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37.86.2207    EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES, REIMBURSEMENT

(1) Reimbursement for an EPSDT service, except as otherwise provided in this rule, is the lowest of the following:

(a) the provider's usual and customary charge for the service;

(b) the reimbursement determined in accordance with the methodologies provided in ARM 37.85.212 and 37.86.105;

(c) the department's Medicaid Mental Health Fee Schedule, except for the by-report method; or

(d) for public agencies, cost based reimbursement as determined in accordance with OMB Circular A-87, Cost Principles for State, Local and Indian Tribal Governments as established and approved by the department. The department adopts and incorporates by reference the OMB Circular A-87, Cost Principles for State, Local and Indian Tribal Governments, as further amended May 14, 2004. A copy of OMB Circular A-87 may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(2) Reimbursement for nutrition and private duty nursing services is specified in the department's fee schedule. The department adopts and incorporates by reference the department's private duty nursing services EPSDT Fee Schedule dated July 2010 and the nutrition EPSDT Fee Schedule dated July 2010. The fee schedules are posted at http://medicaidprovider.hhs.mt.gov. Reimbursement for outpatient chemical dependency treatment is outlined in ARM 37.27.912. A copy of the Nutrition and Private Duty Nursing Services Fee Schedules may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(3) Reimbursement for the therapeutic portion of therapeutic youth group home treatment services is the lesser of:

(a) the amount specified in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in ARM 37.87.901 and a direct care wage add-on, if applicable; or

(b) the provider's usual and customary charges (billed charges).

(4) Reimbursement for the therapeutic portion of therapeutic family care treatment services is the lesser of:

(a) the amount specified in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in ARM 37.87.901 and a direct care wage add-on if, applicable; or

(b) the provider's usual and customary charges (billed charges).

(5) For purposes of (3) and (4), "patient day" means a whole 24-hour period that a person is present and receiving therapeutic youth group home or therapeutic family care services. Even though a person may not be present for a whole 24-hour period, the day of admission is a patient day. The day of discharge is not a patient day.

(6) Reimbursement will be made to a provider for reserving a therapeutic youth group home or therapeutic youth family care (other than permanency therapeutic family care) bed while the recipient is temporarily absent for a therapeutic home visit if:

(a) the recipient's plan of care documents the medical need for therapeutic home visits as part of a therapeutic plan to transition the recipient to a less restrictive level of care;

(b) the recipient is temporarily absent on a therapeutic home visit;

(c) the provider clearly documents staff contact and recipient achievements or regressions during and following the therapeutic home visit; and

(d) the recipient is absent from the provider's facility for no more than three patient days per therapeutic home visit, unless additional days are authorized by the department.

(7) No more than 14 patient days per recipient in each state fiscal year will be allowed for therapeutic home visits.

(8) A service for which a fee is not set in or determinable through the EPSDT provider manual, ARM 37.85.212 or 37.86.105 is reimbursed at a fee negotiated in advance of the provision of the service. A service provided before there is a negotiated fee is reimbursed at an amount determined by the department.

(9) Reimbursements for school-based health related services are specified in the School-Based Health Service Fee Schedule dated October 2010, which is adopted and incorporated by reference. A copy of the School-Based Health Service Fee Schedule is posted at http://medicaidprovider.hhs.mt.gov. Rates are adjusted to reimburse these services at the federal matching assistance percentage (FMAP) rate.

(10) The department will not reimburse providers for two services that duplicate one another on the same day according to the Medicaid Mental Health Plan and Mental Health Services Plan for Youth Services Excluded from Simultaneous Reimbursement (Service Matrix) adopted in ARM 37.87.901.

(11) Information regarding current reimbursement or copies of fee schedules for EPSDT services may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA; NEW, 1992 MAR p. 2788, Eff. 1/1/93; AMD, 1993 MAR p. 1540, Eff. 7/16/93; AMD, 1995 MAR p. 2501, Eff. 11/23/95; AMD, 1997 MAR p. 548, Eff. 3/25/97; AMD, 1998 MAR p. 3219, Eff. 12/4/98; AMD, 1999 MAR p. 1806, Eff. 7/1/99; AMD, 1999 MAR p. 1379, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 1664, Eff. 6/30/00; AMD, 2001 MAR p. 27, Eff. 1/12/01; EMERG, AMD, 2001 MAR p. 989, Eff. 6/08/01; AMD, 2001 MAR p. 1476, Eff. 8/10/01; AMD, 2001 MAR p. 2041, Eff. 10/12/01; AMD, 2001 MAR p. 2156, Eff. 10/26/01; EMERG, AMD, 2002 MAR p. 1328, Eff. 4/26/02; AMD, 2002 MAR p. 1779, Eff. 6/28/02; EMERG, AMD, 2003 MAR p. 1316, Eff. 6/27/03; EMERG, AMD, 2003 MAR p. 1314, Eff. 7/1/03; AMD, 2004 MAR p. 83, Eff. 1/1/04; AMD, 2005 MAR p. 1787, Eff. 9/23/05; AMD, 2006 MAR p. 1635, Eff. 6/23/06; AMD, 2007 MAR p. 1824, Eff. 11/9/07; AMD, 2008 MAR p. 1488, Eff. 4/11/08; AMD, 2008 MAR p. 1980, Eff. 9/12/08; AMD, 2008 MAR p. 2673, Eff. 12/25/08; AMD, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2008 MAR p. 2674, Eff. 12/25/08; AMD, 2009 MAR p. 2029, Eff. 10/30/09; AMD, 2010 MAR p. 1512, Eff. 7/1/10; AMD, 2010 MAR p. 1533, Eff. 7/1/10.

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