(1) The department will provide benefits for a CSHS-eligible child or youth with a covered condition:

(a) if the benefit is not covered by another payment source, with the exception of the Indian health service (IHS) , which is a payer of last resort;

(b) if the department has sufficient federal funds to provide the benefit;

(c) up to a maximum of $12,000 per eligibility year;

(d) up to a maximum of $1,500 each for speech, physical, nutritional, occupational, or respiratory therapy related to a covered condition. For children under age three, CSHS will pay after the early intervention program, part C, of the disabilities services division; and

(e) after all third parties, if any, have paid the provider, in which case the department pays any balance remaining for services not covered by another payment source, within CSHS limits for the services in question.

(2) The department will pay providers directly for CSHS-eligible care and will not reimburse clients.

(3) The department will pay eligible providers after the department receives a signed authorization form and documentation that the care has been provided.

(4) A provider, family, or individual who erroneously or improperly is paid by the department must promptly refund that payment to the department.

(5) A provider who accepts the CSHS level of payment for covered benefits may not seek additional payment from a CSHS client or their family.

(6) The department will pay up to the following limits for orthodontia care:

(a) Payment for orthodontia for CSHS clients who have cleft or craniofacial conditions requiring orthodontia due to a medical condition with orthodontic implications will be subject to the maximum allowable charge published in the department's orthodontic coverage and reimbursement guidelines updated through July, 2001.

(b) Payment will be based on a treatment plan submitted by the provider that meets the requirements of the department's orthodontic coverage and reimbursement guidelines and that includes, at a minimum, a description of the plan of treatment, the provider's estimated usual and customary charge, and a time line for treatment. The department will reimburse 40% of the CSHS allowed amount upon initial billing for each phase of treatment, the remainder being paid in monthly installments as determined by the time line established in the provider's treatment plan for completing orthodontic care.

(c) A client is limited to:

(i) an overall lifetime cap of $7,000 for all orthodontia phases; and

(ii) the maximum for each phase cited in the department's orthodontic coverage and reimbursement guidelines updated through December 1999.

(d) Maximum allowable charges for each phase of orthodontic treatment, time lines for orthodontic phases of care, and the services included in each phase of orthodontic care are listed in the department's orthodontic coverage and reimbursement guidelines. The department hereby adopts and incorporates by reference the department's orthodontic coverage and reimbursement guidelines updated through July, 2001. The guidelines, issued by the department to all providers of orthodontic services, inform providers of the requirements applicable to the delivery of services under the medicaid program. A copy of the department's orthodontic coverage and reimbursement guidelines is available from the Department of Public Health and Human Services, Child and Adult Health Resources Division, Medicaid Services Bureau, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(7) For services to a CSHS client, with the exception of multiple surgeries, a provider will be paid 85% of the actual submitted charge for the approved services.

(8) For multiple surgeries, the department will pay at the following rates:

(a) 85% of the actual charge for multiple surgeries performed during the same admission, but on different days.

(b) for multiple surgeries performed on the same day, under the same anesthesia:

(i) involving a single surgical field or single surgical incision, regardless of how many organ systems are involved, performed by one or two surgeons:

(A) 85% of the actual charge for the first procedure; and

(B) 75% of the actual charge for the second procedure;

(ii) involving two surgical fields or two surgical incisions performed by one surgeon, whether the surgery involves separate organ systems, different anatomical locations, or bilateral surgical procedures:

(A) 85% of the actual charge for the first procedure; and

(B) 75% of the actual charge for the second and each subsequent procedure.

(iii) involving two surgical fields or two surgical incisions performed by two surgeons, whether the surgery involves separate organ systems, different anatomical locations, or bilateral surgical procedures, 85% of the actual charge for the first and second procedures.

(iv) involving bilateral surgical procedures (e.g. bilateral Colles' fracture) :

(A) 85% for the first procedure; and

(B) 75% for the second procedure.

(9) Hospitals and surgicenters will be paid 85% of the actual submitted charge on the date of occurrence for inpatient and outpatient services.

(10) Dentists will be paid 85% of billed charges for an annual dental exam and dental extractions related to active or anticipated orthodontia treatment.

(11) In addition to the above, the department will pay:

(a) the lesser of either the actual charge for drugs and other prescribed supplies, or the price cited in the 2002 Drug Topics Redbook Pharmacy's Fundamental Reference, less 15%, plus a $4.70 dispensing fee and any minor adjustments deemed reasonable by the department to reflect market changes;

(b) 85% of the cost of orthotics and prosthetic devices (orthopedic only) ;

(c) 100% of the cost of specialized formula and foods and prescriptive or non-prescriptive medications prescribed by a physician for inborn errors of metabolism;

(d) 100% of the cost of syringes and disposable medical equipment for the treatment of covered conditions; and

(e) rental or purchase of durable medical equipment authorized by CSHS professional staff.

(12) Clinic services provided at a clinic funded or supported by the department are provided free of charge, regardless of the client's household income.

(13) The department hereby adopts and incorporates by reference the 2002 Drug Topics Redbook Pharmacy's Fundamental Reference, which suggests prices for drugs. Anyone wishing to examine any of the above references may do so by contacting the department's CSHS program at Department of Public Health and Human Services, Child and Adult Health Resources Division, Children's Special Health Services Program, 1218 East Sixth Avenue, Helena, MT 59601, phone: 444-3617.