53-6-113. Department to adopt rules. (1) The department of public health and human services shall adopt appropriate rules necessary for the administration of the Montana medicaid program as provided for in this part and as may be required by federal laws and regulations governing state participation in medicaid under Title XIX of the federal Social Security Act, 42 U.S.C. 1396, et seq., as amended.
     (2) The department shall adopt rules as are necessary to further define for the purposes of this part the services provided under 53-6-101 and to provide that services being used are medically necessary and that the services are the most efficient and cost-effective available. The rules may establish the amount, scope, and duration of services provided under the Montana medicaid program, including the items and components constituting the services.
     (3) The department shall establish by rule the rates for reimbursement of services provided under this part. The department may in its discretion set rates of reimbursement that it determines necessary for the purposes of the program. In establishing rates of reimbursement, the department may consider but is not limited to considering:
     (a) the availability of appropriated funds;
     (b) the actual cost of services;
     (c) the quality of services;
     (d) the professional knowledge and skills necessary for the delivery of services; and
     (e) the availability of services.
     (4) The department shall specify by rule those professionals who may deliver or direct the delivery of particular services.
     (5) The department may provide by rule for payment by a recipient of a portion of the reimbursements established by the department for services provided under this part.
     (6) The department may adopt rules consistent with this part to govern eligibility for the Montana medicaid program. Rules may include but are not limited to financial standards and criteria for income and resources, treatment of resources, nonfinancial criteria, family responsibilities, residency, application, termination, definition of terms, and confidentiality of applicant and recipient information.
     (7) The department may adopt rules limiting eligibility based on criteria more restrictive than that provided in 53-6-131 if required by Title XIX of the federal Social Security Act, 42 U.S.C. 1396, et seq., as may be amended, or if funds appropriated are not sufficient to provide medical care for all eligible persons.
     (8) The department may adopt rules necessary for the administration of medicaid managed-care systems. Rules to be adopted may include but are not limited to rules concerning:
     (a) participation in managed care;
     (b) selection and qualifications for providers of managed care; and
     (c) standards for the provision of managed care.
     (9) (a) The department shall establish by rule income limits for eligibility for extended medical assistance of persons receiving aid to families with dependent children as participants of the FAIM project who lose eligibility because of increased income, as provided in 53-6-134, and shall also establish by rule the length of time for which extended medical assistance will be provided. The department, in exercising its discretion to set income limits and duration of assistance, may consider the amount of funds appropriated by the legislature for the FAIM project.
     (b) Notwithstanding Title 53, chapter 2, part 9, and Title 53, chapter 4, part 6, it is the intent of the legislature that rules may not be adopted except to implement the waiver granted by the U.S. secretary of health and human services under section 1115 of the Social Security Act, 42 U.S.C. 1315, and to implement the FAIM program. Rules may not implement any other program or programs that may result because of federal welfare reform unless the rules are required for compliance with federal law.

     History: En. Sec. 1, Ch. 325, L. 1967; amd. Secs. 47 and 48, Ch. 121, L. 1974; R.C.M. 1947, 71-1511(6); amd. Sec. 4, Ch. 310, L. 1989; amd. Sec. 5, Ch. 711, L. 1989; amd. Sec. 4, Ch. 460, L. 1991; amd. Sec. 26, Ch. 491, L. 1995; amd. Sec. 446, Ch. 546, L. 1995.