Medicaid Benefits: Online Database

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Acute Care Services

Institutional and Clinic Services

Practitioner Services

Prescription Drugs

Physical Therapy and Other Services

Products and Devices

Transportation Services

Other Services

Long-Term Care Services

Community Based Care

Institutional Care

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Benefits by State: Montana (October 2008) Notes

Acute Care Services

Is the Benefit Covered?	Copayment Requirement	Prior Approval Requirement	Coverage Limitations	Reimbursement Methodology	Populations Covered

Institutional and Clinic Services
Clinic Services, by an organized facility or clinic not part of a hospital: Freestanding Ambulatory Surgery Center
Yes	$5/visit			Prospective cost based rate per episode of care using Medicare payment rates	A & B - See state-specific FN
Clinic Services, by an organized facility or clinic not part of a hospital: Public Health and Mental Health Clinics
Yes	$1/visit to Public Health Clinic			Fee for service	A & B - See state-specific FN
Federally Qualified Health Center Services
Yes	$5/visit			Prospective cost based rate/visit	A & B - See state-specific FN
Inpatient Hospital Services, other than in an Institution for Mental Diseases
Yes	$100/admission			Cost based payment using Medicare principles for critical access hospitals,prospective payment/discharge using APR-DRG for all others	A & B - See state-specific FN
Outpatient Hospital Services
Yes	$5/visit			Fee for service with surgical procedures grouped using Medicare methodology, cost based payment for critical access hospitals	A & B - See state-specific FN
Rehabilitation Services: Mental Health and Substance Abuse
Yes		Specified services	Substance abuse treatment limited to state-approved facilities	Fee for service	A & B - See state-specific FN
Rural Health Clinic Services
Yes	$5/visit			Prospective cost based rate/visit	A & B - See state-specific FN
Practitioner Services
Certified Registered Nurse Anesthetist Services
Yes	$4/episode of treatment			Fee for service	A & B - See state-specific FN
Chiropractor Services
No
Dental Services
Yes	$3/visit	Specified services including prosthetics and oral surgery	A - Exam and cleaning 2/year, frequency of x-rays limited by type, bridges limited to anterior teeth and crowns to posterior teeth B - Services limited to emergency treatment for relief of pain and infection and to services essential for employment	Fee for service	A & B - See state-specific FN
Medical and Remedial Care - Other Practitioners

Medical/Surgical Services of a Dentist
Yes	$3/visit	Oral surgery		Fee for service or percentage of charge	A & B - See state-specific FN
Nurse Midwife Services
Yes	$4/visit			Fee for service, some services paid 90% of physician fee	A & B - See state-specific FN
Nurse Practitioner Services
Yes	$4/visit			Fee for service, some services paid 90% of physician fee	A & B - See state-specific FN
Optometrist Services
Yes	$2/visit	Visual training	A - 1 refractive exam/2 years, additional exams allowed for cataract care B - Limited to exams essential for employment	Fee for service	A & B - See state-specific FN
Physician Services
Yes	$4/visit	Specified services		Fee for service	A & B - See state-specific FN
Podiatrist Services
Yes	$4/visit			Fee for service	A & B - See state-specific FN
Psychologist Services
Yes	$3/visit		16 service sessions/year for adults and 24 for children	Fee for service	A & B - See state-specific FN
Prescription Drugs
Prescription Drugs
Yes	$1-$5/Rx depending on drug cost, up to $25 max per month	Specified drugs		AWP-15%, plus cost based dispensing fee between $2 and $4.70	A & B - See state-specific FN
Physical Therapy and Other Services
Occupational Therapy Services
Yes	$2/visit		40 hours/year	Fee for service	A & B - See state-specific FN
Physical Therapy Services
Yes	$2/visit		40 hours/year	Fee for service	A & B - See state-specific FN
Services for Speech, Hearing and Language Disorders
Yes	$3/speech pathology visit, $2/visit audiology service		A - 70 speech pathology visits/year, 30 additional possible with prior approval, audiology services limited to evaluation necessary for provision of hearing aid, B - limited to audiological evaluation necessary for provision of a hearing aid essential for employment	Fee for service	A & B - See state-specific FN
Products and Devices
Dentures
Yes	$5/denture-related visit	Yes	A - 1 full upper and/or lower denture or 1 partial denture/10 years, 1 partial denture/5 years, 1 replacement per lifetime (for lost denture) B - Limited to services essential for employment	Fee for service	A & B - See state-specific FN
Eyeglasses
Yes	$2/pair	2 pair eyeglasses rather than bifocals	A - 1 pair eyeglasses/2 years unless post-cataract surgery or minimum diopter correction criteria met B - Limited to post-cataract surgery lenses or eyeglasses and to eyeglasses essential for employment or related to specified medical conditions including diabetes	Products provided by state's volume purchase contractor, dispensing provider paid fee for service	A & B - See state-specific FN
Hearing Aids
Yes	$2/hearing aid	Yes	B - Limited to hearing aids essential for employment	Fee for service	A & B - See state-specific FN
Medical Equipment and Supplies
Yes	$5/service or item	Med equipment or supply items costing more than $1,000		Fee for service or percentage of charge	A & B - See state-specific FN
Prosthetic and Orthotic Devices
Yes	$5/service or item	Services or items costing more than $1,000	Orthopedic shoes must be attached to brace	Fee for service or percentage of charge	A - See state-specific FN
Transportation Services
Ambulance Services
Yes		Non-emergency transports	All transports must meet specified medical necessity criteria	Fee for service	A & B - See state-specific FN
Non-Emergency Medical Transportation Services
Yes		Yes		See service-specific FN	A & B - See state-specific FN
Other Services
Diagnostic, Screening and Preventive Services
Yes	Dependent upon service and billing provider			Dependent upon service and billing provider	A & B - See state-specific FN
Early and Periodic Screening, Diagnosis and Treatment
See service-specific FN.
Extended Services for Pregnant Women

