(1) Mental health services for a Medicaid adult under the Montana Medicaid program will be reimbursed only if the client is 18 or more years of age and has been determined to have a severe disabling mental illness.

(2) In addition to the requirements contained in rule, the department has developed and published the Addictive and Mental Disorders Division Medicaid Services Provider Manual for Substance Use Disorder and Adult Mental Health (Manual), dated July 1, 2020, which it adopts and incorporates by reference. The purpose of the Manual is to implement requirements for utilization management and services. A copy of the Manual may be obtained from the department by a request in writing to the Department of Public Health and Human Services, Addictive and Mental Disorders Division, 100 N. Park, Ste. 300, P.O. Box 202905, Helena, MT 59620-2905 or at http://dphhs.mt.gov/amdd.aspx.

(3) Medicaid reimbursement for mental health services will be the lowest of:

(a) the provider′s actual (submitted) charge for the service; or

(b) the rate established in the department′s fee schedule. Reimbursement fees are as provided in ARM 37.85.105(5) and 37.85.106(2)(c).

(4) The department may review the medical necessity of services or items at any time either before or after payment in accordance with the provisions of ARM 37.85.410. If the department determines that services or items were not medically necessary or otherwise in compliance with applicable requirements, the department may deny payment or may recover any overpayment in accordance with applicable requirements.

(5) The department or its designee may require providers to report outcome data or measures regarding mental health services, as determined in consultation with providers and consumers.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

(1) These requirements are in addition to those requirements contained in rules generally applicable to Medicaid providers.

(2) Mental health center services may be provided only by a facility that is licensed as a mental health center by the department in accordance with the provisions of Title 50, chapter 5, part 2, MCA, and implementing administrative rules.

(3) Mental health center services must be provided by, or under the direction of a licensed physician.

(4) Mental health center services must be available to individuals continuously throughout the year.

(5) Mental health center services must be provided to an individual in accordance with an individualized strength-based treatment plan developed and maintained in accordance with license requirements.

(6) In addition to the clinical records required by mental health center license rules, the provider must maintain for day treatment services the records required by ARM 37.85.414, which shall include, but are not limited to, documentation of the individual's attendance and activities for the required period of time for the service billed and entry of progress notes in the individual's record at least every 30 days and upon any significant change in the individual's condition.

This rule has been repealed.

(1) The department adopts and incorporates by reference the Medicaid Adult Mental Health fee schedule as provided in ARM 37.85.105(5). A copy of the department's fee schedule is posted at the Montana Medicaid provider web site at www.dphhs.mt.gov/amdd/services/index.shtml. A copy may be obtained from the Department of Public Health and Human Services, Addictive and Mental Disorders Division, PO Box 202905, Helena, MT 59620-2905. Medicaid reimbursement for mental health center services will be the lowest of:

(a) the provider's actual (submitted) charge for the service; or

(b) the department's fee for the service as specified in the department's fee schedules.

(2) The provider reimbursement rate for a covered service for mental health centers is stated in the department's fee schedule adopted and effective at ARM 37.85.105(5). These fees are calculated based on:

(a) the biennial legislative appropriation; and

(b) the estimated demand for covered services during the biennium.

(3) For services for which Medicare does not specify Relative Value Unit as provided in ARM 37.85.105, the department determines the Medicaid fee for adult mental health services as follows:

(a) if there is use resulting in Medicaid reimbursements totaling at least $10,000 in a state fiscal year (SFY), and a minimum of four separate providers have billed the procedure code, then the Medicaid fee is determined by multiplying the average charges by the payment-to-charge ratio;

(b) if there is use resulting in Medicaid reimbursements totaling less than $10,000 in an SFY and fewer than four separate providers have billed the procedure code in an SFY, then the Medicaid fee will be determined by:

(i) reviewing similar procedure codes within the same service scope and adjusting the rate to be equal to a comparable procedure code or the average of similar procedure codes if there is more than one; or

(ii) reviewing similar procedure codes within the same service scope and adjusting the rate to be equal to a comparable procedure code or the average of similar codes plus 10% when severity is higher or increased resources are needed for the service. If the code is determined to have a lesser severity component or fewer resources are required than when compared to the similar procedure code or average of similar procedure codes, the reimbursement rate will equal the comparable procedure code or average of similar procedure codes less 10%.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

(1) ARM 37.88.1401, 37.88.1402, 37.88.1405, 37.88.1406, 37.88.1410, 37.88.1411 and 37.88.1420 specify requirements for the provision of and reimbursement for medicaid nursing facility and hospital services to medicaid recipients who are residents of an institution for mental diseases. These rules are in addition to requirements generally applicable to medicaid providers as otherwise provided in state and federal statutes, rules, regulations and policies.

In ARM 37.88.1401, 37.88.1402, 37.88.1405, 37.88.1406, 37.88.1410, 37.88.1411 and 37.88.1420 the following definitions apply:

(1) "Department" means the Montana department of public health and human services or its agents, including but not limited to parties under contract to perform audit services, claim processing and utilization review.

(2) "Devoted to the provision of inpatient psychiatric hospital care to adults" means an institution for mental disease which is licensed and certified as a hospital and whose goals, purpose and care are designed for and devoted exclusively to providing diagnosis, treatment or care to persons with mental diseases age 18 and older.

