Montana Administrative Code

37.40.323 CALCULATED PROPERTY COST COMPONENT (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-6-101, 53-6-113, MCA History: NEW, 1991 MAR p. 2050, Eff. 11/1/91; AMD, 1992 MAR p. 1617, Eff. 7/31/92; AMD, 1993 MAR p. 1385, Eff. 7/1/93; AMD, 199…

37.40.324 GRANDFATHERED PROPERTY COST COMPONENT (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-101, 53-6-113, MCA History: NEW, 1991 MAR p. 2050, Eff. 11/1/91; AMD, 1992 MAR p. 1617, Eff. 7/31/92; TRANS, from SRS, 2000 MAR p. 489; REP, 2002 MAR p. …

37.40.325 CHANGE IN PROVIDER DEFINED Except as provided in (2) , a change in provider will be deemed to have occurred if the events described in any one of the following (1) (a) through (d) occurs: For sole proprietorship providers, a change in provider occurs where the entire so…

37.40.326 INTERIM PER DIEM RATES FOR NEWLY CONSTRUCTED FACILITIES AND NEW PROVIDERS This rule specifies the methodology the department will use to determine the interim per diem rate for in-state providers, other than ICF/IID providers, which as of July 1 of the rate year have no…

37.40.330 SEPARATELY BILLABLE ITEMS In addition to the amount payable under the provisions of ARM 37.40.307(1) or (4) , the department will reimburse nursing facilities located in the state of Montana for the following separately billable items. Refer to the department's nursing …

37.40.331 ITEMS BILLABLE TO RESIDENTS The department will not pay a provider for any of the following items or services provided by a nursing facility to a resident. The provider may charge these items or services to the nursing facility resident: gifts purchased by residents; so…

37.40.336 REIMBURSEMENT FOR INTERMEDIATE CARE FACILITIES FOR INDIVIDUALS WITH INTELLECTUAL DISABILITIES For intermediate care facility services for individuals with intellectual disabilities provided in facilities located in the state of Montana, the Montana Medicaid program will…

37.40.337 REIMBURSEMENT TO OUT-OF-STATE FACILITIES The department will reimburse nursing facilities located outside the state of Montana for nursing facility services and any other reimbursable services or supplies provided to eligible Montana Medicaid individuals at the Medicaid…

37.40.338 BED HOLD PAYMENTS Except as provided in (6) through (9) for therapeutic home visits, payment will be made to a provider for holding a bed for a resident only if: the provider's facility is full and has a current waiting list of potential residents during each such bed d…

37.40.339 MEDICARE HOSPICE BENEFIT - REIMBURSEMENT In accordance with section 9435(b) of the Omnibus Budget Reconciliation Act of 1986, Public Law 99-509, the department may not pay a nursing facility provider for services provided to an eligible Medicaid/Medicare individual who …

37.40.345 ALLOWABLE COSTS This rule applies for purposes of determining allowable costs for cost reporting periods beginning on or after July 1, 1991. Allowable costs for cost reporting periods beginning prior to July 1, 1991 will be determined in accordance with rules for allowa…

37.40.346 COST REPORTING, DESK REVIEW AND AUDIT Providers must use generally accepted accounting principles to record and report costs. The provider must, in preparing the cost report required under this rule, adjust such costs in accordance with ARM 37.40.345 to determine allowa…

37.40.347 COST SETTLEMENT PROCEDURES The department will notify the provider of any overpayment discovered. The provider may contact the department to seek an agreement providing for repayment of the full overpayment within 60 days of mailing of the overpayment notice. Unless, wi…

37.40.351 THIRD PARTY PAYMENTS AND PAYMENT IN FULL Regardless of any other provision of these rules, a provider may not bill the Medicaid program for any patient day, item, service or other amount which could have been or could be paid by any other payer, including but not limite…

37.40.352 UTILIZATION REVIEW AND QUALITY OF CARE Upon admission and as frequently thereafter as the department may deem necessary, the department or its agents, in accordance with 42 CFR 456 subpart F (1997), may evaluate the necessity of nursing facility care for each Medicaid r…

37.40.360 LIEN AND ESTATE RECOVERY FUNDS FOR ONE-TIME EXPENDITURES (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA History: NEW, 1999 MAR p. 1393, Eff. 6/18/99; TRANS, from SRS, 2000 MAR p. 489; AMD, …

