37.87.1226    OUT-OF-STATE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, REIMBURSEMENT

(1) The Montana Medicaid Program will reimburse a provider of inpatient psychiatric services provided to a youth in a psychiatric residential treatment facility (PRTF) for each patient day, in accordance with the requirements of this subchapter and the Children's Mental Health Bureau Medicaid Services Provider Manual, adopted and incorporated by reference in ARM 37.87.903.

(2)  The Montana Medicaid Program will reimburse a provider for each Medicaid patient day the following bundled per diem rate less any third party or other payments.  The bundled per diem rate for out-of-state PRTF services is the lesser of:

(a)  the amount specified in the department's Medicaid Youth Mental Health fee schedule, as adopted in ARM 37.85.105; or

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

(3) The bundled per diem rate for out-of-state PRTFs services coverage includes the following services:

(a) all services, therapies, and items related to treating the psychiatric condition of the youth;

(b) all services provided by licensed physicians, psychiatrists, midlevel practitioners, psychologists, clinical social workers, and professional counselors;

(c) psychological testing;

(d) lab and pharmacy services; and

(e) supportive services necessary for daily living and safety.

(4) The Montana Medicaid Program will reimburse enrolled providers directly for the following services which are not included in the out-of-state per diem rate:

(a) up to 60 consecutive days of targeted case management services for the purpose of planning the youth's transition to the community. A youth should retain the case manager the youth had prior to entry into PRTF services, if applicable. If the youth is assigned a case manager who is different from the one previous to PRTF services, the case manager must document the rationale for the change; and

(b) a clinical intake assessment by a licensed mental health center, with an endorsement to provide adult services for transition age youth 17 to 18, to determine whether they have a severe and disabling mental illness and if they qualify for adult mental health services.

(5) The Montana Medicaid Program will reimburse state plan ancillary services in addition to the out-of-state bundled per diem rate when these ancillary services are provided by a different provider under arrangement with the PRTF. The ancillary services provided must be:

(a) directed by the PRTF physician;

(b) stated in the treatment plan of the youth; and

(c) documented in the medical records for the youth.

History: 53-6-101, MCA; IMP, 53-6-113, MCA; NEW, 2015 MAR p. 2147, Eff. 12/11/15; AMD, 2017 MAR p. 2287, Eff. 1/1/18; AMD, 2018 MAR p. 458, Eff. 3/1/18; AMD, 2020 MAR p. 691, Eff. 11/1/20; AMD, 2023 MAR p. 1025, Eff. 9/9/23.