Montana Summary -- State Residential Treatment for Behavioral Health Conditions: Regulation and Policy

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State Residential Treatment for Behavioral Health Conditions: Regulation and Policy

MONTANA

This summary of state regulations and policy represents only a snapshot at a point in time, is

not comprehensive, and should not be taken to constitute legal advice or guidance. State

Medicaid requirements are included at the end of this summary.

Types of Facilities

Mental Health (MH) and Substance Use Disorder (SUD): Montana regulates the following two

residential facility types:

• A health care facility is all or a portion of an institution, building, or agency, private or

public, excluding federal facilities, whether organized for profit or not, that is used,

operated, or designed to provide health services, medical treatment, or nursing,

rehabilitative, or preventive care to any individual. The term does not include offices of

private physicians or dentists. The term includes, among others, chemical dependency

facilities, mental health centers, residential care facilities, and residential treatment

facilities.

• Residential psychiatric care: active psychiatric treatment provided in a residential

treatment facility to psychiatrically impaired individuals with persistent patterns of

emotional, psychological, or behavioral dysfunction of such severity as to require 24-hour

supervised care to adequately treat or remedy the individual's condition. Residential

psychiatric care must be individualized and designed to achieve the patient's discharge to

less restrictive levels of care at the earliest possible time.

Mental Health (MH): Montana regulates one type of residential mental health treatment

facility:

• 72-Hour Adult Crisis Stabilization services: medically necessary mental health services

delivered in direct response to a crisis, limited in scope and duration, and delivered or

contracted for by a crisis stabilization provider. The purposes of these services are to

stabilize a crisis, improve diagnostic clarity, find appropriate alternatives to psychiatric

hospitalization, treat those symptoms that can be improved within a brief period of time,

and arrange appropriate follow-up care or to refer an individual to a provider of the

appropriate level of care and treatment.

Substance Use Disorder (SUD): Montana regulates one type of residential substance use

disorder treatment facility, with some subtypes:

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• Chemical dependency treatment facility: a facility especially staffed and equipped to

provide diagnosis, detoxification, treatment, prevention or rehabilitation services for

individuals suffering from chemical dependency. According to Department of Public

Health and Human Services (DPHHS) staff, the chemical dependency regulations pertain

to public or private treatment agencies.

o III.1 Clinically Managed Low-Intensity Residential Treatment: This functions as a

safe, alcohol and drug-free environment for individuals in early stages of recovery

from substance use disorders or individuals who are transitioning to less intensive

levels of treatment services and in need of such housing.

o III.3 Clinically Managed Medium-Intensity Residential Treatment: also identified as:

▪ Halfway house community-based single gender residential homes, these may

be located in residential neighborhoods, comparable to other homes in the

neighborhood, and shall reflect the environment of a home.

▪ Halfway house community-based parent and children residential homes, for

individuals with substance use disorders with dependent child(ren) who need

24-hour supportive housing while undergoing on- or off-site treatment services

for substance use disorder and life skills training for independent living.

o III.5 Clinically Managed High-Intensity Residential Treatment: identified as halfway

house community-based single gender homes which serve individuals who need 24-

hour supportive housing while undergoing on- or off-site treatment services for

substance use disorder and life skills training for independent living.

o III.7 Medically Monitored Inpatient Treatment: medically monitored care to clients

whose withdrawal symptoms are sufficiently severe to require 24-hour inpatient

care with observation, monitoring, and treatment available and delivered by a

multidisciplinary team including 24-hour nursing care under the supervision of a

Montana licensed physician.

o Community-based social detoxification includes levels III-D, III.2-D, and III.7-D as

defined by ASAM.

Unregulated Facilities: No unregulated treatment facilities that fall under the purview of this

summary were identified. We exclude from this summary Residential Treatment Facilities which

pertain to children and adolescents.

Approach

Mental Health (MH) and Substance Use Disorder (SUD): Licensure by the DPHHS is required for

operation of all residential treatment facilities.

