reglab/statecodes huggingface dataset:
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.1 - General Provisions › Rule 37.79.130 - TRANSITION

Current through Register Vol. 13, July 5, 2024
(1) On October 1, 2009, all children
				currently enrolled in the CHIP and the Medicaid children's programs will
				transition from CHIP and Medicaid to the HMK Plan.
(2) The second transition will take place
				when current CHIP enrollees from families with income between 100% and 133% of
				the FPL transition to the CHIP-funded Medicaid expansion program. The
				transition will occur at the time of annual reapplication during federal fiscal
				year 2010 (October 1, 2009 to September 30, 2010). Approximately 10,000 current
				CHIP enrollees will be affected by this transition. The staggered transition
				will occur throughout the year. A parent or guardian of an enrollee in the HMK
				coverage group may apply for the HMK Plus coverage at any time.
(a) For an eligible child in the HMK coverage
				group there is a 12-month family span.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.1 - General Provisions › Rule 37.79.135 - PROSPECTIVE PAYMENT SYSTEM FOR FEDERALLY QUALIFIED HEALTH CENTER (FQHC) REIMBURSEMENT

Current through Register Vol. 13, July 5, 2024
(1) The
				Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA)
				requires states with separate or combined CHIP programs to pay federally
				qualified health centers (FQHCs) and rural health centers (RHCs) using the
				Medicaid outpatient prospective payment system (OPPS) as described in ARM
				37.86.4413. The department adopts
				the Medicaid OPPS rate for children enrolled in the HMK coverage
				group.
53-4-1105,
					 MCA; IMP,
					 53-4-1104,
					 53-4-1105,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.1 - General Provisions › Rule 37.79.140 - OUTREACH EFFORTS

Current through Register Vol. 13, July 5, 2024
(1) The department
				will promote the HMK Plan through a combination of traditional marketing
				methods, social marketing, the development and maintenance of an enrollment
				partner network and collaborative efforts with schools, advocacy groups, health
				care providers, and other community organizations to encourage, assist, and
				actively enroll children in the plan. All outreach will include the name HMK
				Plan on documents associated with the plan including, but not limited to
				advertising, brochures, applications, and membership cards.
53-4-1105,
					 MCA; IMP,
					 53-4-1104,
					 53-4-1105,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.2 - Eligibility › Rule 37.79.201 - ELIGIBILITY

Current through Register Vol. 13, July 5, 2024
(1) An applicant may be eligible for covered
				services under the HMK coverage group if:
(a)
				the applicant is under 19 years of age;
(b) the applicant's social security number is
				provided. Benefits will not be denied or delayed to an otherwise eligible
				applicant pending issuance of his or her social security number;
(c) the family of which the applicant is a
				member has annual family income, without regard to other family resources, at
				or below 250% of the federal poverty level (FPL);
(d) the applicant is a Montana
				resident;
(e) the applicant is a
				U.S. citizen or qualified alien as defined under federal statute;
(f) the applicant is not
				incarcerated;
(g) the applicant is
				not an inpatient in an institution for mental disease on the date of initial
				application or the date of any redetermination of eligibility; and
(h) for three months prior to enrollment the
				applicant has not had creditable private health insurance coverage. This
				requirement is waived if the parent or guardian providing the insurance:
(i) dies;
(ii) is terminated or laid off;
(iii) can no longer work due to a
				disability;
(iv) has a lapse in
				insurance coverage due to new employment;
(v) had insurance coverage that ended because
				the stepparent, who provided the coverage, and the parent divorced;
(vi) had coverage through the Insure Montana
				Program;
(vii) had coverage through
				the Medicaid Health Insurance Premium Payment (HIPP) program;
(viii) paid more than 50% of the insurance
				premium;
(ix) has insurance
				coverage that is not accessible (e.g. coverage is through an HMO in another
				state);
(x) loses Tricare military
				health insurance; or
(xi) has an
				annual aggregate amount of health insurance premiums and cost sharing expenses
				imposed for coverage of the family of a child which exceeds 5% of the family's
				income.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.2 - Eligibility › Rule 37.79.202 - NONQUALIFYING APPLICANTS

Current through Register Vol. 13, July 5, 2024
(1) Applicants
				determined by the department to be eligible for the HMK Plus coverage group are
				eligible to receive the HMK Plus coverage group benefits but not eligible to
				receive the HMK coverage group benefits.
(2) Applicants who are patients in an
				institution for mental diseases on the date of initial application or any
				redetermination of eligibility are not eligible for the HMK coverage group (
				42 CFR
				457.310 ).
(3) Applicants who are incarcerated cannot be
				enrolled in the HMK coverage group.
(4) Applicants who are not eligible for HMK
				coverage group benefits because their family income exceeds the HMK coverage
				group income guideline for the family size will be referred to other health
				care programs for children, as appropriate.
53-4-1004,
					 53-4-1009,
					 53-4-1105,
					 MCA; IMP,
					 53-4-1003,
					 53-4-1004,
					 53-4-1009,
					 53-4-1104,
					 53-4-1105,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.2 - Eligibility › Rule 37.79.206 - ELIGIBILITY REDETERMINATION, NOTICE OF CHANGES

