Administrative Rules of the State of Montana

BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

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In the matter of the adoption of New Rules I through XIII, the amendment of ARM 37.86.2207, 37.86.2219, and 37.86.2221, and the repeal of ARM 37.88.1101 through 37.88.1137 pertaining to Medicaid and MHSP reimbursement for youth mental health services

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NOTICE OF PUBLIC HEARING ON PROPOSED ADOPTION, AMENDMENT, AND REPEAL

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TO:�� All Interested Persons

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�� 1.�On August 22, 2008, at 11:00 a.m., the Department of Public Health and Human Services will hold a public hearing in the Wilderness Room, 2401 Colonial Drive, Helena, Montana, to consider the proposed adoption, amendment, and repeal of the above-stated rules.

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�� 2.�The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process (including reasonable accommodations at the hearing site) or who need an alternative accessible format of this notice.�If you need an accommodation, contact the department no later than 5:00 p.m. on August 11, 2008.�Please contact Rhonda Lesofski, Office of Legal Affairs, Department of Public Health and Human Services, P.O. Box 4210, Helena MT 59604-4210; telephone (406)444-4094; fax (406)444-1970; e-mail [email protected].

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�� 3.�The rules as proposed to be adopted provide as follows:

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�� RULE I�PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, PURPOSE�(1)�The purpose of [RULES I through XIII] is to specify provider participation and program requirements and to define the basis and procedure the department will use to pay for psychiatric residential treatment facility (PRTF) services.

�� (2)�Facilities in which these services are available are referred to as providers.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE II�PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, DEFINITIONS�As used in this subchapter, the following definitions apply:

�� (1)�"Continuity of care payment" means an annual payment made to qualifying hospital based psychiatric residential treatment facilities (PRTF) according to the eligibility criteria and payment calculation methodology in [RULE XI].

�� (2)�"Devoted to the provision of inpatient psychiatric care for persons under the age of 21" means an inpatient psychiatric hospital facility or residential treatment facility whose goals, purpose, and care are designed for and devoted exclusively to persons under the age of 21.

�� (3)�"Hospital based psychiatric residential treatment facility" means a residential treatment facility that meets the requirements of [RULE VIII].

�� (4)�"Inpatient psychiatric services" means psychiatric residential treatment facility, or hospital based psychiatric residential treatment facility services.

�� (5)�"Patient day" means a whole 24-hour period in which a person is present and receiving inpatient psychiatric services.�Even though a person may not be present for a whole 24-hour period, the day of admission and, subject to the limitations and requirements of [RULE X], therapeutic home leave days are patient days.�The day of discharge is not a patient day for purposes of reimbursement.

�� (6)�"Psychiatric residential treatment facility (PRTF)" means a facility other than a hospital that provides psychiatric services only to individuals under age 21.�The PRTF must be licensed by:

�� (a)�the department as a PRTF; or

�� (b)�the appropriate agency as a PRTF or the equivalent in the state where the facility is located.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE III�PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, PARTICIPATION REQUIREMENTS�(1)�These requirements are in addition to those contained in rule generally applicable to Medicaid providers.

�� (2)�PRTF providers, as a condition of participation in the Montana Medicaid program, must comply with the following requirements:

�� (a)�maintain a current license as a PRTF under the rules of the department's Quality Assurance Division to provide PRTF services, or, if the provider's facility is not located within the state of Montana, maintain a current license in the equivalent category under the laws of the state in which the facility is located;

�� (b)�maintain a current certification for Montana Medicaid under the rules of the department's Quality Assurance Division to provide PRTF services or, if the provider's facility is not located within the state of Montana, meet the requirements of (2)(g) and (2)(h);

�� (c)�for all providers, enter into and maintain a current provider enrollment form with the department's fiscal agent to provide psychiatric PRTF services;

�� (d)�license and/or register facility personnel in accordance with applicable state and federal laws;

�� (e)�accept, as payment in full for all operating and property costs, the amounts paid in accordance with the reimbursement method set forth in these rules;

�� (f)�for providers maintaining patient trust accounts, ensure that any funds maintained in those accounts are used only for those purposes for which the youth, legal guardian, or personal representative of the patient has given written authorization.�A provider may not borrow funds from these accounts for any purpose;

�� (g)�maintain accreditation as a PRTF by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), Council on Accreditation (COA), or the Commission on Accreditation of Rehabilitation Facilities (CARF) or any other organization designated by the Secretary of the United States Department of Health and Human Services as authorized to accredit PRTF for Medicaid participation;

�� (h)�submit to the department prior to receiving initial reimbursement payments and thereafter within 30 days after receipt, all accreditation determinations, findings, reports, and related documents issued by the accrediting organization to the provider;