(3) "Hospital" means a facility licensed, accredited or approved under the laws of Montana or a facility operated as a hospital by the state that provides, by or under the supervision of licensed physicians, services for the diagnosis, treatment, rehabilitation and care of persons with mental diseases.

(4) "Institution for mental diseases" means a hospital, nursing facility, or other institution with more than 16 beds which the department has determined is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. An institution for the mentally retarded, including an intermediate care facility for the mentally retarded, is not an institution for mental diseases.

(a) An institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such.

(i) In making a determination of whether an institution is an institution for mental diseases, the department shall consider the guidelines set forth in subsection C of section 4390 of the state medicaid manual, but no single guideline or combination of guidelines shall necessarily be determinative. The state medicaid manual is promulgated by the federal health care financing administration to provide guidance to states on administration of the medicaid program. The department hereby adopts and incorporates herein by reference subsection C of section 4390 of the state medicaid manual (1994) . A copy of subsection C of section 4390 of the state medicaid manual may be obtained from the Department of Public Health and Human Services, Senior and Long Term Care Division, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210.

(5) "Medicaid recipient" means a person who is eligible and receiving assistance under Title XIX of the Social Security Act for nursing facility services.

(6) "Mental disease" means a disease listed as a mental disorder in the current edition of the Diagnostic and Statistical Manual of Mental Diseases but does not include mental retardation, senility and organic brain syndrome.

(7) "Nursing facility services" means services defined in ARM 37.40.302, but not including intermediate care facility services for the mentally retarded.

(8) "Patient contribution" means the total of all of a resident's income from any source available to pay the cost of care, less the resident's personal needs allowance. The patient contribution includes a resident's incurment determined in accordance with applicable eligibility rules.

(9) "Patient day" means a whole 24-hour period that a person is present and receiving nursing facility services, regardless of the payment source. Even though a person may not be present for a whole 24-hour period on the day of admission or day of death, such day will be considered a patient day.

(10) "Provider" means a nursing facility or hospital that meets the provider participation requirements specified in ARM 37.88.1405.

(11) "Resident" means a person admitted to the provider's facility who has been present in the facility for at least one 24-hour period.

(a) complies with the requirements set forth at ARM 37.40.306 for medicaid nursing facility service providers;

(b) has been determined by the department, in accordance with ARM 37.88.1402, to be an institution for mental diseases;

(c) complies with ARM 37.40.352 regarding utilization review and quality of care for nursing facilities; and

(d) enters into and maintains a written agreement with the department that specifies the respective responsibilities of the department and the provider including arrangements for:

(i) joint planning between the parties to the agreement;

(ii) development of alternative methods of care;

(iii) permission for immediate readmission to the institution when the recipient's need for readmission has been determined to be medically necessary;

(iv) access by the department to the recipient, the recipient's records and the facility;

(v) recording, reporting and exchanging medical and social information about recipients; and

(vi) other procedures necessary to carry out the agreement; or

(e) is a hospital which is devoted to the provision of inpatient psychiatric hospital care to adults. A publicly owned hospital devoted to the provision of inpatient psychiatric care to adults shall not be required to enter into and maintain a written agreement as provided in (1) (d) .

(a) an initial review of the recipient's medical, psychiatric and social needs within 30 days after the date of admission;

(b) periodic review of the recipient's medical, psychiatric and social needs;

(c) a determination at least every 90 days of the recipient's need for continued institutional care and for alternative care arrangements;

(d) appropriate medical treatment in the institution; and

(e) appropriate social services.

(1) The Montana medicaid program does not cover and will not reimburse for services provided in institutions for mental diseases, except:

(a) services provided to medicaid recipients ages 18 through 21 and 65 or over in hospitals devoted to the provision of inpatient psychiatric hospital care for adults; or

(b) as provided in ARM 37.88.1401, 37.88.1402, 37.88.1405, 37.88.1406, 37.88.1410, 37.88.1411 and 37.88.1420 for medicaid recipients age 65 or over receiving nursing facility services in a nursing facility that the department has determined to be an institution for mental diseases under ARM 37.88.1402.

(2) For nursing facility services provided to medicaid recipients age 65 years or over in an institution for mental diseases, the Montana medicaid program will pay a provider:

(a) for each patient day, an interim per diem rate, as specified in (3) , minus the amount of the medicaid recipient's patient contribution; and

(b) additional reimbursement for separately billable items as provided in (4) .

(3) The final per diem payment rate for:

(a) the Montana state hospital is $335; and

(b) the Montana mental health nursing care center at Lewistown is $150 for high acuity patients and $100 for low acuity patients.

(4) Separately billable items are those items specified in ARM 37.40.330 and are reimbursable by medicaid according to the provisions of ARM 37.40.330.

(5) For hospital services provided to medicaid recipients age 18 through 21 and 65 or over, the Montana medicaid program will pay hospitals devoted to the provision of inpatient psychiatric hospital care to adults an all-inclusive per diem rate which includes the cost of physician and dental services as well as the cost of the services listed in ARM 37.86.2902(2) .