(1) Coverage for a person in the HELP Program, except as provided in (2), is provided through the HELP Plan.

(2) A person eligible under the HELP Program may be excluded from the HELP Plan and receive coverage through the Aligned Medicaid Alternative Benefit Plan if the person:

(a) lives in a geographical area, including an Indian reservation, where the TPA is unable to make arrangements with sufficient numbers and types of health care providers to offer services to participants;

(b) needs continuity of care that would not otherwise be available or cost-effective through the TPA, including American Indians and Alaska Natives;

(c) has been determined by the department to have exceptional health care needs, including, but not limited to, a medical, mental health, or developmental condition; and

(d) is exempt by federal law, including all individuals with incomes up to 50 percent of the FPL, from premium or cost-sharing obligations and other exemptions not waived by CMS.

(3) The department adopts and incorporates by reference the HELP Plan Evidence of Coverage (EOC) dated January 1, 2016, which is available on the department's web site at http://dphhs.mt.gov/MontanaHealthcarePrograms.

(4) The HELP Plan EOC describes the health care benefits, inclusive of limitations upon those benefits, available to the HELP Plan participants.

(5) Services that are not reimbursable, not medically necessary, experimental, investigational, unproven, or performed in an inappropriate setting are not covered benefits in the HELP Plan.

(6) Prior authorization may be required for certain types and levels of services.