37.57.111    PAYMENT LIMITS AND REQUIREMENTS

(1) The department will provide financial assistance for a CSHS-eligible CYSHCN 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 $2,000 per eligibility year;

(d) for a CYSHCN 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 to the lower of the health care coverage allowed amount or the CSHS allowed amount for the services in question.

(2) When possible, CSHS will pay providers directly for CSHS-eligible services and will not reimburse clients. Clients may be reimbursed if the services were rendered prior to eligibility and proper documentation is provided as requested by CSHS.

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

(4) Any individual who erroneously or improperly receives payment from the department must promptly refund that payment to the department.

(5) A provider who accepts the CSHS level of payment for covered services 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) Orthodontia may only be covered for CYSHCN who have a medical condition with orthodontic implications. This may include but is not limited to: cleft/craniofacial anomalies, facial deformities, speech impediments, Treacher-Collins Syndrome, Marfan Syndrome, or Craniosynostosis.

(7) For services to a CSHS client, a provider will be paid 85% of the actual submitted charge. If the CSHS client has third-party coverage, the department will pay the remaining balance for services to the lower of the health care coverage allowed amount or the CSHS allowed amount of the approved services.

(8) 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 wholesale price cited, less 15%, plus a dispensing fee on the Medicaid point-of-sale system;

(b) 85% of the cost of durable medical equipment to the appropriate amount when allowing financial assistance, or to the maximum amount set by the program for the federal fiscal year;

(c) 85% of the cost of specialized formula and foods and prescriptive or nonprescriptive medications prescribed by a physician for inborn errors of metabolism; and

(d) 85% of the cost of syringes and disposable medical equipment for the treatment of covered conditions.

(9) A CYSHCN who attends interdisciplinary pediatric specialty clinics, supported by CSHS, is not responsible for copays, deductibles, or coinsurance, nor will they be balance-billed.

 

History: 50-1-202, MCA; IMP, 50-1-202, MCA; NEW, 1990 MAR p. 1256, Eff. 6/29/90; AMD, 1992 MAR p. 919, Eff. 5/1/92; AMD, 1994 MAR p. 1836, Eff. 7/8/94; AMD, 1999 MAR p. 2879, Eff. 12/17/99; TRANS, from DHES, 2001 MAR, p. 398; AMD, 2003 MAR p. 1637, Eff. 8/1/03; AMD, 2003 MAR p. 1637, Eff. 8/1/03; AMD, 2012 MAR p. 1672, Eff. 8/24/12; AMD, 2013 MAR p. 1449, Eff. 8/9/13; AMD, 2018 MAR p. 1733, Eff. 8/25/18.