reglab/statecodes huggingface dataset:
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.40 - Targeted Case Management Services for Substance Use Disorders › Rule 37.86.4005 - TARGETED CASE MANAGEMENT SERVICES FOR SUBSTANCE USE DISORDERS, SERVICE COVERAGE

Current through Register Vol. 13, July 5, 2024
(1) TCM services
				must meet all requirements found in ARM
				37.86.3301 through
				37.86.3306.
(2) TCM services for substance use disorders
				include those indicated in ARM
				37.86.4001(2) through
				(5).
(3) TCM services for substance use disorders
				are provided by state-approved chemical dependency treatment programs in
				accordance with these rules and the provisions of ARM
				37.27.901 through ARM
				37.27.912, and
				53-24-208,
				MCA.
(4) TCM services may include
				contacts with noneligible individuals for purposes related to identification of
				the person's needs, accessing needed services, identifying needs and supports
				to assist in obtaining identified services, providing case managers with useful
				feedback, and alerting case managers to changes in the person's
				needs.
(5) TCM does not include:
(a) direct delivery of medical, educational,
				social, or other services to which a person has been referred;
(b) when activities are an integral and
				inseparable component of another covered Medicaid service;
(c) duplicate payments made to public
				agencies or private entities under the State Plan and other program
				authorities;
(d) writing,
				recording, or entering case notes for the person's file;
(e) coordination of the investigation of
				suspected abuse, neglect, and/or exploitation cases;
(f) travel to and from activities, with or
				without the person;
(g) any service
				that does not incorporate the allowable TCM components, even if written into
				the individualized TCM case plan;
(h) Medicaid determination and
				redetermination (arranging for appointments, monitoring completion of needed
				steps for determination are eligible TCM services); and
(i) activities for which a person may be
				eligible that are integral to the administration of another nonmedical program
				such as guardianship, child welfare/child protective services, parole,
				probation, foster care services, or specialized education programs except for
				case management that is included in an individualized education program or
				individualized family service plan consistent with SSA section 1903c for
				services furnished to a child with a disability or to an infant or toddler with
				a disability.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.40 - Targeted Case Management Services for Substance Use Disorders › Rule 37.86.4006 - TARGETED CASE MANAGEMENT SERVICES FOR SUBSTANCE USE DISORDERS, SERVICE REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) Persons
				receiving TCM services are allowed the freedom of choice of any qualified
				Medicaid provider for targeted case management services.
(2) TCM service providers cannot restrict a
				person's access to other Medicaid services.
(3) TCM services will not duplicate payments
				made to public agencies or private entities under the Medicaid program and
				other program authorities.
(4) A
				person cannot be compelled to receive TCM services as a condition of receipt of
				other Medicaid services or condition of receipt of other Medicaid services on
				receipt of TCM services.
(5) TCM
				services must be supported by narrative documentation of all services
				provided.
(6) TCM services must be
				provided according to a TCM plan which must:
(a) be developed jointly by the case manager
				and the person;
(b) identify
				measurable objectives;
(c) specify
				strategies to achieve defined objectives;
(d) identify agencies and contacts which will
				assist in meeting the objectives;
(e) be incorporated into the treatment
				plan;
(f) identify natural and
				community supports to be utilized and developed; and
(g) include an objective to serve the person
				in the least restrictive and most culturally appropriate therapeutic
				environment possible for the person. The TCM plan should also be directed
				toward facilitating preservation of the person in the family unit, preventing
				out-of-community placement, or facilitating the person's return from inpatient
				or residential care.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.40 - Targeted Case Management Services for Substance Use Disorders › Rule 37.86.4007 - TARGETED CASE MANAGEMENT SERVICES FOR SUBSTANCE USE DISORDERS, PROVIDER REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) The requirement
				in (2) is in addition to those requirements contained in rules generally
				applicable to Medicaid providers.
(2) TCM services for substance use disorders
				must be provided by a state-approved substance use disorder treatment program
				that is enrolled in the Montana Medicaid program.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.40 - Targeted Case Management Services for Substance Use Disorders › Rule 37.86.4010 - TARGETED CASE MANAGEMENT SERVICES FOR SUBSTANCE USE DISORDERS, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) TCM services for substance use disorders
				will be reimbursed on a fee per unit of service basis. For purposes of this
				rule, a unit of service is a period of 15 minutes.
(2) The department may, in its discretion,
				designate a single provider to provide targeted case management services in a
				designated geographical region. Any provider designated as the sole case
				management provider for a designated geographical region must, as a condition
				of such designation, agree to serve the entire designated geographical
				region.
(3) The provider
				reimbursement rate for case management services for substance use disorders is
				stated in the department's fee schedule provided in ARM
				37.85.105(5).
(4) The department will pay the lower of the
				following for TCM services:
(a) the
				provider's actual submitted charge for services; or
(b) the amount specified in the State
				Approved Chemical Dependency Program Manual.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.42 - Dialysis Clinics for End Stage Renal Disease › Rule 37.86.4201 - DIALYSIS CLINICS FOR END STAGE RENAL DISEASE, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "Dialysis clinics (DC)" are facilities
				licensed by the officially designated authority in the state where the
				institution is located and certified by the Centers for Medicare and Medicaid
				Services (CMS) to:
(a) furnish outpatient
				maintenance dialysis directly to end stage renal disease (ESRD) patients;
				and
(b) provide training for
				self-dialysis and home dialysis.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.42 - Dialysis Clinics for End Stage Renal Disease › Rule 37.86.4202 - DIALYSIS CLINICS FOR END STAGE RENAL DISEASE, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) These requirements are in addition to
				those contained in ARM
				37.85.401,
				37.85.402,
				37.85.406,
				37.85.407,
				37.85.410,
				37.85.414, and
				37.85.415.
(2) The provision of outpatient maintenance
				dialysis and related services by the Medicaid program will be coordinated with
				the Medicare renal disease program as provided in CFR Title 42 section 413.171
				and 413.172.
(3) Outpatient
				maintenance dialysis and related services in a DC will be provided only to a
				person who has been diagnosed as suffering from chronic ESRD by a
				physician.
53-6-113,
					 MCA; IMP,
					 53-6-101,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.42 - Dialysis Clinics for End Stage Renal Disease › Rule 37.86.4205 - DIALYSIS CLINICS FOR END STAGE RENAL DISEASE, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Reimbursement for outpatient maintenance
				dialysis and other related services provided in a dialysis clinic to include
				the bundled Medicare composite rate is provided in ARM
				37.85.105(3). The
				department will not allow add-on adjustments to the composite rate.
53-6-113,
					 MCA; IMP,
					 53-6-101,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4401 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1) "Allowable costs" are the costs incurred
				by an RHC or FQHC, which are reasonable in amount and necessary and proper to
				the efficient delivery of services. Allowable costs are defined in accordance
				with reasonable cost principles in 42 CFR Parts 405 and 413.
(2) "Baseline PPS rate" is defined as an
				RHC's or FQHC's current PPS rate established in accordance with ARM
				37.86.4413,
				37.86.4420(2),
				37.86.4409,
				or
				37.86.4410,
				as adjusted annually by the Medicare economic index (MEI).
(3) "Category of service" means a type of
				Medicaid covered service that is furnished in an RHC or FQHC.
(4) "Change in the scope of service" means a
				change that affects the type, intensity, duration, or amount of services
				provided by an RHC or FQHC. The change in the scope of service must reasonably
				be expected to last at least one year.
(5) "Crossover claim" means a claim for
				services provided to Medicare/Medicaid dual eligibles or qualified Medicare
				beneficiaries.
(6) "Federally
				qualified health center (FQHC)" means an entity as defined in
				42
				USC 1396d(l)(2). A copy of
				the cited statute is available upon request from the Department of Public
				Health and Human Services, Health Resources Division, Hospital and Physicians
				Services Bureau, 1400 Broadway, P.O. Box 202951, Helena, MT
				59620-2951.
(7) "FQHC services" are
				as defined in
				42
				USC 1396d(l)(2).
(8) "Health professional" means services
				furnished by a:
(a) physician;
(b) nurse practitioner (NP);
(c) physician assistant (PA);
(d) certified nurse-midwife (CNM);
(e) licensed clinical psychologist (LCP);
(f) licensed clinical social
				worker (LCSW);
(g) licensed
				professional counselor (LCPC);
(h)
				licensed marriage and family therapist (LMFT);
(i) licensed addiction counselor (LAC);
				and
(j) clinical pharmacist
				practitioner.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4402 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, VISITS AND ENCOUNTERS

