(1) There is a Montana medicaid program established for the purpose of providing necessary medical services to eligible persons who have need for medical assistance. The Montana medicaid program is a joint federal-state program administered under this chapter and in accordance with Title XIX of the Social Security Act, 42 U.S.C. 1396, et seq., as may be amended. seq. The department of public health and human services shall administer the Montana medicaid program.

(10) Services, procedures, and items of an experimental or cosmetic nature may not be provided.

(10) (a) The amount, scope, and duration of services provided under this part must be determined by the department in accordance with Title XIX of the Social Security Act, 42 U.S.C. 1396, et seq., as may be amended.

(b) The department shall, with reasonable promptness, provide access to all medically necessary services prescribed under the early and periodic screening, diagnosis, and treatment benefit, including access to prescription drugs and durable medical equipment for which the department has not negotiated a rebate.

(11) If available funds are not sufficient to provide medical assistance for all eligible persons, the Services, procedures, and items of an experimental department may or set priorities to limit, reduce, or otherwise curtail the amount, scope, or duration of the cosmetic nature may not be provided. medical services made available under the Montana medicaid program.

(12) Community-based medicaid services, as provided for in part 4 of this chapter, must be provided in accordance with the provisions of this chapter and the rules adopted under this chapter.

(12) (a) Prior to enacting changes to provider rates, medicaid waivers, or the medicaid state plan, the department shall report this information to the following committees in accordance with 5-11-210:

(i) the children, families, health, and human services interim committee;

(ii) the legislative finance committee; and

(iii) the health and human services budget committee.

(b) In its report to the committees, the department shall provide an explanation for the proposed changes and an estimated budget impact to the department over the next 4 fiscal years.

(13) Medicaid payment for personal-care facilities may If available funds are not be made unless sufficient the to provide medical assistance for all eligible persons, department the certifies department may set priorities to limit, reduce, or otherwise curtail the director amount, scope, or duration of the governor's office of budget and medical services made available under the Montana medicaid program planning that payment to this type of provider would, after taking into consideration in the the aggregate, be a cost-effective

(14) (a) If services provided under the Montana medicaid program include gender transition treatment or subsequent treatment directly related to the provision of gender transition treatment, services provided under the program must also include detransition treatment under equivalent cost-sharing policies.

(b) If services provided under the program cease to include gender transition treatment, the program is not required to provide equivalent coverage for detransition treatment, except that the program must provide equivalent coverage to recipients who were enrolled when gender transition treatment was provided and received benefits under that coverage.

(c) For the purposes of this subsection (14), "gender transition treatment" means the following medical treatments provided:

(i) to a female to address her perception that her gender or sex is not female:

(A) surgical procedures, including a vaginectomy, hysterectomy, oophorectomy, ovariectomy, reconstruction of the urethra, metoidioplasty, phalloplasty, scrotoplasty, implantation of erection or testicular protheses, subcutaneous mastectomy, voice surgery, and pectoral implants;

(B) supraphysiologic doses of testosterone or other androgens; or

(C) puberty blockers, such as GnRH agonists or other synthetic drugs that suppress the production of estrogen and progesterone to delay or suppress pubertal development in female minors; and

(ii) to a male to address his perception that his gender or sex is not male:

(A) surgical procedures, including a penectomy, orchiectomy, vaginoplasty, clitoroplasty, vulvoplasty, augmentation mammoplasty, facial feminization surgery, voice surgery, thyroid cartilage reduction, and gluteal augmentation;

(B) supraphysiologic doses of estrogen; or

(C) puberty blockers, such as GnRH agonists or other synthetic drugs that suppress the production of testosterone to delay or suppress pubertal development in male minors.

(2) Medical assistance provided by The department and the Montana medicaid program includes legislature shall consider the following services: funding principles when considering changes in medicaid policy that either increase or reduce services:

(a) inpatient hospital services; protecting those persons who are most vulnerable and most in need, as defined by a combination of economic, social, and medical circumstances;

(b) outpatient hospital services; giving preference to the elimination or restoration of an entire medicaid program or service, rather than sacrifice or augment the quality of care for several programs or services through dilution of funding; and

(c) other laboratory and x-ray services, including minimum mammography examination as defined in 33-22-132; giving priority to services that employ the science of prevention to reduce disability and illness, services that treat life-threatening conditions, and services that support independent or assisted living, including pain management, to reduce the need for acute inpatient or residential care.

