53-6-101. Montana medicaid program -- authorization of services. (1) There is a Montana medicaid program established for the purpose of providing necessary medical services to eligible persons who have need for medical assistance. The Montana medicaid program is a joint federal-state program administered under this chapter and in accordance with Title XIX of the Social Security Act, 42 U.S.C. 1396, et seq., as may be amended. The department of public health and human services shall administer the Montana medicaid program.
(2) Medical assistance provided by the Montana medicaid program includes the following services:
(a) inpatient hospital services;
(b) outpatient hospital services;
(c) other laboratory and x-ray services, including minimum mammography examination as defined in 33-22-132;
(d) skilled nursing services in long-term care facilities;
(e) physicians' services;
(f) nurse specialist services;
(g) early and periodic screening, diagnosis, and treatment services for persons under 21 years of age;
(h) ambulatory prenatal care for pregnant women during a presumptive eligibility period, as provided in 42 U.S.C. 1396a(a)(47) and 42 U.S.C. 1396r-1;
(i) targeted case management services, as authorized in 42 U.S.C. 1396n(g), for high-risk pregnant women;
(j) services that are provided by physician assistants-certified within the scope of their practice and that are otherwise directly reimbursed as allowed under department rule to an existing provider;
(k) health services provided under a physician's orders by a public health department; and
(l) federally qualified health center services, as defined in 42 U.S.C. 1396d(l)(2).
(3) Medical assistance provided by the Montana medicaid program may, as provided by department rule, also include the following services:
(a) medical care or any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law;
(b) home health care services;
(c) private-duty nursing services;
(d) dental services;
(e) physical therapy services;
(f) mental health center services administered and funded under a state mental health program authorized under Title 53, chapter 21, part 2;
(g) clinical social worker services;
(h) prescribed drugs, dentures, and prosthetic devices;
(i) prescribed eyeglasses;
(j) other diagnostic, screening, preventive, rehabilitative, chiropractic, and osteopathic services;
(k) inpatient psychiatric hospital services for persons under 21 years of age;
(l) services of professional counselors licensed under Title 37, chapter 23;
(m) hospice care, as defined in 42 U.S.C. 1396d(o);
(n) case management services as provided in 42 U.S.C. 1396d(a) and 1396n(g), including targeted case management services for the mentally ill;
(o) inpatient psychiatric services for persons under 21 years of age, as provided in 42 U.S.C. 1396d(h), in a residential treatment facility, as defined in 50-5-101, that is licensed in accordance with 50-5-201; and
(p) any additional medical service or aid allowable under or provided by the federal Social Security Act.
(4) Services for persons qualifying for medicaid under the medically needy category of assistance as described in 53-6-131 may be more limited in amount, scope, and duration than services provided to others qualifying for assistance under the Montana medicaid program. The department is not required to provide all of the services listed in subsections (2) and (3) to persons qualifying for medicaid under the medically needy category of assistance.
(5) In accordance with federal law or waivers of federal law that are granted by the secretary of the U.S. department of health and human services, the department of public health and human services may implement limited medicaid benefits, to be known as basic medicaid, for adult recipients who are eligible because they are receiving financial assistance, as defined in 53-4-201, as the specified caretaker relative of a dependent child under the FAIM project and for all adult recipients of medical assistance only who are covered under a group related to a program providing financial assistance, as defined in 53-4-201. Basic medicaid benefits consist of all mandatory services listed in subsections (2)(a) through (2)(l) but may include those optional services listed in subsections (3)(a) through (3)(p) that the department in its discretion specifies by rule. The department, in exercising its discretion, may consider the amount of funds appropriated by the legislature and whether the provision of a particular service is commonly covered by private health insurance plans. However, a recipient who is pregnant, meets the criteria for disability provided in Title II of the Social Security Act, 42 U.S.C. 416, et seq., or is less than 21 years of age is entitled to full medicaid coverage.
(6) The department may implement, as provided for in Title XIX of the Social Security Act, 42 U.S.C. 1396, et seq., as may be amended, a program under medicaid for payment of medicare premiums, deductibles, and coinsurance for persons not otherwise eligible for medicaid.
(7) The department may set rates for medical and other services provided to recipients of medicaid and may enter into contracts for delivery of services to individual recipients or groups of recipients.
(8) The services provided under this part may be only those that are medically necessary and that are the most efficient and cost-effective.
(9) The amount, scope, and duration of services provided under this part must be determined by the department in accordance with Title XIX of the Social Security Act, 42 U.S.C. 1396, et seq., as may be amended.
(10) Services, procedures, and items of an experimental or cosmetic nature may not be provided.
(11) If available funds are not sufficient to provide medical assistance for all eligible persons, the department may set priorities to limit, reduce, or otherwise curtail the amount, scope, or duration of the medical services made available under the Montana medicaid program.
(12) Community-based medicaid services, as provided for in part 4 of this chapter, must be provided in accordance with the provisions of this chapter and the rules adopted under this chapter.
(13) Medicaid payment for personal-care facilities may not be made unless the department certifies to the director of the governor's office of budget and program planning that payment to this type of provider would, in the aggregate, be a cost-effective alternative to services otherwise provided.
History: En. Sec. 2, Ch. 325, L. 1967; amd. Sec. 1, Ch. 261, L. 1971; R.C.M. 1947, 71-1512(part); amd. Sec. 1, Ch. 77, L. 1985; amd. Sec. 1, Ch. 329, L. 1987; amd. Sec. 19, Ch. 97, L. 1989; amd. Sec. 1, Ch. 417, L. 1989; amd. Sec. 1, Ch. 633, L. 1989; amd. Sec. 10, Ch. 649, L. 1989; amd. Sec. 1, Ch. 711, L. 1989; amd. Sec. 1, Ch. 310, L. 1991; amd. Sec. 1, Ch. 388, L. 1991; amd. Secs. 3, 7, Ch. 460, L. 1991; amd. Sec. 4, Ch. 634, L. 1991; amd. Sec. 3, Ch. 663, L. 1991; amd. Sec. 3, Ch. 764, L. 1991; amd. Sec. 6, Ch. 590, L. 1993; amd. Sec. 2, Ch. 14, Sp. L. November 1993; amd. Sec. 25, Ch. 491, L. 1995; amd. Sec. 438, Ch. 546, L. 1995; amd. Sec. 46, Ch. 486, L. 1997; amd. Sec. 36, Ch. 465, L. 2001.