Current through Register Vol. 13, July 5, 2024
(1) A visit is a
				face-to-face encounter between an RHC or FQHC patient and an RHC or FQHC health
				professional for the purpose of providing RHC or FQHC services. Reimbursement
				is available for one encounter per day per eligible member unless it is
				necessary for the member:
(a) to be seen by
				different health professionals with different specialties; or
(b) to be seen multiple times per day due to
				unrelated diagnoses.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4405 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, PROVIDER PARTICIPATION REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) The
				requirements of this subchapter are in addition to those contained in rule
				provisions generally applicable to medicaid providers.
(2) As a condition of participation in the
				Montana medicaid program, a RHC or FQHC must maintain a current Montana
				medicaid provider enrollment according to the requirements of ARM
				37.85.402.
(3) As a condition of participation in the
				Montana medicaid program, a rural health clinic must be and remain certified by
				the medicare program under the conditions of certification specified in 42 CFR
				Part 491, subpart A.
(4) As a
				condition of participation in the Montana medicaid program, an FQHC must be a
				federally qualified health center as defined in
				42 USC
				1396 d(l) (2) (B).
Sec.
					 53-6-113,
					 MCA; IMP, Sec.
					 53-2-201,
					 53-6-101,
					 53-6-111
					 and
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4407 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, RECORD KEEPING AND REPORTS

