Current through Register Vol. 18, September 20, 2024
(1) The department will reimburse nursing
facilities located outside the state of Montana for nursing facility services
and any other reimbursable services or supplies provided to eligible Montana
Medicaid individuals at the Medicaid rate and upon the basis established by the
Medicaid agency in the state in which the facility is located.
(2) The Montana Medicaid program will pay for
nursing facility services or related supplies provided to eligible Montana
Medicaid individuals in nursing facilities located outside the state of Montana
only when one of the following conditions is met:
(a) because of a documented medical
emergency, the resident's health would be endangered if he or she was to return
to Montana for medical services;
(b) the services required are not provided in
Montana;
(c) the required services
and all related expenses are less costly than if the required services were
provided in Montana;
(d) the
recipient is a child in another state for whom Montana makes adoption
assistance or foster care assistance payments; or
(e) the department determines that it is
general practice for recipients in the resident's particular locality to use
medical resources located in another state.
(3) To receive payments, the out-of-state
provider must enroll in the Montana Medicaid program. Enrollment information
and instructions may be obtained from the department's fiscal
intermediary.
(4) The department
will reimburse a nursing facility located outside the state of Montana under
the Montana Medicaid program only if, in addition to meeting other applicable
requirements, the facility has submitted to the department the following
information:
(a) a physician's order
identifying the Montana resident and specifically describing the purpose, cause
and expected duration of the stay;
(b) for nursing facility services, copies of
documents from the facility's state Medicaid agency establishing or stating the
facility's Medicaid per diem rate for the period the services were
provided;
(c) for separately
billable items, copies of documents from the facility's state Medicaid agency
establishing or stating the Medicaid reimbursement payable for such items for
the period the items were provided;
(d) a properly completed level I screening
form for the resident, as required by ARM
37.40.201, et seq.;
(i) To the extent required by ARM 37.40.201,
et seq., a level I screening must be performed prior to entry into the nursing
facility to determine if there is a diagnosis of mental illness or mental
retardation and if so, to conduct assessments which determine the resident's
need for active treatment. A level I screening form may be obtained from the
department.
(e) a copy
of the preadmission-screening determination for the resident completed by the
department or its designee;
(i) Payment will
be made for services no earlier than the date of referral for screening or the
date of screening, whichever is earlier.
(f) the resident's full name, Medicaid ID
number and dates of service;
(g) a
copy of the certification notice from the facility's state survey agency
showing certification for Medicaid during the period services were provided;
and
(h) assurances that, during the
period the billed services were provided, the facility was not operating under
sanctions imposed by Medicare or Medicaid which would preclude
payment.
(5)
Reimbursement to nursing facilities located outside the state of Montana for
Medicare coinsurance days for dually eligible Medicaid and Medicare individuals
shall be limited to the per diem rate established by the facility's state
Medicaid agency, less the Medicaid recipient's patient contribution.
AUTH:
53-2-201,
53-6-113,
MCA IMP:
53-2-201,
53-6-101,
53-6-111,
53-6-113,
MCA