Current through Register Vol. 13, July 5, 2024
(1) Eligibility determinations will be
				effective for a period of 12 months unless one or more of the following changes
				occurs:
(a) the enrollee moves from the state
				of Montana;
(b) the enrollee moves,
				does not notify the department of the new address and the department is unable
				to locate the enrollee;
(c) the
				enrollee is found to have other creditable health coverage;
(d) the enrollee becomes an inmate of a
				public institution;
(e) the
				enrollee attains the age of 19 years;
(f) the enrollee dies; or
(g) the enrollee becomes eligible for HMK
				Plus.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.2 - Eligibility › Rule 37.79.207 - TERMINATION OF ELIGIBILITY AND GUARDIAN LIABILITY

Current through Register Vol. 13, July 5, 2024
(1) The HMK coverage group eligibility
				terminates immediately upon:
(a) death of the
				enrollee; or
(b) incarceration of
				the enrollee.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.2 - Eligibility › Rule 37.79.208 - PROVISIONAL BENEFITS, DETERMINATION OF ELIGIBILITY, AND APPLICATIONS FOR HMK

Current through Register Vol. 13, July 5, 2024
(1) Provisional HMK
				coverage group benefits may be extended to enrollees who would otherwise lose
				health care coverage while awaiting an HMK Plus determination. Provisional
				coverage may be extended to enrollees who:
(a) complete the HMK Plan renewal application
				process before their HMK coverage group benefits are scheduled to
				end;
(b) have been determined
				potentially eligible for HMK Plus coverage; and
(c) are awaiting an HMK Plus eligibility
				determination.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.2 - Eligibility › Rule 37.79.209 - ELIGIBILITY VERIFICATION REVIEWS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1009,
					 MCA; IMP,
					 53-4-1004,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.301 - COVERED BENEFITS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1004,
					 53-4-1009,
					 53-4-1105,
					 MCA; IMP,
					 53-4-1003,
					 53-4-1004,
					 53-4-1009,
					 53-4-1104,
					 53-4-1105,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.302 - COVERAGE LIMITATIONS

Current through Register Vol. 13, July 5, 2024
(1) There is no
				lifetime limit on the dollar value of benefits per enrollee.
(2) Pre-existing conditions of each enrollee
				are covered as of the effective date of enrollment if the condition would be
				otherwise covered.
(3) A newborn of
				an HMK coverage group enrollee shall have all medically necessary benefits
				covered by the HMK coverage group program for 31 days after the newborn's date
				of live birth. Coverage for the newborn shall begin the day of live birth,
				without regard to whether the newborn is hospitalized on the date of
				coverage.
53-4-1004,
					 53-4-1009,
					 53-4-1105,
					 MCA; IMP,
					 53-4-1003,
					 53-4-1004,
					 53-4-1009,
					 53-4-1104,
					 53-4-1105,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.303 - BENEFITS NOT COVERED (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1004,
					 53-4-1009,
					 53-4-1105,
					 MCA; IMP,
					 53-4-1003,
					 53-4-1004,
					 53-4-1005,
					 53-4-1009,
					 53-4-1104,
					 53-4-1105,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.304 - SERVICES COVERED

Current through Register Vol. 13, July 5, 2024
(1) The department
				adopts and incorporates by reference the HMK Evidence of Coverage dated January
				1, 2023, which is available on the department's web site at
www.hmk.mt.gov
.
(2) The HMK Evidence of Coverage describes
				the health care benefits available to an HMK coverage group enrollee if the
				service is medically necessary. Prior authorization may be required and
				copayments may apply.
AUTH:
					 53-4-1009,
					 53-4-1105, MCA; IMP:
					 53-4-1005,
					 53-4-1109,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.307 - INPATIENT HOSPITAL BENEFITS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1009,
					 MCA; IMP,
					 53-4-1003,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.308 - OUTPATIENT HOSPITAL BENEFITS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1009,
					 MCA; IMP,
					 53-4-1003,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.309 - PHYSICIAN AND ADVANCED PRACTICE REGISTERED NURSE BENEFITS, LIMITATIONS, AND EXCLUSIONS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1009,
					 MCA; IMP,
					 53-4-1003,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.312 - PRESCRIPTION DRUG BENEFITS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1004,
					 53-4-1009,
					 53-4-1105,
					 MCA; IMP,
					 53-4-1003,
					 53-4-1004,
					 53-4-1009,
					 53-4-1104,
					 53-4-1105,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.313 - LABORATORY AND RADIOLOGY BENEFITS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1009,
					 MCA; IMP,
					 53-4-1003,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.316 - MENTAL HEALTH BENEFITS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1009,
					 MCA; IMP,
					 53-4-1003,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.317 - SUBSTANCE USE DISORDER BENEFITS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1004,
					 53-4-1009,
					 53-4-1105,
					 MCA; IMP,
					 53-4-1003,
					 53-4-1004,
					 53-4-1009,
					 53-4-1104,
					 53-4-1105,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.321 - VISION BENEFITS