Current through Register Vol. 13, July 5, 2024
(1) A provider must
				meet the record keeping and other requirements of ARM
				37.85.414 in addition to the
				requirements of this rule.
(2) A
				provider must make and maintain adequate financial and statistical records in
				accordance with generally accepted accounting principles, as defined by the
				American institute of certified public accountants. The provider's records must
				be sufficient to allow the department and its agents to determine payment for
				the RHC or FQHC services provided to medicaid recipients and to provide a
				record that may be audited using generally accepted auditing standards. Such
				records must be maintained for a period of six years, three months after a cost
				report is filed with respect to the period covered by such records or until
				such cost report is finally settled, whichever is later.
(3) The records described in (2) must be
				available at the provider facility at all reasonable times and shall be subject
				to inspection, review and audit by the department or its agents, the United
				States department of health and human services, the general accounting office,
				the Montana legislative auditor, and other governmental agencies as authorized
				by law.
(4) Upon failure or refusal
				of the provider to make available and allow access to such records, or to
				report an increase or decrease in scope of services, the department may recover
				in full all payments made to the provider during the reporting period to which
				such records relate and may suspend any further payments to the provider until
				such time as the provider fully complies with this rule.
(5) No later than 30 days prior to the
				beginning of its initial reporting period as a new provider or following a
				change in ownership, a provider must submit to the department or its agent an
				estimate of budgeted costs and visits for RHC or FQHC services for the
				reporting period in the form and detail required by the department and such
				other information as the department may require to establish a rate as provided
				at ARM 37.86.4413.
Sec.
					 53-6-113,
					 MCA; IMP, Sec.
					 53-2-201,
					 53-6-101,
					 53-6-111
					 and
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4408 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, REQUIREMENTS FOR CHANGE IN SCOPE OF SERVICE REQUEST

Current through Register Vol. 13, July 5, 2024
(1)
				An RHC or FQHC experiences a change in scope of service if it has experienced a
				change in the type, intensity, duration, or amount of an RHC or FQHC service. A
				change in scope of service may result in an incremental change to the baseline
				PPS rate.
(2) An RHC or FQHC must
				apply to the department if it experiences a change in scope of service, even if
				the change in scope of service will not result in an incremental change to the
				baseline PPS rate. An RHC or FQHC must follow the procedures in ARM 37.86.4409
				and ARM 37.86.4410 to apply for a change in scope of service.
(3) A change in scope of service is limited
				to the following circumstances, and an RHC or FQHC applying for a change in
				scope of service must demonstrate at least one of the following:
(a) the addition of a new service not
				incorporated in the baseline PPS rate or deletion of a service incorporated in
				the baseline PPS rate;
(b) the
				addition or deletion of a covered Medicaid RHC or FQHC service under the State
				Plan;
(c) a change necessary to
				maintain compliance with amended state or federal regulations or regulatory
				requirements;
(d) a change in
				service due to a change in applicable technology or medical practices utilized
				by the RHC or FQHC not otherwise paid for through state or federal
				funds;
(e) a change in the types of
				patients served, including but not limited to, populations with HIV/AIDS,
				populations with other chronic diseases, or homeless, elderly, migrant, or
				other special populations that require more intensive and frequent care,
				corresponding to a change in the services provided by the RHC or
				FQHC;
(f) a change in operating
				costs attributable to capital expenditures corresponding to a change in the
				services provided by the RHC or FQHC; or
(g) a change in the provider mix, including,
				but not limited to:
(i) a transition from
				mid-level providers to physicians with a corresponding change in the services
				provided by the RHC or FQHC; or
(ii) the addition or removal of specialty
				providers with a corresponding change in the services provided by the RHC or
				FQHC.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4409 - PROSPECTIVE CHANGE IN SCOPE OF SERVICE