�� (i)�provide PRTF services according to the service requirements for individuals under age 21 specified in Title 42 CFR, part 441, subpart D (2008).�The department adopts and incorporates by reference Title 42 CFR, part 441, subpart D. A copy of these regulations may be obtained through the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951;

�� (j)�agree to indemnify the department in the full amount of the state and federal shares of all Medicaid inpatient psychiatric services reimbursement paid to the facility during any period when federal financial participation is unavailable due to facility failure to meet the conditions of participation specified in these rules or due to other facility deficiencies or errors.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE IV�PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, ADMINISTRATIVE REVIEW AND FAIR HEARING PROCEDURES

�� (1)�The right to administrative review and fair hearing shall be in accordance with the provisions of ARM 37.5.310.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE V �PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, CERTIFICATION OF NEED FOR SERVICES, UTILIZATION REVIEW AND INSPECTIONS OF CARE�(1)�Prior to admission and as frequently as the department deems necessary, the department or its agents may evaluate the medical necessity and quality of services for each Medicaid client.

�� (a)�In addition to the other requirements of these rules, the provider must provide to the department or its agent upon request any records related to services or items provided to a Medicaid client.

�� (b)�The department may contract with and designate public or private agencies or entities, or a combination of public and private agencies and entities, to perform utilization review, inspections of care, and other functions under this rule as an agent of the department.

�� (2)�The department or its agents may conduct periodic inspections of care in PRTFs participating in the Medicaid program.

�� (3)�Medicaid reimbursement is not available for PRTF services unless the provider submits to the department or its designee a complete and accurate certificate of need for services that complies with the requirements of 42 CFR, part 441, subpart D (2008) and these rules.

�� (a)�For youth determined Medicaid eligible by the department at the time of admission to the facility, the certificate of need must:

�� (i)�be completed, signed, and dated prior to, but no more than 30 days before admission; and

�� (ii)�be made by an independent team of health care professionals that has competence in diagnosis and treatment of mental illness and that has knowledge of the youth's situation, including the youth's psychiatric condition.�The team must include a physician that has competence in diagnosis and treatment of mental illness, preferably in child psychiatry, and a licensed mental health professional.�No more than one member of the team of health care professionals may be professionally or financially associated with a PRTF program.

�� (b)�For youth who are transferred between levels of inpatient psychiatric care within the same facility, the certificate of need may be completed by the facility-based team responsible for the plan of care within 14 days after admission provided that the:

�� (i)�admission has been prior authorized by the department or the department's designee.

�� (c)�For youth who apply for and become Medicaid eligible after admission to the facility, the certificate of need must be made by the facility-based team responsible for the plan of care as specified in 42 CFR, 441.156:

�� (i)�within 90 days of the eligibility determination and must cover any period before application for which claims are made; and

�� (ii)�services are determined medically necessary by the department or the department's designee.

�� (d)�All certificates of need must be actually and personally signed by each team member, except that signature stamps may be used if the team member actually and personally initials the document over the signature stamp.

�� (4)�An authorization by the department or its utilization review agent under this rule is not a final or conclusive determination of medical necessity and does not prevent the department or its agents from evaluating or determining the medical necessity of services or items at any time.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE VI�PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES

�� (1)�Inpatient psychiatric services are services that comply with the requirements of this subchapter and the applicable federal regulations and are provided in a PRTF that is devoted to the provision of inpatient psychiatric care for persons under the age of 21.

�� (2)�42 CFR 440.160 and 441.150 through 441.156 (2008) provide definitions and program requirements and the department adopts and incorporates them by reference.�A copy of the regulations may be obtained through the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2905.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE VII�PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, TREATMENT REQUIREMENTS�(1)�PRTF services must include active treatment designed to achieve the youth's discharge to a less restrictive level of care at the earliest possible time.

�� (2)�PRTF services must be provided under the direction of a licensed physician.�

�� (3) �The PRTF plan of care must be comprehensive and address all psychiatric, medical, psychological, social behavioral, developmental, and chemical dependency treatment needs.

�� (4)�PRTF services include only treatment or services provided in accordance with all applicable licensure, certification, and accreditation requirements, and these rules.

