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(1) The interim rate for services provided to youths as the term "youth" is defined at ARM 37.87.102 for PRTF providers located in the state of Montana is composed of:

(a) the psychiatric service rate provided in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in ARM 37.86.2207;

(b) a direct care wage add-on through a contract with the department, if applicable; and

(c) a facility specific add-on rate for medical and authorized ancillary costs, not already included in the base rate for psychiatric care at the facility.

(2) The ancillary rate in (1)(c) will be adjusted retrospectively when:

(a) allowable ancillary costs are reported using auditable data, standardized forms, instructions, definitions, and timelines supplied by the department; and

(b) ancillary costs in the facility-specific aggregate for all discharges, for Montana Medicaid paid youth, in a state fiscal year exceed or are less than 5% of the reimbursement that the facility received as an interim rate. If the costs exceed the aggregate by more than 5%:

(i) the department will reimburse the facility for costs exceeding 105% of the agregate;

(ii) the facility will reimburse the department for costs less than 95% of the aggregate; and

(iii) no adjustments to reimbursement will be made by either the department or the facility for costs within 5% of the aggregate ancillary rate payment.

(3) The psychiatric service rate is an all-inclusive bundled per diem rate, and includes:

(a) all therapies, services, and items not specifically designated as an ancillary service that are provided while the youth is an inpatient in the PRTF;

(b) services provided by licensed psychologists, licensed clinical social workers, and licensed professional counselors; and

(c) lab and pharmacy costs related to the youth's psychiatric condition with the exception noted in (4)(r) pharmacy for post-discharge medication.

(4) Ancillary services are provided by or include the following:

(a) ambulatory surgical center;

(b) audiologist;

(c) chiropractor;

(d) dentist, denturist, and orthodontist;

(e) durable medical equipment;

(f) emergency room services not related to the psychiatric condition;

(g) eyeglasses;

(h) federally qualified health center;

(i) hearing provider and hearing aides;

(j) hospital;

(k) licensed addiction counselor;

(l) medical transportation and ambulance services;

(m) mental health center;

(n) MRI, or other diagnostic services;

(o) nutritionist;

(p) optometrist and ophthalmologist;

(q) outpatient hospital not relative to the psychiatric condition;

(r) pharmacy for post-discharge medication;

(s) physical and speech therapist;

(t) physician, psychiatrist, and mid-level practitioner;

(u) podiatrist;

(v) public health clinic;

(w) respiratory therapy;

(x) rural health clinic;

(y) targeted case management; and

(z) any other Medicaid service provided to the youth receiving PRTF in-patient care not related to the youth's psychiatric condition may be considered an ancillary service.

(5) If a youth receiving in-patient care in a PRTF has an unusually expensive medical condition that requires a higher ancillary rate, prior to the cost settlement process, the PRTF may request interim reimbursement for the ancillary care. The department at its discretion may grant the youth specific request if the PRTF:

(a) submits a request in writing to the department with documentation of the expenses; and

(b) interim payments must be requested within 90 days of the date of service and will be taken into consideration during the ancillary cost settlement process described in (2). Payment of these claims will be made by the department within 90 days from the date all requirements for payment are met.

(6) Reimbursement will be made to a PRTF provider for reserving a bed while the youth is temporarily absent for a therapeutic home visit if:

(a) the youth's plan of care documents the medical need for therapeutic home visits as part of a therapeutic plan to transition the youth to a less restrictive level of care;

(b) the youth is temporarily absent on a therapeutic home visit;

(c) the provider clearly documents staff contact and youth achievements or regressions during and following the therapeutic home visit; and

(d) the youth is absent from the provider's facility for no more than three patient days per therapeutic home visit, unless additional days are authorized by the department.

(7) No more than 14 patient days per youth in each state fiscal year will be allowed for therapeutic home visits.

(8) Providers must bill for PRTF services using the revenue codes designated by the department.

(9) Notice of the youth's admission and discharge dates must be submitted to the department or its designee the day of admission or discharge. A $100 fine may be imposed against the facility for each instance where the department does not receive timely notification.

History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, MCA; NEW, 2008 MAR p. 2674, Eff. 1/1/09.

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