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(1) These requirements are in addition to those contained in rule provisions generally applicable to Medicaid providers.

(2) Except as otherwise permitted by federal law, inpatient hospital services must be ordered by a physician or dentist licensed under state law.

(3) Inpatient hospital services include:

(a) bed and board;

(b) nursing services and other related services;

(c) use of hospital facilities;

(d) medical social services;

(e) drugs, biologicals, supplies, appliances, and equipment;

(f) other diagnostic or therapeutic items, or services provided in the hospital and not specifically excluded in ARM 37.85.207; and

(g) medical or surgical services provided by interns or residents-in-training in hospitals with teaching programs approved by the Council on Medical Education of the American Medical Association, the Bureau of Professional Education of the American Osteopathic Association, the Council on Dental Education of the American Dental Association or the Council on Podiatry Education of the American Podiatry Association.

(4) Clinical trials are limited to:

(a) Medicaid coverage of routine costs plus reasonable and necessary items and services used to diagnose and treat complications arising from participation in all qualifying clinical trials;

(b) trials that are directly funded or supported by centers or cooperating groups funded by the National Institutes of Health (NIH), Center for Disease Control (CDC), Agency for Healthcare Research and Quality (AHRQ), Department of Defense (DOD), or the Veterans Administration (VA); and

(c) clinical trial drugs, devices, and procedures are not reimbursable.

(5) Inpatient hospital services provided outside the borders of the United States will not be reimbursed by the Montana Medicaid program.

(6) Inpatient hospital providers must comply with the applicable conditions of participation for hospitals as authorized in 42 CFR 482.

(7) Acute care psychiatric hospitals must comply with 42 CFR 440.160, 42 CFR 441 subpart D, and the applicable conditions of participation for hospitals as authorized in 42 CFR 482.

(8) Effective July 1, 2014, all hospitals that perform deliveries must have a hard stop policy regarding early elective deliveries and nonmedically necessary cesarean sections. The policy must have the following parts:

(a) no nonmedically necessary inductions or cesarean sections prior to 39 weeks and 0/7 days gestation, and no nonmedically necessary cesarean sections at any gestation;

(b) confirmation of weeks gestation must be determined by the American Congress of Obstetricians and Gynecologists guidelines. At least one of the following guidelines must be met:

(i) fetal heart tones must have been documented for 20 weeks by nonelectronic fetoscope or 30 weeks by doppler;

(ii) 36 weeks since a positive serum or urine pregnancy test that was performed by a reliable laboratory; or

(iii) an ultrasound prior to 20 weeks gestation that confirms the gestational age of at least 39 weeks.

(c) if pregnancy care was not initiated prior to 20 weeks gestation, the gestational age may be documented from first day of the last menstrual period (LMP); and

(d) a multistep review process prior to all inductions and cesarean sections, including a requirement that the final decision be made by the perinatology chair/obstetrical chair, OB director, or medical director.

History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA; NEW, 1983 MAR p. 756, Eff. 7/1/83; AMD, 1987 MAR p. 905, Eff. 7/1/87; AMD, 1987 MAR p. 2168, Eff. 11/28/87; AMD, 1989 MAR p. 281, Eff. 2/10/89; AMD, 1993 MAR p. 1520, Eff. 7/16/93; AMD, 1994 MAR p. 1732, Eff. 7/1/94; AMD, 1995 MAR p. 1162, Eff. 7/1/95; AMD, 1999 MAR p. 2078, Eff. 9/24/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2008 MAR p. 1983, Eff. 10/1/08; AMD, 2010 MAR p. 1534, Eff. 7/1/10; AMD, 2014 MAR p. 1415, Eff. 7/1/14; AMD, 2016 MAR p. 829, Eff. 5/7/16.

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