�� (5)�PRTF services include, at a minimum, a seven day supply of medication and a prescription for, at a minimum, a 30 day supply of medication on discharge from the facility.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE VIII�HOSPITAL BASED PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY, REQUIREMENTS�(1)�A hospital based PRTF must be paid as specified in ARM 37.86.2904, 37.86.2905, 37.86.2907, 37.86.2910, 37.86.2912, 37.86.2916, 37.86.2918, 37.86.2920, 37.86.2925, 37.86.2928, 37.86.2931, 37.86.2935, and 37.86.2940.�It must also meet the following requirements:

�� (a)�the PRTF must be in a hospital facility that includes inpatient psychiatric hospital beds and provides inpatient hospital psychiatric care to individuals under age 21.�The PRTF beds and the hospital beds must be owned and operated by a single entity, and they must be located in an integrated facility;

�� (b)�the PRTF must be located in Montana;

�� (c)�the inpatient psychiatric hospital beds and the PRTF beds must be served by a common administrative and support staff;

�� (d)�the PRTF must be served by no less than one full-time equivalent psychiatrist for every 25 youth;

�� (e)�both the hospital and the PRTF must have an organized medical staff that is on call and available within 20 minutes, 24 hours a day, seven days a week; and

�� (f)�both the hospital and the PRTF must have 24-hour nursing care by licensed registered nurses.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE IX �PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY, INTERIM RATE AND COST SETTLEMENT PROCESS�(1)�The interim rate for services provided to youths as the term "youth" is defined at [RULE I as proposed in MAR Notice No. 37-447] for PRTF providers located in the state of Montana is composed of:

�� (a)�the psychiatric service rate provided in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in ARM 37.86.2207;

�� (b)�a direct care wage add-on through a contract with the department, if applicable; and

�� (c) �a facility specific add-on rate for medical and authorized ancillary costs, not already included in the base rate for psychiatric care at the facility.

�� (2)�The ancillary rate in (1)(c) will be adjusted retrospectively when:

�� (a)�allowable ancillary costs are reported using auditable data, standardized forms, instructions, definitions, and timelines supplied by the department; and

�� (b)�ancillary costs in the aggregate for all discharges in a state fiscal year exceed or are less than 5% of the reimbursement that the facility received as an interim rate.�If the costs exceed the aggregate by more than 5%:

�� (i)�the department will reimburse the facility for costs exceeding 105% of the agregate;

�� (ii)�the facility will reimburse the department for costs less than 95% of the aggregate; and

�� (iii)�no adjustments to reimbursement will be made by either the department or the facility for costs within 5% of the aggregate ancillary rate payment.

�� (3)�The psychiatric service rate is an all-inclusive bundled per diem rate, and includes:

�� (a)�all therapies, services, and items not specifically designated as an ancillary service that are provided while the youth is an inpatient in the PRTF;

�� (b)�services provided by licensed psychologists, licensed clinical social workers, and licensed professional counselors; and

�� (c)�lab and pharmacy costs related to the youth's psychiatric condition.

�� (4)�Ancillary services are provided by or include the following:

�� (a)�ambulatory surgical center;

�� (b)�audiologist;

�� (c)�chiropractor;

�� (d)�dentist, denturist, and orthodontist;

�� (e)�durable medical equipment;

�� (f)�emergency room services not related to the psychiatric condition;

�� (g)�eyeglasses;

�� (h)�federally qualified health center;

�� (i)�hearing provider and hearing aides;

�� (j)�hospital;

�� (k)�licensed addiction counselor;

�� (l)�medical transportation and ambulance services;

�� (m)�mental health center;

�� (n)�nutritionist;

�� (o)�optometrist and ophthalmologist;

�� (p)�outpatient hospital not relative to the psychiatric condition;

�� (q)�physical and speech therapist;

�� (r)�physician, psychiatrist, and mid-level practitioner;

�� (s)�podiatrist;

�� (t)�public health clinic;

�� (u)�respiratory therapy;

�� (v)�rural health clinic;

�� (w)�targeted case management;

�� (x)�at a minimum, a seven day supply of medication on discharge; and

�� (y)�any other Medicaid service provided to the youth receiving PRTF inpatient care not related to the youth's psychiatric condition may be considered an ancillary service.

�� (5)�If a youth receiving inpatient care in a PRTF has a medical condition that requires a higher ancillary rate, prior to the cost settlement process, the PRTF may request interim reimbursement for the ancillary care.�The department at its discretion may grant the youth specific request if the PRTF:

�� (a)�submits a request in writing to the department with documentation of the expenses; and

�� (b)�interim payments must be requested in the quarter of the state fiscal year in which the expense was incurred and will be taken into consideration during the ancillary cost settlement process described in (2).

�� (6)�Reimbursement will be made to a PRTF provider for reserving a bed while the youth is temporarily absent for a therapeutic home visit if:

�� (a)�the youth's plan of care documents the medical need for therapeutic home visits as part of a therapeutic plan to transition the youth to a less restrictive level of care;

�� (b)�the youth is temporarily absent on a therapeutic home visit;

�� (c)�the provider clearly documents staff contact and youth achievements or regressions during and following the therapeutic home visit; and

�� (d)�the youth is absent from the provider's facility for no more than three patient days per therapeutic home visit, unless additional days are authorized by the department.

�� (7)�No more than 14 patient days per youth in each state fiscal year will be allowed for therapeutic home visits.