Current through Register Vol. 13, July 5, 2024
(1) Vision benefits
				and medical eye care include:
(a) services
				for the medical treatment of diseases or injury to the eye;
(b) vision exams; and
(c) a dispensing fee for eyeglasses which are
				ordered from the department's contractor and provided by a licensed physician,
				opthamologist, optometrist or optician working within the scope of the
				profession.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.322 - EYEGLASS BENEFITS

Current through Register Vol. 13, July 5, 2024
(1) Eyeglasses
				shall be paid by the department through a single volume purchase
				contract.
(2) An enrollee is
				limited to one pair of eyeglasses per 365 day period unless additional pairs
				are necessary due to any of the following circumstances:
(a) cataract surgery;
(b).50 diopter change in correction in
				sphere;
(c).75 diopter change in
				cylinder;
(d).5 prism diopter
				change in vertical prism;
(e).50
				diopter change in the near reading power;
(f) a minimum of a 5 degree change in axis of
				any cylinder less than or equal to 3.00 diopters;
(g) a minimum of 3 degree change in axis of
				any cylinder greater than 3.00 diopters;
(h) any 1 prism diopter or more change in
				lateral prism; or
(i) the inability
				of the enrollee to wear bifocals because of a diagnosed medical
				condition.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.325 - AUDIOLOGY BENEFITS (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1004,
					 53-4-1009,
					 53-4-1105,
					 MCA; IMP,
					 53-4-1003,
					 53-4-1004,
					 53-4-1009,
					 53-4-1104,
					 53-4-1105,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.3 - Benefits › Rule 37.79.326 - DENTAL BENEFITS

Current through Register Vol. 13, July 5, 2024
(1) The maximum
				dental benefits paid under the basic dental plan will be 85% of the billed
				services received. Up to $1,615 in basic dental care will be paid per benefit
				year for each enrollee. For example, $1,900 in services received results in
				$1,615 paid.
(a) Providers may not balance
				bill the enrollee, parent, or guardian for the remaining 15% of the billed
				charges.
(b) Providers may bill the
				enrollee, parent, or guardian for services received in excess of $1,900 per
				benefit year.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.5 - Enrollment Provisions › Rule 37.79.501 - COST SHARING PROVISIONS

Current through Register Vol. 13, July 5, 2024
(1) Except as
				provided in (2) and (3), the parent or guardian of each HMK coverage group
				enrollee whose family income is greater than 100% of the federal poverty level
				must pay to the provider of service the following copayments not to exceed the
				cost of service:
(a) $25 per admission for
				inpatient hospital services including hospitalization for physical, mental, and
				substance abuse reasons;
(b) $5 per
				visit for emergency room services;
(c) $5 per visit for outpatient hospital
				visits including outpatient treatment for physical, mental, and substance abuse
				reasons; and
(d) $3 per visit for
				physician, APRN, PA, optometrist, audiologist, mental health professional,
				substance abuse counselor, or other covered health care provider
				services.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.5 - Enrollment Provisions › Rule 37.79.503 - ENROLLMENT

Current through Register Vol. 13, July 5, 2024
(1) The HMK coverage group will accept
				without restriction eligible applicants in the order in which they are received
				for enrollment until the maximum enrollment, at which time eligible applicants
				will be put on a waiting list and will be enrolled when spaces become
				available. Applicants come off the waiting list and are enrolled based on the
				date they were determined eligible.
(2) Except for a newborn child, a child's HMK
				enrollment begins the later of:
(a) the first
				day of the month an application is received so long as the child is determined
				to meet all eligibility criteria;
(b) the first day of the month the family
				reports a new child, who meets all HMK eligibility criteria, joined the
				family;
(c) the first day of the
				month after an insurance delay period has ended; or
(d) the month funding is sufficient to enroll
				the applicant from the waiting list.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.5 - Enrollment Provisions › Rule 37.79.504 - RIGHT TO CHOOSE PRIMARY CARE PROVIDER (REPEALED)

