Title 53, Title 53

(1) Medical assistance under the Montana medicaid program may be granted to a U.S. citizen or a qualified alien as defined in 8 U.S.C. 1641 who is determined by the department of public health and human services to be a Montana resident and, in its discretion, to be eligible as f…

(1) Within 1 year of a program participant's enrollment in the program, the department shall use available claims data and other information collected directly from the participant to assess whether the participant would be better served in a coordinated care or other treatment m…

(1) To ensure that the Montana medicaid program is administered efficiently and effectively, the department shall strengthen existing programs that manage the way members obtain approval for medical services and shall establish additional programs designed to reduce costs and imp…

(1) The department of corrections and the department of public health and human services shall reimburse health care service for individuals identified in subsection (2) at the rates adopted by the department for the medicaid program under Title 53, chapter 6, part 1, if the heal…

If the federal medical assistance percentage for medical services provided to individuals eligible for medicaid-funded services pursuant to 53-6-1304 is set below the levels established in 42 U.S.C. 1396d(y)(1) on the effective date of this section, the continuation of coverage u…

(1) (a) A program participant shall report to the department a permanent increase in income that would affect the participant's eligibility for the program. The change must be reported within 30 days of the change in income. (b) A short-term increase in income that is caused by o…

(1) There is a Montana HELP Act account in the state special revenue fund to the credit of the department. (2) Money from the following sources must be deposited in the account: (a) the taxpayer integrity fees provided for in 15-30-2660; (b) the outpatient hospital utilization fe…

(1) The department may adopt rules as necessary to carry out this part. (2) The department and the department of labor and industry may, in coordination, adopt rules as necessary for the implementation of the employment and reemployment assessments and workforce development activ…

(1) Subject to subsection (2), application for assistance under this part may be made in any local office of public assistance. The application must be presented in the manner and on the form prescribed by the department. All individuals wishing to apply must have the opportunity…

(1) The department shall report the following information to the legislative finance committee and the children, families, health, and human services interim committee quarterly: (a) the number of individuals who were determined eligible for medicaid-funded services pursuant to 5…

(1) The local office of public assistance shall promptly determine the eligibility of each applicant under this part in accordance with the rules of the department. Each applicant must be informed of the right to a fair hearing and of the confidential nature of the information gi…

(1) In providing for the extension of eligibility for medical assistance under subsection (2), the department may provide for health insurance or other health coverage in accordance with subsections 1925(a)(4)(B) and 1925(b)(4)(C) of Title XIX of the Social Security Act, 42 U.S.C…

Pursuant to 50-4-1004, the Montana medicaid program may not reimburse or provide coverage for any medical treatment prohibited in 50-4-1004(1)(a) or (1)(b).

If allowed by federal law, the principal and all interest or other income contained within an account established in accordance with Title 15, chapter 61, may not be treated as an asset of the employee or account holder or as an asset of a dependent of the employee or account hol…

As used in this part, unless expressly provided otherwise, the following definitions apply: (1) "Abuse" means conduct by a provider or other person involving disregard of and an unreasonable failure to conform with the statutes, regulations, and rules governing the medical assist…

(1) When conducting an overpayment audit, the department or an auditor shall: (a) allow the provider at least 30 days to comply with a request to provide records; (b) include in a request for records adequate information to allow the provider to identify the particular records so…

(1) Except as provided in subsection (2): (a) in conducting an initial overpayment audit, the department or an auditor may not use statistical sampling extrapolation for automated reviews and may not rely on extrapolation to determine or support the amount of an overpayment deter…

(1) (a) A provider's request for an administrative review of an overpayment determination may include a request for peer review of any clinical or professional judgment upon which the overpayment determination relies. A clinical or professional judgment includes but is not limite…

(1) The department or an auditor shall conclude an overpayment audit and notify the provider in writing of the audit results, including any overpayment determination, within 90 days of: (a) the receipt of all records requested in the department's or the auditor's initial record r…

At least once a year the department shall publish and make accessible on its website the following information regarding all medicaid overpayment audits: (1) the number and type of issues reviewed; (2) the number of medical and other records requested from providers; (3) the numb…

In order to carry out the requirements of 53-6-160(6) and to reduce claims errors, the department shall provide: (1) educational and training programs for providers at least twice a year to discuss a summary of audit results, common issues and problems, mistakes identified throug…

(1) An auditor performing or participating in an overpayment audit, overpayment determination, or related activity is subject to the same laws and regulations that would apply to the department in carrying out the same functions. (2) This part does not apply to the medicaid fraud…

At least once a year, the department shall conduct auditor evaluation hearings to identify issues, recommend or require corrective actions, and provide for ongoing and future evaluation of auditor performance. With input from providers, including comments gathered at the auditor …

Any cost incurred by the department of public health and human services in implementing 53-6-111 and this part must be absorbed into the department's existing budget.