37.40.361 DIRECT CARE AND ANCILLARY SERVICES WORKERS' WAGE REPORTING/ADDITIONAL PAYMENTS INCLUDING LUMP SUM PAYMENTS FOR DIRECT CARE AND ANCILLARY SERVICES WORKERS' WAGE AND BENEFIT INCREASES Effective for each state fiscal year and for the six months thereafter, nursing faciliti…

37.40.401 SWING-BED HOSPITALS, DEFINITIONS A swing-bed hospital is a licensed hospital, critical access hospital (CAH) with swing-bed approval or licensed medical assistance facility which is medicare-certified to provide posthospital SNF care as defined in 42 CFR 409.20. Swing-b…

37.40.402 SWING-BED HOSPITALS, PROVIDER PARTICIPATION REQUIREMENTS To participate and be reimbursed as a swing-bed hospital service provider in the Montana medicaid program, a hospital must meet all of the following requirements: The hospital is a swing-bed hospital as defined in…

37.40.405 SWING-BED HOSPITALS, SPECIAL SERVICE REQUIREMENTS Before admitting a Medicaid recipient to a swing-bed, the swing-bed hospital must meet all of the following requirements: the hospital must obtain a preadmission screening to determine the level of care required by the p…

37.40.406 SWING-BED HOSPITALS, REIMBURSEMENT Montana medicaid will reimburse swing-bed hospitals as provided in this rule for swing-bed hospital services provided in accordance with all applicable swing-bed hospital service requirements specified in ARM 37.40.401, 37.40.402, 37.4…

37.40.408 FACILITY POLICY REQUIREMENTS The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The policies must provide that the facility will: not use verbal, …

37.40.409 SPECIALIZED REHABILITATIVE SERVICES If specialized rehabilitative services such as but not limited to physical therapy, speech-language pathology, occupational therapy, and mental health rehabilitative services for mental illness and mental retardation are required in t…

37.40.412 RESIDENT ACTIVITIES PROGRAM The facility must provide for an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well being of each resident. The activities program must be directed by a qualified professional who: is …

37.40.416 RESIDENT RIGHTS The swing-bed hospital must be in substantial compliance with the requirements set forth in this rule pertaining to resident rights. A provider must protect and promote the rights of each resident, including each of the following rights: The resident has…

37.40.420 RESIDENT TRANSFER AND DISCHARGE RIGHTS The resident has the following transfer and discharge rights. Transfer and discharge includes movement of a resident to a bed outside of the swing-bed hospital facility whether or not that bed is in the same physical plant. Transfe…

37.40.421 RESIDENT POST DISCHARGE RIGHTS When the facility anticipates discharge, a resident must have a discharge summary that includes: a recapitulation of the resident's stay; a final summary of the resident's status which includes: medically defined conditions and prior medic…

37.40.422 DIRECT CARE AND ANCILLARY SERVICES WORKERS' WAGE REPORTING/ADDITIONAL PAYMENTS INCLUDING LUMP SUM PAYMENTS FOR DIRECT CARE AND ANCILLARY SERVICES WORKERS' WAGE AND BENEFIT INCREASES Effective for the calendar year January through December, swing-bed hospitals must repor…

37.40.701 HOME HEALTH SERVICES DEFINITIONS "Home health agency" means an entity licensed by the Montana Department of Public Health and Human Services, certified by Medicare, and enrolled as a Medicaid provider. "Home health aide services" means services of a certified home healt…

37.40.702 HOME HEALTH SERVICES, REQUIREMENTS These requirements are in addition to those rule provisions generally applicable to Medicaid providers. A home health agency must be: licensed by the Montana department of public health and human services; Medicare certified; and an en…

37.40.705 HOME HEALTH SERVICES, REIMBURSEMENT Reimbursement fees for home health services are as referenced in ARM 37.85.105(4). Home health services reimbursement includes the following services: nursing or therapy service; home health aide visit; and medical supplies, equipment…

37.40.801 HOSPICE, DEFINITIONS "Department" means the Montana Department of Public Health and Human Services. Except for the definition of "physician," the definitions of terms defined under42 CFR 418.3 apply for purposes of this subchapter. "Physician" means an individual licens…

37.40.802 ADOPTION AND INCORPORATION BY REFERENCE For purposes of this subchapter, the department adopts and incorporates by reference the following sections of the Code of Federal Regulations (CFR) that are in effect as of October 1, 2022: 42 CFR 418.3, which sets forth definiti…

