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| Montana Administrative Register Notice 37-467 | No. 8 04/30/2009 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Concerned Persons 1. On May 20, 2009, at 1:30 p.m., the Department of Public Health and Human Services will hold a public hearing in the auditorium of the Department of Public Health and Human Services Building, 111 North Sanders, Helena, Montana, to consider the proposed amendment of the above-stated rules. 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 or need an alternative accessible format of this notice. If you require an accommodation, contact Department of Public Health and Human Services no later than 5:00 p.m. on May 11, 2009, to advise us of the nature of the accommodation that you need. Please contact Rhonda Lesofski, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail [email protected]. 3. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined: 37.85.212 RESOURCE BASED RELATIVE VALUE SCALE (RBRVS) REIMBURSEMENT FOR SPECIFIED PROVIDER TYPES (1) For purposes of this rule, the following definitions apply: (a) remains the same. (b) "Conversion factor" means a dollar amount by which the relative value units, or the base and time units for anesthesia services, are multiplied in order to (i) physician services, which applies to the following health care professionals listed in (2): physicians, mid-levels, podiatrists, public health clinics, independent diagnostic testing facilities, nutrition providers, QMB and EPSDT chiropractors, and dentists rendering medical procedures (ii) allied services, which applies to the following health care professionals listed in (2): physical therapists, occupational therapists, speech therapists, optometrists, opticians, audiologists, and school-based services. The conversion factor for allied services for state fiscal year 2010 is $30.49; (iii) mental health services, which applies to the following health care professionals listed in (2): psychologists, licensed clinical social workers, and licensed professional counselors. The conversion factor for mental health services for state fiscal year 2010 is $25.95; (iv) anesthesia services, which applies to anesthesia services. The conversion factor for anesthesia services for state fiscal year 2010 is $26.25. (c) "Conversion factor category" means the four categories of providers for purposes of calculating Medicaid fees. The categories are physician services, allied services, mental health services, and anesthesia services. (e) "Provider rate of reimbursement adjustment" means the change to the RBRVS fee calculated for a procedure based on the health care professional delivering the service. (f) "Rate variable" means a multiplier in the rate equation, such as a policy adjustor, a provider rate of reimbursement, or pricing modifier, that changes the RBRVS rate for a procedure or service. (g) "RBRVS fee" for a covered procedure means the amount calculated by multiplying the relative value units (or the base and time units for anesthesia services) for the procedure by the appropriate conversion factor. If applicable, a rate variable may be applied to the RBRVS fee to calculate the Montana Medicaid fee for the procedure. (2) through (2)(t) remain the same. (3) Except as set forth in (8) through (12)(a)(vi), the RBRVS fee for a covered service (4) The conversion factor for physician services is calculated as stated in sections 53-6-124 through 126, MCA. The conversion factor for allied services, mental health services, and anesthesia services is calculated as follows: (a) The total RVUs for the prior period is calculated as the sum of the product of the RVUs for a procedure code multiplied by the number of times the procedure code was paid in a prior period. (b) The total RVUs for the prior period is multiplied by the projected change in utilization to estimate utilization during the appropriation period. (c) The Montana Legislature's appropriation for the period is divided by the estimated utilization for the period to calculate the conversion factor. (d) The RVU assigned to each procedure code is multiplied by the appropriate conversion factor to calculate the RBRVS fee for a particular procedure code. (7) The RVUs for most services are adopted from the resource based RBRVS. For services for which the RBRVS does not specify RVUs, the department sets those RVUs as follows: (a) through (7)(a)(ii)(C) remain the same. (8) Except for physician administered drugs as provided in ARM 37.86.105(4), clinical, laboratory services, and anesthesia services, if neither Medicare nor Medicaid sets RVUs, then reimbursement is by report. (a) remains the same. (b) For state fiscal year (9) through (9)(b)(iii) remain the same. (10) For anesthesia services the department pays the lower of the following for procedure codes with fees: (a) remains the same. (b) a fee determined by multiplying the anesthesia conversion factor by the sum of the applicable base and time units, and then multiplying the product by (c) the department pays the lower of the following for procedure codes without fees: (i) the provider's usual and customary charges for the services; or (ii) the by report rate. (11) For providers listed at ARM 37.85.212(2) billing for durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS), except for the bundled items as provided in (13); the department pays: (a) the fee listed on the Medicaid fee schedule as provided in ARM 37.86.1807; or (b) if there is no fee in (11)(a), the amount determined by multiplying the by report rate provided in (8)(b) by the billed charges. (12) Subject to the provisions of (12)(a), when billed with a modifier, payment for procedures established under the provisions of (7) is a percentage of the rate established for the procedures. (a) The methodology to determine the specific percent for each modifier is as follows: (i) and (ii) remain the same. (iii) The department's list of the specific percents for the modifiers used by Medicaid as amended through (iv) through (14) remain the same. IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA 37.86.205 MID-LEVEL PRACTITIONER SERVICES, REQUIREMENTS AND REIMBURSEMENT (1) through (5)(b) remain the same. (6) Reimbursement for immunizations, family planning services, administration of injectables, radiology, laboratory and pathology, cardiography