Current through Register Vol. 13, July 5, 2024
53-4-1009,
					 MCA; IMP,
					 53-4-1003,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.5 - Enrollment Provisions › Rule 37.79.505 - DISENROLLMENT

Current through Register Vol. 13, July 5, 2024
(1) Participation in the HMK coverage group
				is voluntary and an enrollee may withdraw from the program at any time.
(a) HMK coverage group benefits may be
				terminated for good cause if the enrollee, parent, or guardian has violated
				rules adopted by the Montana Commissioner of Insurance for enrollment with an
				insurer.
(b) Good cause is defined
				as provided in Montana insurance law and rules and does not include an adverse
				change in health status.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.6 - Services and Provider Requirements › Rule 37.79.601 - CONTRACT FOR SERVICES

Current through Register Vol. 13, July 5, 2024
(1) The department
				may contract as it determines appropriate and in conformity with state and
				federal procurement law for services to administer the HMK coverage
				group.
53-4-1004,
					 53-4-1009,
					 53-4-1105,
					 MCA; IMP,
					 53-4-1003,
					 53-4-1004,
					 53-4-1009,
					 53-4-1104,
					 53-4-1105,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.6 - Services and Provider Requirements › Rule 37.79.602 - PROVISION OF BENEFITS

Current through Register Vol. 13, July 5, 2024
(1) The department
				may impose the following requirements in the provision of benefits:
(a) the use of certain types of providers to
				the extent allowed by law;
(b)
				prior authorization for benefits other than emergency services;
(c) directing an enrollee to the appropriate
				level of care for receipt of covered benefits; and
(d) denial of payment to a provider for
				benefits provided to an enrollee if the participation requirements in this rule
				are not met by the enrollee or the enrollee's parent, or guardian.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.6 - Services and Provider Requirements › Rule 37.79.605 - PARTICIPATING PROVIDERS

Current through Register Vol. 13, July 5, 2024
(1) The third party
				administrator must offer to federally qualified health centers (FQHCs), rural
				health clinics (RHCs), Title X family planning providers, Indian health
				services providers, tribal health providers, urban Indian centers, migrant
				health centers, and county public health departments terms and conditions that
				are at least as favorable as those offered to other providers.
(2) The department and the third party
				administrator will deny payment to a provider who is currently suspended or
				terminated by the Medicaid or the Medicare program in any state.
(3) Participating providers shall be licensed
				or certified in Montana or in the case of out-of-state providers, in the state
				in which they practice.
(4)
				Physicians, advanced practice registered nurses, and physician assistants shall
				either have admitting privileges to at least one general or critical shortage
				area hospital or shall have a mechanism in place to ensure hospitalization when
				appropriate.
(5) In addition to the
				cost sharing provisions outlined in ARM
				37.79.501, participating providers
				may bill the enrollee, parent, or guardian for services provided to a HMK
				coverage group enrollee, which are not covered benefits.
(6) A third party administrator may not
				prohibit a participating provider from:
(a)
				discussing a treatment option with an enrollee, parent, or guardian;
				or
(b) advocating on behalf of an
				enrollee within the utilization review or grievance processes established by
				the third party administrator.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.6 - Services and Provider Requirements › Rule 37.79.606 - REIMBURSEMENT OF THIRD PARTY ADMINISTRATOR

Current through Register Vol. 13, July 5, 2024
(1)
				In consideration for all services rendered by a third party administrator under
				a contract with the department, the third party administrator will receive
				payment for services provided as agreed in the contract.
53-4-1009,
					 MCA; IMP,
					 53-4-1003,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.6 - Services and Provider Requirements › Rule 37.79.607 - UTILIZATION REVIEW AND QUALITY ASSURANCE

Current through Register Vol. 13, July 5, 2024
(1)
				The third party administrator shall have adequate staff and procedures to
				assure that health care provided to enrollees is medically necessary and
				appropriate.
(2) The third party
				administrator shall comply with and cooperate in any external quality review
				that may be implemented by the department or its designee. An external quality
				review may include participation in the design of the review, collection of
				data, and making data available to the department or its designee.
53-4-1009,
					 MCA; IMP,
					 53-4-1003,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.79 - HEALTHY MONTANA KIDS (HMK) › Subchapter 37.79.8 - Hearing and Appeal Procedures › Rule 37.79.801 - GRIEVANCE AND APPEAL PROCEDURES