�� (8)�Providers must bill for PRTF services using the revenue codes designated by the department.

�� (9)�Notice of the youth's admission and discharge dates must be submitted to the department or its designee the day of admission or discharge.�A $100 fine may be imposed against the facility for each instance where the department does not receive timely notification.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE X�PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, REIMBURSEMENT�(1)�For PRTF services provided on or after October 1, 2008, the Montana Medicaid program will pay a provider for each patient day as provided in these rules.

�� (a)�Medicaid payment is not allowable for treatment or services provided in a PRTF that are not consistent with the definition of PRTF in [RULE II] and unless all other applicable requirements are met.

�� (2)�For inpatient psychiatric services provided by a PRTF in the state of Montana, the Montana Medicaid program will pay a provider, for each Medicaid patient day, a bundled per diem interim rate as specified in (3), less any third party or other payments.�The interim rate is defined in [RULE IX].

�� (3)�The statewide bundled per diem interim rate for inpatient psychiatric services is the lesser of:

�� (a)�the amount specified in the department's Medicaid Mental Health and Mental Health Services Plan Fee Schedule, Individuals Under 18 Years of Age; or

�� (b)�the provider's usual and customary charges (billed charges).

�� (4)�Out-of-state PRTF providers who are not hospital based will be reimbursed 50% of their usual and customary charges.�Reimbursement will include all Medicaid covered psychiatric, medical, ancillary, and chemical dependency services.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE XI�PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY, CONTINUITY OF CARE PAYMENT�(1)�Hospital based residential treatment facilities as defined in [RULE VIII] qualify for a continuity of care payment.

�� (a)�The amount of the continuity of care adjustor payment will be calculated and paid annually.

�� (b)�The amount will be determined by the department according to the following formula:�CCA=[M/D]*P:

�� (i)�"CCA" represents the calculated continuity of care payment;

�� (ii)�"M" is the number of Medicaid inpatient residential days provided by the facility for which the continuity of care payment is being calculated;

�� (iii)�"D" is the total number of Medicaid inpatient residential days provided by all eligible facilities; and

�� (iv)�"P" is the total amount available for distribution via the continuity of care payments.�P equals 4% of the revenue generated by the Montana hospital utilization fee, plus federal financial participation.

�� (2)�The number of Medicaid days shall be determined from the department's Medicaid paid claim data for the most recent calendar year that ended at least 12 months prior to the calculation of the continuity of care payment.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE XII�PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY, CHEMICAL DEPENDENCY ASSESSMENT AND TREATMENT�(1) �PRTF services include chemical dependency (CD) assessment and treatment according to the American Society of Addictions Medicine PPC-2R Manual (Second Edition, Revised April 2001) for youth with a primary SED diagnosis who have a co-occurring CD diagnosis.

�� (2) �Assessment and treatment must be provided by a licensed addiction counselor if the youth has a co-occurring diagnosis of substance dependency or abuse.

�� (3)�CD treatment includes the following services based on the individual plan of care developed with the youth:

�� (a) �assessment;

�� (b) �individual therapy;

�� (c) �group therapy; and

�� (d) �family therapy.

�� (4) �For youth with a co-occurring diagnosis of substance abuse or dependency outpatient services must be included in the discharge plan as needed.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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�� RULE XIII �PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY, ASSESSMENT SERVICES�(1) �PRTF assessment services must comply with the requirements of this subchapter and the applicable federal regulations for PRTF services.

�� (2) �PRTF assessment services:

�� (a) �require prior authorization by the department or its designee;

�� (b) �are short-term lengths of stay, 14 days or less;

�� (c) �are reimbursed 15% higher than the department's current Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule for PRTF services.

�� (3) �Assessment services include the following, as clinically indicated:

�� (a) �diagnostic and functional assessment;

�� (b) �medication evaluation;

�� (c) �psychological and IQ testing;

�� (d) �chemical dependency assessment; and

�� (e) �supported group or independent living needs assessment.

�� (4)�Assessment services include a written report within 14 days after the discharge that includes clear recommendations for treatment of the youth.

�� (5)�If the PRTF admission continues beyond the assessment period and becomes a regular admission, the department will not reimburse at the higher rate for assessment services.

�� (a)�If the youth is re-admitted to the facility within 30 days of the assessment, the admission for assessment may be subject to department review and full recovery.

�� (6)�Assessment services must be provided by qualified staff or contractors operating within the scope of their practice.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, MCA

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4.�The rules as proposed to be amended provide as follows.�New matter is underlined.�Matter to be deleted is interlined.

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�� 37.86.2207�EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT SERVICES (EPSDT), REIMBURSEMENT�(1) through (2) remain the same.

