Montana Administrative Code

37.82.702 NONFINANCIAL REQUIREMENTS, NONINSTITUTIONALIZED FAIM FINANCIAL ASSISTANCE RELATED FAMILIES AND CHILDREN Individuals eligible for FAIM financial assistance are presumed to have met the nonfinancial requirements of the Medicaid program. For individuals under 19 who are no…

37.82.703 FINANCIAL REQUIREMENTS, NONINSTITUTIONALIZED FAIM FINANCIAL ASSISTANCE RELATED FAMILIES AND CHILDREN Individuals eligible for FAIM financial assistance are presumed to have met all the financial requirements for Medicaid eligibility. Notwithstanding the above and in acc…

37.82.704 THREE MONTH RETROACTIVE COVERAGE, NONINSTITUTIONALIZED FAIM FINANCIAL ASSISTANCE RELATED FAMILIES AND CHILDREN Three month retroactive coverage will be provided to individuals determined eligible for Medicaid under this subchapter if: they received medical services duri…

37.82.710 RESOURCE EXCLUSIONS: FAMILY MEDICAID FOR NONINSTITUTIONALIZED CATEGORICALLY NEEDY CHILDREN AND FAMILIES In determining eligibility for noninstitutionalized categorically needy children and families under the family Medicaid coverage groups in regard to the factor of res…

37.82.901 GROUPS COVERED, NON-INSTITUTIONALIZED SSI-RELATED INDIVIDUALS AND COUPLES Medicaid will be provided to: Aged, blind or disabled individuals or couples receiving SSI, including: those receiving SSI pending final determination of blindness or disability; those receiving S…

37.82.902 NON-FINANCIAL REQUIREMENTS, NON-INSTITUTIONALIZED SSI-RELATED INDIVIDUALS AND COUPLES Aged, blind or disabled individuals or couples receiving SSI, mandatory state supplements, or only a state supplementary payment under the optional state supplementary program are pres…

37.82.903 FINANCIAL REQUIREMENTS, NON-INSTITUTIONALIZED SSI-RELATED INDIVIDUALS AND COUPLES Aged, blind or disabled individuals or couples receiving SSI, mandatory state supplements, or only a state supplementary payment under the optional state supplementary program are presumed…

37.82.904 THREE MONTH RETROACTIVE COVERAGE, NON-INSTITUTIONALIZED SSI-RELATED INDIVIDUALS AND COUPLES Three month retroactive coverage will be provided to individuals determined eligible for medicaid under this subchapter if: they received medical services during any of the three…

37.82.910 RESOURCE EXCLUSIONS: AGED, BLIND, AND DISABLED MEDICAID FOR NONINSTITUTIONALIZED INDIVIDUALS AND COUPLES In determining eligibility for noninstitutionalized categorically needy individuals and couples under the aged, blind, and disabled Medicaid coverage groups in regar…

37.83.201 QUALIFIED MEDICARE BENEFICIARIES, APPLICATION AND ELIGIBILITY FOR MEDICAID A person is a qualified medicare beneficiary eligible for medicaid, as provided for in Title 37, chapter 83, subchapter 8, if the person: is entitled to medicare Part A benefits as provided for i…

37.83.202 QUALIFIED MEDICARE BENEFICIARIES, EFFECTIVE DATE OF ELIGIBILITY A person is eligible for the receipt of medicaid benefits at the beginning of the following month after the department determines that the person is a qualified medicare beneficiary. Authorizing statute(s):…

37.83.401 QUALIFIED DISABLED WORKING INDIVIDUALS, APPLICATION AND ELIGIBILITY FOR MEDICAID A qualified disabled working individual (QDWI) is an individual: who is entitled to enroll in hospital insurance benefits (medicare Part A) under 42 USC 1395i-2a because he lost premium-fre…

