1. (1) An HMO must provide the following services:

   1. (a) inpatient hospital services as defined at ARM 37.86.2901 and 37.86.2902;
   2. (b) outpatient hospital services as defined at ARM 37.86.3001 and 37.86.3002;
   3. (c) physician services as defined at ARM 37.86.101 and 37.86.104;
   4. (d) family planning services as defined at ARM 37.86.1701 and 37.86.1705;
   5. (e) home health services as defined at ARM 37.40.701 and 37.40.702;
   6. (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;
   7. (g) non-hospital laboratory and x-ray services as defined at ARM 37.86.911;
   8. (h) rural health clinic services as defined at ARM 37.86.4001;
   9. (i) ambulance services as defined at ARM 37.86.2601 and 37.86.2602;
   10. (j) ambulatory surgical center services as defined at ARM 37.86.1401, 37.86.1402 and 37.86.1405;
   11. (k) chiropractor services as defined at ARM 37.86.2206(2) (b) ;
   12. (l) diagnostic clinic services as defined at ARM 37.86.1401 and 37.86.1402;
   13. (m) nutrition services as defined at ARM 37.86.2206(2) (a) ;
   14. (n) federally qualified health center services as defined at ARM 37.86.4401;
   15. (o) hospice services as defined at ARM 37.40.801 and 37.40.806;
   16. (p) mid-level practitioner services as defined at ARM 37.86.201 and 37.86.202;
   17. (q) immunizations recommended by the advisory committee on immunization practices;
   18. (r) occupational therapy services as defined at ARM 37.86.601;
   19. (s) physical therapy services as defined at ARM 37.86.601;
   20. (t) podiatry services as defined at ARM 37.86.501 and 37.86.505;
   21. (u) private duty nursing services as defined at ARM 37.86.2206(2) (f) ;
   22. (v) county public health clinic services as defined at ARM 37.86.1401 and 37.86.1402;
   23. (w) respiratory therapy services as defined at ARM 37.86.2206(2) (d) ;
   24. (x) immunizations and well child screens provided by school based providers;
   25. (y) speech therapy services as defined at ARM 37.86.601;
   26. (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
   27. (aa) transplant services as defined at ARM 37.86.4701 and 37.86.4705.
   28. (bb) prescription drugs supplied by a participating provider or a provider with a family planning and/or public health clinic;
   29. (cc) 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;
   30. (dd) optometric/ophthalmic services for medical conditions of the eye.

2. (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:

   1. (a) family planning services:

      1. (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;
      2. (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;
      3. (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;
      4. (iv) sterilizations as defined at ARM 37.86.104;
      5. (v) screening, testing, and treatment of and pre- and post-test counseling for sexually transmitted diseases and HIV;
      6. (vi) family planning supplies provided by Title X clinics; and
      7. (vii) rubella and hepatitis B immunizations.
   2. (b) immunizations provided by a public health clinic;
   3. (c) blood lead level testing provided by a public health clinic; or
   4. (d) emergency service.
3. (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. (4) An enrollee is eligible for all non-covered services and may obtain non-covered services in the usual manner.

Authorizing statute(s): Sec. 53-2-201 and 53-6-113, MCA

Implementing statute(s): Sec. 53-2-201, 53-6-101, 53-6-113 and 53-6-116, MCA

History: 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.