(1) An individual is eligible for covered services under the plan if:
(a) the individual is an adult with a severe disabling mental illness; and the family of which the individual is a member has a total family income, without regard to other family resources, at or below 150% of the most recently published federal poverty level (FPL);
(b) the individual has been denied Medicaid eligibility, is ineligible for Medicaid by virtue of being a patient in an institution for mental diseases, or has applied for Medicaid and the application is pending. An individual who meets Medicaid eligibility requirements but does not apply for Medicaid is not eligible to receive services under the plan;
(c) the total number of adults who can be eligible for MHSP at any time is within the limits set by the department as provided in (6); and
(d) the individual is eligible for Medicare, is enrolled in a Medicare prescription drug plan or Medicare Advantage Plan, and has applied for subsidy extra help from the Social Security Administration and, if necessary, premium assistance from Big Sky Rx.
(2) If a person who is determined eligible for the plan based upon a pending Medicaid application is later determined to be eligible for Medicaid:
(a) any payment received by the provider under the plan for services provided during the effective period of Medicaid eligibility must be refunded to the department; and
(b) all services provided to the individual during the effective period of Medicaid eligibility may be billed to Medicaid according to applicable Medicaid requirements.
(3) For purposes of determining the total family income under (1) :
(a) the family may not spend down to the required level of income;
(b) family debts, expenses, and other financial circumstances are not considered; and
(c) the most recently published FPL is the FPL most recently published in the Federal Register as of the end of the month immediately preceding the month in which the application is submitted.
(4) Members must comply with the procedures specified by the department in accordance with ARM 37.89.118 to obtain or access services under the plan.
(5) This subchapter is not intended to and does not establish an entitlement for any individual to be determined eligible for or to receive any services under the plan. The department may, in its discretion, limit services, rates, eligibility, and the number of persons determined eligible under the plan based upon such factors as availability of funding, the degree of financial need, the degree of medical need or other factors.
(a) If the department determines with respect to the plan that it is necessary to reduce, limit, suspend or terminate eligibility or benefits, reduce provider reimbursement rates, reduce or eliminate service coverage or otherwise limit services, benefits or provider participation rates, in a manner other than provided in this subchapter, the department may implement such changes by providing ten days advance notice published in Montana major daily newspapers with statewide circulation, and by providing:
(i) ten days advance written notice of any individual eligibility and coverage changes to affected members; and
(ii) ten days advance written notice of coverage, rate, and provider participation changes to affected providers.
(6) If the department determines that the average per-case cost of Mental Health Services Plan expenditures times the number of enrollees will exceed total appropriations, it will suspend enrollment of new recipients.
(a) The department will place the names of persons applying for enrollment who would be eligible but for the suspension of new enrollments on a waiting list.
(b) When total MHSP enrollment falls below the number which, when multiplied by the average per-case cost, equals total appropriations, the department will enroll persons whose names appear on the waiting list. Enrollment from the waiting list will be made in order of severity of need, with qualified applicants whose needs are most severe first as determined by the department based on the following:
(ii) functional impairment as evaluated by a licensed mental health professional designated by the department; or
(iii) availability of appropriate alternative means to obtain treatment.
(c) no person enrolled in the MHSP on September 1, 2008, shall be determined ineligible solely as a result of the determination by the department provided for in (6)(a).
(d) notwithstanding the provisions of (6)(a) through (c), the department may enroll a qualified applicant if the applicant is:
(i) a patient at Montana State Hospital (MSH) ready for discharge; or
(ii) a person with recurrent thoughts of death, recurrent suicidal ideation or suicide attempt, or a specific plan for committing suicide.