MEDICAID PRIMARY CARE SERVICES

37.86.5014 HEALTH MAINTENANCE ORGANIZATIONS: REIMBURSEMENT OF HMOS 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 prov…

37.86.5020 HEALTH MAINTENANCE ORGANIZATIONS: ACCESS TO SERVICES An enrollee must have the opportunity to choose a primary care provider to the extent possible and medically appropriate from any of the participating primary care providers in the enrollee's HMO. The HMO may assign …

37.86.5025 HEALTH MAINTENANCE ORGANIZATIONS: GRIEVANCE PROCEDURES An enrollee has the right of appeal as provided at ARM 37.5.304, 37.5.305, 37.5.307, 37.5.310, 37.5.311, 37.5.313, 37.5.316, 37.5.318, 37.5.322, 37.5.325, 37.5.328, 37.5.331, 37.5.334 and 37.5.337. An HMO must have…

37.86.5026 HEALTH MAINTENANCE ORGANIZATIONS: RECORDS AND CONFIDENTIALITY An HMO must comply with the provisions of ARM 37.86.414 regarding maintenance and retention of medical and fiscal records. An HMO must submit reports and maintain records as required in the contract with the…

37.86.5027 HEALTH MAINTENANCE ORGANIZATIONS: RECIPIENT EDUCATION An HMO must have written instructions for enrollees in the use of all services provided. The policy must include, but is not limited to, written information on service restrictions and limitations regarding appropri…

37.86.5035 HEALTH MAINTENANCE ORGANIZATIONS: QUALITY ASSURANCE An HMO must have in effect an internal quality assurance system as specified in the contract. An internal quality assurance system must meet the requirements of 42 CFR 434.34. The department hereby adopts and incorpor…

37.86.5036 HEALTH MAINTENANCE ORGANIZATIONS: THIRD PARTY The HMO is responsible for investigating third party resources and seeking payment from these sources. The HMO may retain all funds collected from third party resources. A complete record of all payments received from third…

37.86.505 PODIATRY SERVICES, REQUIREMENTS These requirements are in addition to those rule provisions generally applicable to Medicaid providers. The department or its designated review organization may conduct utilization and peer review of podiatry services. Authorizing statute…

37.86.506 PODIATRY SERVICES, REIMBURSEMENT Reimbursement for podiatry services is in accordance with the methodologies described in ARM 37.85.212 and 37.86.105. Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-6-101, 53-6-111, 53-6-131, 53-6-141, MCA Hi…

37.86.5101 PASSPORT TO HEALTH PROGRAM: AUTHORITY The department has been granted by the United States Department of Health and Human Services (HHS), as provided in 42 U.S.C. 1396n(b), the authority to establish a primary care case management program for Medicaid members. Authoriz…

37.86.5102 PASSPORT TO HEALTH PROGRAM: DEFINITIONS "Case management" means directing and overseeing the delivery of certain services to an enrollee. "Clinic" means a federally qualified health center, a rural health clinic, an Indian health service clinic on a reservation, or any…

37.86.5103 PASSPORT TO HEALTH PROGRAM: ELIGIBILITY The department may require a Medicaid member to enroll and participate in the Passport to Health Program, unless exempted from or ineligible for participation as defined by ARM 37.86.5102(7) or (8). At the department's discretion…

37.86.5104 PASSPORT TO HEALTH PROGRAM: ENROLLMENT IN THE PROGRAM The department will notify a Medicaid member required by ARM 37.86.5103 to enroll in the program that the member must enroll in the program. The member required to enroll in the program must select a primary care pr…

37.86.5110 PASSPORT TO HEALTH PROGRAM: SERVICES A member must obtain services directly from, or through, a Passport referral by the member's primary care provider except for: obstetrical services, both inpatient and outpatient; family planning services as defined in Social Securi…

37.86.5111 PASSPORT TO HEALTH PROGRAM: PRIMARY CARE PROVIDERS REQUIREMENTS A primary care provider must meet the following requirements: enroll as a Medicaid provider; provide primary care; sign a Passport agreement for primary care case management; and keep a paper or electronic…

