ARM 37.90.408. HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: REIMBURSEMENT

(1) The department adopts and incorporates by reference the Medicaid Home and Community-Based Services for Adults with Severe and Disabling Mental Illness fee schedule. Unless otherwise provided for in rule, the provider reimbursement rate for waiver program services is stated in the department's fee schedule as provided in ARM 37.85.105(5)(b). These fees are calculated based on: (a) the biennial legislative appropriation; and (b) the estimated demand of covered services during the biennium. (2) Medicaid reimbursement for the SDMI HCBS waiver program will be the lesser of: (a) the provider's usual and customary charge for the service; or (b) the rate established in the department's Medicaid fee schedule adopted and incorporated into ARM 37.85.105(5)(b). (3) The SDMI HCBS waiver program is the payor of last resort and will not reimburse a service that otherwise is or should be paid by another source. (4) The SDMI HCBS waiver program will not reimburse for services provided to individuals of an enrolled member's household or family. (5) All SDMI HCBS services, except for case management, must be prior authorized before delivery of services. Services that are delivered before prior authorization is received will not be approved and, if reimbursed, may be subject to repayment.