Mont. Admin. r. 37.86.5007

Current through Register Vol. 23, December 6, 2024

Rule 37.86.5007 - HEALTH MAINTENANCE ORGANIZATIONS: COVERED SERVICES

(1) An HMO must provide the following services:

(a) inpatient hospital services as defined at ARM 37.86.2901 and 37.86.2902;

(b) outpatient hospital services as defined at ARM 37.86.3001 and 37.86.3002;

(c) physician services as defined at ARM 37.86.101 and 37.86.104;

(d) family planning services as defined at ARM 37.86.1701 and 37.86.1705;

(e) home health services as defined at ARM 37.40.701 and 37.40.702;

(f) early periodic screening, diagnosis and treatment services for individuals under the age of 21 (EPSDT) as defined at ARM 37.86.1401, 37.86.1402, 37.86.2201, 37.86.2205 and 37.86.2206;

(g) non-hospital laboratory and x-ray services as defined at ARM 37.86.911;

(h) rural health clinic services as defined at ARM 37.86.4001;

(i) ambulance services as defined at ARM 37.86.2601 and 37.86.2602;

(j) ambulatory surgical center services as defined at ARM 37.86.1401, 37.86.1402 and 37.86.1405 ;

(k) chiropractor services as defined at ARM 37.86.2206(2) (b);

(l) diagnostic clinic services as defined at ARM 37.86.1401 and 37.86.1402;

(m) nutrition services as defined at ARM 37.86.2206(2) (a);

(n) federally qualified health center services as defined at ARM 37.86.4401;

(o) hospice services as defined at ARM 37.40.801 and 37.40.806;

(p) mid-level practitioner services as defined at ARM 37.86.201 and 37.86.202;

(q) immunizations recommended by the advisory committee on immunization practices;

(r) occupational therapy services as defined at ARM 37.86.601;

(s) physical therapy services as defined at ARM 37.86.601;

(t) podiatry services as defined at ARM 37.86.501 and 37.86.505;

(u) private duty nursing services as defined at ARM 37.86.2206(2) (f);

(v) county public health clinic services as defined at ARM 37.86.1401 and 37.86.1402;

(w) respiratory therapy services as defined at ARM 37.86.2206(2) (d);

(x) immunizations and well child screens provided by school based providers;

(y) speech therapy services as defined at ARM 37.86.601;

(z) targeted case management services for high risk pregnant women as defined at ARM 37.86.3301, 37.86.3305, 37.86.3006, 37.86.3401, 37.86.3402 and 37.86.3405; and

(aa) transplant services as defined at ARM 37.86.4701 and 37.86.4705.

(ab) prescription drugs supplied by a participating provider or a provider with a family planning and/or public health clinic;

(ac) durable medical equipment limited to diabetic supplies, oxygen, prosthetics, ostomy or incontinence supplies and only if supplied by a participating provider or a provider with a family planning and/or public health clinic;

(ad) optometric/ophthalmic services for medical conditions of the eye.

(2) An enrolled recipient may obtain the following covered services through self-referral to a participating or nonparticipating provider and the HMO must reimburse the provider of a service to which the enrollee may self-refer:

(a) family planning services:

(i) for enrollees with reproductive capacity, reproductive health exams comprised of taking history and conducting a physical assessment when such an exam is necessary to obtain birth control supplies or to determine the most appropriate birth control method or supply;

(ii) patient counseling and education for the following: contraception, sexuality, infertility, pregnancy, preconceptual care, pregnancy options, disease, HIV/AIDS, sterilizations, nutrition to maximize reproductive health, the need for rubella and hepatitis B immunizations, and other topics related to the patient's reproductive and general health;

(iii) lab tests to detect the presence of conditions affecting reproductive health, such as those involving the thyroid, cholesterol/triglycerides, prolactin, pregnancy tests, and diagnosis of infertility;

(iv) sterilizations as defined at ARM 37.86.104;

(v) screening, testing, and treatment of and pre- and post-test counseling for sexually transmitted diseases and HIV;

(vi) family planning supplies provided by Title X clinics; and

(vii) rubella and hepatitis B immunizations.

(b) immunizations provided by a public health clinic;

(c) blood lead level testing provided by a public health clinic; or

(d) emergency service.

(3) If a nonparticipating provider detects a problem outside the scope of family planning services as defined above, such provider shall refer the enrollee back to the HMO.

(4) An enrollee is eligible for all non-covered services and may obtain non-covered services in the usual manner.

Mont. Admin. r. 37.86.5007

NEW, 1995 MAR p. 2155, Eff. 9/29/95; AMD, 1997 MAR p. 548, Eff. 3/25/97; AMD, 1997 MAR p. 1210, Eff. 7/8/97; AMD, 1997 MAR p. 1269, Eff. 7/22/97; AMD, 1998 MAR p. 2045, Eff. 7/31/98; AMD, 1999 MAR p. 1301, Eff. 7/1/99; TRANS, from SRS, 2000 MAR p. 481; AMD, 2000 MAR p. 866, Eff. 3/31/00.

Sec. 53-2-201 and 53-6-113, MCA; IMP, Sec. 53-2-201, 53-6-101, 53-6-113 and 53-6-116, MCA;