37.86.5112 PASSPORT TO HEALTH PROGRAM: REIMBURSEMENT Reimbursement for primary care case management services is as follows: $3.00 per enrollee per month for individuals categorically eligible for Aged, Blind, Disabled and Medically Frail Medicaid; or $1.00 per enrollee per month …

37.86.5120 PASSPORT TO HEALTH PROGRAM: FAIR HEARING An enrollee or a provider has the right to appeal an adverse action in accordance with ARM 37.5.304, 37.5.305, 37.5.307, 37.5.310, 37.5.311, 37.5.313, 37.5.316, 37.5.318, 37.5.322, 37.5.325, 37.5.328, 37.5.331, 37.5.334 and 37.5…

37.86.5201 HEALTH IMPROVEMENT PROGRAM: DEFINITIONS (REPEALED) Authorizing statute(s): 53-6-101, 53-6-113, MCA Implementing statute(s): 53-6-101, 53-6-113, MCA History: NEW, 2003 MAR p. 2892, Eff. 12/25/03; AMD, 2007 MAR p. 978, Eff. 7/6/07; AMD, 2010 MAR p. 1544, Eff. 6/25/10; RE…

37.86.5202 HEALTH IMPROVEMENT PROGRAM: GENERAL (REPEALED) Authorizing statute(s): 53-6-101, 53-6-113, MCA Implementing statute(s): 53-6-101, 53-6-113, MCA History: NEW, 2003 MAR p. 2892, Eff. 12/25/03; AMD, 2007 MAR p. 978, Eff. 7/6/07; AMD, 2010 MAR p. 1544, Eff. 6/25/10; REP, 2…

37.86.5204 CRITERIA FOR DETERMINING MEDICAID AND HEALTHY MONTANA KIDS PLUS (HMK PLUS) ELIGIBLE INDIVIDUALS MANAGED UNDER THE HEALTH IMPROVEMENT PROGRAM (REPEALED) Authorizing statute(s): 53-6-101, 53-6-113, MCA Implementing statute(s): 53-6-101, 53-6-113, MCA History: NEW, 2007 M…

37.86.5205 HEALTH IMPROVEMENT PROGRAM: CLIENT ELIGIBILITY AND ASSIGNMENT (REPEALED) Authorizing statute(s): 53-6-101, 53-6-113, MCA Implementing statute(s): 53-6-101, 53-6-113, MCA History: NEW, 2003 MAR p. 2892, Eff. 12/25/03; AMD, 2007 MAR p. 978, Eff. 7/6/07; AMD, 2010 MAR p. …

37.86.5206 HEALTH IMPROVEMENT PROGRAM: SCOPE OF SERVICES AND REIMBURSEMENT (REPEALED) Authorizing statute(s): 53-6-101, 53-6-113, MCA Implementing statute(s): 53-6-101, 53-6-113, MCA History: NEW, 2003 MAR p. 2892, Eff. 12/25/03; AMD, 2010 MAR p. 1544, Eff. 6/25/10; REP, 2018 MAR…

37.86.5303 PASSPORT TO HEALTH'S TEAM CARE PROGRAM A recipient may be subject to restrictions on, or prior approval for, physician related services, pharmacy services or any other services covered by the Medicaid Program if the department determines that the recipient's utilizatio…

37.86.5306 TEAM CARE PROGRAM: REIMBURSEMENT Reimbursement for team care case management services is $6.00 a month for each enrollee. A provider may be reimbursed for team care case management for an enrollee for a month during which case management or medical care was not provide…

37.86.5401 PURPOSE The rules in this chapter implement Montana Medicaid diabetes and cardiovascular disease prevention services. Diabetes and cardiovascular disease prevention services are evidence-based to assist in preventing Medicaid eligible individuals from developing diabet…