Current through Register Vol. 13, July 5, 2024
(1)
				A prospective change in scope of service is a change the RHC or FQHC plans to
				implement in the future. An RHC or FQHC may file an application for a
				prospective change in scope of service and, if approved, may receive a
				temporary PPS rate, pending final approval of the incremental change to the
				baseline PPS rate.
(2) An
				application is deemed timely if the department receives the completed
				application for a prospective change in scope of service no later than 120 days
				in advance of the prospective change in scope of service, or otherwise the
				application is deemed untimely.
(3)
				An application is completed if it includes the information in (4), and, if
				applicable, (5).
(4) To apply for a
				prospective change in scope of service rate adjustment, an RHC or FQHC must
				submit the following application materials:
(a) a narrative description of each change in
				scope of service;
(b) the date on
				which the change in scope of service is scheduled to occur;
(c) a description of each cost center(s) on
				the cost report that will be affected by the change in scope of
				service;
(d) the cost report for
				the fiscal year prior to the year in which the prospective change in scope of
				service is scheduled to be implemented; and
(e) a projected cost report for the fiscal
				year in which the change in scope of service is implemented, which considers
				the change in scope of service. If a projected cost report cannot be completed,
				the RHC or FQHC must provide sufficient cost and encounter information to
				establish a temporary rate.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4410 - RETROSPECTIVE CHANGE IN SCOPE OF SERVICE

Current through Register Vol. 13, July 5, 2024
(1)
				A retrospective change in scope of service occurs when a change took place in
				the past and the RHC or FQHC is seeking to adjust its rate based on that
				change. An approved retrospective change in scope of service request may result
				in an incremental change to the baseline PPS rate.
(2) An RHC or FQHC may apply for an
				incremental change to the baseline PPS rate for a retrospective change in scope
				of service once per calendar year. In order to be deemed timely, the completed
				application must be received by the department no later than six months after
				the close of the RHC's or FQHC's fiscal year in which the change in scope of
				service occurred, or otherwise the application is untimely. A completed
				application must include the information in (3) and, if applicable,
				(4).
(3) To apply for an
				incremental change to the baseline PPS rate for a retrospective change in scope
				of service, an RHC or FQHC must submit the following application materials:
(a) a narrative description of each change in
				scope of service, including how services were provided both before and after
				the change;
(b) the RHC's or
				FQHC's as-filed Medicare cost reports for the fiscal year prior to the change
				in scope of service, and the fiscal year in which the change in scope of
				service occurred;
(c) for FQHCs the
				Uniform Data System reports for the calendar year prior to the change in scope
				of service, and the calendar year in which the change in scope of service
				occurred;
(d) a description of each
				cost center on the cost report affected by the change in scope of
				service;
(e) an attestation
				statement that certifies the accuracy, truth, and completeness of the
				information in the application signed by an officer or administrator of the RHC
				or FQHC; and
(f) any approved
				changes in scope of project as defined by the Health Resources and Services
				Administration (HRSA).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4412 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) This subchapter specifies requirements
				applicable to provision of and reimbursement for RHC and FQHC services. These
				rules are in addition to requirements generally applicable to Medicaid
				providers as otherwise provided in state and federal statute, rules,
				regulations, and policies.
(2)
				Unless otherwise provided in these rules, this subchapter applies to rate years
				beginning on or after January 1, 2001. Reimbursement and other substantive RHC
				and FQHC requirements for earlier periods are subject to the laws, regulations,
				rules, and policies then in effect. Procedural and other nonsubstantive
				provisions of these rules are effective upon adoption.
(3) All RHCs and FQHCs will be reimbursed on
				a prospective payment system (PPS) beginning January 1, 2001 and each
				succeeding calendar year. The PPS will apply equally to provider based and
				independent RHCs and FQHCs.
(4) On
				January 1 of each succeeding calendar year, the rate for the preceding year
				must be adjusted by the percentage increase in the medicare economic index
				(MEI) applicable to primary care services for that calendar year.
(5) The department will reimburse the RHC or
				FQHC for the rate change in (4) retroactive to the effective date of January 1
				of the calendar year, beginning with January 1, 2002.
(6) For RHCs or FQHCs that had their initial
				Medicaid prospective payment system base visit rate calculated in 2001 or
				starting with the third fiscal year (for "new" RHCs or FQHCs as defined at ARM
				37.86.4413
				), the prospective payment system per visit rate may be adjusted to take into
				account any increase or decrease in the scope of service.
(7) Effective July 1, 2017, approved RHCs and
				FQHCs participating in Promising Pregnancy Care (PPC) will be reimbursed an
				enhanced PPS rate. Therefore, RHCs and FQHCs will be reimbursed their existing
				PPS rate plus an additional amount, in accordance with the fee schedule adopted
				and effective as provided in ARM
				37.85.105,
				whenever a member attends the educational aspect of the PPC session.
(8) Effective July 1, 2017, RHCs and FQHCs
				will be reimbursed separately for long-acting reversible contraceptives (LARCs)
				in addition to their PPS rate. LARCs include intrauterine devices (IUDs) and
				birth control implants.
AUTH:
					 53-2-201,
					 53-6-113,
					 MCA; IMP:
					 53-6-101,
					 53-6-111,
					 53-6-113,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4413 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, ESTABLISHMENT OF INTERIM PAYMENT FOR NEW RHC OR FQHC

