(1) To receive disease management services an eligible client must be:

(a) a recipient of Montana Medicaid;

(b) diagnosed with at least one of the chronic conditions selected for program management as determined by Montana Medicaid under ARM 37.86.5204; and

(c) within the specified age criteria as determined under ARM 37.86.5204 for the chronic condition selected for program management.

(2) A client must not be:

(a) receiving mental health service plan (MHSP) benefits, specified low income Medicare beneficiary (SLMB) benefits, qualified Medicare beneficiary (QMB) benefits, qualified individual program (QI) benefits, or both Medicare and Medicaid (dual eligibility) benefits;

(b) residing in a nursing home or institutional setting;

(c) receiving Medicaid benefits through presumptive eligibility;

(d) eligible for third party coverage that provides disease management program services or requires administrative controls that would duplicate or interfere with Montana Medicaid's disease management program; or

(e) receiving case management services that disease management program services would duplicate.

(3) A client meeting the eligibility requirements in this rule:

(a) is automatically enrolled in the disease management program;

(b) is notified of the enrollment in writing;

(c) may request a disenrollment at any time; and

(d) may request a re-enrollment at any time.