Substance Use Disorder (SUD): The Department of Public Health and Human Services (DPHHS),

Department of Chemical Dependency Programs reviews and approves all chemical dependency

treatment providers in the state prior to operation if their facilities are to be enrolled in the

Medicaid program, receive block grant funding, receive alcohol earmarked revenue funds, or

under certain other circumstances.

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Processes of Licensure or Certification and Accreditation

Mental Health (MH) and Substance Use Disorder (SUD):

• Licensure by DPHHS is required for operation of residential treatment facilities. Licensure

duration is 1-3 years, depending on type, after which a renewal application is required. An

annual inspection is also required for licensure, which shall be unannounced and focus on

minimum quality standards for operation.

• Accreditation is not required, but accreditation by DNV Healthcare, Inc., the Healthcare

Facilities Accreditation Program, or the Joint Commission confers upon the accredited

facility eligibility for licensure.

• The state does not require a certificate of need; however, the statute governing SUD

treatment requires a demonstration of need for the facility to obtain licensure.

Mental Health (MH):

• Regulations pertinent to 72-hour crisis stabilization are for Medicaid-enrolled facilities,

and individuals meeting the definition of crisis are presumptively eligible for services and

reimbursement under the state Medicaid regulations. Crisis stabilization may be

performed in different settings but must be licensed.

Substance Use Disorder (SUD):

• DPHHS will issue approval for the following components of chemical dependency

treatment services: detoxification (emergency care), inpatient hospital, inpatient free

standing, intermediate (transitional living), and outpatient. Programs providing

detoxification (non-medical) must also provide at least one of the other components

listed above. The certificate of approval shall be obtained annually. Programs must submit

an application and submit to inspection. The department will issue an annual certificate of

approval to those approved chemical dependency treatment programs which remain in

substantial compliance with the regulations.

Cause-Based Monitoring

Mental Health (MH) and Substance Use Disorder (SUD): All residential facilities are required, as

a condition of licensure, before February 1 of every year, to submit an annual report for the

preceding calendar year to the department. Additionally, information and statistical reports

which are considered necessary by the department for health planning and resource

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development activities must be made available to the public and the health planning agencies

within the state. Corrective action may be taken by the department should it believe there is a

violation of standards or regulations. In addition to its annual licensure inspections, the

department may inspect any facility for compliance with regulations, license requirements, or

by order.

Substance Use Disorder (SUD): The department reserves the right to periodically inspect

licensed facilities. Each approved public or private treatment facility shall, on request, file with

the department data, statistics, schedules, and information that the department reasonably

requires. Additionally, the program shall develop and conduct program self-evaluations and

report results to the governing body. The department may revoke or suspend approval of any

service component if a program ceases to provide those services for which it has been

approved.

Access Requirements

Substance Use Disorder (SUD): The program shall admit and care for only those persons for

whom they can provide care and services appropriate to the person's physical, emotional, and

social needs. If a chemically dependent person is not admitted to an approved treatment

program for the reason that adequate and appropriate treatment is not available at that

program or facility, the administrator shall refer that person to another treatment program at

which adequate and appropriate treatment is available. Approved chemical dependency

treatment programs shall provide services to persons with alcohol and alcohol related

problems, or to their families, without regard to source of referral, race, color, creed, national

origin, religion, sex, age or handicap. Researchers did not locate requirements related to wait

times.

Staffing

Mental Health (MH): For crisis stabilization services, all providers must be enrolled in Medicaid

or employed/contracted by an enrolled provider. All providers must complete a 72 Hour

Provider Enrollment Addendum. Providers are required to hire or subcontract with mental

health professionals and mental health direct care staff, ensure the availability of immediate

mental health evaluation and crisis stabilization services, ensure staff and subcontractors are

trained and skilled in delivery of program services, implement appropriate, culturally

competent services, and maintain a thorough knowledge of community resources.