37.40.805 HOSPICE, CONDITIONS OF PARTICIPATION The hospice must be licensed under state law and must meet Medicare's conditions of participation for hospice programs and have a valid provider agreement with Medicare as conditions of enrollment in Medicaid. Medicare conditions of …

37.40.806 HOSPICE, COVERED SERVICES To be covered, hospice services must meet the following requirements: they must be reasonable and necessary for the palliation or management of the terminal illness as well as related conditions; thebeneficiary must elect hospice care in accord…

37.40.807 HOSPICE CONDITION OF PARTICIPATION: INTERDISCIPLINARY GROUP, CARE PLANNING, AND COORDINATION OF SERVICES (REPEALED) Authorizing statute(s): 53-6-113 MCA Implementing statute(s): 53-6-101 MCA History: NEW, 1989 MAR p. 842, Eff. 7/1/89; TRANS, from SRS, 2000 MAR p. 489; A…

37.40.808 HOSPICE, CERTIFICATION OF TERMINAL ILLNESS In order to be eligible to elect hospice care under Medicaid, a beneficiarymust be certified as being terminally ill in accordance with Medicare certification requirements under 42 CFR 418.22. Authorizing statute(s): 53-6-113, …

37.40.815 HOSPICE, ELECTION AND WAIVER OF OTHER BENEFITS A beneficiaryeligible for hospice care ortheir representative must file an election statement with a particular hospice in order to receive such care. The department will follow Medicare regulations andguidelines in adminis…

37.40.816 HOSPICE, REVOCATION OF ELECTION A beneficiaryor their representative may revoke thebeneficiary's election of hospice care at any time during an election period. The department will follow Medicare regulations and guidelines in administering this provision, including 42 …

37.40.825 HOSPICE, CHANGE OF HOSPICE A beneficiaryor their representative may change once in each election period the designation of the particular hospice from which hospice care will be received. The department will follow Medicare regulations andguidelines in administering thi…

37.40.830 HOSPICE, REIMBURSEMENT Medicaid payment for covered hospice care will be made in accordance with the specific categories of covered hospice care and the payment amounts and procedures established by Medicare under 42 CFR 418.301 through 418.312. The specific categories …

37.40.901 HOME DIALYSIS FOR END STAGE RENAL DISEASE, DEFINITION Home dialysis service for end stage renal disease is the provision of equipment required for the renal dialysis of a recipient in his home. Related services includes training at a certified home dialysis training cen…

37.40.902 HOME DIALYSIS 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 and 37.85.414. The provision of home dialysis and related services by the medicaid program shall be…

37.40.905 HOME DIALYSIS FOR END STAGE RENAL DISEASE, REIMBURSEMENT Reimbursement for equipment shall be the lesser of the following: the provider's usual and customary charges which are reasonable; or the medicaid established fee for that service. Payment to a nonrelated individu…

37.41.101 PURPOSE The purpose of the department's State Unit on Aging within the Senior and Long Term Care Division is to develop and administer the State Plan on Aging in accordance with the requirements of the Older Americans Act, Pub. L. No. 89-73 (1965), as amended and codifi…

37.41.102 DEFINITIONS In addition to the definitions contained in 52-3-401, MCA, the following definitions apply to this subchapter: "Administration for Community Living/Administration on Aging" means the agency within the U.S. Department of Health and Human Services that is resp…

37.41.107 DESIGNATION OF PLANNING AND SERVICE AREAS The department may designate as a planning and service area: any unit of general-purpose local government; or any district or combination of districts. The department shall designate and fix the number of planning and service ar…

37.41.108 DESIGNATION OF AREA AGENCIES In accordance with applicable provisions of section 305 of the Older Americans Act, 42 U.S.C. § 3025, the department may designate an entity as an area agency in a planning and service area after considering the following factors: geographic…

37.41.109 DEPARTMENT AGING SERVICES HEARING PROCEDURES A designated area agency is entitled to a hearing if it is aggrieved by an adverse department: disapproving a plan or plan amendment submitted by the agency; disapproving an area plan for non-compliance with the requirements …

37.41.110 FUNCTIONS OF AREA AGENCY Pursuant to the applicable provisions of section 306 of the Older Americans Act, 42 U.S.C. § 3026, each designated area agency shall: develop and administer a four-year area plan for a comprehensive and coordinated delivery system within a plann…