37.40.337    REIMBURSEMENT TO OUT-OF-STATE FACILITIES

(1) The department will reimburse nursing facilities located outside the state of Montana for nursing facility services and any other reimbursable services or supplies provided to eligible Montana Medicaid individuals at the Medicaid rate and upon the basis established by the Medicaid agency in the state in which the facility is located.

(2) The Montana Medicaid program will pay for nursing facility services or related supplies provided to eligible Montana Medicaid individuals in nursing facilities located outside the state of Montana only when one of the following conditions is met:

(a) because of a documented medical emergency, the resident's health would be endangered if he or she was to return to Montana for medical services;

(b) the services required are not provided in Montana;

(c) the required services and all related expenses are less costly than if the required services were provided in Montana;

(d) the recipient is a child in another state for whom Montana makes adoption assistance or foster care assistance payments; or

(e) the department determines that it is general practice for recipients in the resident's particular locality to use medical resources located in another state.

(3) To receive payments, the out-of-state provider must enroll in the Montana Medicaid program. Enrollment information and instructions may be obtained from the department's fiscal intermediary.

(4) The department will reimburse a nursing facility located outside the state of Montana under the Montana Medicaid program only if, in addition to meeting other applicable requirements, the facility has submitted to the department the following information:

(a) a physician's order identifying the Montana resident and specifically describing the purpose, cause and expected duration of the stay;

(b) for nursing facility services, copies of documents from the facility's state Medicaid agency establishing or stating the facility's Medicaid per diem rate for the period the services were provided;

(c) for separately billable items, copies of documents from the facility's state Medicaid agency establishing or stating the Medicaid reimbursement payable for such items for the period the items were provided;

(d) a properly completed level I screening form for the resident, as required by ARM 37.40.201, et seq.;

(i) To the extent required by ARM 37.40.201, et seq., a level I screening must be performed prior to entry into the nursing facility to determine if there is a diagnosis of mental illness or mental retardation and if so, to conduct assessments which determine the resident's need for active treatment. A level I screening form may be obtained from the department.

(e) a copy of the preadmission-screening determination for the resident completed by the department or its designee;

(i) Payment will be made for services no earlier than the date of referral for screening or the date of screening, whichever is earlier.

(f) the resident's full name, Medicaid ID number and dates of service;

(g) a copy of the certification notice from the facility's state survey agency showing certification for Medicaid during the period services were provided; and

(h) assurances that, during the period the billed services were provided, the facility was not operating under sanctions imposed by Medicare or Medicaid which would preclude payment.

(5) Reimbursement to nursing facilities located outside the state of Montana for Medicare coinsurance days for dually eligible Medicaid and Medicare individuals shall be limited to the per diem rate established by the facility's state Medicaid agency, less the Medicaid recipient's patient contribution.

History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA; NEW, 1991 MAR p. 2050, Eff. 11/1/91; AMD, 1992 MAR p. 1617, Eff. 7/31/92; AMD, 1994 MAR p. 1881, Eff. 7/8/94; AMD, 1998 MAR p. 1749, Eff. 6/26/98; TRANS, from SRS, 2000 MAR p. 489; AMD, 2003 MAR p. 1294, Eff. 7/1/03; AMD, 2015 MAR p. 824, Eff. 7/1/15; AMD, 2017 MAR p. 1670, Eff. 9/23/17.