§ 53-6-113 — Department To Adopt Rules

53-6-113 . Department to adopt rules. (1) The department shall adopt appropriate rules necessary for the administration of the Montana medicaid program as provided for in this part and that may be required by federal laws and regulations governing state participation in medicaid under Title XIX of the Social Security Act, 42 U.S.C. 1396, et seq., as amended.
(2) The department shall adopt rules that are necessary to further define for the purposes of this part the services provided under 53-6-101 and to provide that services being used are medically necessary and that the services are the most efficient and cost-effective available. The rules may establish the amount, scope, and duration of services provided under the Montana medicaid program, including the items and components constituting the services.
(3) The department shall establish by rule the rates for reimbursement of services provided under this part. The department may in its discretion set rates of reimbursement that it determines necessary for the purposes of the program. In establishing rates of reimbursement, the department may consider but is not limited to considering:
(a) the availability of appropriated funds;
(b) the actual cost of services;
(c) the quality of services;
(d) the professional knowledge and skills necessary for the delivery of services; and
(e) the availability of services.
(4) The department shall specify by rule those professionals who may:
(a) deliver or direct the delivery of particular services; and
(b) deliver services by means of telehealth in accordance with 53-6-122 .
(5) The department may provide by rule for payment by a recipient of a portion of the reimbursements established by the department for services provided under this part.
(6) (a) The department may adopt rules consistent with this part to govern eligibility for the Montana medicaid program, including the medicaid program provided for in 53-6-195 . Rules may include but are not limited to financial standards and criteria for income and resources, treatment of resources, nonfinancial criteria, family responsibilities, residency, application, termination, definition of terms, confidentiality of applicant and recipient information, and cooperation with the state agency administering the child support enforcement program under Title IV-D of the Social Security Act, 42 U.S.C. 651, et seq.
(b) The department may not apply financial criteria below $15,000 for resources other than income in determining the eligibility of a child under 19 years of age for poverty level-related children's medicaid coverage groups, as provided in 42 U.S.C. 1396a(l)(1)(B) through (l)(1)(D).
(c) The department may not apply financial criteria below $15,000 for an individual and $30,000 for a couple for resources other than income in determining the eligibility of individuals for the medicaid program for workers with disabilities provided for in 53-6-195 .
(d) (i) The department may not adopt rules or policies requiring a person who is eligible for medicaid pursuant to 53-6-131 (1)(e)(ii)(A) to:
(A) make only a cash payment to qualify for medicaid under that subsection; or
(B) only incur medical expenses as a means of qualifying for medicaid under that subsection.
(ii) If a person eligible for medicaid under 53-6-131 (1)(e)(ii)(A) is participating in a home and community-based services waiver, the department shall count as an eligible medical expense any medical service or item that a nonwaiver medicaid member is allowed to count as a medical expense to qualify for medicaid under 53-6-131 (1)(e)(ii)(A).
(iii) Nothing in this subsection (6)(d) may be construed as preventing a person from making only a cash payment to qualify for medicaid pursuant to 53-6-131 (1)(e)(ii)(A).
(7) The department may adopt rules limiting eligibility based on criteria more restrictive than that provided in 53-6-131 if required by Title XIX of the Social Security Act, 42 U.S.C. 1396, et seq., as may be amended, or if funds appropriated are not sufficient to provide medical care for all eligible persons.
(8) The department may adopt rules necessary for the administration of medicaid managed care systems. Rules to be adopted may include but are not limited to rules concerning:
(a) participation in managed care;
(b) selection and qualifications for providers of managed care; and
(c) standards for the provision of managed care.
(9) Subject to subsection (6), the department shall establish by rule income limits for eligibility for extended medical assistance of persons receiving section 1931 medicaid benefits, as defined in 53-4-602 , who lose eligibility because of increased income to the assistance unit, as that term is defined in the rules of the department, as provided in 53-6-134 , and shall also establish by rule the length of time for which extended medical assistance will be provided. The department, in exercising its discretion to set income limits and duration of assistance, may consider the amount of funds appropriated by the legislature.
(10) Unless required by federal law or regulation, the department may not adopt rules that exclude a child from medicaid services or require prior authorization for a child to access medicaid services if the child would be eligible for or able to access the services without prior authorization if the child was not in foster care.
(11) (a) When establishing rates of reimbursement for services provided under this part, the department may adopt by rule medicare fee schedules issued by the centers for medicare and medicaid services of the United States department of health and human services.
(b) If the department adopts fee schedules as provided in subsection (11)(a), the schedules automatically incorporate changes and updates furnished by the centers for medicare and medicaid services that are made during the year. The provisions of 2-4-307 do not apply to automatic updates of the fee schedules.

Legislative History

En. Sec. 1, Ch. 325, L. 1967; amd. Secs. 47 and 48, Ch. 121, L. 1974; R.C.M. 1947, 71-1511(6); amd. Sec. 4, Ch. 310, L. 1989; amd. Sec. 5, Ch. 711, L. 1989; amd. Sec. 4, Ch. 460, L. 1991; amd. Sec. 26, Ch. 491, L. 1995; amd. Sec. 446, Ch. 546, L. 1995; amd. Sec. 47, Ch. 486, L. 1997; amd. Sec. 37, Ch. 465, L. 2001; amd. Sec. 1, Ch. 502, L. 2005; amd. Sec. 2, Ch. 452, L. 2009; amd. Sec. 11, Ch. 363, L. 2013; amd. Sec. 1, Ch. 287, L. 2015; amd. Sec. 2, Ch. 442, L. 2017; amd. Sec. 2, Ch. 155, L. 2021; amd. Sec. 11, Ch. 497, L. 2021; amd. Sec. 5, Ch. 301, L. 2025.