37.83.402 QUALIFIED DISABLED WORKING INDIVIDUALS, EFFECTIVE DATE OF ELIGIBILITY A person is eligible for QDWI benefits as of the date that all eligibility criteria set forth in ARM 37.83.401 are met and he is enrolled in medicare Part A under 42 USC 1395i-2a. Retroactive coverage…

37.83.406 QUALIFIED DISABLED WORKING INDIVIDUALS, MEDICAID BENEFITS Medicaid benefits for a qualified disabled working individual are limited to payment of the monthly medicare hospital insurance (Part A) premium. Authorizing statute(s): Sec. 53-6-113, MCA Implementing statute(s)…

37.83.501 SPECIFIED LOW INCOME MEDICARE BENEFICIARIES, APPLICATION AND ELIGIBILITY FOR MEDICAID A person is a specified low income medicare beneficiary eligible for medicaid as provided in (7) of this rule if the person: is entitled to medicare Part A benefits as provided in 42 U…

37.83.801 MEDICAID COVERAGE FOR QUALIFIED MEDICARE BENEFICIARIES ARM Title 37, chapter 83 implements medicaid coverage, as provided for in Section 301 of the Medicare Catastrophic Coverage Act of 1988 and House Bills 452 and 453 of the 51st Montana legislature for the costs of me…

37.83.802 QUALIFIED MEDICARE BENEFICIARIES, DEFINITIONS "Assignment" means an agreement between the medicare carrier and a medicare provider under which the carrier makes payment to the provider rather than the recipient, and the provider agrees to accept the medicare allowable r…

37.83.805 QUALIFIED MEDICARE BENEFICIARIES, GENERAL REQUIREMENTS A qualified medicare beneficiary is subject to the requirements in the following rules: ARM 37.86.5303 concerning prior approval and restrictions on provider; and ARM 37.82.206 concerning the provisions of assistanc…

37.83.810 QUALIFIED MEDICARE BENEFICIARIES, PAYMENT OF MEDICARE PREMIUMS Medicaid will cover the medicare Part B insurance premium for a qualified medicare beneficiary. Medicaid will cover the medicare Part A insurance premium for a qualified medicare beneficiary who is not eligi…

37.83.811 QUALIFIED MEDICARE BENEFICIARIES, COVERAGE OF DEDUCTIBLES AND COINSURANCE FOR MEDICARE SERVICES ALSO COVERED BY FULL MEDICAID For a qualified medicare beneficiary, medicaid will participate in the deductibles and coinsurance for the following medicare services also cove…

37.83.812 QUALIFIED MEDICARE BENEFICIARIES, PAYMENT FOR CHIROPRACTIC SERVICES AS MEDICARE SERVICES NOT COVERED BY FULL MEDICAID (REPEALED) Authorizing statute(s): 53-2-201, 53-6-113, MCA Implementing statute(s): 53-6-101, 53-6-131, MCA History: NEW, 1989 MAR p. 835, Eff. 6/30/89;…

37.83.820 QUALIFIED MEDICARE BENEFICIARIES, FREE CHOICE OF PROVIDERS Any qualified medicare beneficiary may obtain services from any institution, agency, pharmacy, or practitioner licensed and qualified to perform such services and participating under the medicaid program, unless…

37.83.821 QUALIFIED MEDICARE BENEFICIARIES, PROVIDER REQUIREMENTS As a condition of participation in the Montana medicaid program, including the qualified medicare beneficiary program, all providers of service shall abide by all applicable state and federal statutes and regulatio…

37.83.822 QUALIFIED MEDICARE BENEFICIARIES, PROVIDER CHOICE OF PARTICIPATION AND OTHER RIGHTS A provider may choose to provide services to a person either as a private pay client or as a medicaid client. A medicaid client is a person who is medicaid eligible either as a qualified…

37.83.825 QUALIFIED MEDICARE BENEFICIARIES, PAYMENTS TO PROVIDERS Payments for services provided to medicaid qualified medicare beneficiaries may only be made to a provider. A provider in order to receive payments must be enrolled in the medicaid program. Medicaid payment will be…