Current through Register Vol. 13, July 5, 2024
(1)
				The interim Medicaid prospective payment system (PPS) base per-visit rate for a
				newly qualified RHC or FQHC or an FQHC shifting from non-state government
				operated to privately operated shall be equal to 100% of the average PPS rate
				for other RHCs or FQHCs located in the same or adjacent area with a similar
				caseload. In the event that there is no such RHC or FQHC, payment shall be made
				in accordance with the methodology provided in (2).
(2) If there is no RHC or FQHC located in the
				same or adjacent area with a similar caseload, the interim PPS rate shall be
				equal to the RHC's or FQHC's total projected allowable costs divided by the
				RHC's or FQHC's total projected allowable visits. The provider must submit to
				the department or its agent an estimate of budgeted costs and visits for the
				RHC or FQHC for the reporting period in the form and detail required by the
				department and such other information as the department may require to
				establish a rate. The projected allowable cost and allowable visit information
				is subject to a reasonableness review by the department.
(3) At the end of the RHC's or FQHC's first
				two complete fiscal years, the department will establish the facility specific
				baseline PPS rate.
(4) The
				department must receive the RHC's or FQHC's as-filed Medicare cost reports for
				the first two complete fiscal years no later than six months after the end of
				the RHC's or FQHC's first two complete fiscal years, or otherwise the request
				is deemed untimely.
(a) The department may
				request additional information from the RHC or FQHC, and the facility is
				required to submit the requested information within 30 days of the department's
				request. If the requested information is not received within that timeframe,
				the request is deemed untimely. The request for additional information will
				include a notice that failure to submit the materials within the requested 30
				calendar days will result in suspension of payments for Medicaid services
				billed to the department until such time as the supplemental materials are
				received by the department.
(b) If
				the department has not received the materials in (4)(a) thirty days prior to
				the expiration of the six month deadline, the department shall send a notice to
				the RHC or FQHC and inform it that failure to submit the materials in a timely
				manner will result in suspension of payments for Medicaid services billed to
				the department until such time as the materials are received by the
				department.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4414 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, SUPPLEMENTAL PAYMENTS IN CASE OF MANAGED CARE

Current through Register Vol. 13, July 5, 2024
(1) In the case
				of services furnished by an RHC or FQHC pursuant to a contract between the RHC
				or FQHC and a managed care entity (as defined in section 1932(a) (1) (B) and
				1932(a) (1) (C) of the Social Security Act), payment to the RHC or FQHC shall
				be a supplemental payment equal to the amount (if any) by which the amount
				determined under medicaid prospective payment system exceeds the amount of the
				payments provided under the contract.
(2) The supplemental payment required shall
				be made quarterly.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-2-201,
					 53-6-101,
					 53-6-111
					 and
					 53-6-113,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.44 - Rural Health Clinics and Federally Qualified Health Centers › Rule 37.86.4420 - RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, ALTERNATIVE PAYMENT METHODOLOGIES

Current through Register Vol. 13, July 5, 2024
(1) In the case
				of a catastrophic event or extraordinary circumstance that would directly
				impact the cost of medical services provided by an RHC or FQHC, or upon mutual
				agreement of the department and the RHC or FQHC the department may provide for
				payment in any year to an RHC or FQHC for services described in section 1905(a)
				(2) (B) and (C) of the Social Security Act in an amount determined under an
				alternative payment methodology that:
(a) is
				agreed to by the department and the RHC or FQHC; and
(b) results in payment to the RHC or FQHC of
				an amount which is at least equal to the amount.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.45 - Promising Pregnancy Care › Rule 37.86.4501 - PROMISING PREGNANCY CARE - DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1)
				"Group prenatal care" means a combination of individual prenatal care with
				facilitated group education and support. The groups consist of four to twelve
				pregnant women with similar due dates.
(2) "Promising Pregnancy Care (PPC)" means
				the Montana Healthcare Programs reimbursable group prenatal care program. The
				Montana Healthcare Programs include:
(a)
				Montana Medicaid;
(b) Healthy
				Montana Kids (HMK);
(c) HMK Plus
				Medicaid; and
(d) the Health and
				Economic Livelihood Plan (HELP).
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.45 - Promising Pregnancy Care › Rule 37.86.4502 - PROMISING PREGNANCY CARE - GENERAL PROVISIONS

