(1) Services available through the program are reimbursed as provided in this rule.

(2) Program services are reimbursed at the lower of the following:

(a) the provider's usual and customary charge for the services; or

(b) the fees stated in Appendix A with an effective date of August 1, 2011 contained in the program's Psychiatric Residential Treatment Facility Home and Community-Based Services Waiver for Youth with Serious Emotional Disturbance Provider Policy Manual dated October 2010. The department adopts and incorporates by reference the provider policy manual which may be obtained through the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 North Sanders, P.O. Box 4210, Helena, MT 59604-4210.

(3) Reimbursement is not made for a service that is otherwise available from another source.

(4) No copayment is imposed on services provided through the program.

(5) A geographical factor of $.50 per mile may be available to a family support specialist, wraparound facilitator, caregiver peer-to-peer specialist, or a home-based therapist when the following circumstances are met:

(a) the provider is traveling out of the location where the provider has its regular office, excluding satellite offices;

(b) the provider is traveling a distance greater than 35 miles one way from the office to the youth's home;

(c) the geographical factor will include the initial 35 miles and return trip;

(d) the geographical factor is prior authorized by the plan manager; and

(e) the geographical factor and those providers authorized to receive it are included in the youth's plan of care.