(1) The Montana Medicaid Program establishes provider reimbursement rates for medically necessary, covered services based on the estimated demand for services and the legislative appropriation and federal matching funds. Provider reimbursement rates are stated in fee schedules for covered services applicable to the identified Medicaid program. New rates are established by revising the identified program's fee schedule and adopting the new fees as of the stated effective date of the schedule. Copies of the department's current fee schedules are posted at http://medicaidprovider.hhs.mt.gov and may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951. A description of the method for setting the reimbursement rate and the administrative rules applicable to the covered service is published in the chapter or subchapter of this title regarding that service. The department will make quarterly updates as necessary to the fee schedule noted in this rule to include new procedure codes and applicable rates and removal of terminated procedure codes.

(2) The department adopts and incorporates by reference, the resource-based relative value scale (RBRVS) reimbursement methodology for specific providers as described in ARM 37.85.212 on the date stated.

(a) Resource-based relative value scale (RBRVS) means the version of the Medicare resource-based relative value scale contained in the Medicare Physician Fee Schedule adopted by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services and published at 77 Federal Register 68892 (November 16, 2012), effective January 1, 2013 which is adopted and incorporated by reference.

(b) Fee schedules are effective July 1, 2013. The conversion factor for physician services is $34.32. The conversion factor for allied services is $23.08. The conversion factor for mental health services is $24.29. The conversion factor for anesthesia services is $28.10.

(c) Policy adjustors are effective July 1, 2013. The maternity policy adjustor is 112%. The family planning policy adjustor is 105%. The psychological testing for youth policy adjustor is 145%.

(d) The by-report rate is effective July 1, 2013 and is 44% of the provider's usual and customary charges.

(e) The specific percents for modifiers adopted by the department is effective July 1, 2013.

(f) Psychiatrists receive a 112% provider rate of reimbursement adjustment to the reimbursement of physicians effective July 1, 2013.

(g) Midlevel practitioners receive a 90% provider rate of reimbursement adjustment to the reimbursement of physicians for those services described in ARM 37.86.205(5)(b) effective July 1, 2013.

(h) Optometric services receive a 112% provider rate of reimbursement adjustment to the reimbursement for allied services as provided in ARM 37.85.105(2) effective January 1, 2014.

(i) Reimbursement for physician-administered drugs described at ARM 37.86.105 is determined at 42 CFR 414.904.

(3) The department adopts and incorporates by reference, the fee schedule for the following programs within the Health Resources Division, on the date stated.

(a) The inpatient hospital services fee schedule and inpatient hospital base fee schedule rates including:

(i) the APR-DRG fee schedule for inpatient hospitals as provided in ARM 37.86.2907, effective July 1, 2013; and

(ii) the Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), outlier thresholds, and APR grouper version 29 are contained in the APR-DRG Table of Weights and Thresholds effective July 1, 2013. The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds effective July 1, 2013.

(b) The outpatient hospital services fee schedules including:

(i) the Outpatient Prospective Payment System (OPPS) fee schedule as published by the Centers for Medicare and Medicaid Services (CMS) in 71 Federal Register 226, effective January 1, 2007, and reviewed annually by CMS as required in 42 CFR 419.5 as updated by the department;

(ii) the conversion factor for outpatient services on or after July 1, 2013 is $50.61;

(iii) the Medicaid statewide average outpatient cost to charge ratio is 44.5%; and

(iv) the bundled composite rate of $267.24 for services provided in an outpatient maintenance dialysis clinic effective on or after July 1, 2013.

(c) The hearing aid services fee schedule, as provided in ARM 37.86.805, is effective January 1, 2014.

(d) The Relative Values for Dentists, as provided in ARM 37.86.1004, reference published in 2013 resulting in a dental conversion factor of $31.89 and fee schedule is effective July 1, 2013.

(e) The dental services covered procedures, the Dental and Denturist Program Provider Manual, as provided in ARM 37.86.1006, is effective July 1, 2013.

