(1) The purpose of these rules is to implement 53-6-1312, MCA, which establishes the Medicaid schedule of rates as the reimbursement rates that the State of Montana (State) pays for health care services provided to an individual who does not qualify for Medicaid, Medicare, a health insurer, or another private or governmental program that pays for health care costs and is:

(a) in the custody of the Department of Corrections; or

(b) a resident, by commitment or otherwise, of the Montana State Hospital, the Montana Mental Health Nursing Care Center, the Montana Chemical Dependency Center, or the Montana Developmental Center.

(2) The State will process these health care claims through the Department of Public Health and Human Services' Medicaid claims processing agent.

(1) To receive payment from the State for health care services provided to an individual identified in 53-6-1312, MCA, a provider must:

(a) be enrolled as a Montana Medicaid provider;

(b) accept the Montana Medicaid rates as full payment for all health care services; and

(c) comply with the requirements of this subchapter.

(2) A provider who accepts an individual identified in 53-6-1312, MCA, as a patient is agreeing to accept the Medicaid rate as payment in full.

(3) In service settings where an individual identified in 53-6-1312, MCA, is accepted as a patient by a provider who arranges for services by other providers, all providers performing services are deemed to have accepted reimbursement from the State at the Montana Medicaid rates.

(4) A provider may not "balance bill" or seek payment in addition to, or in lieu of, the payment by the State. "Balance bill" means a provider bills the patient, or responsible party, the difference between the amount the state reimburses for services and what the provider chooses to charge.

(1) Except for the administrative rules listed in (2), the provider requirements of ARM Title 37, chapter 85, subchapter 4, "Provider Requirements," apply to the delivery of health care services provided to an individual identified in 53-6-1312, MCA. For the purposes of this subchapter, a reference to "Montana Medicaid" or "Medicaid" in ARM Title 37, chapter 85, subchapter 4 is understood to mean payments made under 53-6-1312, MCA.

(2) The following administrative rules do not apply to providers receiving payment for services provided to an individual identified in 53-6-1312, MCA:

(a) ARM 37.85.407, Third Party Liability;

(b) ARM 37.85.411, Provider Rights;

(c) ARM 37.85.415, Medical Assistance Medicaid Payment; and

(d) ARM 37.85.416, Statistical Sampling Audits.

(3) A provider who disputes a payment is entitled to an administrative hearing on the matter according to the procedures of the department responsible for payment. A provider who is aggrieved by a final written decision is entitled to a judicial review of the decision.

(1) The cost sharing requirements of ARM 37.84.108 and 37.85.204 do not apply to the individuals identified in 53-6-1312, MCA. An individual identified in 53-6-1312, MCA, is neither a member nor a program participant as defined at 53-6-1302, MCA.