Administrative Rules of the State of Montana

BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

In the matter of the adoption of New Rules I, II, and III and the amendment of ARM 37.88.101, 37.88.901, 37.88.905, 37.88.906, and 37.88.907 pertaining to Medicaid mental health center services for adults with severe disabling mental illness

)

)

)

)

)

)

)

NOTICE OF ADOPTION AND AMENDMENT

TO: All Concerned Persons

1. On June 25, 2009, the Department of Public Health and Human Services published MAR Notice No. 37-475 pertaining to the public hearing on the proposed adoption and amendment of the above-stated rules at page 985 of the 2009 Montana Administrative Register, Issue Number 12.

2. The department has amended ARM 37.88.905, 37.88.906, and 37.88.907 as proposed.

3. The department has adopted the following rules as proposed with the following changes from the original proposal. Matter to be added is underlined. Matter to be deleted is interlined.

RULE I (37.88.903) MENTAL HEALTH CENTER SERVICES FOR ADULTS, DEFINED (1) A mental health center ~~must~~ may provide:

(a) through (2) remain as proposed.

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

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

RULE II (37.88.908) MENTAL HEALTH CENTER SERVICES FOR ADULTS, PROGRAM OF ASSERTIVE COMMUNITY TREATMENT (PACT) (1) A program of assertive community treatment (PACT) is a self-contained clinical treatment:

(a) through (f) remain as proposed.

(g) maintains a ratio of at least one staff person, not including a psychiatrist, or peer specialist for each nine persons served. Assertive community treatment teams must be approved by the Addictive and Mental Disorders Division; and

(h) assertive community treatment teams must be approved by the Addictive and Mental Disorders Division, and comply ~~complies~~ with the Montana Program of Assertive Community Treatment (PACT) Standards. The department adopts and incorporates by reference the Montana PACT Standards (2009) which set forth the standards of treatment for adults with SDMI. A copy of the standards may be obtained from the Addictive and Mental Disorders Division, P.O. Box 202905, Helena, MT 59620-2905.

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

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

RULE III (37.88.909) MENTAL HEALTH CENTER SERVICES FOR ADULTS, INTENSIVE COMMUNITY-BASED REHABILITATION FACILITY

(1) "Intensive community-based rehabilitation facility" means an adult mental health group home that provides medically necessary rehabilitation services to adults with severe disabling mental illness who have a history of institutional placements due to mental illness and a history of repeated unsuccessful placements in less intensive community-based programs. The provider must provide the following services to individuals:

(a) through (d) remain as proposed.

(e) discharge planning for transition to a less restrictive setting ~~when appropriate~~; and

(f) remains as proposed.

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

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

4. The department has amended the following rules as proposed, but with the following changes from the original proposal, new matter underlined, deleted matter interlined:

37.88.101 MEDICAID MENTAL HEALTH SERVICES FOR ADULTS, AUTHORIZATION REQUIREMENTS (1) and (2) remain as proposed.

(3) Adult intensive outpatient therapy services may be medically necessary for a person with safety and security needs who has demonstrated the ability and likelihood of benefit from continued outpatient therapy. The person must meet the requirements of (3)(a) or (b). The person must also meet the requirements of (3)(c). The person has:

(a) a DSM-IV diagnosis with a severity specifier of moderate or severe of mood disorder (293.31, 293.33, 293.34, 293.83, 295.70, 296.7, 296.22, 296.23, 296.24, 296.32, 296.33, 296.34, 296.42, 296.43, 296.44, 296.80, 296.89); or

(b) through (9) remain as proposed.

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

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

37.88.901 MENTAL HEALTH CENTER SERVICES FOR ADULTS, DEFINITIONS (1) through (3)(b)(vi) remain as proposed.

(4) "Co-occurring capability" means a mental health program can, for individuals who are eligible for mental health services:

(a) through (18) remain as proposed.

