MEDICAID PRIMARY CARE SERVICES

37.86.3801 CASE MANAGEMENT SERVICES FOR CHILDREN AT RISK OF ABUSE AND NEGLECT, DEFINITIONS (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-101, MCA History: NEW, 1997 MAR p. 496, Eff. 3/11/97; TRANS, from SRS, 2000 MAR p. 481; REP, 2017 MAR p. 1906,…

37.86.3805 CASE MANAGEMENT SERVICES FOR CHILDREN AT RISK OF ABUSE AND NEGLECT, COVERAGE (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-101, MCA History: NEW, 1997 MAR p. 496, Eff. 3/11/97; TRANS, from SRS, 2000 MAR p. 481; REP, 2017 MAR p. 1906, Ef…

37.86.3806 MEDICAID REIMBURSED CASE MANAGEMENT SERVICES FOR CHILDREN AT RISK OF ABUSE AND NEGLECT, ELIGIBILITY (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-101, MCA History: NEW, 1997 MAR p. 496, Eff. 3/11/97; TRANS, from SRS, 2000 MAR p. 481; AM…

37.86.3810 MEDICAID REIMBURSED CASE MANAGEMENT SERVICES FOR CHILDREN AT RISK OF ABUSE AND NEGLECT, PROVIDER REQUIREMENTS (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-101, MCA History: NEW, 1997 MAR p. 496, Eff. 3/11/97; TRANS, from SRS, 2000 MAR …

37.86.3811 MEDICAID REIMBURSED CASE MANAGEMENT SERVICES FOR CHILDREN AT RISK OF ABUSE AND NEGLECT, REIMBURSEMENT (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-101, MCA History: NEW, 1997 MAR p. 496, Eff. 3/11/97; TRANS, from SRS, 2000 MAR p. 481; …

37.86.3901 TARGETED CASE MANAGEMENT SERVICES FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS, DEFINITIONS The definitions of targeted case management services for children and youth with special health care needs are as follows: "Care plan" means a specific written plan that is based…

37.86.3902 TARGETED CASE MANAGEMENT SERVICES FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS, ELIGIBILITY A child who is receiving Medicaid or is presumptively eligible for Medicaid is eligible for targeted case management services for children and youth with special health care need…

37.86.3905 TARGETED CASE MANAGEMENT SERVICES FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS, COVERAGE The following services are reimbursable targeted case management services for children and youth with special health care needs: comprehensive assessment and periodic reassessment; …

37.86.3906 TARGETED CASE MANAGEMENT SERVICES FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS, PROVIDER REQUIREMENTS These requirements are in addition to those contained in rule and statutory provisions generally applicable to medicaid providers. To be qualified as a provider of targ…

37.86.3910 TARGETED CASE MANAGEMENT SERVICES FOR CHILDREN WITH SPECIAL HEALTH CARE NEEDS, REIMBURSEMENT Targeted case management services for children and youth with special health care needs are reimbursed at the lower of the following: the provider's customary charge to the gen…

37.86.4001 TARGETED CASE MANAGEMENT SERVICES FOR SUBSTANCE USE DISORDERS, DEFINITIONS "Adult" means a person 21 years of age or older. "Assessment" and "periodic reassessment" means determining the need for any medical, educational, social, or other services. These assessment act…

37.86.4002 TARGETED CASE MANAGEMENT SERVICES FOR SUBSTANCE USE DISORDERS, ELIGIBILITY TCM services are available under ARM 37.86.4001, 37.86.4002, 37.86.4005, 37.86.4006, 37.86.4007, and 37.86.4010 only to persons who meet the following criteria: Youth who are 20 years of age or …

37.86.4005 TARGETED CASE MANAGEMENT SERVICES FOR SUBSTANCE USE DISORDERS, SERVICE COVERAGE TCM services must meet all requirements found in ARM 37.86.3301 through 37.86.3306. TCM services for substance use disorders include those indicated in ARM 37.86.4001(2) through (5). TCM se…

37.86.4006 TARGETED CASE MANAGEMENT SERVICES FOR SUBSTANCE USE DISORDERS, SERVICE REQUIREMENTS Persons receiving TCM services are allowed the freedom of choice of any qualified Medicaid provider for targeted case management services. TCM service providers cannot restrict a person…

37.86.4007 TARGETED CASE MANAGEMENT SERVICES FOR SUBSTANCE USE DISORDERS, PROVIDER REQUIREMENTS The requirement in (2) is in addition to those requirements contained in rules generally applicable to Medicaid providers. TCM services for substance use disorders must be provided by …

37.86.4010 TARGETED CASE MANAGEMENT SERVICES FOR SUBSTANCE USE DISORDERS, REIMBURSEMENT 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. The department may, in i…

37.86.4201 DIALYSIS CLINICS FOR END STAGE RENAL DISEASE, DEFINITIONS "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: furn…

37.86.4202 DIALYSIS CLINICS FOR END STAGE RENAL DISEASE, REQUIREMENTS 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. The provision of outpatient maintenance dialysis and related service…