�� (3)�Except as provided in (4), the reimbursement rate for the therapeutic portion of therapeutic youth group home treatment services provided on or after October 1, 2007 is the lesser of:

�� (a)�the amount specified in the department's Medicaid Mental Health Fee Schedule.�The department adopts and incorporates by reference the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule dated ~~October 1, 2007~~ July 1, 2008.�A copy of the fee schedule may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951; or

�� (b) through (4)(b) remain the same.

�� (5)�Each provider of therapeutic youth group home services will report allowable costs for SFY 2008 that starts July 1, 2007 using auditable data, standardized forms, instructions, definitions, and timelines supplied by the department.

�� (a) remains the same.

�� (b)�Reports of allowable costs for SFY 2008 must be received by the department before ~~August 15~~ October 1, 2008.

�� (6)�Reimbursement for the therapeutic portion of therapeutic family care treatment services is the lesser of:

�� (a)�the amount specified in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in (3)(a) and a direct care wage add-on ~~as provided in ARM 37.88.1111~~, if applicable; or

�� (b) and (7) remain the same.

�� (8)�Reimbursement will be made to a provider for reserving a therapeutic youth group home or therapeutic youth family care (other than permanency therapeutic family care) bed while the recipient is temporarily absent ~~only~~ for a therapeutic home visit if:

�� (a) through (c) remain the same.

�� (d)�the recipient is absent from the provider's facility for no more than three patient days per ~~absence~~ therapeutic home visit, unless additional days are authorized by the department.

�� (9)�No more than 14 patient days per recipient in each ~~rate~~ state fiscal year will be allowed for therapeutic home visits.

�� (10) and (11) remain the same.

�� (12)�The department will not reimburse providers for two services that duplicate one another on the same day.�The department adopts and incorporates by reference the Medicaid ~~Children's~~ Mental Health Plan and ~~Children's~~ Mental Health Services Plan ~~(CHMSP)~~ for youth Services Excluded from Simultaneous Reimbursement dated ~~September 1, 2005~~ October 1, 2008.�A copy of the ~~CHMSP~~ Services Excluded from Simultaneous Reimbursement is posted on the internet at the department's web site at www.dphhs.mt.gov/mentalhealth/children/childrensmentalhealthservicesmatrix.pdf or may be obtained by writing the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

�� (13) remains the same.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.86.2219�EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), THERAPEUTIC YOUTH GROUP HOME SERVICES�(1) through (3) remain the same.

�� (4)�For recipients determined Medicaid eligible by the department as of the time of admission to the therapeutic youth group home, the certificate of need required under (2) must be:

�� (a) remains the same.

�� (b)�made by a team of health care professionals that has competence in diagnosis and treatment of mental illness, and that has knowledge of the recipient's situation, including the recipient's psychiatric condition.�The team must include a physician that has competence in diagnosis and treatment of mental illness, preferably in child psychiatry, and ~~must be~~ a licensed mental health professional.�The certificate of need must also be signed by an intensive case manager employed by a mental health center or other individual knowledgeable about local mental health services as designated by the department.�No more than one member of the team of health care professionals may be professionally or financially associated with a therapeutic youth group home program.

�� (5) through (6) remain the same.

�

�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.86.2221�EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), THERAPEUTIC FAMILY CARE TREATMENT SERVICES�(1) through (3) remain the same.

�� (4)�For recipients determined Medicaid eligible by the department as of the time of admission to the therapeutic youth family care, the certificate of need required under (2) must be:

�� (a) remains the same.

�� (b)�made by a team of health care professionals that has competence in diagnosis and treatment of mental illness and that has knowledge of the recipient's situation, including the recipient's psychiatric condition.�The team must include a physician that has competence in diagnosis and treatment of mental illness, preferably in child psychiatry, and ~~must be~~ a licensed mental health professional.�The certificate of need must also be signed by an intensive case manager employed by a mental health center or other individual knowledgeable about local mental health services as designated by the department.�No more than one member of the team of health care professionals may be professionally or financially associated with a therapeutic family care program.

�� (5) through (6) remain the same.

�

�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 5.�The rules as proposed to be repealed provide as follows:

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�� 37.88.1101�INPATIENT PSYCHIATRIC SERVICES, PURPOSE, is found on page 37-21709 of the Administrative Rules of Montana.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1102�INPATIENT PSYCHIATRIC SERVICES, DEFINITIONS, is found on page 37-21710 of the Administrative Rules of Montana.

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�� AUTH:�2-4-201, 53-2-201, 53-6-113, MCA

�� IMP:�� 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-149, MCA

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�� 37.88.1105�INPATIENT PSYCHIATRIC SERVICES, PARTICIPATION REQUIREMENTS, is found on page 37-21713 of the Administrative Rules of Montana.