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

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

5. The department has thoroughly considered the comments and testimony received. A summary of the comments received and the department's responses are as follows:

COMMENT #1: Rule I (37.88.903) as proposed states that "A mental health center must provide: . . ." I question the use of the word must. Will all mental health centers be required to provide all of the listed services under proposed Rule I (37.88.903)?

RESPONSE #1: No, the proposed rule was not intended to require all mental health centers to provide all the listed services. Accordingly, the department has substituted the word "may" for the word "must" in Rule I (37.88.903).

COMMENT #2: Please keep recreational services as part of community-based psychiatric rehabilitation and support (CBPRS) funding.

RESPONSE #2: The proposed rule makes no change to ARM 37.88.901(3)(b)(vi) "activities which are purely recreational in nature." Therapeutic recreational activities may be provided as CBPRS if they are part of the individual's individualized strength-based treatment plan.

COMMENT #3: In ARM 37.88.901(4), "Co-occurring capability" means a mental health program can:

(a) screen all individuals for substance use disorders;

(b) provide access to outpatient therapists trained to diagnose and work with substance abusers;

(d) collaborate with another provider to access necessary consultation when an individual also requires services from that provider.

Please provide clarification that mental health centers should be able to work with persons who present with primary substance use disorders and have no qualifying SDMI diagnosis.

RESPONSE #3: The department agrees and has adopted language in the final rule making clear that this expectation applies to individuals who have been determined eligible for mental health services. The amendments to ARM 37.88.101 now refer to diagnoses instead of SDMI. An individual who has one of the listed diagnoses can be treated at the mental health center for a primary diagnosis of substance abuse.

COMMENT #4: In ARM 37.88.901(4), "Co-occurring capability" means a mental health program can:

(b) provide access to outpatient therapists trained to diagnose and work with substance abusers;

This statement should be revised to state: "(b) provide access, either onsite or through referral, to outpatient therapists trained to diagnose and work with substance abusers."

RESPONSE #4: The department disagrees, and will retain the language originally proposed stating that this requirement pertains to individuals with qualifying mental health diagnoses who have co-occurring substance abuse diagnoses.

Publicly funded treatment is available for individuals with diagnoses of chemical dependency. Individuals with diagnoses of substance abuse do not have access to these services. Therefore, individuals with qualifying mental health diagnoses and co-occurring substance abuse diagnoses need to be served onsite rather than through referral. Continuity of care is best served with onsite therapists.

COMMENT #5: I recommend changing Rule III(e) (37.88.909) discharge planning for transition to a less restrictive setting when appropriate and to (e) discharge planning for transition to a less restrictive setting. Please eliminate the phrase: "when appropriate."

It is my opinion that discharge planning should always be part of any treatment plan. Otherwise, the consumer and the provider will have no benchmark to indicate when they are done.

RESPONSE #5: The department agrees and has deleted the phrase "when appropriate."

COMMENT #6: Please include a requirement that every program of assertive community treatment team must employ at least one peer specialist.

RESPONSE #6: The department agrees, but believes Rule II (37.88.908) already requires at least one peer specialist per team. It includes the statement:

(h) complies with the Montana Program of Assertive Community Treatment (PACT) Standards. The department adopts and incorporates by reference the Montana PACT Standards (2009) which set forth the standards of treatment for adults with SDMI. A copy of the standards may be obtained from the Addictive and Mental Disorders Division, P.O. Box 202905, Helena, MT 59620-2905.

The Montana PACT Standards (2009) include the requirement of at least one peer specialist per team. Please see the response to comment #7, below.

COMMENT #7: Please add "or peer specialist" to Rule II(g) (37.88.908) for calculating the ratio of staff to persons served.

RESPONSE #7: The department agrees and has added the phrase "or peer specialist" to Rule II (37.88.908) as requested by several commentors.

/s/ John Koch /s/ Hank Hudson

Rule Reviewer Anna Whiting Sorrell, Director

Public Health and Human Services

Certified to the Secretary of State August 17, 2009.