) a COBRA continuation coverage
				qualifying event is:
(A) death of the covered
				employee;
(B) termination or
				reduction of hours of the covered employee's employment;
(C) divorce or legal separation of the
				covered employee from the employee's spouse;
(D) the covered employee becoming eligible
				for benefits under Medicare; or
(E)
				a dependent child ceases to be a dependent child under the applicable plan
				requirements.
(e) it is cost effective to pay the health
				plan premiums according to the definition of cost effective in (2) of ARM
				37.82.424.