Substance Use Disorder (SUD): For chemical dependency treatment programs, there shall be

sufficient qualified and certified chemical dependency counselors, clerical and other support

staff, to ensure the attainment of program service objectives and properly maintain the

chemical dependency treatment facility. Supervision of all professional and support staff must

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be clearly demonstrated, and policies must include assurance there is an identified clinical

supervisor who is a licensed addiction counselor who oversees the implementation of services

to assure quality and appropriateness of care rendered to clients. A program administrator is

responsible to the governing body and is responsible for the daily operation of the facility.

“Adequate” staff to meet client requests for services and professional counseling staff is

required and client ratios should be at an “acceptable level” as determined by the department.

A planned, supervised orientation shall be provided to each new employee.

For Level III.7, staffing requirements include but are not limited to the following: (i) a physician

licensed under Title 37, MCA, available on call 24 hours a day, 7 days a week to evaluate clients

and prescribe medications; (ii) staff available in sufficient numbers and trained to respond to

substance-related and co-occurring disorders of admitted clients; (iii) a registered nurse

licensed under Title 37, MCA, who is responsible for the supervision of nursing staff and the

administration of detox protocols; and (iv) support staff such as licensed practical nurses,

certified nurse assistants, rehabilitation aides etc. in sufficient numbers to assure the safety of

clients.

For community-based social detoxification, staffing requirements include but are not limited to

the following: (i) physician-approved protocols for the monitoring of clients in withdrawal

including when and under what circumstances clients should be transferred to a health care

facility; (ii) a written agreement with the health care facility or physician providing for

emergency services when needed; (iii) written procedures specifying how staff will respond to

emergencies and for the transfer of medically unstable patients; (iv) sufficient staff on duty

trained in CPR and the detox protocols on each shift to be followed to assure clients safe

withdrawal from substances; and (v) if medications are provided, there is a current prescription

in the client's name and staff are trained in medication administration procedures which are

documented in policies and procedures.

For Level III.1, staffing or security measures must be sufficient to assure the safety of residents.

For Level III.3 single gender residential homes, staffing or security measures must be sufficient

to assure the safety of residents.

For Level III.3 halfway house community-based parent and children residential homes, to be

licensed, a provider must meet the following: (a) 24-hour staffing patterns or security patterns

to afford sufficient security to assure the safety of residents, with the availability of 24-hour

telephone consultation of a licensed clinician with competence in the treatment of substance

dependence disorders. Staffing requirements may include but are not limited to: (i) licensed

addiction counselor (LAC); (ii) individuals trained in managing co-occurring disorders; (iii) case

managers that have a minimum of two years of higher education or four or more years of

related work experience and orientation to the facility's policies and procedures; and (iv)

rehabilitation aides that have a minimum of a high school diploma or GED and orientation to

the facilities policies and procedures.

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For Level III.5, to be licensed, a provider must meet the following: (a) 24-hour staffing patterns

or security patterns to afford sufficient security to assure the safety of residents, with the

availability of 24-hour telephone consultation of a licensed clinician with competence in the

treatment of substance dependence disorders. Staffing requirements may include but are not

limited to: (i) licensed addiction counselor (LAC); (ii) individuals trained in managing co-

occurring disorders; (iii) case managers that have a minimum of two years of higher education

or four or more years of related work experience and orientation to the facility's policies and

procedures; and (iv) rehabilitation aides that have a minimum of a high school diploma or GED

and orientation to the facilities policies and procedures.

Placement

Mental Health (MH): Mental health practitioners must complete a face-to-face crisis

evaluation; determine if the individual meets crisis definition; and complete the 72 Hour Crisis

Stabilization or Crisis Intervention and Response form; and fax or e-mail form to the Addictive

and Mental Disorders Division Benefits Management Team. Researchers did not locate any

requirement related to use of the LOCUS.