(d) skilled nursing services in long-term care facilities;

(e) physicians' services;

(f) nurse specialist services;

(g) early and periodic screening, diagnosis, and treatment services for persons under 21 years of age;

(h) ambulatory prenatal care for pregnant women during a presumptive eligibility period, as provided in 42 U.S.C. 1396a(a)(47) and 42 U.S.C. 1396r-1;

(i) targeted case management services, as authorized in 42 U.S.C. 1396n(g), for high-risk pregnant women;

(j) services that are provided by physician assistants-certified within the scope of their practice and that are otherwise directly reimbursed as allowed under department rule to an existing provider;

(k) health services provided under a physician's orders by a public health department; and

(l) federally qualified health center services, as defined in 42 U.S.C. 1396d(l)(2).

(3) Medical assistance provided by the Montana medicaid program may, as provided by department rule, also include includes the following services:

(a) medical care or any other type of remedial care recognized under state law, furnished by inpatient hospital services; licensed practitioners within the scope of their practice as defined by state law;

(b) home health care outpatient hospital services;

(c) private-duty nursing services; other laboratory and x-ray services, including minimum mammography examination as defined in 33-22-132;

(d) dental services; skilled nursing services in long-term care facilities;

(e) physical therapy physicians' services;

(f) mental health center services administered and funded under a state mental health program authorized under nurse specialist services; Title 53, chapter 21, part 2;

(g) clinical social worker services; early and periodic screening, diagnosis, and treatment services for persons under 21 years of age, in accordance with federal regulations and subsection (10)(b);

(h) prescribed drugs, dentures, and prosthetic devices; ambulatory prenatal care for pregnant women during a presumptive eligibility period, as provided in 42 U.S.C. 1396a(a)(47) and 42 U.S.C. 1396r-1;

(i) prescribed eyeglasses; targeted case management services, as authorized in 42 U.S.C. 1396n(g), for high-risk pregnant women;

(j) other diagnostic, screening, preventive, rehabilitative, chiropractic, and osteopathic services; services that are provided by physician assistants within the scope of their practice and that are otherwise directly reimbursed as allowed under department rule to an existing provider;

(k) inpatient psychiatric hospital health services for persons provided under 21 years of age; a physician's orders by a

(l) services of professional counselors licensed under Title 37, chapter 23; federally qualified health center services, as defined in 42 U.S.C. 1396d(l)(2);

(m) hospice care, as defined routine patient costs for qualified individuals enrolled in 42 U.S.C. 1396d(o); an approved clinical trial for cancer as provided in 33-22-153;

(n) case management for children 18 years of age services and younger, habilitative services as provided defined in 42 U.S.C. 1396d(a) and 1396n(g), including targeted case management services for the mentally

(o) inpatient psychiatric services for persons under 21 years of age, as provided by in a 42 U.S.C. 1396d(h), person certified in a residential treatment facility, as defined in accordance 50-5-101, that is licensed in with 37-2-318 to provide services in accordance with 50-5-201; the

(p) any additional medical service or aid allowable under or provided by the federal Social Security fertility preservation services in accordance with 33-22-2103; and Act.

(q) planned home births for women with a low risk of adverse birth outcomes, as established by the appropriate licensing board, that are attended by certified nurse-midwives licensed under Title 37, chapter 8, or direct-entry midwives licensed under Title 37, chapter 27. Coverage under this section includes prenatal care and postpartum care.

(4) Services for persons qualifying for Medical medicaid assistance under provided by the medically needy category of assistance Montana medicaid program may, as described in 53-6-131 may be more limited in amount, scope, and duration than services provided to others qualifying for assistance under by the department Montana medicaid program. The department is not required to provide all of rule, also include the services listed in subsections (2) and (3) to persons qualifying for medicaid under the medically following services: needy category of assistance.

(a) medical care or any other type of remedial care recognized under state law, furnished by licensed practitioners within the scope of their practice as defined by state law;

(b) home health care services[, including services provided by pediatric complex care assistants licensed pursuant to 37-2-603];

(c) private-duty nursing services;

(d) dental services;

(e) physical therapy services;

(f) mental health center services administered and funded under a state mental health program authorized under Title 53, chapter 21, part 10;

(g) clinical social worker services;

(h) prescribed drugs, dentures, and prosthetic devices;

(i) prescribed eyeglasses;

(j) other diagnostic, screening, preventive, rehabilitative, chiropractic, and osteopathic services;

(k) inpatient psychiatric hospital services for persons under 21 years of age;

(l) services of clinical professional counselors licensed under Title 37, chapter 39;

(m) services of a marriage and family therapist licensed under Title 37, chapter 39;

(n) hospice care, as defined in 42 U.S.C. 1396d(o);

(o) case management services, as provided in 42 U.S.C. 1396d(a) and 1396n(g), including targeted case management services for the mentally ill;

(p) services of psychologists licensed under Title 37, chapter 17;

(q) inpatient psychiatric services for persons under 21 years of age, as provided in 42 U.S.C. 1396d(h), in a residential treatment facility, as defined in 50-5-101, that is licensed in accordance with 50-5-201;

(r) services of behavioral health peer support specialists certified under Title 37, chapter 39, provided to adults 18 years of age and older with a diagnosis of a mental disorder, as defined in 53-21-102;

(s) services of doulas licensed under Title 37, chapter 77;

(t) direct patient care agreements, as provided for in 50-4-107; and

(u) any additional medical service or aid allowable under or provided by the federal Social Security Act.

