(1) "Allowable costs" are the costs incurred by an RHC or FQHC, which are reasonable in amount and necessary and proper to the efficient delivery of services. Allowable costs are defined in accordance with reasonable cost principles in 42 CFR Parts 405 and 413.

(2) "Baseline PPS rate" is defined as an RHC's or FQHC's current PPS rate established in accordance with ARM 37.86.4413, 37.86.4420(2), 37.86.4409, or 37.86.4410, as adjusted annually by the Medicare economic index (MEI).

(3) "Category of service" means a type of Medicaid covered service that is furnished in an RHC or FQHC.

(4) "Change in the scope of service" means a change that affects the type, intensity, duration, or amount of services provided by an RHC or FQHC. The change in the scope of service must reasonably be expected to last at least one year.

(5) "Crossover claim" means a claim for services provided to Medicare/Medicaid dual eligibles or qualified Medicare beneficiaries.

(6) "Federally qualified health center (FQHC)" means an entity as defined in 42 USC 1396d(l)(2). A copy of the cited statute is available upon request from the Department of Public Health and Human Services, Health Resources Division, Hospital and Physicians Services Bureau, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(7) "FQHC services" are as defined in 42 USC 1396d(l)(2).

(8) "Health professional" means services furnished by a:

(a) physician;

(b) nurse practitioner (NP);

(c) physician assistant (PA);

(d) certified nurse-midwife (CNM);

(e) licensed clinical psychologist (LCP);

(f) licensed clinical social worker (LCSW);

(g) licensed professional counselor (LCPC);

(h) licensed marriage and family therapist (LMFT); 

(i) licensed addiction counselor (LAC); and

(j) clinical pharmacist practitioner.

(9) "Incremental change" means a positive or negative adjustment to a baseline PPS rate.

(10) "Independent entity" means an RHC or an FQHC that is not a provider-based entity.

(11) "Interim PPS rate" is the rate established when an RHC or FQHC initially opens and is set in accordance with ARM 37.86.4413(1) and (2).

(12) "Provider" means the entity enrolled in the Montana Medicaid program as an RHC or FQHC.

(13) "Provider-based entity" means an FQHC or RHC that is an integral and subordinate part of a hospital, skilled nursing facility, or home health agency that is participating in the Medicare program and that is operated with other departments of the provider under common licensure, governance and professional supervision.

(14) "Reporting period" means a period of 12 consecutive months specified by an RHC or FQHC as the period for which the entity must report its costs and utilization. The reporting period must correspond to the provider's fiscal year. The first and last reporting periods may be less than 12 months.

(15) "Rural health clinic (RHC)" means an entity as defined in 42 USC 1396d(l)(1).

(16) "Rural health clinic (RHC) services" are as defined in 42 USC 1396(l)(1).

(17) "Temporary PPS rate" is the rate established in accordance with ARM 37.86.4410.

(18) "Visit" has the meaning set forth in ARM 37.86.4402.


History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA; NEW, 1998 MAR p. 2045, Eff. 7/31/98; AMD, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2001 MAR p. 2043, Eff. 10/12/01; AMD, 2005 MAR p. 975, Eff. 6/17/05; AMD, 2015 MAR p. 761, Eff. 7/1/15; AMD, 2016 MAR p. 1712, Eff. 10/1/16; AMD, 2017 MAR p. 908, Eff. 7/1/17; AMD, 2019 MAR p. 1866, Eff. 10/19/19; AMD, 2021 MAR p. 1232, Eff. 9/25/21.