(1) Authorized medically necessary mental health services for a covered diagnosis are covered under the plan for members, except as provided in this subchapter, include:

(a) evaluation and assessment of psychiatric conditions by licensed and enrolled mental health professionals as defined in ARM 37.89.103;

(b) physician services as defined in ARM 37.86.101 and mid-level practitioner services as defined in ARM 37.86.202, for screening and identifying psychiatric conditions and for medication management;

(c) a psychotropic drug formulary, as specified in (4);

(d) medication management, including lab services necessary for management of prescribed medications medically necessary with respect to a covered diagnosis; and

(e) mental health center services provided by a licensed mental health center contracted with the department for services to adults enrolled in the plan.

(2) The department may require prior authorizations for any particular services designated by the department in accordance with ARM 37.89.118.

(a) Members must comply with the procedures required by the department in accordance with ARM 37.89.118 to obtain or access services under the plan.

(3) Coverage of medically necessary mental health services for a covered diagnosis will not be denied solely because the member also has a noncovered diagnosis.

(4) The plan covers the medically necessary psychotropic medications listed in the department's mental health services plan drug formulary if medically necessary with respect to a covered diagnosis. The department may revise the formulary from time to time. A copy of the current formulary may be obtained from the Department of Public Health and Human Services, Addictive and Mental Disorders Division, P.O. Box 202905, Helena, MT 59620-2905.

(5) Except as provided in (5)(a), the plan covers medically necessary mental health services for covered diagnoses for members who are residents of nursing facilities, regardless of whether the services are provided in the nursing facility.

(a) The plan does not cover services defined as "nursing facility services" in ARM 37.40.302 or otherwise required by law to be provided by the nursing facility and does not cover or reimburse the nursing facility for services provided by the nursing facility.

(6) The plan covers medically necessary mental health services for any covered diagnosis for a member with a primary diagnosis of mental retardation or developmental disability, but does not cover treatment, habilitation, or other services required by the member's mental retardation or developmental disability.

(7) The plan does not cover:

(a) inpatient or emergency hospital services;

(b) any form of transportation services; and

(c) drug or alcohol detoxification.

(8) A member who is an inmate in or incarcerated in a correctional or detention facility is not entitled to services under the plan, except as specifically provided in these rules.

(a) The plan covers discharge planning services in relation to a covered diagnosis prior to release from a correctional or detention facility for a member who is:

(i) within 60 days of release;

(ii) a prisoner in a correctional or detention facility; or

(iii) a forensic patient admitted to the Montana state hospital.

(b) A member incarcerated in a local government criminal detention facility who has not been adjudicated may receive medically necessary mental health services for covered diagnosis during incarceration, except that the plan does not cover the member's security or detention needs.

(c) A member may receive medically necessary mental health services for covered diagnoses after leaving the correctional or detention facility, except that the plan does not cover the individual's security or detention needs.

(9) This subchapter is not intended to and does not establish an entitlement for any individual to be determined eligible for or to receive services under the plan. The category of services, the particular provider of services, the duration of services, and other specifications regarding the services to be covered for a particular member may be determined and may be restricted by the department or its designee based upon and consistent with the services medically necessary for the member, the availability of appropriate alternative services, the relative cost of services, the member's treatment plan objectives, the availability of funding, the degree of financial need, and the degree of medical need.

(a) If the department determines with respect to the plan that it is necessary to reduce, limit, suspend or terminate eligibility or benefits, reduce provider reimbursement rates, reduce or eliminate service coverage or otherwise limit services, benefits or provider participation, in a manner other than provided in this subchapter, the department may implement such changes by providing ten days advance notice published in Montana major daily newspapers with statewide circulation, and by providing:

(i) ten days advance written notice of any individual eligibility and coverage changes to affected members; and

(ii) ten days advance written notice of coverage, rate, and provider participation changes to affected providers.