Current through Register Vol. 13, July 5, 2024
(1) These requirements are in addition to
				those requirements contained in rule and statutory provisions generally
				applicable to Medicaid providers.
(2) For purposes of Medicaid reimbursement,
				providers must be a state-approved program.
(3) Pregnant members of Montana Healthcare
				Programs are eligible for Promising Pregnancy Care.
(4) The department must approve educational
				materials.
(5) A pregnancy notebook
				that includes personal health tracking and education materials must be provided
				to class participants.
(6) Data on
				all pregnant Medicaid members under the provider's care must be collected and
				reported to the department. The required data elements are available at the
				department's website at
http://medicaidprovider.mt.gov
.
(7) Classes must be provided in a group
				setting.
(8) Individual assessment
				will occur in a private area of the group space.
(9) Each class must include time for the
				participants to interact with other participants.
(10) The classes must be facilitated and have
				a planned learning objective.
(11)
				Participants must engage in self-care activities.
(12) The program must include the following
				information:
(a) nutrition
				information;
(b) healthy lifestyle
				choices;
(c) breastfeeding
				education;
(d) body changes in
				pregnancy;
(e) stress
				management;
(f) family
				planning;
(g) labor education,
				including types of delivery;
(h)
				newborn care;
(i) preventing shaken
				baby syndrome;
(j) preventing
				sudden infant death syndrome (SIDS); and
(k) postpartum care and
				adjustments.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.45 - Promising Pregnancy Care › Rule 37.86.4503 - PROMISING PREGNANCY CARE - REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Promising Pregnancy Care is reimbursed at
				the lower of the following:
(a) the
				provider's usual and customary charge to the general public for the service;
				or
(b) the department's current fee
				schedule under ARM
				37.85.105 for the appropriate
				provider type.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.47 - Organ Transplant Services › Rule 37.86.4701 - ORGAN TRANSPLANTATION, DEFINITIONS

Current through Register Vol. 13, July 5, 2024
(1)
				"Organ transplantation" means the implantation of a functional human organ for
				the purpose of maintaining all or a major part of that organ function in the
				recipient.
(2) "Tissue
				transplantation" means the implantation of functional, human tissue. For
				purpose of the transplantation rules, tissue transplants include only corneal,
				bone marrow, and peripheral stem cell transplants.
(3) Organ and tissue transplantation includes
				the transplant surgery and those activities directly related to the
				transplantation. These activities may include:
(a) evaluation of the patient as a potential
				transplant candidate;
(b)
				pre-transplant preparation including histo-compatibility testing
				procedures;
(c) post surgical
				hospitalization;
(d) outpatient
				care, including Federal Drug Administration (FDA) approved medications deemed
				necessary for maintenance or because of resulting complications.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.47 - Organ Transplant Services › Rule 37.86.4705 - ORGAN TRANSPLANTATION, REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1) This rule provides the requirements for
				Medicaid coverage of organ and tissue transplantations. The requirements in
				this rule are in addition to those contained in ARM
				37.85.401,
				37.85.402,
				37.85.406,
				37.85.407,
				37.85.410,
				37.85.412,
				37.85.413,
				37.85.414, and
				37.85.415.
(2) General requirements for Medicaid
				coverage of transplantations are as follows:
(a) Medicaid will only cover medically
				necessary organ or tissue transplants.
(i)
				Services must comply with Medicare coverage guidelines for organ or tissue
				transplant service.
(ii) If
				Medicare coverage guidelines are not available, the department or the
				department's designated review organization will review the requested
				transplant surgery to determine whether the surgery is medically necessary and
				is not experimental or investigational.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.47 - Organ Transplant Services › Rule 37.86.4706 - ORGAN TRANSPLANTATION, REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) Reimbursement for physician services in
				organ transplantation is provided in accordance with the methodologies
				described in ARM
				37.85.212 and
				37.86.105.
(2) All hospital services for organ and
				tissue transplantation are reimbursed as provided for in ARM 37.85.212,
				37.86.2801, 37.86.2806, 37.86.2907, 37.86.2916, 37.87.3005, 37.87.3009,
				37.87.3020, 37.87.3025, and 37.87.3037.
53-2-201,
					 53-6-113,
					 MCA; IMP,
					 53-2-201,
					 53-6-101,
					 53-6-131,
					 53-6-141,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5002 - HEALTH MAINTENANCE ORGANIZATIONS: RECIPIENT ELIGIBILITY

