These Montana Medicaid rules govern reimbursement and participation requirements for Institutions for Mental Diseases (IMDs), specifically inpatient psychiatric hospitals devoted to adult care and nursing facilities determined to be IMDs. Providers must meet participation requirements including compliance with nursing facility standards, maintaining individual treatment plans with periodic reviews, and entering into written agreements with the department. Medicaid reimbursement is generally excluded for IMD services except for recipients ages 18–21 and 65+ in inpatient psychiatric hospitals, and recipients age 65+ receiving nursing facility services in a department-designated IMD.
View official source37.88.1401 INSTITUTIONS FOR MENTAL DISEASES, PURPOSE (1) ARM 37.88.1401 , 37.88.1402 , 37.88.1405 , 37.88.1406 , 37.88.1410 , 37.88.1411 and 37.88.1420 specify requirements for the provision of and reimbursement for medicaid nursing facility and hospital services to medicaid recipients who are residents of an institution for mental diseases. These rules are in addition to requirements generally applicable to medicaid providers as otherwise provided in state and federal statutes, rules, regulations and policies. Authorizing statute(s): Sec. 53-2-201 and 53-6-113 , MCA Implementing statute(s): Sec. 53-2-201 , 53-6-101 , 53-6-111 and 53-6-113 , MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 195; AMD, 2000 MAR p. 2036, Eff. 7/28/00. 37.88.1402 INSTITUTIONS FOR MENTAL DISEASES, DEFINITIONS In ARM 37.88.1401 , 37.88.1402 , 37.88.1405 , 37.88.1406 , 37.88.1410 , 37.88.1411 and 37.88.1420 the following definitions apply: (1) "Department" means the Montana department of public health and human services or its agents, including but not limited to parties under contract to perform audit services, claim processing and utilization review. (2) "Devoted to the provision of inpatient psychiatric hospital care to adults" means an institution for mental disease which is licensed and certified as a hospital and whose goals, purpose and care are designed for and devoted exclusively to providing diagnosis, treatment or care to persons with mental diseases age 18 and older. (3) "Hospital" means a facility licensed, accredited or approved under the laws of Montana or a facility operated as a hospital by the state that provides, by or under the supervision of licensed physicians, services for the diagnosis, treatment, rehabilitation and care of persons with mental diseases. (4) "Institution for mental diseases" means a hospital, nursing facility, or other institution with more than 16 beds which the department has determined is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. An institution for the mentally retarded, including an intermediate care facility for the mentally retarded, is not an institution for mental diseases. (a) An institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. (i) In making a determination of whether an institution is an institution for mental diseases, the department shall consider the guidelines set forth in subsection C of section 4390 of the state medicaid manual, but no single guideline or combination of guidelines shall necessarily be determinative. The state medicaid manual is promulgated by the federal health care financing administration to provide guidance to states on administration of the medicaid program. The department hereby adopts and incorporates herein by reference subsection C of section 4390 of the state medicaid manual (1994) . A copy of subsection C of section 4390 of the state medicaid manual may be obtained from the Department of Public Health and Human Services, Senior and Long Term Care Division, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210. (5) "Medicaid recipient" means a person who is eligible and receiving assistance under Title XIX of the Social Security Act for nursing facility services. (6) "Mental disease" means a disease listed as a mental disorder in the current edition of the Diagnostic and Statistical Manual of Mental Diseases but does not include mental retardation, senility and organic brain syndrome. (7) "Nursing facility services" means services defined in ARM 37.40.302 , but not including intermediate care facility services for the mentally retarded. (8) "Patient contribution" means the total of all of a resident's income from any source available to pay the cost of care, less the resident's personal needs allowance. The patient contribution includes a resident's incurment determined in accordance with applicable eligibility rules. (9) "Patient day" means a whole 24-hour period that a person is present and receiving nursing facility services, regardless of the payment source. Even though a person may not be present for a whole 24-hour period on the day of admission or day of death, such day will be considered a patient day. (10) "Provider" means a nursing facility or hospital that meets the provider participation requirements specified in ARM 37.88.1405 . (11) "Resident" means a person admitted to the provider's facility who has been present in the facility for at least one 24-hour period. Authorizing statute(s): Sec. 53-2-201 and 53-6-113 , MCA Implementing statute(s): Sec. 53-2-201 , 53-6-101 , 53-6-111 and 53-6-113 , MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 195; AMD, 2000 MAR p. 2036, Eff. 7/28/00. 