and echocardiography services and for (a) through (10) remain the same. IMP: 53-6-101, MCA 4. The Department of Public Health and Human Services (department) is proposing amendments to ARM 37.85.212 and 37.86.205. Montana Medicaid is a program administered by the department that pays for medical assistance to qualified low income and disabled Montana residents. Montana and the federal government jointly fund the program. Montana pays providers for service delivered to eligible individuals enrolled in the Medicaid program. These rule amendments are necessary to give notice of the reimbursement rate changes for state fiscal year 2010. These changes are based on the state fiscal year 2010 and 2011 appropriations by the 61st Legislature. Medicaid reimbursement rates are calculated based on the Montana Legislature's appropriations and the department's estimates of service utilization during the appropriation period. Fee schedules are generated by multiplying the American Medical Association's and the Center for Medicare and Medicaid's (CMS) jointly determine relative value units (RVUs) for a covered procedure by the Montana Medicaid conversion factor established for the provider type. ARM 37.85.212 The department is proposing to add definitions for clarity and provide more detail about how it calculates the four conversion factors used to set rates. It is also making its annual rule amendment to set the rate Montana Medicaid reimburses providers based on the Legislature's appropriation for state fiscal year 2010. The proposed amendments are necessary to update the Resource Based Relative Value Scale (RBRVS) fees paid to enrolled providers in accordance with the RVUs published in the Federal Register in November 2008. The change in rates is effective July 1, 2009. The option of not updating RVUs and RBRVS fees was considered and rejected because the department wants to continue to reimburse providers as accurately as possible using current RBRVS and RVUs. The proposed amendments to state the details of the calculation of the four conversion factors is not a change in the method of calculating rates. The department is stating the detail in rule to comply with recent requests for additional information by the CMS, the federal agency that administers the federal Medicaid program. ARM 37.85.212 is also being amended to change the "by report" reimbursement rate from 45% to 46%. This is also an annual change based on the information contained in 37.85.212(8). The "by report" reimbursement method is used for the relatively small number of procedures that do not have sufficient data to calculate a fee schedule rate. The by-report rate is a ratio of the previous years' reimbursement to the total amount billed. ARM 37.85.212(11) is amended to replace the term "durable medical equipment and supplies" with the current term used by CMS "durable medical equipment, prosthetics, orthotics and medical supplies" (DMEPOS). This rule is also edited for clarity but not for a substantive change in policy. The department is clarifying rule language to more clearly state that the fees for DMEPOS set by this rule only apply to incidental billing for DMEPOS by the providers identified in ARM 37.85.212(2) if the equipment or supply is not bundled as part of the provider fee. The general requirements for DMEPOS coverage and billing are stated in ARM Title 37, chapter 86, part 18.
ARM 37.86.205 Most services that mid-level practitioners perform are reimbursed at the lower of usual and customary charges or 90% of the RBRVS rate for physicians. ARM 37.86.205(6), however, reimburses mid-level practitioners at the lower of usual and customary charges or 100% of the RBRVS rate for early and periodic screening, diagnostic and treatment (EPSDT) services. EPSDT services are a subset of services provided to individuals under the age of 21. It has been the practice of the department for several years to pay mid-level practitioners at 100% of the RBRVS rate for physicians for all services to individuals under 21 years of age, not just for EPSDT services. The department does this to improve access to services for Medicaid clients under 21. This rule amendment conforms the administrative rule to the current rate. The option of not amending the mid-level practitioner reimbursement language was considered and rejected because the department wants to match administrative rules to business practices. Amendment of these rules impacts approximately 75,000 Medicaid clients and 6,000 providers.
Fiscal Impact:
The estimated cumulative fiscal impact of these rules is based on the Legislative Appropriation for ARM 37.85.212 Resource Based Relative Value Scale (RBRVS) provider type services in House Bill 2 as of April 15, 2009. Total Cost State General Fund Federal Match SFY 2010 $1,065,121 $251,049 $814,072 The Legislature is in session on the date this notice is filed with the Secretary of State. The final rule will reflect the final appropriation as determined by the Legislature. 5. The department intends to apply these rules effective July 1, 2009. In the event the rules are amended retroactively no negative impact is anticipated. 6. Concerned persons may submit their data, views, or arguments either orally or in writing at the hearing. Written data, views, or arguments may also be submitted to: Rhonda Lesofski, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail [email protected], and must be received no later than 5:00 p.m., May 28, 2009. 7. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing. 8. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 6 above or may be made by completing a request form at any rules hearing held by the department. 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 the 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. In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems. 10. The bill sponsor contact requirements of 2-4-302, MCA, do not apply. /s/ Geralyn Driscoll /s/ Anna Whiting Sorrell Rule Reviewer Anna Whiting Sorrell, Director Public Health and Human Services Certified to the Secretary of State April 20, 2009.
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A directory of state agencies is available online at http://www.mt.gov/govt/agencylisting.asp.
For questions about the organization of the ARM or this web site, contact [email protected].