Current through Register Vol. 13, July 5, 2024
(1) A third
				party administrator must have a written procedure, approved in writing by the
				department before implementation, for resolution of grievances or complaints
				brought by enrollees or their parents or guardians either individually or as a
				class. In a situation requiring urgent care or emergency care, the department
				may require the third party administrator to expedite resolution of a grievance
				within a time line established by the department.
(2) Except when the HMK coverage group
				eligibility has been denied, an enrollee, parent, or guardian must exhaust the
				third party administrator's grievance procedure before appeal of the matter may
				be made to the department.
(3) An
				applicant, parent, or guardian aggrieved by a denial, suspension, or
				termination of the HMK coverage group eligibility or an enrollee, parent, or
				guardian aggrieved by a final grievance decision of a third party
				administrator, including but not limited to a reduction or denial of benefits,
				may request a fair hearing in accordance with ARM
				37.5.304,
				37.5.307,
				37.5.313,
				37.5.322,
				37.5.325,
				37.5.328,
				37.5.331,
				37.5.334, and
				37.5.337.
(4) If a written request for hearing is not
				received by the department within 90 days after the date a notice of adverse
				action is mailed by the department or a final grievance decision is mailed by a
				third party administrator, the hearing officer may deny a hearing as provided
				in ARM 37.5.313.
(5) Continuation
				of HMK benefits during an appeal process will be applied as specified in ARM
				37.5.316(3) through
				(15).
53-4-1009,
					 MCA; IMP,
					 53-4-1003,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.1 - General Requirements › Rule 37.80.101 - PURPOSE AND GENERAL LIMITATIONS

Current through Register Vol. 13, July 5, 2024
(1) This
				chapter pertains to the Best Beginnings Program, which administers payment for
				child care services.
(2) Financial
				assistance may be available to pay a portion of a working parent's child care
				costs. Payment may only be made to:
(a) a
				licensed child care center;
(b) a
				registered group child care home;
(c) a registered family child care home; or
(d) a provider of family, friend,
				or neighbor care as that term is defined at ARM
				37.95.102;
				or
(e) a relative care
				provider.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.1 - General Requirements › Rule 37.80.103 - CONFIDENTIALITY

Current through Register Vol. 13, July 5, 2024
(1) Use and disclosure of information is
				allowed only for the following purposes:
(a)
				to administer child care assistance under this chapter;
(b) to determine eligibility and amount of
				assistance for any other needs-based federally funded public assistance program
				for low income persons;
(c) to
				report possible child abuse or neglect to the appropriate agency or authority
				or respond to requests for information from an appropriate agency or authority
				investigating possible child abuse or neglect;
(d) to assist the Child Support Services
				Division or any other agency or entity authorized to conduct child support
				enforcement activities;
(e) to
				provide the applicant or recipient's current address to a state or local law
				enforcement officer, if the officer documents that the person is a fugitive
				felon whose arrest is the responsibility of the officer; additionally, the
				officer must provide the name and social security number of the recipient by
				written request;
(f) to provide
				information necessary for emergency medical or other critical needs;
(g) to provide information relevant to a
				child care licensing investigation; and
(h) any other disclosure required by law.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.1 - General Requirements › Rule 37.80.104 - CHILD CARE ASSISTANCE HEARING RIGHTS

Current through Register Vol. 13, July 5, 2024
(1)
				A parent who has applied for or is receiving child care assistance under this
				chapter and who is subject to any adverse action, as defined in ARM
				37.5.304, by the department or the
				department's agent is entitled to a fair hearing in accordance with ARM
				37.5.103.
52-2-704,
					 53-4-212,
					 MCA; IMP,
					 52-2-713,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.2 - Eligibility › Rule 37.80.201 - NONFINANCIAL REQUIREMENTS FOR ELIGIBILITY AND PRIORITY FOR ASSISTANCE

Current through Register Vol. 13, July 5, 2024
(1) In addition to the income requirements of
				ARM
				37.80.202,
				parents must work or attend school or vocational training to receive child care
				payments.
(a) With the exceptions in (2), a
				two parent household must work a total of 120 hours per month, but there is no
				minimum number of hours that each parent must work each month.
(b) A single parent must work a minimum of 60
				hours each month or attend school or vocational training full-time. A single
				parent must be working a minimum of 40 hours each month if attending school or
				vocational training part-time.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.2 - Eligibility › Rule 37.80.202 - FINANCIAL REQUIREMENTS FOR ELIGIBILITY; PAYMENT FOR CHILD CARE SERVICES; PARENT'S COPAYMENT

