This subchapter establishes Montana Medicaid provider participation requirements, program standards, and reimbursement methodology for Psychiatric Residential Treatment Facility (PRTF) services. Providers must maintain current licensure, Medicaid certification, and accreditation, and must comply with federal PRTF regulations under 42 CFR 441 subpart D. Treatment plans must be comprehensive, reviewed at least every 30 days by a multidisciplinary team, and aimed at transitioning youth to less restrictive care. Reimbursement is paid as a bundled per diem rate for both in-state and out-of-state PRTFs, with additional payments available for certain ancillary services and hospital-based facilities.
View official source37.87.1201 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, PURPOSE (1) The purpose of ARM Title 37, chapter 87, subchapter 12 is to specify provider participation and program requirements and to define the basis and procedure the department will use to pay for psychiatric residential treatment facility (PRTF) services. (2) Facilities in which these services are available are referred to as providers. Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2011 MAR p. 1154, Eff. 6/24/11; AMD, 2015 MAR p. 2147, Eff. 12/11/15. 37.87.1202 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, DEFINITIONS As used in this subchapter, the following definitions apply: (1) "Continuity of care payment" means an annual payment made to qualifying hospital-based psychiatric residential treatment facilities (PRTF) according to the eligibility criteria and payment calculation methodology in ARM 37.87.1224 . (2) "Devoted to the provision of inpatient psychiatric care for persons under the age of 21" means an inpatient psychiatric hospital facility or residential treatment facility whose goals, purpose, and care are designed for and devoted exclusively to persons under the age of 21. (3) "Hospital-based psychiatric residential treatment facility" means a residential treatment facility that meets the requirements of ARM 37.87.1207 . (4) "Inpatient psychiatric services" means psychiatric residential treatment facility services, or hospital-based psychiatric residential treatment facility services. (5) "Patient day" means a whole 24-hour period in which a person is present and receiving inpatient psychiatric services. Even though a person may not be present for a whole 24-hour period, the day of admission and, subject to the limitations and requirements of ARM 37.87.1223 , therapeutic home leave days are patient days. The day of discharge is not a patient day for purposes of reimbursement. (6) "Psychiatric residential treatment facility (PRTF)" is defined in the Children's Mental Health Bureau Medicaid Services Provider Manual, adopted and incorporated by reference in ARM 37.87.903 . (7) "Therapeutic Home Visit (THV)" is defined in the Children's Mental Health Bureau Medicaid Services Provider Manual, adopted and incorporated by reference in ARM 37.87.903 . Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2010 MAR p. 1511, Eff. 6/25/10; AMD, 2011 MAR p. 1154, Eff. 6/24/11; AMD, 2013 MAR p. 2433, Eff. 12/27/13; AMD, 2015 MAR p. 2147, Eff. 12/11/15; AMD, 2020 MAR p. 691, Eff. 11/1/20. 37.87.1203 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES (1) Inpatient psychiatric services are services that comply with the requirements of this subchapter and the applicable federal regulations and are provided in a psychiatric residential treatment facility (PRTF) that is devoted to the provision of inpatient psychiatric care for persons under the age of 21. (2) 42 CFR 440.160 and Title 42 CFR, part 441, subpart D provide federal definitions and federal PRTF program requirements. The department adopts and incorporates by reference 42 CFR 440.160 (2010) and Title 42 CFR, part 441, subpart D (2010). A copy of the regulations may be obtained through the Department of Public Health and Human Services, Developmental Services Division, 111 N. Sanders, P.O. Box 4210, Helena, MT 59620-4210. Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2015 MAR p. 2147, Eff. 12/11/15. 37.87.1206 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, PARTICIPATION REQUIREMENTS (1) These requirements are in addition to those contained in rule generally applicable to Medicaid providers. (2) Psychiatric residential treatment facility (PRTF) providers, as a condition of participation in the Montana Medicaid program, must comply with the following requirements: (a) maintain a current license as a residential treatment facility under the rules of the department's Quality Assurance Division to provide PRTF services, or, if the provider's facility is not located within the state of Montana, maintain a current license in an equivalent category under the laws of the state in which the facility is located; (b) maintain a current PRTF certification for Medicaid participation by