Family Planning Services
See service-specific FN.
Laboratory and X-Ray Services, outside Hospital or Clinic
Yes	$4/service			Fee for service	A & B - See state-specific FN
Targeted Case Management
Yes				Fee for service	A & B - See state-specific FN

Long-Term Care Services


Community Based Care
Home and Community Based Services Waiver
Yes			Services for the following populations: 2, 4 & 8 - See service-specific FN	Dependent upon the services provided	A - See state-specific FN
Home Health Services, includes nursing services, home health aides, and medical supplies/equipment
Yes	$3/visit	Yes	75 nursing visits/year; 100 visits/year including nursing, home health aide and therapy visits; services not covered at same time as personal care	Percentage of charge using a percentage of Medicare allowable cost as ceiling	A & B - See state-specific FN
Hospice Care
Yes				Prospective rates based on Medicare methodology	A & B - See state-specific FN
Personal Care Services
Yes			40 hours/week	Negotiated hourly rates	A - See state-specific FN
Private Duty Nursing Services
Yes		Yes		Fee for service	A - See state-specific FN
Program of All-Inclusive Care for the Elderly
No
Institutional Care
Inpatient Hospital, Nursing Facility and Intermediate Care Facility Services In Institutions for Mental Diseases, age 65 and older
Yes		Therapeutic leave exceeding 3 days	Hosp leave days not covered, 24 therapeutic leave days/year	Prospective cost based per diem, up to Medicare limits	A - See state-specific FN
Inpatient Psychiatric Services, under age 21
Yes		Therapeutic leave exceeding 3 days	14 therapeutic leave days/year	Prospective cost based all-inclusive per diem	A - See state-specific FN
Intermediate Care Facility Services for the Mentally Retarded
Yes		Therapeutic leave exceeding 3 days	Hosp leave days not covered, 24 therapeutic leave days/year	Prospective cost based per diem with limits	A - See state-specific FN
Nursing Facility Services, other than in an Institution for Mental Diseases
Yes		Therapeutic leave exceeding 3 days	Hosp leave days not covered, 24 therapeutic leave days/year	Prospective per diem using statewide price limits, acuity adjusted	A & B - See state-specific FN
Religious Non-Medical Health Care Institution and Practitioner Services
No

Notes: This State has an approved Section 1115 Waiver from CMS under which it extended Medicaid eligibility to parents and caretaker relatives of dependent children as described in Sections 1925 and 1931 of the Social Security Act and who are age 21 through 64 and neither pregnant nor disabled. The Basic Medicaid Waiver for Able-Bodied Adults was modeled after the State’s welfare reform demonstration from the mid-1990s, and provides mandatory Medicaid benefits as well as a limited package of optional services. Specified services are not covered, including audiology, dental, durable medical equipment, eyeglasses, optometry and ophthalmology for routine eye exams, personal care services and hearing aids, but are available through the Essentials for Employment program if services are essential to obtaining or maintaining employment, consistent with a typical work-related insurance program. The State provides coverage for emergency dental situations, medical conditions of the eye and certain medical supplies such as diabetic supplies and oxygen, as well as services that may be essential for employment. The State’s traditional Medicaid population is identified on the tables as “A” and the expansion population covered under the waiver is identified on the tables as “B.” Cost sharing requirements are the same for both groups.