Substance Use Disorder (SUD): For chemical dependency treatment programs, dimensional

admission, continued stay and discharge criteria must be developed for each component to

promote the least restrictive level of care. The ASAM Patient Placement Criteria 2R establishes

the level of care and must be used for placement, continued stay, discharge criteria, and

ongoing assessment of the client throughout the course of treatment.

Treatment and Discharge Planning and Aftercare Services

Mental Health (MH): Treatment/service planning and discharge planning requirements are

required for crisis stabilization services. Care coordination and the arrangement of appropriate

follow-up care are required services as a condition of licensure.

Substance Use Disorder (SUD): An individualized treatment plan specifically tailored to meet

the needs of the individual client shall be prepared and maintained on a current basis for each

client. The treatment plan must be initiated within 3 days of admission to residential

treatment. Regular multidisciplinary reviews must be documented. A continuing care plan is

required prior to discharge which addresses, at a minimum: (A) support group

recommendations; (B) continuing care service provider's contact name, contact number, and

initial appointment; (C) health care and/or medication follow-up; and (D) goals for continuing

care. Specific requirements regarding discharge planning by facility type are identified below in

Section 2.g as required services.

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Treatment Services

Mental Health (MH): The specific services reimbursable by the state are limited to: (i) a

psychiatric diagnostic interview examination; (ii) care coordination; (iii) individual

psychotherapy; (iv) family psychotherapy with or without patient; (v) one to one community-

based psychiatric rehabilitation and support; (vi) crisis management services; and (vii) services

delivered by a primary care provider for screening and identifying psychiatric conditions and for

medication management.

Substance Use Disorder (SUD): The ASAM criteria govern residential care. Program policies and

procedures must describe in detail the program services. Among other things, policies must

address ensuring a person needing detoxification will be immediately referred to a

detoxification provider, if available, unless the person needs acute care in a hospital; and

limitations and requirements of group counseling sessions to include client/staff appropriate

for the level of care being rendered. Clinical policies also must address, among other things: the

use of self-help groups; arranging for medical consultation when clinically needed; arranging

for psychiatric consultation when clinically indicated; policies addressing a facility's ability to

provide dual diagnosis services; and a description of services showing there are arrangements

in place for coordination and collaboration to provide any services that are not provided on-

site. Case management services policies and procedures must be provided in conjunction with

or as part of the client's substance use disorder treatment and recovery.

For Level III.7, service requirements include: (i) a written agreement with a state approved

chemical dependency treatment facility to provide ongoing care following client discharge from

the detoxification service; (ii) there shall be a discharge note that addresses the referral and

service needs of the client for follow-up treatment or care; (iii) medication administration and

on-going assessment of the client which are documented in the client record; (iv) written

medication orders specifying the name, dose, and route of administration signed by the

prescribing physician; (v) meals and snacks in sufficient quantities to assure the nutritional

needs of the clients are met; and (vi) written policies and procedures specifying how the facility

will provide for the transfer of patients when indicated, to an acute care hospital.

For community-based social detoxification, service requirements include: (i) an initial physical

examination by a qualified professional that assures the client can be safely detoxified in a

nonmedical setting and documented in the client record; (ii) regular vital signs are taken and

recorded by staff trained to recognize symptoms indicating the client is becoming physically

unstable; (iii) meals and snacks in sufficient quantities to meet the nutritional needs of the

client; (iv) there shall be a written discharge plan that assures necessary referrals and

continuing treatment services; (v) all entries in the client record will be signed and dated by

staff providing the service; and (vi) a written agreement with an approved addiction treatment

provider assuring acceptance of client for treatment upon discharge from the detoxification

service.

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For Level III.1, service requirements must include: (i) admission and length of stay criteria

defining individuals appropriate for this setting; (ii) how all treatment and supportive services

are generally off-site in community-based agencies; and (iii) assurance the program is designed

and focused on helping individuals with limited life skills and generally focus on helping

individuals achieve employment, maintain a daily schedule of work, support group meetings,

assigned treatment sessions, and learning how to cooperate and assume responsibility in a

community setting.