Current through Register Vol. 13, July 5, 2024
(1) Financial
				eligibility for child care assistance is based on a household's monthly income
				as defined in ARM
				37.80.102.
				A household whose income is below 150% of the Federal Poverty Guideline (FPG)
				for a household of that size is eligible for child care assistance.
(2) At annual redetermination, a household
				not receiving temporary assistance for needy families (TANF), whose income
				exceeds 150% and is below 185% of the FPG for a household of its size is
				eligible for child care assistance under graduated eligibility. To qualify for
				graduated eligibility, the following apply:
(a) eligibility is given for a 12 month
				eligibility period; and
(b) all
				other non-TANF eligibility requirements must be met.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.2 - Eligibility › Rule 37.80.203 - REQUIREMENT TO REPORT CHANGES

Current through Register Vol. 13, July 5, 2024
(1)
				Applicants and recipients of child care assistance must report to the resource
				and referral agency administering their case any change in their child care
				provider within one business day of the change.
(2) Applicants and recipients of child care
				assistance must report by phone, email, written communication, or in person to
				the resource and referral agency administering their case any change in the
				following circumstances within ten calendar days from the date the change
				occurs:
(a) a change in work, training, or
				educational status;
(b) an increase
				in the household's monthly gross income above 85 percent of State Median Income
				(SMI); or
(c) a change in mailing
				address, residential address, or phone number.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.2 - Eligibility › Rule 37.80.204 - AT-HOME INFANT CARE (REPEALED)

Current through Register Vol. 13, July 5, 2024
52-2-111,
					 52-2-704,
					 53-2-201,
					 53-4-212,
					 MCA; IMP,
					 52-2-704,
					 52-2-713,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.2 - Eligibility › Rule 37.80.205 - CHILD CARE RATES: PAYMENT REQUIREMENTS

Current through Register Vol. 13, July 5, 2024
(1)
				The department calculates provider rates based on market rate surveys required
				by the Child Care and Development Block Grant Act of 2014. A half-time day rate
				is calculated for five or less hours of care during a calendar day. A full-time
				day rate is calculated for more than five hours and up to 12 hours during a
				calendar day.
(2) Provider rates
				are listed on the Early Childhood Services Bureau website for each child care
				provider type.
(3) Child care
				authorization and corresponding authorization plans may authorize payment for
				extended care of more than 12 hours during a calendar day. When care is
				provided for more than 12 but less than 18 hours per day, the full-day rate
				multiplied by 1.25 will be paid. When the authorization and corresponding
				authorization plan specifies service exceeding 18 hours of care during a
				calendar day, the full-day rate multiplied by 1.5 will be paid.
(4) Providers are paid for actual attendance
				when the child is present if a child attends less than 85% of the authorized
				time listed on the authorization plan.
(5) Providers are paid the entire monthly
				amount listed on the authorization plan when a child attends at least 85% of
				the authorized time listed on the authorization plan.
(6) The provider rates in the Child Care
				Manual, section 1-4, are the maximum rates payable.
(7) The rate charged by a child care provider
				for children whose child care is paid for by the department cannot exceed the
				rate charged to private pay parents for the same service.
(8) The department has the discretion to
				adjust rates for children with special needs or disabilities.
(9) The department has the discretion to
				adjust rates for child care provided during non-traditional hours as defined in
				ARM
				37.80.102.
(a) In order for an adjusted rate to be paid,
				the approved care must be provided for at least one hour between 6 p.m. to 6
				a.m. Monday through Friday or after 6 p.m. Friday to 6 a.m. Monday.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.2 - Eligibility › Rule 37.80.206

Current through Register Vol. 13, July 5, 2024
AUTH:
					 52-2-704,
					 MCA IMP:
					 52-2-704,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.2 - Eligibility › Rule 37.80.207 - BEST BEGINNINGS CHILD CARE SCHOLARSHIP PRESCHOOL

Current through Register Vol. 13, July 5, 2024
(1) The Best Beginnings Child Care
				Scholarship will not reimburse child care services during preschool program
				hours at any of the following settings:
(a)
				public or preschool settings, described in ARM
				10.63.101;
(b) state funded preschool programs;
				or
(c) Head Start or other
				federally funded preschool programs.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.2 - Eligibility › Rule 37.80.208 - CARE PROVIDED IN THE CHILD'S HOME

Current through Register Vol. 13, July 5, 2024
(1) Child
				care assistance paid for care provided in a child's home must be approved by
				the department's Early Childhood Services Bureau.
(2) Subsidized care provided in a child's
				home can only be paid to approved Family, Friend, and Neighbor and relative
				care providers.
(3) One of the
				following criteria must be met to receive payment for subsidized care in a
				child's home:
(a) a child approved as a child
				with disabilities or a child with special needs;
(b) a child of a teen parent; or
(c) a child whose parent works
				non-traditional hours.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.3 - Provider Requirements › Rule 37.80.301 - REQUIREMENTS FOR CHILD CARE FACILITIES, COMPLIANCE WITH EXISTING RULES, CERTIFICATION