37.86.4205 DIALYSIS CLINICS FOR END STAGE RENAL DISEASE, REIMBURSEMENT 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 no…

37.86.4401 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, DEFINITIONS "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…

37.86.4402 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, VISITS AND ENCOUNTERS 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 fo…

37.86.4405 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, PROVIDER PARTICIPATION REQUIREMENTS The requirements of this subchapter are in addition to those contained in rule provisions generally applicable to medicaid providers. As a condition of participation in the…

37.86.4406 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, SERVICE REQUIREMENTS The Montana Medicaid program will cover and reimburse under the RHC or FQHC programs only those services that are RHC services or FQHC services as defined in ARM 37.86.4401 and subject to…

37.86.4407 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, RECORD KEEPING AND REPORTS A provider must meet the record keeping and other requirements of ARM 37.85.414 in addition to the requirements of this rule. A provider must make and maintain adequate financial an…

37.86.4408 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, REQUIREMENTS FOR CHANGE IN SCOPE OF SERVICE REQUEST 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…

37.86.4409 PROSPECTIVE CHANGE IN SCOPE OF SERVICE 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 P…

37.86.4410 RETROSPECTIVE CHANGE IN SCOPE OF SERVICE 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 resu…

37.86.4412 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, REIMBURSEMENT 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 provid…

37.86.4413 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, ESTABLISHMENT OF INTERIM PAYMENT FOR NEW RHC OR FQHC 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 o…

37.86.4414 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, SUPPLEMENTAL PAYMENTS IN CASE OF MANAGED CARE 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…

37.86.4420 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, ALTERNATIVE PAYMENT METHODOLOGIES 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…

37.86.4501 PROMISING PREGNANCY CARE - DEFINITIONS "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. "Promising Pregnancy Care (PPC)" means…

37.86.4502 PROMISING PREGNANCY CARE - GENERAL PROVISIONS These requirements are in addition to those requirements contained in rule and statutory provisions generally applicable to Medicaid providers. For purposes of Medicaid reimbursement, providers must be a state-approved prog…

37.86.4503 PROMISING PREGNANCY CARE - REIMBURSEMENT Promising Pregnancy Care is reimbursed at the lower of the following: the provider's usual and customary charge to the general public for the service; or the department's current fee schedule under ARM 37.85.105 for the appropri…

37.86.4701 ORGAN TRANSPLANTATION, DEFINITIONS "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. "Tissue transplantation" means the implantation of functional, huma…

37.86.4705 ORGAN TRANSPLANTATION, REQUIREMENTS 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,…

37.86.4706 ORGAN TRANSPLANTATION, REIMBURSEMENT Reimbursement for physician services in organ transplantation is provided in accordance with the methodologies described in ARM 37.85.212 and 37.86.105. All hospital services for organ and tissue transplantation are reimbursed as pr…

37.86.5001 HEALTH MAINTENANCE ORGANIZATIONS: DEFINITIONS "Administrative contractor for managed care" means the entity the department contracts with to perform certain administrative functions of the managed health care programs. "Basic medicaid" means the program of medicaid ser…

37.86.5002 HEALTH MAINTENANCE ORGANIZATIONS: RECIPIENT ELIGIBILITY A recipient in any one of the following categories is eligible to enroll with an HMO contracting with the department: a FAIM or family-related recipient required by ARM 37.86.5103 to participate in a primary care …

37.86.5005 HEALTH MAINTENANCE ORGANIZATIONS: ENROLLMENT Recipient enrollment with an HMO contracting with the department is voluntary, except as noted below. Individuals 21 years of age or older receiving medicaid or medically needy assistance as participants of the FAIM project,…

37.86.5006 HEALTH MAINTENANCE ORGANIZATIONS: DISENROLLMENT 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 …

37.86.5007 HEALTH MAINTENANCE ORGANIZATIONS: COVERED SERVICES An HMO must provide the following services: inpatient hospital services as defined at ARM 37.86.2901 and 37.86.2902; outpatient hospital services as defined at ARM 37.86.3001 and 37.86.3002; physician services as defin…

37.86.501 PODIATRY SERVICES, DEFINITIONS "Orthotic" means a mechanical device to assist in restoring normal function of the foot, applied to the foot or used with the shoe either as an insert for the shoe or as an attachment to the exterior of the shoe. "Podiatry services" means …

37.86.5010 HEALTH MAINTENANCE ORGANIZATIONS: CONTRACTS FOR SERVICES 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. An HMO, entering …

37.86.5011 HEALTH MAINTENANCE ORGANIZATIONS: PROVISION OF SERVICES An HMO may impose the following requirements in the provision of services: the use of certain types of providers; the preauthorization for services and use of network providers other than emergency services, famil…

37.86.5012 HEALTH MAINTENANCE ORGANIZATIONS: PARTICIPATING PROVIDERS 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. The HMO must offer to: medica…

37.86.5013 HEALTH MAINTENANCE ORGANIZATIONS: REIMBURSEMENT OF PROVIDERS 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…