For Level III.3 single gender residential homes, service requirements include: (i) these homes as

transitional versus permanent living environments and how they provide interim supports and

services for persons with substance use disorders and related problems; (ii) admission criteria

indicating that the individual is appropriate for these settings; (iii) define the criteria for the

length of stay in the facilities; (iv) how clinical treatment is provided either on- or off-site; and

(v) how life skills training including vocational services is incorporated into daily residential

living to prepare residents to assume permanent housing and independent living.

For Level III.3 halfway house community-based parent and children residential homes, services

requirements include: (i) the delivery of ASAM Level III.3 treatment services either on- or off-

site; (ii) admission criteria indicating individuals appropriate for these settings; (iii) how the

treatment needs of both the parent(s) and child(ren) are identified and addressed; (iv) how life

skills training is provided as part of the daily living regimen and includes a curriculum to address

independent living skills, vocational skills, and parenting skills; (v) how services are coordinated

to meet special needs of this population such as childcare, legal services, medical care, and

transportation; (vi) how age appropriate services are made available for children as needed;

(vii) assurance of a single gender of parent will be living at the facility; and (viii) assurance for

safe visitation.

For Level III.5, service requirements include: (i) the delivery of ASAM Level III.5 treatment

services either on or off-site; (ii) admission criteria indicating individuals appropriate for these

settings; (iii) how the treatment needs are identified and addressed; (iv) how life skills training

is provided as part of the daily living regimen and includes a curriculum to address independent

living skills and vocational skills; (v) how services are coordinated to meet special needs of this

population such as legal services, medical care, and transportation; and (vi) assurance for safe

visitation.

Patient Rights and Safety Standards

Mental Health (MH): All crisis stabilization services must notify the member or the member's

designated representative in writing of a decision denying eligibility or a request for services.

Clients have a right to grievance procedures for such denial. No regulations regarding restraint

or seclusion were located, nor that grievances be reported to the state.

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Substance Use Disorder (SUD): All facilities should ensure that each client shall have access to

an established client grievance procedure. No regulations regarding restraint or seclusion were

located, nor that grievances be reported to the state.

Quality Assurance or Improvement

Mental Health (MH): Requirements regarding residential services were not explicitly described

in the state regulations.

Substance Use Disorder (SUD): Chemical dependency treatment facilities shall have a quality

management committee representative of administration and staff. The quality management

committee is responsible for: (a) developing a written plan for a continuous quality

improvement program organization wide; (b) implementing the quality improvement plan and

monitoring the quality and appropriateness of services; (c) meeting at least on a quarterly basis;

(d) identifying problems, taking corrective action as indicated, and monitoring results of those

actions; and (e) at least annually, reviewing and updating the quality improvement plan.

Governance

Mental Health (MH): Requirements regarding residential services were not explicitly described

in the state regulations.

Substance Use Disorder (SUD): Chemical Dependency Programs must have a governing body

responsible for the conduct of the program. The governing body shall establish a philosophy of

policies and goals governing admissions, discharges, length of stay, diagnostic groups to be

served, scope of services, treatment regimens, staffing patterns, recommendations for

continued treatment by referral or otherwise, and provision for a continuing evaluation of the

program.

The governing body shall be responsible for providing personnel, facilities, and equipment

needed to carry out the goals and objectives of the program and meet the needs of the

residents.

Special Populations

Mental Health (MH): Requirements regarding residential services were not explicitly described

in the state regulations.

Substance Use Disorder (SUD): Among other outcome measures required of chemical

dependency programs are ones related to services to critical populations including priority in

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the following order: (ai) pregnant injecting drug users; (aii) pregnant substance abusers; (b)

injecting drug users and those individuals infected with the etiologic agent for AIDS; (c) women

with dependent children; (d) clients receiving Supplemental Security Income (SSI) or Social

Security Disability Insurance (SSDI); (e) homeless clients; and (f) aging clients.

