(1) Reimbursement for an EPSDT service, except as otherwise provided in this rule, is the lowest of the following:

(a) the provider's usual and customary charge for the service;

(b) the reimbursement determined in accordance with the methodologies provided in ARM 37.85.212 and 37.86.105;

(c) the department's Medicaid Mental Health Fee Schedule, except for the by-report method; or

(d) for public agencies, cost based reimbursement as determined in accordance with OMB Circular A-87, Cost Principles for State, Local and Indian Tribal Governments as established and approved by the department. The department adopts and incorporates by reference the OMB Circular A-87, Cost Principles for State, Local and Indian Tribal Governments, as further amended August 29, 1997. A copy of OMB Circular A-87 may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(2) Reimbursement for outpatient chemical dependency treatment, nutrition, and private duty nursing services is specified in the department's fee schedule. This cross reference does not outline reimbursement. The department adopts and incorporates by reference the department's private duty nursing services EPSDT Fee Schedule dated July 2008 and the nutrition EPSDT Fee Schedule dated July 2008. The fee schedules are posted at http://medicaidprovider.hhs.mt.gov. Reimbursement for outpatient chemical dependency treatment is outlined in ARM 37.27.912. A copy of the fee schedule may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(3) Except as provided in (4), the reimbursement rate for the therapeutic portion of therapeutic youth group home treatment services provided on or after October 1, 2007 is the lesser of:

(a) the amount specified in the department's Medicaid Mental Health Fee Schedule. The department adopts and incorporates by reference the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule dated October 1, 2007. A copy of the fee schedule may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951; or

(b) the provider's usual and customary charges (billed charges).

(4) If a provider does not comply with the cost reporting requirements in (5), the final reimbursement rate for the therapeutic portion of therapeutic youth group home treatment services provided during state fiscal year (SFY) 2008, July 1, 2007 through June 30, 2008 will be determined by adjusting the interim rate adopted in (3)(a) for the provider so that the total amount received for SFY 2008 equals the lesser of:

(a) the amounts specified in the department's Medicaid Mental Health and Mental Health Services Plan, Individual Under 18 Years of Age Fee Schedule dated July 15, 2005 which is adopted and incorporated by reference, if a provider does not comply with the cost reporting requirements set forth in (5). A copy of the fee schedule may be obtained from the Department of Public Health and Human Services, Health Resources Division, Children's Mental Health Bureau, 1400 Broadway, P.O. Box 202951, Helena MT 59620-2951; or

(b) the provider's usual and customary charges (billed charges).

(5) Each provider of therapeutic youth group home services will report allowable costs for SFY 2008 that starts July 1, 2007 using auditable data, standardized forms, instructions, definitions, and timelines supplied by the department.

(a) The cost study will be performed on an individually licensed therapeutic youth group home basis; and

(b) Reports of allowable costs for SFY 2008 must be received by the department before August 15, 2008.

(6) Reimbursement for the therapeutic portion of therapeutic family care treatment services is the lesser of:

(a) the amount specified in the department's Medicaid Mental Health and Mental Health Services Plan Individuals Under 18 Years of Age Fee Schedule adopted in (3)(a) and a direct care wage add-on as provided in ARM 37.88.1111, if applicable; or

(b) the provider's usual and customary charges (billed charges).

(7) For purposes of (3) and (4), "patient day" means a whole 24-hour period that a person is present and receiving therapeutic youth group home or therapeutic family care services. Even though a person may not be present for a whole 24-hour period, the day of admission is a patient day. The day of discharge is not a patient day.

(8) Reimbursement will be made to a provider for reserving a therapeutic youth group home or therapeutic youth family care (other than permanency therapeutic family care) bed while the recipient is temporarily absent only if:

(a) the recipient's plan of care documents the medical need for therapeutic home visits as part of a therapeutic plan to transition the recipient to a less restrictive level of care;

(b) the recipient is temporarily absent on a therapeutic home visit;

(c) the provider clearly documents staff contact and recipient achievements or regressions during and following the therapeutic home visit; and

(d) the recipient is absent from the provider's facility for no more than three patient days per absence.

(9) No more than 14 patient days per recipient in each rate year will be allowed for therapeutic home visits.

(10) A service for which a fee is not set in or determinable through the EPSDT provider manual, ARM 37.85.212 or 37.86.105 is reimbursed at a fee negotiated in advance of the provision of the service. A service provided before there is a negotiated fee is reimbursed at an amount determined by the department.

(11) Reimbursements for school-based health related services are specified in the School Based Health Service Fee Schedule dated October 2007, which is adopted and incorporated by reference. A copy of the school-based health service fee schedule is posted at http://medicaidprovider.hhs.mt.gov. Rates are adjusted to reimburse these services at the federal matching assistance percentage (FMAP) rate.

(12) The department will not reimburse providers for two services that duplicate one another on the same day. The department adopts and incorporates by reference the Medicaid Children's Mental Health Plan and Children's Mental Health Services Plan (CHMSP) Services Excluded from Simultaneous Reimbursement dated September 1, 2005. A copy of the CHMSP Services Excluded from Simultaneous Reimbursement is posted on the internet at the department's web site at www.dphhs.mt.gov/mentalhealth/children/

childrensmentalhealthservicesmatrix.pdf or may be obtained by writing the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(13) Information regarding current reimbursement or copies of fee schedules for EPSDT services may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.