37.83.826 QUALIFIED MEDICARE BENEFICIARIES, COPAYMENTS A qualified medicare beneficiary is responsible for copayments to the same extent as a medicaid recipient under the provisions of ARM 37.85.204. Authorizing statute(s): Sec. 53-2-201 and 53-6-113, MCA Implementing statute(s):…

37.83.830 QUALIFIED MEDICARE BENEFICIARIES, BILLING The requirements for billing medicaid are as follows: Claims for qualified medicare beneficiaries must be submitted to medicare first. Claims for medicare Part A insurance services must be submitted to the medicare Part A insura…

37.83.831 QUALIFIED MEDICARE BENEFICIARIES, DETERMINATION OF MEDICAL NECESSITY For services to qualified medicare beneficiaries, medicaid may accept medicare's determination of medical necessity for services which require approval prior to service delivery or review prior to paym…

37.84.101 HELP ACT: PURPOSE The purpose of this subchapter is to implement the Montana Health and Economic Livelihood Partnership Act (HELP Act) enacted by the 64th Montana Legislature, Ch. 368, L. 2015 MT, and House Bill 658 enacted by the 66th Montana Legislature, Ch. 21, L. 20…

37.84.102 HELP ACT: DEFINITIONS "American Indian and Alaska Native" means an American Indian, Alaska Native, or other individual who is eligible for health services through the Indian Health Service, tribes and tribal organizations, or urban Indian organizations. "Certification" …

37.84.103 HELP ACT: ELIGIBILITY FOR COVERAGE An individual qualifies for Medicaid coverage under the HELP Program if the person is a Montana resident who meets the eligibility criteria for Medicaid coverage as authorized at 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) (2015) and 42 C.F.R. …

37.84.106 HELP ACT: BENEFITS Coverage for a person in the HELP Program is provided through the Medicaid Alternative Benefit Plan. Authorizing statute(s): 53-2-215, 53-6-113, 53-6-1318, MCA Implementing statute(s): 53-2-215, 53-6-101, MCA History: NEW, 2015 MAR p. 2294, Eff. 1/1/1…

37.84.107 HELP ACT: PREMIUMS A HELP participant must pay a premium equal to two percent of the prorated share of the participant's annual household income. The premium will be billed in twelve equal monthly amounts. Except as provided in subsection (3), the premiums must: be set …

37.84.108 HELP ACT: HELP PLAN COPAYMENTS (REPEALED) Authorizing statute(s): 53-2-215, 53-6-113, 53-6-1305, 53-6-1318, MCA Implementing statute(s): 53-2-215, 53-6-101, 53-6-1306, MCA History: NEW, 2015 MAR p. 2294, Eff. 1/1/16; REP, 2017 MAR p. 2326, Eff. 1/1/18.

37.84.109 HELP ACT: HELP PLAN REIMBURSEMENT (REPEALED) Authorizing statute(s): 53-2-215, 53-6-113, 53-6-1305, 53-6-1318, MCA Implementing statute(s): 53-2-215, 53-6-101, 53-6-1305, MCA History: NEW, 2015 MAR p. 2294, Eff. 1/1/16; REP, 2017 MAR p. 2326, Eff. 1/1/18.

37.84.112 HELP ACT: HELP PLAN PROVIDER QUALIFICATIONS (REPEALED) Authorizing statute(s): 53-2-215, 53-6-113, 53-6-1305, 53-6-1318, MCA Implementing statute(s): 53-2-215, 53-6-101, 53-6-113, 53-6-1305, MCA History: NEW, 2015 MAR p. 2294, Eff. 1/1/16; REP, 2017 MAR p. 2326, Eff. 1/…