37.88.1405 INSTITUTIONS FOR MENTAL DISEASES, PROVIDER PARTICIPATION REQUIREMENTS (1) An institution for mental diseases, as a condition of participation in the Montana medicaid program, under ARM 37.88.1401 , 37.88.1402 , 37.88.1405 , 37.88.1406 , 37.88.1410 , 37.88.1411 and 37.88.1420 must be a provider that meets the following requirements: (a) complies with the requirements set forth at ARM 37.40.306 for medicaid nursing facility service providers; (b) has been determined by the department, in accordance with ARM 37.88.1402 , to be an institution for mental diseases; (c) complies with ARM 37.40.352 regarding utilization review and quality of care for nursing facilities; and (d) enters into and maintains a written agreement with the department that specifies the respective responsibilities of the department and the provider including arrangements for: (i) joint planning between the parties to the agreement; (ii) development of alternative methods of care; (iii) permission for immediate readmission to the institution when the recipient's need for readmission has been determined to be medically necessary; (iv) access by the department to the recipient, the recipient's records and the facility; (v) recording, reporting and exchanging medical and social information about recipients; and (vi) other procedures necessary to carry out the agreement; or (e) is a hospital which is devoted to the provision of inpatient psychiatric hospital care to adults. A publicly owned hospital devoted to the provision of inpatient psychiatric care to adults shall not be required to enter into and maintain a written agreement as provided in (1) (d) . Authorizing statute(s): Sec. 53-6-113 , MCA Implementing statute(s): Sec. 53-2-201 , 53-6-101 , 53-6-111 and 53-6-113 , MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 195; AMD, 2000 MAR p. 2036, Eff. 7/28/00. 37.88.1406 INSTITUTIONS FOR MENTAL DISEASES, INDIVIDUAL TREATMENT PLANS (1) Institutions for mental diseases providing services under ARM 37.88.1401 , 37.88.1402 , 37.88.1405 , 37.88.1406 , 37.88.1410 , 37.88.1411 and 37.88.1420 must provide for and maintain recorded individual plans of treatment and care to ensure that institutional care maintains the recipient at, or restores the recipient to, the greatest possible degree of health and independent functioning. The plans must include: (a) an initial review of the recipient's medical, psychiatric and social needs within 30 days after the date of admission; (b) periodic review of the recipient's medical, psychiatric and social needs; (c) a determination at least every 90 days of the recipient's need for continued institutional care and for alternative care arrangements; (d) appropriate medical treatment in the institution; and (e) appropriate social services. Authorizing statute(s): Sec. 53-6-113 , MCA Implementing statute(s): Sec. 53-2-201 , 53-6-101 , 53-6-111 and 53-6-113 , MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 195. 37.88.1410 INSTITUTIONS FOR MENTAL DISEASES, REIMBURSEMENT (1) The Montana medicaid program does not cover and will not reimburse for services provided in institutions for mental diseases, except: (a) services provided to medicaid recipients ages 18 through 21 and 65 or over in hospitals devoted to the provision of inpatient psychiatric hospital care for adults; or (b) as provided in ARM 37.88.1401 , 37.88.1402 , 37.88.1405 , 37.88.1406 , 37.88.1410 , 37.88.1411 and 37.88.1420 for medicaid recipients age 65 or over receiving nursing facility services in a nursing facility that the department has determined to be an institution for mental diseases under ARM 37.88.1402 . (2) For nursing facility services provided to medicaid recipients age 65 years or over in an institution for mental diseases, the Montana medicaid program will pay a provider: (a) for each patient day, an interim per diem rate, as specified in (3) , minus the amount of the medicaid recipient's patient contribution; and (b) additional reimbursement for separately billable items as provided in (4) . (3) The final per diem payment rate for: (a) the Montana state hospital is $335; and (b) the Montana mental health nursing care center at Lewistown is $150 for high acuity patients and $100 for low acuity patients. (4) Separately billable items are those items specified in ARM 37.40.330 and are reimbursable by medicaid according to the provisions of ARM 37.40.330 . (5) For hospital services provided to medicaid recipients age 18 through 21 and 65 or over, the Montana medicaid program will pay hospitals devoted to the provision of inpatient psychiatric hospital care to adults an all-inclusive per diem rate which includes the cost of physician and dental services as well as the cost of the services listed in ARM 37.86.2902 (2) . Authorizing statute(s): Sec. 53-2-201 and 53-6-113 , MCA Implementing statute(s): Sec. 53-6-101 and 53-6-113 , MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 195; AMD, 2000 MAR p. 2036, Eff. 7/28/00. 37.88.1411 INSTITUTIONS FOR MENTAL DISEASES, BILLING AND PAYMENT (1) Providers must bill for all services and supplies in accordance with the provisions of ARM 37.85.406 . The department will pay a provider on a monthly basis the amount determined in accordance with these rules upon receipt of an appropriate billing which reports the number of patient days provided to authorized medicaid recipients during the billing period. Authorizing statute(s): Sec. 53-6-113 , MCA Implementing statute(s): Sec. 53-2-201 , 53-6-101 , 53-6-111 and 53-6-113 , MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 195. 37.88.1420 INSTITUTIONS FOR MENTAL DISEASES, ADMINISTRATIVE REVIEW AND FAIR HEARING PROCEDURES (1) Providers may appeal adverse determinations by the department through the administrative review and fair hearing procedures specified in ARM 46.12.1268 . Authorizing statute(s): Sec. 2-4-201 and 53-6-113 , MCA Implementing statute(s): Sec. 2-4-201 , 53-2-201 , 53-6-101 , 53-6-111 and 53-6-113 , MCA History: NEW, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 195.