Chemical dependency treatment programs that address dual diagnosis populations are defined

as follows:

• "Dual diagnosis capable (DDC)" means treatment programs address co-occurring mental

and substance-related disorders in their policies and procedures, assessment, treatment

planning, program content, and discharge planning are described as "dual diagnosis

capable". Such programs have arrangements in place for coordination and collaboration

with mental health services. They also can provide psychopharmacologic monitoring and

psychological assessment and consultation, either on-site or through coordination

consultation with off-site providers. Program staff is able to address the interaction

between mental and substance-related disorders and their effect on the patient's

readiness to change, as well as relapse and recovery environment issues, through

individual and group content. Nevertheless, the primary focus of DDC programs is the

treatment of substance-related disorders.

• "Dual diagnosis enhanced (DDE)" describes treatment programs that incorporate policies,

procedures, assessments, treatment, and discharge planning processes that

accommodate patients who have co-occurring mental and substance-related disorders.

Mental health symptom management groups are incorporated into addiction treatment.

Motivational enhancement therapies specifically designed for those with co-occurring

mental and substance-related disorders are more likely available (particularly in

outpatient settings) and, ideally, there is close collaboration or integration with a mental

health program that provides crises back-up services and access to mental health case

management and continuing care. In contrast to dual diagnosis capable services, dual

diagnosis enhanced services place their primary focus on the integration of services for

mental and substance-related disorders in their staffing, services, and program content.

Chemical dependency treatment programs must have policies and procedures that encompass

critical population requirements to include how pregnant woman resources and referral

options will be made available so staff can make referrals as indicated by client needs including:

(i) ensuring a pregnant woman who is not seen by a private physician, physician assistant-

certified, nurse practitioner, or advanced practice registered nurse is referred to one of these

providers for determination of prenatal care needs; and (ii) discussing pregnancy specific issues

and resources.

Location of Regulatory and Licensing Requirements

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Department of Public Health and Human Services regulations

; Department of Public Health

and Human Services regulations

; Alcoholism and Drug Dependence statute

; Department of

Public Health and Human Services

. Regulatory data collected June 14, 2019.

Other Information Sources

I. Coy and C. S. Anderson (DPHHS); National Conference of State Legislatures CON Program

Overview, http://www.ncsl.org/research/health/con-certificate-of-need-state-laws.aspx

See http://www.mtrules.org/gateway/Subchapterhome.asp?scn=37%2E89%2E5.

See http://www.mtrules.org/gateway/ChapterHome.asp?Chapter=37%2E27.

See http://www.mtrules.org/gateway/Subchapterhome.asp?scn=37%2E106.14.

See https://leg.mt.gov/bills/1997/mca_toc/53_24.htm.

See https://leg.mt.gov/bills/1997/mca_toc/50_5.htm.

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MONTANA MEDICAID

This summary of state regulations and policy represents only a snapshot at a point in time, is

not comprehensive, and should not be taken to constitute legal advice or guidance. State

Medicaid requirements are included at the end of this summary.

Approach

Mental Health (MH) and Substance Use Disorder (SUD): The Montana Department of Public

Health and Human Services (DPHHS) oversees the state Medicaid program. Montana does not

reimburse for services in IMDs for adults younger than age 65. Montana historically has not

relied on the in lieu of provision or on Disproportionate Share Hospital (DSH) payments for

reimbursement of some services in Institutions for Mental Diseases (IMDs). The state does not

have a relevant Section 1115 waiver.

Mental Health (MH): Montana Medicaid only provides mental health treatment for members

with a severe disabling mental illness.

Types of Facilities

Mental Health (MH):

• Crisis Stabilization Program: a short-term emergency, 24-hour care, treatment, and

supervision for crisis intervention and stabilization. It is a residential alternative of fewer

than 16 beds to divert from Acute Inpatient Hospitalization. The service includes medically

monitored residential services to provide psychiatric stabilization on a short-term basis.