Current through Register Vol. 13, July 5, 2024
(1) A recipient in any one of the following
				categories is eligible to enroll with an HMO contracting with the department:
(a) a FAIM or family-related recipient
				required by ARM
				37.86.5103 to participate in a
				primary care case management program; or
(b) an SSI recipient or SSI-related recipient
				required by ARM
				37.86.5103 to participate in a
				primary care case management program.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5005 - HEALTH MAINTENANCE ORGANIZATIONS: ENROLLMENT

Current through Register Vol. 13, July 5, 2024
(1) Recipient enrollment with an HMO
				contracting with the department is voluntary, except as noted below.
(a) Individuals 21 years of age or older
				receiving medicaid or medically needy assistance as participants of the FAIM
				project, and who are not pregnant, are required to enroll in an HMO if one is
				available in the enrollment area and has not reached its maximum enrollment. If
				the HMOs in the enrollment area are at maximum enrollment, the individual must
				participate in the passport to health program as required in ARM
				37.86.5101, et seq.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5006 - HEALTH MAINTENANCE ORGANIZATIONS: DISENROLLMENT

Current through Register Vol. 13, July 5, 2024
(1) An enrollee may request, without good
				cause, disenrollment from an HMO at any time, except that an individual
				required to enroll in an HMO per ARM
				37.86.5005(1) (a)
				 may disenroll only for good cause as defined
				in (11) of this rule.
(2) A
				disenrollment request must be accompanied by a choice for another managed
				health care provider.
(3)
				Disenrollment is requested by either completing a form designated by the
				administrative contractor for managed care or by a written or oral request to
				the administrative contractor for managed care.
(a) The form must be available through the
				same locations as specified in ARM
				37.86.5005 for the enrollment
				form.
(b) An HMO or any other
				entity responsible for making the form available upon receiving a form or a
				request, must forward the form or request to the administrative contractor for
				managed care within 3 working days.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5010 - HEALTH MAINTENANCE ORGANIZATIONS: CONTRACTS FOR SERVICES

Current through Register Vol. 13, July 5, 2024
(1) The department may enter into a contract
				with an HMO with a certificate of authority under the provisions of
				33-31-201,
				et seq., MCA, to provide any of the services specified in ARM
				37.86.5007.
(2) An HMO, entering into a contract with the
				department, must meet the requirements in
				53-6-705,
				MCA.
(3) A contract for the
				provision of services through an HMO must meet the requirements of 42 CFR part
				434. The department hereby adopts and incorporates by reference 42 CFR part
				434, dated October 1998. A copy of the incorporated provisions may be obtained
				through the Department of Public Health and Human Services, Health Policy and
				Services Division, 1400 Broadway, P.O. Box 202951, Helena, MT
				59620-2951.
(4) An HMO entering
				into a contract with the department for the delivery of services assumes the
				risk that the costs of performance may exceed the consideration available
				through the capitation rate and otherwise.
(5) An HMO must provide the department with
				documented assurances to show that the HMO is not likely to become insolvent.
				This requirement may be satisfied by documenting compliance with
				33-31-216,
				MCA.
(6) An HMO may not in any
				manner hold an enrollee responsible for the debts of the HMO.
(7) A contract with an HMO must:
(a) list the covered services to be provided
				by the HMO;
(b) specify the method
				and rate of reimbursement; and
(c)
				provide for disclosure of ownership and subcontractor relationship;
				and
(d) owners, directors,
				officers, or partners of the HMO must certify that they meet federal
				nondebarment requirements.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5011 - HEALTH MAINTENANCE ORGANIZATIONS: PROVISION OF SERVICES

Current through Register Vol. 13, July 5, 2024
(1) An HMO may impose the following
				requirements in the provision of services:
(a) the use of certain types of
				providers;
(b) the preauthorization
				for services and use of network providers other than emergency services, family
				planning, immunizations and blood lead testing at a public health
				clinic;
(c) the use of network
				providers, on a self-referral basis, for obstetrical, gynecological, and
				maternity services;
(d) directing
				an enrollee to the appropriate level of care for receipt of covered services;
				and
(e) denial of payment to a
				provider for services provided to an enrollee if the participation requirements
				in this rule are not met by the enrollee; or
(f) if a recipient is mandated into an HMO
				and chooses to go to an FQHC that is not on the provider panel, approval for
				services is not required, but the recipient must inform the HMO before
				receiving services.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5012 - HEALTH MAINTENANCE ORGANIZATIONS: PARTICIPATING PROVIDERS