All medical assistance cases approved under this part must be reviewed as often as required under the rules of the department of public health and human services.

(1) Except as provided in this section, the department may not impose a lien upon the property of an applicant for or recipient of medical assistance. (2) A lien for recovery of medical assistance paid or to be paid under this chapter may be imposed against the real or personal p…

Except as otherwise provided in 53-6-167 through 53-6-169, 53-6-171 through 53-6-189, and the provisions of other parts of this title, the only relatives that may be held responsible for payment of medical assistance under the program are the husband or wife of the individual, th…

(1) Recognizing the importance of consumer control over personal assistance services in a self-directed service model, the legislature directs the department of public health and human services and the department of labor and industry to adopt administrative rules authorizing a p…

(1) The department shall seek exemptions under federal medicaid law or regulations to protect Indian health services and tribal facilities from changes in eligibility categories, covered services, and reimbursement levels under the medicaid program that could potentially result i…

(1) There is an account in the federal special revenue fund established pursuant to 17-2-102 to be known as the Indian health service federal revenue account. (2) Funds in the account are statutorily appropriated, as provided in 17-7-502, to the department for medicaid benefits f…

(1) There is a hospital medicaid reimbursement account in the state special revenue fund provided for in 17-2-102. (2) All money collected under 15-66-102, except for the money deposited pursuant to 15-66-102(3)(b) into the Montana HELP Act special revenue account provided for in…

The department of public health and human services may receive private funds and nonfederal and nonstate public funds for its medical assistance programs. Donated funds must be matched with federal funds whenever possible.

This part may be cited as the "Prompt Cost Report Reimbursement Act".

(1) The legislature finds that providers of service that participate in medicare and Montana medicaid are required to submit information to achieve the settlement of costs relating to health care social services rendered to beneficiaries. The submitted cost reports cover the prov…

(1) (a) To reimburse a provider as quickly as possible, the department of public health and human services shall perform a tentative retroactive adjustment when a cost report is received by the applicable medicare administrative contractor. (b) Costs must be accepted as reported …

There is a medicaid reserve account in the state special revenue fund provided for in 17-2-102. Money in the account must be used by the department for medicaid benefits after June 30, 2011. Any interest or income earned on the account must be deposited in the account. Each calen…

(Temporary -- effective on occurrence of contingency) Ambulance medicaid reimbursement special revenue account -- statutory appropriation. (1) There is an ambulance medicaid reimbursement account in the state special revenue account provided for in 17-2-102 to the credit of the d…

As used in this part, unless expressly provided otherwise, the following definitions apply: (1) "Abuse" means conduct by an applicant, recipient, provider, or other person involving disregard of and an unreasonable failure to conform with the statutes, regulations, and rules gove…

(1) There is a medicaid fraud control unit in the department of justice. The unit is under the supervision and control of the attorney general and, subject to the availability of appropriated funds, consists of the agents and employees of the department of justice whom the attorn…

(1) The medicaid fraud control unit shall: (a) investigate and prosecute under applicable criminal statutes fraud and abuse by applicants, recipients, providers, or any other persons, including but not limited to cases referred by the department; (b) review any complaint of patie…

All local, county, and state departments and agencies shall cooperate with the medicaid fraud control unit and its agents and employees to effectuate the purposes of the unit.

Records, documents, and other information obtained in the course of an investigation by the medicaid fraud control unit or its agents, employees, or attorneys may be disclosed: (1) in accordance with the Montana Criminal Justice Information Act of 1979, as provided in Title 44, c…

(1) (a) A person who submits to a medicaid agency an application, claim, report, document, or other information that is or may be used to determine eligibility for medicaid benefits, eligibility to participate as a provider, or the right to or the amount of payment under the medi…

The department of public health and human services shall establish a standardized cost reporting process for certain medicaid service providers. The cost report information will be used to inform the department and the legislature about the adequacy of medicaid rates.

(1) The department of public health and human services shall include the following services in its cost reporting process: (a) adult mental health; (b) children's mental health; (c) substance use disorder; (d) developmental disabilities; and (e) senior and long-term care. (2) Ser…

(1) The department of public health and human services shall establish a cost reporting process that: (a) implements a standardized cost reporting format that includes recognized revenues and expenditures incurred by medicaid service providers; (b) identifies medicaid service pro…