(5) In accordance with waivers of federal law that are granted by Services for persons qualifying for medicaid under the secretary medically needy category of the U.S. department of health and human services, the department of public health and human assistance, services may as implement described in 53-6-131, may limited be medicaid benefits, to be known as basic medicaid, for adult recipients who are eligible because more limited they are receiving FAIM financial assistance, as defined in 53-4-702, as the specified caretaker relative of a dependent child under the FAIM project amount, scope, and duration than services provided to others qualifying for all adult recipients of medical assistance only who are covered under a group related to the the program of FAIM financial assistance, as defined in 53-4-702. Basic Montana medicaid benefits consist program. The department is not required to provide of all all mandatory of the services listed in subsections (2)(a) through (2)(l) but may include those optional services listed in subsections (3)(a) through (3)(p) (3) and (4) to persons qualifying for medicaid under that the department in its discretion specifies by rule. The department, in exercising its discretion, may consider medically needy category the amount of funds appropriated by the legislature for the FAIM project and whether the provision of a assistance. particular service is commonly covered by private health insurance plans. However, a recipient who is pregnant, meets the criteria for disability provided in Title II of the Social Security Act, 42 U.S.C. 416, et seq., or is less than 21 years of age is entitled to full medicaid coverage.

(6) The department may implement, as provided for in Title XIX In accordance with federal law or waivers of federal law that are granted by the Social Security Act, 42 U.S.C. 1396, et seq., as may be amended, a program under secretary medicaid for payment of medicare premiums, deductibles, the U.S. department of health and coinsurance for persons not otherwise eligible for medicaid. human services, the department may implement limited medicaid benefits, to be known as basic medicaid, for adult recipients who are eligible because they are receiving cash assistance, as defined in 53-4-201, as the specified caretaker relative of a dependent child and for all adult recipients of medical assistance only who are covered under a group related to a program providing cash assistance, as defined in 53-4-201. Basic medicaid benefits consist of all mandatory services listed in subsection (3) but may include those optional services listed in subsections (4)(a) through (4)(u) that the department in its discretion specifies by rule. The department, in exercising its discretion, may consider the amount of funds appropriated by the legislature, whether approval has been received, as provided in 53-1-612, and whether the provision of a particular service is commonly covered by private health insurance plans. However, a recipient who is pregnant, meets the criteria for disability provided in Title II of the Social Security Act, 42 U.S.C. 416, et seq., or is less than 21 years of age is entitled to full medicaid coverage.

(7) The department may set rates implement, as for provided medical and other services provided to recipients of for medicaid and may enter into contracts for delivery in Title XIX of services to individual recipients or groups of recipients. the Social Security Act, 42 U.S.C. 1396, et seq., as may be amended, a program under medicaid for payment of medicare premiums, deductibles, and coinsurance for persons not otherwise eligible for medicaid.

(8) The services provided under this part may be only those that are medically necessary and that are the most efficient and cost-effective.

(8) (a) The department may set rates for medical and other services provided to recipients of medicaid and may enter into contracts for delivery of services to individual recipients or groups of recipients.

(b) The department shall strive to close gaps in services provided to individuals suffering from mental illness and co-occurring disorders by doing the following:

(i) simplifying administrative rules, payment methods, and contracting processes for providing services to individuals of different ages, diagnoses, and treatments. Any adjustments to payments must be cost-neutral for the biennium beginning July 1, 2017.

(ii) publishing a report on an annual basis that describes the process that a mental health center or substance use disorder facility, as those terms are defined in 50-5-101, must utilize in order to receive payment from Montana medicaid for services provided to individuals of different ages, diagnoses, and treatments.

(9) The amount, scope, and duration of services provided under this part must may be determined by only those that are medically necessary and that are the department in accordance with Title XIX of the Social Security Act, 42 U.S.C. 1396, et most efficient and cost-effective. seq., as may be amended.

Montana medicaid program -- – authorization of services

Bracketed language in subsection (4)(b) terminates June 30, 2031--sec. 10, Ch. 628, L. 2023; subsection (4)(s) terminates December 31, 2030--sec. 10, Ch. 597, L. 2025.

Temporary

Montana medicaid program – authorization of services

Bracketed language in subsection (4)(b) terminates June 30, 2031--sec. 10, Ch. 628, L. 2023; subsection (4)(s) terminates December 31, 2030--sec. 10, Ch. 597, L. 2025.

Effective October 1, 2026