Sec. 10.09.33.08. Limitations

A. An eligible individual may not receive services from a health home provider that is not the individual’s PRP, MTS, or OTP provider.

B. Health home services do not restrict or otherwise affect:

(1) Eligibility for Title XIX benefits or other available benefits or programs, except as limited by §E of this regulation;

(2) The freedom of a participant to select from all available services for which the participant is found to be eligible; or

(3) A participant’s free choice among providers in the Medical Assistance Program.

C. A health home may not bill the Department for:

(1) Activities that have already been billed to or counted towards a service requirement for another Medical Assistance Program or other program;

(2) Activities not consistent with the definition of health home services under this chapter;

(3) Activities delivered as part of institutional discharge planning that are not comprehensive transitional care services delivered by the health home; or

(4) A participant’s health home per member per month rate more than once per month.

D. The Department may not reimburse for monthly health home services unless the individual receiving health home services:

(1) Is Medicaid eligible at the time of service delivery and engaged in treatment or rehabilitation with either OTP or PRP or MTS services;

(2) Is enrolled as a health home member at the billing health home provider; and

(3) Has received a minimum of two health home services in the stated month that has been documented in eMedicaid.

E. Reimbursement will not be made for health home services if the participant is receiving a comparable service under another Medical Assistance Program or other program.

F. A participant’s health home provider may not be the participant’s family member.