Revise medicaid laws related to direct primary care

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ENROLLED BILL
AN ACT GENERALLY REVISING MEDICAID LAWS RELATED TO DIRECT PRIMARY CARE; ALLOWING
FOR COVERAGE OF DIRECT PRIMARY CARE CONTRACTS UNDER THE MONTANA MEDICAID
PROGRAM; PROHIBITING THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES FROM
REQUIRING A MEDICAID ENROLLEE TO PARTICIPATE IN A PRIMARY CARE CASE MANAGEMENT
SERVICE IF THE ENROLLEE ENTERS INTO A DIRECT PRIMARY CARE CONTRACT; PROVIDING A
DEFINITION OF DIRECT PRIMARY CARE CONTRACT; PROVIDING AN APPROPRIATION; AMENDING
SECTIONS 53-6-101, 53-6-116, AND 53-6-124, MCA; AND PROVIDING AN EFFECTIVE DATE.
BE IT ENACTED BY THE LEGISLATURE OF THE STATE OF MONTANA:
Section 1. Section 53-6-101, MCA, is amended to read:
"53-6-101. Montana medicaid program -- authorization of services. (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. The
department shall administer the Montana medicaid program.
(2) The department and the legislature shall consider the following funding principles when
considering changes in medicaid policy that either increase or reduce services:
(a) protecting those persons who are most vulnerable and most in need, as defined by a
combination of economic, social, and medical circumstances;
(b) 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) giving priority to services that employ the science of prevention to reduce disability and illness,
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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.
(3) Medical assistance provided by the Montana medicaid program includes the following services:
(a) inpatient hospital services;
(b) outpatient hospital services;
(c) other laboratory and x-ray services, including minimum mammography examination as defined
in 33-22-132;
(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, in accordance with federal regulations and subsection (10)(b);
(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 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;
(l) federally qualified health center services, as defined in 42 U.S.C. 1396d(l)(2);
(m) routine patient costs for qualified individuals enrolled in an approved clinical trial for cancer as
provided in 33-22-153;
(n) for children 18 years of age and younger, habilitative services as defined in 53-4-1103;
(o) services provided by a person certified in accordance with 37-2-318 to provide services in
accordance with the Indian Health Care Improvement Act, 25 U.S.C. 1601, et seq.;
(p) fertility preservation services in accordance with 33-22-2103; and
(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
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8, or direct-entry midwives licensed under Title 37, chapter 27. Coverage under this section includes prenatal
care and postpartum care.
(4) Medical assistance provided by the Montana medicaid program may, as provided by
department rule, also include the following services:
(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;
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(s) direct patient care agreements, as provided for in 50-4-107; and
(s)(t) any additional medical service or aid allowable under or provided by the federal Social Security
Act.
(5) Services for persons qualifying for medicaid under the medically needy category of assistance,
as described in 53-6-131, may be more limited in amount, scope, and duration than services provided to others
qualifying for assistance under the Montana medicaid program. The department is not required to provide all of
the services listed in subsections (3) and (4) to persons qualifying for medicaid under the medically needy
category of assistance.
(6) In accordance with federal law or waivers of federal law that are granted by the secretary of the
U.S. department of health and 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)(s) (4)(t) 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 implement, as provided for in Title XIX of 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) (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
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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
chemical dependency 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 services provided under this part may be only those that are medically necessary and that
are the most efficient and cost-effective.
(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) Services, procedures, and items of an experimental or cosmetic nature may not be provided.
(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:
(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) If available funds are not sufficient to provide medical assistance for all eligible persons, the
department may set priorities to limit, reduce, or otherwise curtail the amount, scope, or duration of the medical
services made available under the Montana medicaid program after taking into consideration the funding
principles set forth in subsection (2). (Subsection (3)(o) terminates September 30, 2025--sec. 1, Ch. 298, L.
2023; bracketed language in subsection (4)(b) terminates June 30, 2031--sec. 10, Ch. 628, L. 2023.)"
Section 2. Section 53-6-116, MCA, is amended to read:
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"53-6-116. Medicaid managed care -- capitated health care. (1) The department of public health
and human services, in its discretion, may develop managed care and capitated health care systems for
medicaid recipients.