Current through Register Vol. 13, July 5, 2024
(1) An HMO, except as otherwise provided in
				this rule, may select the providers of medical services the HMO determines
				necessary to meet its contractual obligations with the department.
(2) The HMO must offer to:
(a) medicaid-enrolled targeted case managers
				for high risk pregnant women who serve recipients in the enrollment area, terms
				and conditions that are at least as favorable as those offered to other
				participating providers providing this service and that substantially meet the
				same access and credentialing criteria as like participating providers;
				and
(b) federally qualified health
				centers or rural health clinics which serve recipients in the enrollment area,
				terms and conditions, excluding reimbursement, that are at least as favorable
				as those offered to other primary care providers, providing the FQHC or RHC
				substantially meets the same access and credentialing criteria as the HMO's
				other primary care providers.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5013 - HEALTH MAINTENANCE ORGANIZATIONS: REIMBURSEMENT OF PROVIDERS

Current through Register Vol. 13, July 5, 2024
(1) An HMO must reimburse a federally
				qualified health center or a rural health clinic which is a participating
				provider either the same payment per enrollee or service made to other primary
				care providers or the facility specific medicaid interim rate for each enrollee
				visit.
(2) An HMO need not
				reimburse, except as otherwise provided in this rule, claims for medically
				necessary services provided by non-participating providers if the same service
				is covered by the HMO under its contract with the department.
(3) An HMO must reimburse medically necessary
				family planning services as defined in ARM
				37.86.5007(3) 
				provided by a nonparticipating family planning provider to an enrollee who
				sought the services without referral.
(4) An HMO must reimburse immunizations and
				blood lead testing provided by a public health clinic to an enrollee.
(5) An HMO must reimburse nonparticipating
				providers for services for urgent conditions, emergencies or emergency room
				screenings provided to an enrollee.
(6) An HMO, owned, controlled or sponsored by
				or affiliated with a religious organization, must reimburse a covered service
				received by an enrollee that the HMO does not make available due to the service
				constituting a violation of the religious tenets of the organization, to which
				the HMO is related.
(7) An HMO is
				not responsible for reimbursement of the disproportionate share payments for
				inpatient hospital services provided to an enrollee.
(8) An HMO must reimburse services for an
				urgent condition, emergency or emergency room screens in an amount that is not
				less than the department's medicaid rates for those services.
Sec.
					 53-2-201
					 and
					 53-6-113,
					 MCA; IMP, Sec.
					 53-2-201,
					 53-6-101,
					 53-6-113
					 and
					 53-6-116,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.86 - MEDICAID PRIMARY CARE SERVICES › Subchapter 37.86.50 - Health Maintenance Organizations (HMO) › Rule 37.86.5014 - HEALTH MAINTENANCE ORGANIZATIONS: REIMBURSEMENT OF HMOS

Current through Register Vol. 13, July 5, 2024
(1) In consideration for all services
				rendered by an HMO under a contract with the department, the HMO will receive a
				payment each month for each enrollee. This payment is the capitation rate.
				Except as otherwise provided in this rule, the capitation rate represents the
				total obligation of the department with respect to the costs of medical care
				and services provided to each enrollee under the contract.
(a) The capitation rate must be actuarially
				determined.
(b) The capitation rate
				must be:
(i) based on medicaid
				fee-for-service expenses incurred in the provision of the HMO-covered services
				to a non-HMO population of similar characteristics during the base fiscal year;
				and
(ii) based on services that are
				reasonably available to the enrollees of the HMO.
(c) The capitation rate may not exceed the
				cost to the department of providing the same services to an actuarially
				equivalent nonenrolled population group.
(d) The capitation rate may be updated
				annually.
(e) The capitation rate
				does not include:
(i) any amounts for the
				recoupment of losses suffered by an HMO for risks assumed under the contract or
				any previous risk contract;
(ii)
				any disproportionate share payments;
(iii) any payments made by the department
				reflecting the difference between the amounts paid to participating federally
				qualified health centers and rural health clinics by the HMO and the reasonable
				cost of providing services to enrollees; and
(iv) any payments made as a result of
				reinsurance purchased by an HMO from the department.
(f) At a minimum, the capitation rate must be
				5% less than the upper payment limit. The department may reduce the capitation
				rates under the conditions set forth in the contract if there is a funding
				shortfall.