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�� AUTH:�53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1106�INPATIENT PSYCHIATRIC SERVICES, REIMBURSEMENT, is found on page 37-21717 of the Administrative Rules of Montana.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1107�INPATIENT PSYCHIATRIC SERVICES, COST SETTLEMENT AND UNDERPAYMENT, is found on page 37-21723 of the Administrative Rules of Montana.

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�� AUTH:�53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1110�SERVICE ACCESS RATE ADJUSTMENT PAYMENT, ELIGIBILITY AND COMPUTATION, is found on page 37-21727 of the Administrative Rules of Montana.

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�� AUTH:�53-6-113, 53-21-201, MCA

�� IMP:�� 53-6-101, 53-6-113, 53-21-201, MCA

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�� 37.88.1115�INPATIENT PSYCHIATRIC SERVICES, ADMINISTRATIVE REVIEW AND FAIR HEARING PROCEDURES, is found on page 37-21737 of the Administrative Rules of Montana.

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�� AUTH:�2-4-201, 53-6-113, MCA

�� IMP:�� 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1116�INPATIENT PSYCHIATRIC SERVICES, CERTIFICATION OF NEED FOR SERVICES, UTILIZATION REVIEW AND INSPECTIONS OF CARE, is found on page 37-21739 of the Administrative Rules of Montana.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1119�INPATIENT HOSPITAL PSYCHIATRIC CARE, is found on page 37-21745 of the Administrative Rules of Montana.

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�� AUTH:�2-4-201, 53-2-201, 53-6-113, MCA

�� IMP:�� 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1121�INPATIENT PSYCHIATRIC SERVICES, is found on page 37-21747 of the Administrative Rules of Montana.

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�� AUTH:�2-4-201, 53-2-201, 53-6-113, MCA

�� IMP:�� 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1125�INPATIENT PSYCHIATRIC HOSPITALS, REIMBURSEMENT, is found on page 37-21751 of the Administrative Rules of Montana.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1129�RESIDENTIAL PSYCHIATRIC CARE, is found on page 37-21757 of the Administrative Rules of Montana.

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�� AUTH:�2-4-201, 53-2-201, 53-6-113, MCA

�� IMP:�� 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1131�HOSPITAL BASED RESIDENTIAL TREATMENT CENTERS, REQUIREMENTS, is found on page 37-21759 of the Administrative Rules of Montana.

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�� AUTH:�2-4-201, 53-2-201, 53-6-113, MCA

�� IMP:�� 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1133�RESIDENTIAL TREATMENT CENTERS, REIMBURSEMENT, is found on page 37-21759 of the Administrative Rules of Montana.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

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�� 37.88.1137�RESIDENTIAL TREATMENT CENTERS, CONTINUITY OF CARE PAYMENT, is found on page 37-21769 of the Administrative Rules of Montana.

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�� AUTH:�53-2-201, 53-6-113, MCA

�� IMP:�� 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-149, MCA

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�� 6.�The Department of Public Health and Human Services (department) is proposing a 1.67% rate increase for youth mental health services reimbursement under the Medicaid Mental Health Fee Schedule for state fiscal year (SFY) 2009.�The department intends to make the increased rates effective July 1, 2008.

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The department is updating the administrative rule that requires a case manager sign the certificate of need (CON) for therapeutic group home, therapeutic family care, and residential treatment facility services.�CMS has indicated case management may not be used as a "gate keeper".�The department is proposing to take out the requirement that a CON be signed by a case manager.�The department is updating the Medicaid Mental Health and Mental Health Service Plan for Youth, Services Excluded from Simultaneous Reimbursement chart.�This chart indicates which mental health services are seen as a duplicate service when provided on the same day. �The department is proposing to combine half-day treatment with day treatment in the same column.�The proposed chart adds moderate and permanent therapeutic foster care.

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The inpatient psychiatric care administrative rules would be changed to psychiatric residential treatment facility (PRTF) rules to align them with federal regulations.�The definition of inpatient psychiatric acute hospital is found at ARM 37.86.2901, and the reimbursement rules are found at ARM 37.86.2801 and 37.86.2905.�The proposed changes would simplify public access to reimbursement rules for all hospital types and units.�A U.S. Department of Health and Human Services Appeals Board New York decision dated February 8, 2007 interprets the PRTF rate to be bundled and to include psychiatric, medical, and ancillary services.�The department's rules currently refer to PRTFs as residential treatment facilities and bundle the reimbursement rate to include psychiatric services only.�The department does not see a practical alternative to bundling all Medicaid services provided to youth in a PRTF.�PRTFs will have to provide or pay for the medical or ancillary services youth need while an inpatient in a PRTF.�No Federal Financial Participation (FFP) is available for Medicaid services outside the bundled rate. �This includes in-state and out-of-state PRTF providers enrolled in Montana Medicaid.