(2) The department may contract with one or more persons for the management of comprehensive
physical health services and the management of comprehensive mental health services for medicaid recipients.
The department may contract for the provision of these services by means of a fixed monetary or capitated
amount for each recipient.
(3) A managed care system is a program organized to serve the medical needs of medicaid
recipients in an efficient and cost-effective manner by managing the receipt of medical services for a
geographical or otherwise defined population of recipients through appropriate health care professionals.
(4) The provision of medicaid services through managed care and capitated health care systems is
not subject to the limitations provided in 53-6-104. The managed care or capitated health care system that is
provided to a defined population of recipients may be based on one or more of the medical assistance services
provided for in 53-6-101.
(5) The proposed systems, referred to in subsection (1), must be submitted to the legislative
finance committee. The legislative finance committee shall review the proposed systems at its next regularly
scheduled meeting and shall provide any comments concerning the proposed systems to the department. The
department shall provide a copy of any reports made to the legislative finance committee concerning the
proposed systems to the legislature in accordance with 5-11-210.
(6) A managed care or capitated health care system, except for a primary care case management
service, that requires for implementation a waiver from the centers for medicare and medicaid is subject to the
provisions of Title 53, chapter 6, part 7.
(7) The department may not require an enrollee to participate in a primary care case management
service if the enrollee enters into a direct patient care agreement pursuant to 50-4-107."
Section 3. Section 53-6-124, MCA, is amended to read:
"53-6-124. Definitions. As used in 53-6-101, 53-6-116, 53-6-125, 53-6-127, and this section, the
following definitions apply:
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(1) "Conversion factor" means the dollar value that is multiplied by the appropriate relative value
unit to calculate a price for a service provided by a physician.
(2) "Department" means the department of public health and human services.
(3) "Direct patient care agreement" means an agreement for health care services as provided for in
50-4-107.
(3)(4) "Medicaid" means the Montana medical assistance program established under Title 53, chapter
6.
(4)(5) "Physician" has the meaning provided in 37-3-102.
(5)(6) "Policy adjuster" means a factor by which the fee determined under 53-6-125 is multiplied to
increase the fee paid by medicaid for certain categories of services.
(6)(7) "Relative value unit" means a numerical value assigned in the resource-based relative value
scale to each procedure code used to bill for services provided by a physician.
(7)(8) "Resource-based relative value scale" means the medicare resource-based relative value scale
contained in the physician's medicare fee schedule adopted by the centers for medicare and medicaid services
of the U.S. department of health and human services."
Section 4. Appropriation. There is appropriated $5,000 from the general fund to the department of
public health and human services for the biennium beginning July 1, 2025, for the purposes of implementing
[this act].
Section 5. Effective date. [This act] is effective July 1, 2025.
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I hereby certify that the within bill,
HB 953, originated in the House.
___________________________________________
Chief Clerk of the House
___________________________________________
Speaker of the House
Signed this _______________________________day
of____________________________________, 2025.
___________________________________________
President of the Senate
Signed this _______________________________day
of____________________________________, 2025.
HOUSE BILL NO. 953
INTRODUCED BY E. BUTTREY
AN ACT GENERALLY REVISING MEDICAID LAWS RELATED TO DIRECT PRIMARY CARE; ALLOWING FOR
COVERAGE OF DIRECT PRIMARY CARE CONTRACTS UNDER THE MONTANA MEDICAID PROGRAM;
PROHIBITING THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES FROM REQUIRING A
MEDICAID ENROLLEE TO PARTICIPATE IN A PRIMARY CARE CASE MANAGEMENT SERVICE IF THE
ENROLLEE ENTERS INTO A DIRECT PRIMARY CARE CONTRACT; PROVIDING A DEFINITION OF DIRECT
PRIMARY CARE CONTRACT; PROVIDING AN APPROPRIATION; AMENDING SECTIONS 53-6-101, 53-6-
116, AND 53-6-124, MCA; AND PROVIDING AN EFFECTIVE DATE.