The service reduces disability and restores members to previous functional levels by

promptly intervening and stabilizing when crisis situations occur. The focus is on goals for

recovery, preventing continued exacerbation of symptoms, and decreasing risk of need

for hospitalization or higher levels of care.

Substance Use Disorder (SUD):

• ASAM 3.1 SUD Clinically Managed Low-Intensity Residential Adult: This is a licensed

community-based residential home that functions as a supportive, structured living

environment. Members are provided stability and skills building to help prevent or

minimize continued substance use. SUD treatment services are provided on-site or off-

site.

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• ASAM 3.5 SUD Clinically Managed High-Intensity Residential Adult: This is a clinically

managed residential treatment program providing 24-hour structured residential

treatment. Members are provided a planned regimen of 24-hour professionally directed

SUD treatment. Services focus on stabilizing the member to transition into a less intensive

level of care or community setting.

• ASAM 3.7 SUD Medically Monitored Intensive Inpatient Adult: This provides medically

monitored inpatient treatment services. According to the companion summary to this

document, this level of treatment is available in residential settings and the Medicaid

Behavioral Health Manual indicates it may be provided by a state-approved substance use

disorder program licensed to provide this level of care.

Processes of Medicaid Enrollment

Mental Health (MH) and Substance Use Disorder (SUD):

• As a condition of participation in the Montana Medicaid program, all providers must

comply with all applicable state and federal statutes, rules and regulations, including but

not limited to federal regulations and statutes found in Title 42 of the Code of Federal

Regulations and the United States Code governing the Medicaid Program and all

applicable Montana statutes and rules governing licensure and certification. Sanctions

may be imposed on providers.

• Providers must enroll in the Montana Medicaid program for each category of services to

be provided. Required licensure must be maintained.

Staffing

Mental Health (MH): Requirements regarding residential services were not explicitly described

in the state Medicaid regulations.

Substance Use Disorder (SUD): ASAM Levels 3.1, 3.5, and 3.7 must be provided by a state-

approved substance use disorder program licensed to provide the level of care.

For Level 3.5, programs are staffed by Licensed Addictions Counselors and behavioral health

staff. There is access to medical staff.

For Level 3.7, programs are staffed by physicians, nurses, Licensed Addictions Counselors, and

behavioral health staff.

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Placement

Mental Health (MH) and Substance Use Disorder (SUD): Each Medicaid member receiving

behavioral health treatment must have a current comprehensive assessment conducted by an

appropriately licensed mental health professional or licensed addictions counselor trained in

clinical assessments and operating within the scope of practice of their respective license. For a

member receiving SUD treatment services, the assessment must be relevant and organized

according to the six dimensions of the ASAM Criteria.

Mental Health (MH): Crisis Stabilization Programs do not require prior authorization. Medical

necessity criteria require the presence of any mental health diagnosis from the current version

of the DSM as the primary diagnosis and at least one of the following: dangerousness to self;

dangerous to others; or grave disability. Continued stay criteria also must be satisfied.

Substance Use Disorder (SUD): An appropriately licensed mental health professional with SUD

within the scope of their professional license, or a licensed addiction counselor, must certify the

member continues to meet the criteria for having a SUD annually. The clinical assessment must

document how the member meets the criteria for having a SUD. The most current edition of

the ASAM criteria must be used to establish the appropriate level of care for placement into

services.

For ASAM 3.1, 3.3, and 3.7, medical necessity criteria require that a member must meet the

moderate or severe SUD criteria and meet the ASAM criteria for diagnostic and dimensional

admission criteria. Prior authorization is required. The member must continue to meet the SUD

criteria with a severity specifier of moderate or severe and meet the ASAM criteria diagnostic

and dimensional admission criteria. For ASAM 3.7, results of the initial lab results at admission

will be required for the continued stay review.