(f) The outpatient drugs reimbursement, dispensing fees range as provided in ARM 37.86.1105(2)(b) is effective July 1, 2013:

(i) a minimum of $2.00 and a maximum of $4.94 for brand-name and nonpreferred generic drugs;

(ii) a minimum of $2.00 and a maximum of $6.52 for preferred brand-name and generic drugs and generic drugs not identified on the preferred list.

(g) The outpatient drugs reimbursement, compound drug dispensing fee range as provided in ARM 37.86.1105(4), will be $12.50, $17.50, or $22.50 based on the level of effort required by the pharmacist, effective July 1, 2013.

(h) The outpatient drugs reimbursement, vaccine administration fee as provided in ARM 37.86.1105(5), will be $21.32 for the first vaccine and $13.38 for each additional administered vaccine, effective July 1, 2013.

(i) The out-of-state providers will be assigned a $3.50 dispensing fee.

(j) The outpatient drugs reimbursement, unit dose prescriptions fee as provided in ARM 37.86.1105(9), will be $0.75 per pharmacy-packaged unit dose medication, effective November 1, 2013.

(k) The home infusion therapy services fee schedule, as provided in ARM 37.86.1506, is effective July 1, 2013.

(l) Montana Medicaid adopts and incorporates by reference the Region D Supplier Manual which outlines the Medicare coverage criteria for Medicare covered durable medical equipment, local coverage determinations (LCDs), and national coverage determinations (NCDs) as provided in ARM 37.86.1802, effective January 1, 2014. The prosthetic devices, durable medical equipment, and medical supplies fee schedule, as provided in ARM 37.86.1807, is effective January 1, 2014.

(m) The early and periodic screening, diagnostic and treatment (EPSDT) services fee schedules for private duty nursing, nutrition and orientation, and mobility specialists as provided in ARM 37.86.2207(2), is effective July 1, 2013.

(n) The transportation and per diem fee schedule, as provided in ARM 37.86.2405, is effective July 1, 2013.

(o) The specialized nonemergency medical transportation fee schedule, as provided in ARM 37.86.2505, is effective July 1, 2013.

(p) The ambulance services fee schedule, as provided in ARM 37.86.2605, is effective July 1, 2013.

(4) The department adopts and incorporates by reference, the fee schedule for the following programs within the Senior and Long Term Care Division on the date stated:

(a) Home and community-based services for elderly and physically disabled persons fee schedule, as provided in ARM 37.40.1421, is effective July 1, 2013.

(b) Home health services fee schedule, as provided in ARM 37.40.705, is effective July 1, 2013.

(c) Personal assistance services fee schedule, as provided in ARM 37.40.1105, is effective July, 2013.

(d) Self-directed personal assistance services fee schedule, as provided in ARM 37.40.1303, is effective July 1, 2013.

(5) The department adopts and incorporates by reference, the fee schedule for the following programs within the Addictive and Mental Disorders Division on the date stated:

(a) Case management services for adults with severe disabling mental illness reimbursement, as provided in ARM 37.86.3515, is effective July 1, 2013.

(b) Mental health center services for adults reimbursement, as provided in ARM 37.88.907, is effective July 1, 2013.

(c) Home and community-based services for adults with severe disabling mental illness, reimbursement, as provided in ARM 37.90.408, is effective July 1, 2013.

(d) Targeted case management services for substance use disorders, reimbursement, as provided in ARM 37.86.4010, is effective July 1, 2013.

(6) The department adopts and incorporates by reference, the fee schedule for the following programs within the Developmental Services Division, on the date stated.

(a) Mental health services for youth, as provided in ARM 37.87.901 in the Medicaid Youth Mental Health Services Fee Schedule, is effective January 1, 2014.

(b) Mental health services for youth, as provided in ARM 37.87.1313 in the 1915(i) HCBS State Plan Program for Youth with Serious Emotional Disturbance Fee Schedule, is effective July 1, 2013.

(c) Mental health services for youth, as provided in ARM 37.87.1030 in the 1915(c) HCBS Bridge Waiver for Youth with Serious Emotional Disturbance Fee Schedule, is effective July 1, 2013.