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PRTF recipients are not expected to see an increase in costs.�Benefits should remain the same.�The department will have more PRTF cost reports to review.�The department will reimburse the PRTFs a percentage of the medical and ancillary expenses they incur. �PRTFs will likely not receive the same Medicaid rate for medical and ancillary services for their recipients.�Some of these expenses will be paid by the department at the end of the year through cost settlements.�The department is not able to estimate what those additional expenses will be.

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Proposed new Rules I through XIII are part of a reorganization of the mental health rules for youth with serious emotional disturbance (SED).�Currently, those rules are located throughout the many rules for the department.�The department is proposing the rule reorganization because it has proved difficult for consumers and providers to locate rules for youth with SED.�Also, department staff will more readily maintain the rule set and maintain compliance with federal and state law and regulations should requirements change.

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RULE I

Proposed new Rule I is substantially similar to ARM 37.88.1101.�It does not increase or decrease fees, costs, or benefits.�No fiscal or benefit effects are expected as a result of this proposed rule.

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RULE II

Proposed new Rule II is similar to ARM 37.88.1102.�Language was changed from "residential treatment facility" to "psychiatric residential treatment facility" or "PRTF" consistent with current terminology in the Code of Federal Regulations. �The department is also proposing to tie the definition of "PRTF" to "residential treatment facility".

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RULE III

Proposed new Rule III is substantially similar to ARM 37.88.1105.�Language was changed to update "residential treatment facility" to "psychiatric residential treatment facility" or "PRTF".�"Addictive and Mental Disorders Division" would be changed to "Health Resource Division", reflecting a 2005 reorganization of the department.�The council on accreditation (COA), commission on accreditation of rehabilitation facilities (CARF) along with the joint commission on accreditation of health care organizations (JCAHO) would be added.�COA and CARF are recognized by the United States Department of Health and Human Services to accredit psychiatric residential treatment facilities.

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RULE IV

Proposed new Rule IV is substantially similar to ARM 37.88.1115.

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RULE V

Proposed new Rule V is substantially similar to ARM 37.88.1116.�Language was changed to take out the case management signature requirement on the certificate of need (CON) for residential treatment facility services.�New federal regulations for case management prohibit one Medicaid service being a requirement to receive other Medicaid services.�Therefore, targeted case management cannot be used as a "gate keeper" for other services.�� Requiring the case management service signature on the CON, even if the reason for their signature is to make sure other less restrictive services are not available to meet the youth's needs.�The option of having another individual designated by the department has only been used when there is not a case manager working with the youth.�The federal regulations governing inpatient psychiatric services do not require a case management signature on the CON.

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RULE VI

This proposed new Rule VI is substantially similar to ARM 37.88.1121.�Language would be changed from "residential treatment facility" to "PRTF".�"Addictive and Mental Disorders Division" would be updated to "Health Resource Division".

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RULE VII

Proposed new Rule VII was adapted from ARM 37.88.1129.�The term "inpatient psychiatric care" would be changed to "residential psychiatric care".�Specific language from the federal regulations for "psychiatric hospital" and "psychiatric residential treatment facility" was added.�Specific language regarding active treatment, an individualized plan of care, specific discharge plan requirements, and review time frames was also added.�The proposed new Rule VII contains language from the federal regulations specifying what is required in the plan of care to reflect the bundled service requirement.

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RULE VIII

Proposed new Rule VIII is substantially similar to ARM 37.88.1131 except the term "residential treatment center" was changed to "PRTF".

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RULE IX

Proposed new Rule IX is drawn from ARM 37.88.1133.�The term "residential treatment center" was changed to "PRTF".�The bundled PRTF rate would include psychiatric, medical, and ancillary services to be consistent with the interpretation of federal regulations expressed in the Appeals Board New York decision.�Cost report and cost settlement language is added so the department can reimburse in-state PRTFs a percentage of their medical, CD treatment, and physician service expenses.�The department will define these expenses as ancillary.�Cost settlement will occur at the end of each calendar or state fiscal year.�

Chemical dependency services are being added to PRTF services. The department believes many youth receiving PRTF services also have a co-occurring substance abuse or dependency diagnosis that should be treated concurrently with their psychiatric diagnosis at this high level of care.

Pharmacy and laboratory costs for treatment of a youth's psychiatric condition will now be included as part of the interim rate.�Pharmacy and lab costs for treatment of a medical condition may be cost settled at the end of the year.�Under current rules they were included in the bundled rate.

The department proposes a process to request interim payments from the department for youth who have medical conditions that require a higher level of compensation.�Interim payments may be made if prior approved.�If a provider does not request interim payments in the quarter of the state fiscal year they were incurred, they will have to wait until they complete a cost report and use a form approved by the department.