Treatment and Discharge Planning and Aftercare Services

Mental Health (MH) and Substance Use Disorder (SUD): Based upon the findings of the

assessment(s) described in 2.e, the Medicaid provider of mental health or SUD services must

establish an individualized treatment plan for each member that must, among other things,

identify the problem area that will be the focus of the treatment to include symptoms,

behaviors, and/or functional impairments and identify the goals that are person-centered, long-

term, recovery oriented. It must be reviewed and updated as required in ARM or whenever

there is a significant change in the member’s condition and/or situation. The treatment plan

review must be comprehensive regarding the member’s response to treatment and result in

either an amended treatment plan or a statement of the continued appropriateness of the

existing plan.

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Treatment Services

Mental Health (MH) and Substance Use Disorder (SUD): Services must be medically necessary.

Mental Health (MH): Crisis Stabilization Program is billed as a bundled service and includes the

following: (a) 24-hour direct care staff; (b) 24-hour on call mental health professional; (c) crisis

stabilization services; (d) psychotropic medications administered and monitoring behavior

during the crisis stabilization period; (e) observation of symptoms and behaviors; and (f)

support or training for self-management of psychiatric symptoms. It is not required that each

member receiving the crisis stabilization bundle receive every service listed above. Medically

necessary services must be provided and documented in the treatment plan and the services

received must be documented clearly in the member’s treatment file.

Substance Use Disorder (SUD): All ASAM levels must adhere to the ASAM criteria service

standards for service planning and level of care placement characteristic category standards.

These categories include: (a) therapies; (b) support systems; (c) assessment/ITP review; (d)

staff; and (e) documentation.

For ASAM 3.1, the service includes a minimum of 5 hours per week of professionally directed

treatment services.

For ASAM 3.3, medically necessary services must be provided and documented in the

treatment plan and the services received must be documented clearly in the member’s

treatment file.

For ASAM 3.7, members are provided a planned regimen of 24-hour professionally directed

evaluation, observation, medical management/monitoring, and SUD treatment. Medically

necessary services must be provided and documented in the treatment plan and the services

received must be documented clearly in the member’s treatment file.

Care Coordination

Mental Health (MH) and Substance Use Disorder (SUD): Requirements regarding residential

services were not explicitly described in the state Medicaid regulations.

Quality Assurance or Improvement

Mental Health (MH) and Substance Use Disorder (SUD): The department or the utilization

review contractor may perform retrospective clinical record reviews for two purposes: (a) to

determine medical necessity of a provided service; or (b) as requested by the provider to

establish the medical necessity for payment when the member has become Medicaid eligible

Montana-16

retroactively or the provider has not enrolled in Montana Medicaid prior to the admission of

the member.

Special Populations

Mental Health (MH) and Substance Use Disorder (SUD): Requirements regarding residential

services were not explicitly described in the state Medicaid regulations.

Location of Medicaid Requirements

Montana Rule 37: Public Health and Human Services

; Addictive and Mental Disorders Division

Medicaid Services Provider Manual for Substance Use Disorder and Adult Mental Health

Regulatory data collected January 9, 2020.

Other Information Sources

Kaiser Family Foundation. State Options for Medicaid Coverage of Inpatient Behavioral Health

Services. KFF: San Francisco. November 2019 http://files.kff.org/attachment/Report-Brief-

State-Options-for-Medicaid-Coverage-of-Inpatient-Behavioral-Health-Services

This state summary is part of the report “State Residential Treatment for Behavioral Health

Conditions: Regulation and Policy”. The full report and other state summaries are available at

https://aspe.hhs.gov/state-bh-residential-treatment.

See http://www.mtrules.org/Gateway/Department.asp?DeptNo=37.

See https://dphhs.mt.gov/Portals/85/amdd/documents/AMDDMcdManualSUDMHOct19.pdf.