37.84.115 HELP ACT: HELP PLAN GRIEVANCE AND APPEAL PROCESS (REPEALED) Authorizing statute(s): 53-2-215, 53-6-113, 53-6-1305, 53-6-1318, MCA Implementing statute(s): 53-2-215, 53-6-101, 53-6-113, 53-6-1305, MCA History: NEW, 2015 MAR p. 2294, Eff. 1/1/16; REP, 2017 MAR p. 2326, Ef…

37.84.116 HELP ACT: COMMUNITY ENGAGEMENT ACTIVITY PARTICIPATION: REQUIREMENTS A participant shall participate in a minimum average of 80 hours per month of qualifying community engagement activities each reporting period unless exempt from participation as defined in (2). A parti…

37.84.117 HELP ACT: COMMUNITY ENGAGEMENT ACTIVITY PARTICIPATION: DATA REVIEW The department shall make reasonable efforts to review available electronic data sources on a monthly basis to identify and document compliance with or exemption from community engagement activity partic…

37.84.118 HELP ACT: COMMUNITY ENGAGEMENT ACTIVITY PARTICIPATION: QUALIFYING ACTIVITIES Time spent in one or more of the following qualifying activities may be counted toward the community engagement activity participation requirements as provided under ARM 37.84.116: employment; …

37.84.119 HELP ACT: COMMUNITY ENGAGEMENT ACTIVITY PARTICIPATION: INCOME-BASED EXEMPTION A participant is exempt from community engagement activity participation requirements if a participant's income exceeds an amount equal to or above the average of 80 hours per month multiplied…

37.84.120 HELP ACT: COMMUNITY ENGAGEMENT ACTIVITY PARTICIPATION: STANDARD EXEMPTIONS A participant is exempt from the community engagement activity participation requirements if the participant is: medically frail consistent with 42 C.F.R. 440.315. The department shall review hea…

37.84.121 HELP ACT: COMMUNITY ENGAGEMENT ACTIVITY PARTICIPATION: HARDSHIP EXEMPTIONS A participant is exempt from community engagement activity participation requirements if the participant: is hospitalized or is caring for an immediate family member who has been hospitalized; th…

37.84.122 HELP ACT: COMMUNITY ENGAGEMENT ACTIVITY PARTICIPATION: COVERAGE SUSPENSION A participant who does not meet the age-based exclusion found in ARM 37.84.117(2)(a) or an income, standard, or hardship exemption and fails to comply with the community engagement activity parti…

37.84.123 HELP ACT: COMMUNITY ENGAGEMENT ACTIVITY PARTICIPATION: AUDIT REQUIREMENTS On a quarterly basis, the Quality Assurance Division shall prepare, plan, and execute an audit to test compliance with community engagement participation requirements from a random sample of parti…

37.85.104 EFFECTIVE DATES OF PROVIDER FEE SCHEDULES FOR MONTANA NON-MEDICAID SERVICES The department adopts and incorporates by reference the fee schedule for the following programs within the Behavioral Healthand Developmental DisabilitiesDivision on the dates stated: Mental hea…

37.85.105 EFFECTIVE DATES, CONVERSION FACTORS, POLICY ADJUSTERS, AND COST-TO-CHARGE RATIOS OF MONTANA MEDICAID PROVIDER FEE SCHEDULES The Montana Medicaid Program establishes provider reimbursement rates for medically necessary, covered services based on the estimated demand for …

37.85.106 MEDICAID BEHAVIORAL HEALTH TARGETED CASE MANAGEMENT FEE SCHEDULE The Montana Medicaid Program establishes provider reimbursement rates for medically necessary, covered services based on the estimated demand for services and the legislative appropriation and federal matc…

37.85.1101 PURPOSE (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.

37.85.1103 DEFINITIONS (REPEALED) (REPEALED) Authorizing statute(s): 53-6-113, MCA Implementing statute(s): 53-6-111, MCA History: NEW, 2011 MAR p. 1374, Eff. 7/29/11; REP, 2025 MAR, 37-1102, Eff. 2/22/25.