Rule language was added requiring that providers notify the department when recipients are discharged.�Other Medicaid providers will not be reimbursed as long as the youth is in a PRTF.�Other Medicaid providers will be able to bill for services rendered for Medicaid eligible youth upon discharge.�

Out-of-state PRTFs would be reimbursed 50% of their usual and customary charges.�This language was inadvertently dropped from the rule last year and is being added back in to ensure that reimbursement for those facilities is appropriate.�

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RULE X

This proposed rule was based on ARM 37.88.1106.�Language was changed to update the reimbursement rate effective "October 1, 2008".�The term "residential treatment facility" would be replaced with "PRTF".�Out-of-state inpatient hospital psychiatric services would be paid at the hospital rates in ARM 37.86.2905.

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RULE XI

Proposed new Rule XI is substantially similar to ARM 37.88.1137, except the term "residential treatment facility" was changed to "psychiatric residential treatment facility".

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RULE XII

Chemical dependency services would be added to PRTF services.�� The department believes many youth receiving PRTF services also have a co-occurring substance abuse or dependency diagnosis.�These disorders should be treated concurrently with their psychiatric diagnosis(es) at this high level of care.�

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RULE XIII

Proposed new Rule XIII contains short-term assessment service language to address the need for a more comprehensive assessment or reassessment at the PRTF level of care.�Some youth are difficult to diagnose.�Their clinical presentation changes, cognitive, psychological testing, or additional assessments need to be completed timely to receive appropriate treatment.

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ARM 37.88.1110

The department is proposing repeal of the rule pertaining to service access rate adjustment payment, eligibility, and computation.�It has never been approved by the Centers for Medicare and Medicaid Services and was never implemented by the department.

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ARM 37.86.2207

The department proposes to amend this rule to update the Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule, and update the Medicaid Mental Health and Mental Health Service Plan for Youth, Services Excluded from Simultaneous Reimbursement chart.�This chart indicates which mental health services may not be reimbursed when received on the same day.�Some services may be reimbursed on the same day if prior authorized.�A copy of the proposed fee schedule and chart can be accessed on the department's web site, www.dphhs.mt.gov/mentalhealth/children.�A hard copy may be obtained by writing the department at Department of Public Health and Human Services, Health Resources Division, Children's Mental Health Bureau, P.O. Box 202951, Helena, MT 59620-2951.

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ARM 37.86.2219 and 37.86.2221

The department is proposing to amend these rules to take out the rule language requiring a case manager sign the certificate of need.

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ARM 37.88.1101 through 37.88.1137

The department is proposing repeal of ARM 37.88.1101 through 37.88.1137 because they would be replaced by proposed new Rules I through XIII.

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Estimated Financial and Budget Impacts

The proposed new Rules I through XIII would not significantly change the overall costs of mental health services to youths under the age of 18.

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The 1.67% provider rate increases will increase overall expenditures $3,067,386 for SFY 2009.

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Persons and Entities Affected

There are three in-state and approximately 30 out-of-state PRTFs enrolled in Montana Medicaid.�There were 418 youth served in a PRTF (in and out-of-state) in SFY 2007.�PRTFs will likely not receive the same Medicaid rate for medical and ancillary services for their recipients.�These expenses will be paid for by the department at the end of the year through cost settlements.�The department is not able to estimate what those additional expenses will be at this time.�Paid claim reports are being completed by the department to establish the ancillary service rate, per individual PRTF, based on SFY 2007 data.

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�� 7.�The department intends proposed new Rules I through XIII to be effective October 1, 2008.�The amended rules if adopted will be applied retroactively to July 1, 2008.�There will be no detrimental effects on providers or recipients.

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�� 8.�Interested persons may submit comments orally or in writing at the hearing.�Written comments may also be submitted to Rhonda Lesofski, Office of Legal Affairs, Department of Public Health and Human Services, P.O. Box 4210, Helena MT 59604-4210, no later than 5:00 p.m. on August 28, 2008.�Comments may also be faxed to (406)444-1970 or e-mailed to [email protected].�The department maintains lists of persons interested in receiving notice of administrative rule changes.�These lists are compiled according to subjects or programs of interest.�To be included on such a list, please notify this same person or complete a request form at the hearing.

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�� 9.�An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. �The Secretary of State strives to make the electronic copy of this notice conform to the official version of the notice as printed in the Montana Administrative Register, but advises all concerned persons that, in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered. �The web site may be unavailable at times, due to system maintenance or technical problems.

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�� 10.�The bill sponsor notice requirements of 2-4-302, MCA, do not apply.

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�� 11.�The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct the hearing.

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/s/ John Koch�� /s/ John Chappuis��

Rule Reviewer�� Director, Public Health and Human Services

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Certified to the Secretary of State July 21, 2008.

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