Current through Register Vol. 13, July 5, 2024
(1) Child care
				facilities must be in compliance with the licensing and registration
				requirements ARM Title 37, chapter 95 to receive payment under this chapter.
				Loss of eligibility for funds under this chapter for failing to comply with
				child care facility licensing and registration requirements including group
				size and staff-to-child ratios, as well as program requirements, as stipulated
				in the Best Beginnings Child Care Scholarship Manual is in addition to other
				remedies available for such violations.
(2) The provider is responsible for informing
				parents who are receiving child care assistance under this chapter that the
				provider's license, or registration has been revoked or expired. The provider
				may not bill the household for payments denied by the department due to the
				provider's failure to comply with licensing, certification, or registration
				requirements.
(3) Child care
				providers must be certified or recognized by the department or its designated
				agent as eligible to receive payment under this chapter. All applicable forms
				must be completed and submitted for approval. Registered and licensed
				facilities are approved by the Child Care Licensing Program of the department's
				Quality Assurance Division. Facilities licensed or registered by other entities
				must be recognized by the Child Care Licensing Program of the department's
				Quality Assurance Division.
(4) A
				provider's eligibility to receive state payment under a state-assisted child
				care program may be terminated if:
(a) the
				provider willfully misrepresents services provided, as set out in ARM
				37.80.316(4)
				or
				37.80.502(6);
				or
(b) the provider refuses access
				to the child care setting and child records during business hours to the
				following personnel:
(i) employees or other
				agents of state or local government, investigating child care services, or
				child abuse or neglect;
(ii) child
				care resource and referral agency personnel; or
(iii) health, building, or fire officials
				investigating child care facility health and safety issues.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.3 - Provider Requirements › Rule 37.80.305

Current through Register Vol. 13, July 5, 2024
AUTH:
					 52-2-704,
					 MCA; IMP:
					 52-2-704,
					 52-2-713,
					 52-2-721,
					 52-2-722,
					 52-2-723,
					 52-2-731,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.3 - Provider Requirements › Rule 37.80.306

Current through Register Vol. 13, July 5, 2024
AUTH:
					 52-2-704,
					 MCA; IMP:
					 52-2-704,
					 52-2-713,
					 52-2-721,
					 52-2-722,
					 52-2-723,
					 52-2-731,
					 MCA
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.3 - Provider Requirements › Rule 37.80.315 - RIGHTS AND RESPONSIBILITIES AGREEMENT

Current through Register Vol. 13, July 5, 2024
(1)
				In addition to complying with all other certification requirements, providers
				must sign a rights and responsibilities agreement under this chapter, on the
				form provided by the department. Parents are provided a copy of the providers'
				rights and responsibilities.
52-2-704,
					 MCA; IMP,
					 52-2-704,
					 52-2-713,
					 52-2-721,
					 52-2-722,
					 52-2-723,
					 52-2-731,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.3 - Provider Requirements › Rule 37.80.316 - REQUIREMENTS AND PROCEDURES FOR CHILD CARE PAYMENTS

Current through Register Vol. 13, July 5, 2024
(1) Except as provided in (2) and (3), the
				provider will receive payment for child care services when the care is provided
				outside the child's home.
(2)
				Payment will be made to the parent when a care giver, who does not live with
				the parent or child, provides child care in the child's home.
(3) Payment will be made to the provider when
				the provider participates in a tiered reimbursement program, as referenced in
				ARM
				37.80.205(6).
				Tiered reimbursement programs are intended to benefit the higher quality child
				care provider.
(4) In the case of
				direct payment to the parents, the parents and/or the provider bear sole
				responsibility:
(a) for obtaining provider
				registration through ARM
				37.95.103
				prior to claiming payment for covered child care under this chapter;
				and
(b) for resolving disputes as
				to proper payment arising between the parent(s) and the provider.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.3 - Provider Requirements › Rule 37.80.317 - AUTHORIZATION OF SERVICES - AUTHORIZATION PLANS

Current through Register Vol. 13, July 5, 2024
(1) Child care assistance is provided for
				through an authorization of services and an authorization plan. The
				authorization of services and authorization plan include the following
				information:
(a) number of children
				authorized to receive child care assistance;
(b) number of hours per week
				authorized;
(c) number of months
				authorized;
(d) name of the child
				care provider;
(e) amount of child
				care payment based on the number of hours per week authorized; and
(f) amount of monthly copayment that the
				parent must pay to the provider.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.5 - Termination of Services › Rule 37.80.501 - TERMINATION OF CHILD CARE ASSISTANCE