37.86.5402 DEFINITIONS For purposes of Montana Medicaid diabetes and cardiovascular disease prevention services, the following definitions apply: "After core program" means six consecutive monthly sessions. "Core program" means 16 consecutive weekly sessions. "Eligible client" me…

37.86.5403 DIABETES AND CARDIOVASCULAR DISEASE PREVENTION SERVICES GENERAL Diabetes and cardiovascular disease prevention services include the following evidence-based intervention services: Group nutrition counseling to prevent diabetes and cardiovascular disease; and Physical a…

37.86.5404 DIABETES AND CARDIOVASCULAR DISEASE PREVENTION SERVICES REIMBURSEMENT Reimbursement for diabetes and cardiovascular disease prevention services to eligible providers is in accordance with fee-for-service fee schedules for appropriate provider types posted on the depart…

37.86.601 THERAPY SERVICES, DEFINITIONS In ARM 37.86.601, 37.86.605, 37.86.606, and 37.86.610, the following definitions apply: "Assistant/aide" means an assistant, aide or other person authorized under and practicing in accordance with the applicable provisions of Title 37, MCA,…

37.86.605 THERAPY SERVICES, PROVIDER REQUIREMENTS These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers. As a condition of participation in the Montana Medicaid program, a therapist must: maintain a current license iss…

37.86.606 THERAPY SERVICES, SERVICE REQUIREMENTS AND RESTRICTIONS The requirements and restrictions in this rule apply for purposes of coverage and reimbursement of therapy services under the Montana Medicaid program. Except as otherwise provided by these rules, therapy services …

37.86.610 THERAPIES, REIMBURSEMENT Providers must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained, in the Health Care Financing Administration's Common Procedure Coding System (HCPCS). Information regarding billing c…

37.86.701 AUDIOLOGY SERVICES, PROVIDER REQUIREMENTS These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers. Audiology service providers, as a condition of participation in the Montana Medicaid program, must: maintain a …

37.86.702 AUDIOLOGY SERVICES, SERVICE REQUIREMENTS, AND RESTRICTIONS The following requirements and restrictions apply for purposes of coverage and reimbursement of audiology services under the Montana Medicaid program. Audiology services are hearing aid evaluations and basic aud…

37.86.705 AUDIOLOGY SERVICES, REIMBURSEMENT Providers must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained in the Health Care Financing Administration's Common Procedure Coding System (HCPCS). Information regarding b…

37.86.801 HEARING AID SERVICES, DEFINITIONS "Audiologist" means a person holding a current audiology license issued by the Montana Board of Speech-Language Pathologists and Audiologists under Title 37, chapter 15, MCA, to engage in selling, dispensing, or fitting hearing aids. "L…

37.86.802 HEARING AID SERVICES, REQUIREMENTS, AND LIMITATIONS These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers. Over-the-counter hearing aids are not a covered benefit. A prescription hearing aid may be covered un…

37.86.805 HEARING AID SERVICES, REIMBURSEMENT The department will pay the lowest of the following for covered hearing aid services and items: the provider's reasonable usual and customary charge for the service or item; the amount specified for the particular service or item in t…

37.86.901 COLLABORATIVE PRACTICE DRUG THERAPY MANAGEMENT - DEFINITIONS "Clinical pharmacist practitioner" means a pharmacist who meets the requirements outlined in ARM 24.174.526 and is licensed in the State of Montana. "Collaborative practice drug therapy management" means face-…

37.86.902 COLLABORATIVE PRACTICE DRUG THERAPY MANAGEMENT - REQUIREMENTS AND ELIGIBILITY These requirements are in addition to those requirements contained in administrative rule and statutory provisions generally applicable to Medicaid providers. A clinical pharmacist practitione…

37.86.905 COLLABORATIVE PRACTICE DRUG THERAPY MANAGEMENT - REIMBURSEMENT Reimbursement for collaborative practice drug therapy management is reimbursed only to the medical practitioner or facility, at the lower of the following: the provider's usual and customary charge to the ge…