the state in which the facility is located as required by the Centers for Medicare and Medicaid; (c) for all providers, enter into and maintain a current provider enrollment form with the department's fiscal agent to provide psychiatric PRTF services; (d) license and/or register facility personnel in accordance with applicable state and federal laws; (e) for providers maintaining patient trust accounts, ensure that any funds maintained in those accounts are used only for those purposes for which the youth or legal representative has given written authorization. A provider may not borrow funds from these accounts for any purpose; (f) maintain accreditation as a PRTF by an organization designated by the Secretary of the United States Department of Health and Human Services as authorized to accredit PRTF for Medicaid participation; (g) submit to the department within 30 days of receipt, all documentation issued by the accrediting organization to the provider; (h) agree to indemnify the department in the full amount of the state and federal shares of all Medicaid inpatient psychiatric services reimbursement paid to the facility during any period when federal financial participation is unavailable due to facility failure to meet the conditions of participation specified in these rules or due to other facility deficiencies or errors. Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2010 MAR p. 1511, Eff. 6/25/10; AMD, 2011 MAR p. 1154, Eff. 6/24/11; AMD, 2015 MAR p. 2147, Eff. 12/11/15. 37.87.1207 HOSPITAL-BASED PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, REQUIREMENTS (1) A hospital-based psychiatric residential treatment facility (PRTF) must meet the following requirements: (a) the PRTF must be in a hospital facility that includes inpatient psychiatric hospital beds and provides inpatient hospital psychiatric care to individuals under age 21. The PRTF beds and the hospital beds must be owned and operated by a single entity, and they must be located in an integrated facility; (b) the PRTF must be located in Montana; (c) the inpatient psychiatric hospital beds and the PRTF beds must be served by a common administrative and support staff; (d) the PRTF must be served by no less than one full-time equivalent psychiatrist for every 25 youth; (e) both the hospital and the PRTF must have an organized medical staff that is on call and available within 20 minutes, 24 hours a day, seven days a week; and (f) both the hospital and the PRTF must have 24-hour nursing care by licensed registered nurses. Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2015 MAR p. 2147, Eff. 12/11/15. 37.87.1215 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, ASSESSMENT SERVICES (1) Psychiatric residential treatment facility (PRTF) assessment services are provided by in-state PRTF facilities and must comply with the requirements of this subchapter and the applicable federal regulations for PRTF services. (2) PRTF assessment services: (a) require prior authorization by the department or its designee; (b) are short-term lengths of stay, 14 days or less; (c) are reimbursed 15% higher than the department's current Medicaid Youth Mental Health Fee Schedule for PRTF Services. (3) Assessment services include the following, as clinically indicated: (a) diagnostic and functional assessment; (b) medication evaluation; (c) psychological and IQ testing; (d) substance use disorder assessment; and (e) supported group or independent living needs assessment. (4) Assessment services include a written report within 14 days after the discharge that includes clear recommendations for treatment of the youth. (5) If the PRTF admission continues beyond the assessment period and becomes a regular admission, the department will not reimburse at the higher rate for assessment services. (a) If the youth is re-admitted to the facility within 30 days of the assessment, the admission for assessment may be subject to department review and full recovery. Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2015 MAR p. 2147, Eff. 12/11/15. 37.87.1216 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, BENEFIT LIMITS, CERTIFICATION OF NEED, UTILIZATION REVIEW AND INSPECTIONS OF CARE REQUIREMENTS (1) Prior to admission and as frequently as the department deems necessary, the department or its agents may evaluate the medical necessity and quality of services for each Medicaid member. (a) In addition to the other requirements of these rules, the provider must provide to the department or its agent upon request any records related to services or items provided to a Medicaid member. (b) The department may contract with and designate public or private agencies or entities, or a combination of public and private agencies and entities, to perform utilization review, inspections of care, and other functions under this rule as an agent of the department. (2) The department or its agents may conduct periodic inspections of care in PRTFs participating in the Medicaid program. (3) A provider must submit a certificate of need as described in the Children's Mental Health Bureau Medicaid Services Manual, adopted and incorporated by reference in ARM 37.87.903 . (4) An authorization by the department or its utilization review agent under this rule is not a final or conclusive determination of medical necessity and does not prevent the department or its agents from evaluating or determining the medical necessity of services or items at any time. Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2013 MAR p. 270, Eff. 3/1/13; AMD, 2015 MAR p. 2147, Eff. 12/11/15. 37.87.1217 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES, TREATMENT REQUIREMENTS (1) PRTF services must include active treatment designed to achieve the discharge of the youth to a less restrictive level of care at the earliest possible time. (2) PRTF services must be provided under the direction of a licensed physician. (3) The PRTF treatment plan must be comprehensive and address all psychiatric, medical, educational, psychological, social, behavioral, and developmental treatment needs. (4) The treatment plan and discharge plan for the youth must be reviewed at least every 30 days at the multidisciplinary treatment team meeting, and more frequently if there is a significant change in the condition of the youth. The multidisciplinary treatment team must be consistent with 42 CFR 441.156 . The parent or legal representative of the youth must be invited to participate in these meetings, and given adequate notice to participate. Adequate notice means generally a week unless the condition of the youth dictates otherwise. (5) PRTF services include only treatment or services provided in accordance with all applicable licensure, certification, and accreditation requirements, and these rules. (6) The content of the treatment plan and discharge plan must meet all minimum state and federal requirements. Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2009 MAR p. 2486, Eff. 1/1/10; AMD, 2011 MAR p. 1154, Eff. 6/24/11; AMD, 2013 MAR p. 270, Eff. 3/1/13; AMD, 2013 MAR p. 2433, Eff. 12/27/13; AMD, 2015 MAR p. 2147, Eff. 12/11/15; AMD, 2020 MAR p. 691, Eff. 11/1/20. 37.87.1223 IN-STATE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES, REIMBURSEMENT (1) The Montana Medicaid Program will reimburse providers of inpatient psychiatric services provided to a youth in a psychiatric residential treatment facility (PRTF) for each patient day, which is consistent with the definition of a PRTF and all other applicable requirements are met. (2) The Montana Medicaid Program will pay a provider for each Medicaid patient day, the following bundled per diem rate less any third party or other payments. The bundled per diem rate for in-state PRTF services is the lesser of: (a) the amount specified in the department's Medicaid Youth Mental Health fee schedule, as adopted in ARM 37.85.105 ; or (b) the provider's usual and customary charges. (3) The bundled per diem rate for in-state PRTFs coverage includes the following services: (a) services, therapies, and items related to treating the psychiatric condition of the youth; (b) services provided by licensed psychologists, licensed clinical social workers, and licensed professional counselors; (c) psychological testing; (d) lab and pharmacy services related to treating the psychiatric condition of the youth; and (e) supportive services necessary for daily living and safety. (4) A direct-care wage add-on is reimbursed in addition to the in-state per diem through a contract with the department or in the bundled per diem rate, as applicable. (5) The Montana Medicaid Program will reimburse enrolled providers directly for the following services which are not included in the in-state per diem rate: (a) services provided by a licensed physician, psychiatrist, or midlevel practitioner; (b) non-psychotropic medication and related lab services; (c) adult mental health center evaluations for transition age youth 17 to 18, to determine whether or not they qualify for adult mental health services and have a severe and disabling mental illness; and (d) up to 60 consecutive days of targeted case management services for the purpose of planning the youth's transition to the community. A youth should retain the case manager the youth had prior to entry into PRTF services, if applicable. If the youth is assigned a case manager who is different from the one previous to PRTF services, the case manager must document the rationale for the change. (6) The Montana Medicaid Program will reimburse state plan ancillary services in addition to the in-state PRTF bundled per diem rate when these ancillary services are provided by a PRTF or by a different provider under arrangement with the PRTF. The ancillary services provided must be: (a) directed by a PRTF physician; (b) stated in the treatment plan of the youth; and (c) maintained in the medical records for the youth. Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2009 MAR p. 418, Eff. 4/17/09; AMD, 2009 MAR p. 2486, Eff. 1/1/10; AMD, 2011 MAR p. 1154, Eff. 6/24/11; AMD, 2013 MAR p. 270, Eff. 3/1/13; AMD, 2013 MAR p. 2433, Eff. 12/31/13; AMD, 2014 MAR p. 2147, Eff. 9/19/14; AMD, 2015 MAR p. 2147, Eff. 12/11/15; AMD, 2020 MAR p. 691, Eff. 11/1/20. 37.87.1224 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES, CONTINUITY OF CARE PAYMENT (1) Hospital-based psychiatric residential treatment facilities as defined in ARM 37.87.1207 qualify for a continuity of care payment. (a) The amount of the continuity of care adjustor payment will be calculated and paid annually. (b) The amount will be determined by the department according to the following formula: CCA=[M/D]*P: (i) "CCA" represents the calculated continuity of care payment; (ii) "M" is the number of Medicaid inpatient residential days provided by the facility for which the continuity of care payment is being calculated; (iii) "D" is the total number of Medicaid inpatient residential days provided by all eligible facilities; and (iv) "P" is the total amount available for distribution via the continuity of care payments. P equals 4% of the revenue generated by the Montana inpatient hospital utilization fee, plus federal financial participation. (2) The number of Medicaid days must be from the department's paid claims data for the most recent calendar year. Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2008 MAR p. 2360, Eff. 1/1/09; AMD, 2019 MAR p. 2382, Eff. 1/1/20. 37.87.1225 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, ADMINISTRATIVE REVIEW AND FAIR HEARING PROCEDURES (1) The right to administrative review and fair hearing shall be in accordance with the provisions of ARM 37.5.310 . Authorizing statute(s): 53-2-201 , 53-6-113 , MCA Implementing statute(s): 53-2-201 , 53-6-101 , 53-6-111 , MCA History: NEW, 2008 MAR p. 2360, Eff. 1/1/09. 37.87.1226 OUT-OF-STATE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, REIMBURSEMENT (1) The Montana Medicaid Program will reimburse a provider of inpatient psychiatric services provided to a youth in a psychiatric residential treatment facility (PRTF) for each patient day, in accordance with the requirements of this subchapter and the Children's Mental Health Bureau Medicaid Services Provider Manual, adopted and incorporated by reference in ARM 37.87.903 . (2) The Montana Medicaid Program will reimburse a provider for each Medicaid patient day the following bundled per diem rate less any third party or other payments. The bundled per diem rate for out-of-state PRTF services is the lesser of: (a) the amount specified in the department's Medicaid Youth Mental Health fee schedule, as adopted in ARM 37.85.105 ; or (b) the provider's usual and customary charges. (3) The bundled per diem rate for out-of-state PRTFs services coverage includes the following services: (a) all services, therapies, and items related to treating the psychiatric condition of the youth; (b) all services provided by licensed physicians, psychiatrists, midlevel practitioners, psychologists, clinical social workers, and professional counselors; (c) psychological testing; (d) lab and pharmacy services; and (e) supportive services necessary for daily living and safety. (4) The Montana Medicaid Program will reimburse enrolled providers directly for the following services which are not included in the out-of-state per diem rate: (a) up to 60 consecutive days of targeted case management services for the purpose of planning the youth's transition to the community. A youth should retain the case manager the youth had prior to entry into PRTF services, if applicable. If the youth is assigned a case manager who is different from the one previous to PRTF services, the case manager must document the rationale for the change; and (b) a clinical intake assessment by a licensed mental health center, with an endorsement to provide adult services for transition age youth 17 to 18, to determine whether they have a severe and disabling mental illness and if they qualify for adult mental health services. (5) The Montana Medicaid Program will reimburse state plan ancillary services in addition to the out-of-state bundled per diem rate when these ancillary services are provided by a different provider under arrangement with the PRTF. The ancillary services provided must be: (a) directed by the PRTF physician; (b) stated in the treatment plan of the youth; and (c) documented in the medical records for the youth. Authorizing statute(s): 53-6-101 , MCA Implementing statute(s): 53-6-113 , MCA History: NEW, 2015 MAR p. 2147, Eff. 12/11/15; AMD, 2017 MAR p. 2287, Eff. 1/1/18; AMD, 2018 MAR p. 458, Eff. 3/1/18; AMD, 2020 MAR p. 691, Eff. 11/1/20; AMD, 2023 MAR p. 1025, Eff. 9/9/23.