Current through Register Vol. 13, July 5, 2024
(1) Child
				care assistance will be terminated if any of the following occurs:
(a) the household does not apply for
				redetermination;
(b) a parent has
				been given a grace period and does not meet the activity requirement or is not
				participating in the TANF funded case assistance program at the end of the
				grace period;
(c) the parent
				voluntarily makes a written request to the child care resource and referral
				agency worker that child care services be closed;
(d) a family moves outside of the state of
				Montana; or
(e) the child has had
				a span of more than five unexplained absences reported by the child care
				facility specified in the authorization and corresponding authorization plan
				and there is no indication that the child will be receiving care at that
				facility in the near future.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.5 - Termination of Services › Rule 37.80.502 - CHILD CARE OVERPAYMENT

Current through Register Vol. 13, July 5, 2024
(1) A child care
				provider or a parent who has reason to believe an overpayment or underpayment
				of child care assistance has occurred must notify the department within ten
				days.
(2) If an audit of the case
				shows monies received fall under ARM
				37.80.506(1)(a),
				(b), (c), and (d), the department may recover
				the amount of any child care payment made to a child care provider or to a
				parent which is in excess of the amount to which the provider or parent was
				entitled.
(a) If an overpayment is due to an
				intentional program violation of the parent, the parent must repay the
				overpayment to the department.
(b)
				If an overpayment is due to any error, act, or omission of the provider,
				whether intentional or otherwise, the provider must repay the overpayment to
				the department.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.5 - Termination of Services › Rule 37.80.506 - INTENTIONAL PROGRAM VIOLATIONS

Current through Register Vol. 13, July 5, 2024
(1) An
				intentional program violation occurs when:
(a) a parent or guardian receives, or
				attempts to receive, child care assistance based on a false or misleading
				statement, misrepresentation, concealment, or withholding of relevant facts or
				information;
(b) a parent or
				guardian knowingly fails to comply with the requirements for receiving child
				care assistance;
(c) a provider
				receives, or attempts to receive, a child care assistance payment based on a
				false or misleading statement, misrepresentation, concealment, or withholding
				of relevant facts or information; or
(d) a parent, guardian, or provider knowingly
				fails to comply with the requirements of the Montana Child Care Act, this
				chapter, or ARM Title 37, chapter 95.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.5 - Termination of Services › Rule 37.80.507 - INTENTIONAL PROGRAM VIOLATION SANCTIONS

Current through Register Vol. 13, July 5, 2024
(1)
				The department has the discretion, based on the circumstances of the violation,
				to determine the appropriate sanction for the first intentional program
				violation. The department may impose any of the following sanctions on a
				parent/guardian or provider for a first intentional program violation:
(a) issue the intentional program violation
				even if there is no overpayment due;
(b) require repayment of child care
				assistance payments related to the program violation; or
(c) require repayment of child care
				assistance payments related to the program violation and terminate the
				parent/guardian or provider, or both, from the Child Care Assistance
				Program.
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.6 - Child Care Quality Improvement Programs › Rule 37.80.601 - BEST BEGINNINGS QUALITY CHILD CARE MINI GRANTS (REPEALED)

Current through Register Vol. 13, July 5, 2024
52-2-704,
					 53-2-201,
					 53-4-212,
					 MCA; IMP,
					 52-2-704,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.6 - Child Care Quality Improvement Programs › Rule 37.80.602 - BEST BEGINNINGS QUALITY CHILD CARE MERIT PAY (REPEALED)

Current through Register Vol. 13, July 5, 2024
52-2-704,
					 53-2-111,
					 MCA; IMP,
					 52-2-704,
					 52-2-111,
					 52-2-112,
					 52-2-711,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.6 - Child Care Quality Improvement Programs › Rule 37.80.603 - INFANT-TODDLER CARE GIVER CERTIFICATION (REPEALED)

Current through Register Vol. 13, July 5, 2024
52-2-111,
					 52-2-704,
					 53-2-201,
					 MCA; IMP,
					 52-2-704,
					 MCA;
Administrative Rules of Montana › Department 37 - PUBLIC HEALTH AND HUMAN SERVICES › Chapter 37.80 - CHILD CARE ASSISTANCE › Subchapter 37.80.6 - Child Care Quality Improvement Programs › Rule 37.80.604 - REQUIREMENTS FOR CHILD CARE FACILITY PARTICIPATION IN THE BEST BEGINNINGS STAR QUALITY TIERED REIMBURSEMENT PROGRAM (REPEALED)

Current through Register Vol. 13, July 5, 2024
52-2-704,
					 53-4-212,
					 MCA; IMP,
					 52-2-704,
					 52-2-721,
					 53-4-212,
					 MCA;