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| Montana Administrative Register Notice 37-481 | No. 3 02/11/2010 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF
TO: All Concerned Persons 1. On August 13, 2009, the Department of Public Health and Human Services published MAR Notice No. 37-481 pertaining to the public hearing on the proposed adoption and amendment of the above-stated rules at page 1378 of the 2009 2. The department has adopted the following rule as proposed with the following changes from the original proposal. Matter to be added is underlined. Matter to be deleted is interlined. RULE I (37.86.3503) CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, SEVERE DISABLING MENTAL ILLNESS (1) "Severe disabling mental illness" means with respect to a person who is 18 or more years of age that the person meets the requirements of (1)(a), (b), (c), or (d). The person must also meet the requirements of (1)(e). The person: (a) and (b) remain as proposed. (c) has a DSM-IV-TR diagnosis of: (i) through (ii) remain as proposed. (iii) mood disorder (293.83, 296.22, 296.23, 296.24, 296.32, 296.33, 296.34, 296.40, 296.42, 296.43, 296.44, 296.52, 296.53, 296.54, 296.62, 296.63, 296.64, 296.7, 296.80, 296.89); (iv) remains as proposed (v) disorder due to a general medical condition (293.0 (vi) through (e)(v) remain as proposed. 3. The department has amended the following rules as proposed, but with the following changes from the original proposal, new matter underlined, deleted matter interlined:
37.86.3501 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, DEFINITIONS (1) "Case management" services means services furnished to assist Medicaid and mental health services plan eligible individuals who reside in a community setting, or are transitioning to a community setting, in gaining access to needed medical, social, educational, and other services. (2) through (4) remain as proposed. 37.86.3505 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, SERVICE COVERAGE (1) Case management services for adults with severe and disabling mental illness include: (a) comprehensive assessment and (i) through (iii) remain as proposed. (b) development (and periodic revision) of a specific care plan based on the information collected through the assessment that: (i) and (ii) remain as proposed. (iii) identifies a course of action to respond to the assessed needs of the eligible individual and to avert crisis. (c) remains as proposed. (d) monitoring and follow-up activities, including activities and contacts to ensure that the care plan is effectively implemented and (i) through (2) remain as proposed. (3) Case management may include contacts with noneligible individuals that are directly related to the identification of the eligible individual's needs and care, for the purpose of helping the eligible individual access services, identifying needs and supports to assist the eligible individual in obtaining services, providing case managers with useful feedback, (4) "Case management" does not include the: (a) direct delivery of a medical, educational, social, or other service to which an eligible individual has been referred; and (b) transportation (5) remains as proposed. (6) Case management reimbursement requirements include those described in (1) through (5) and the following: (a) case managers must inform eligible individuals they have the right to refuse case management at the time of eligibility determination and annually thereafter at the time of reassessment; and (b) providers must document in the case record that the individual has been informed and if the individual has refused services. IMP: 53-2-201, 53-6-101, 53-6-113, MCA 37.86.3506 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, SERVICE REQUIREMENTS (1) through (8) remain as proposed. (9) Case management services must be provided on a one-to-one basis, to an individual by one case (10) through (12) remain as proposed. 37.86.3515 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, REIMBURSEMENT (1) Case management services for adults with severe disabling mental illness will be reimbursed on a fee per unit of service basis as follows (a) (i) the provider's actual submitted charge for services; or (ii) the amount specified in the department's Medicaid fee schedule. (2) remains as proposed. IMP: 53-2-201, 53-6-101, 53-6-113, MCA 4. 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: Case management services should include advocacy. RESPONSE #1: Although it is not specifically listed, the department recognizes advocacy as a part of referral and related activities, depending upon the needs identified in the individual's care plan. COMMENT #2: Under the proposed changes in ARM 37.86.3505(1)(d), would it be necessary to write advocacy into an individual's care plan? Who decides to include advocacy as a follow-up activity? Who decides whether services are adequate to meet the needs of the individual? RESPONSE #2: As indicated above in response #1, advocacy can be part of an individual's care plan. It is best to list all the activities and services that will be provided in an individual's care plan. The individual and their treatment team will determine which services are included in the care plan and whether they are adequate. COMMENT #3: Case management services should include crisis response. RESPONSE #3: The case management functions of monitoring and follow-up may include crisis response when a case manager is monitoring the implementation of an individual's care and crisis plans. Face-to-face crisis response that does not require intervention by a mental health professional may be billed as community-based psychiatric rehabilitation and support (CBPRS). COMMENT #4: We are concerned that, under the proposed changes, case management services would no longer include direct contact with the client. RESPONSE #4: All of the identified case management functions (comprehensive assessment and reassessment; development of a plan; referral and related activities; and monitoring and follow-up activities) may include face-to-face contact with the client. Direct contact that does not involve one of these functions may not be billed as case management. COMMENT #5: We disagree with the department's finding that recipients will not be affected by changes in targeted case management rules. RESPONSE #5: The department acknowledges that these rules may affect a recipient's choice of who provides activities of daily living and other direct services, but the amount and quality of services should not change. COMMENT #6: Transportation and daily living assistance should remain a part of case management services. RESPONSE #6: Federal regulations clearly permit transportation and assistance with activities of daily living to be billed as CBPRS activities. COMMENT #7: We are concerned that the reimbursement rate for CBPRS is not adequate. RESPONSE #7: The department acknowledges the commentor's concerns. However, reimbursement rates are outside the scope of the proposed amendments. COMMENT #8: Do the proposed changes prohibit billing CBPRS for transportation, education, training, and the other services mentioned? RESPONSE #8: No. Please see ARM 37.88.901(5). Community-based psychiatric rehabilitation and support services are provided on a face-to-face basis with the recipient, family members, teachers, employers, or other key individuals in the recipient's life when such contacts are clearly necessary to meet goals established in the recipient's individual treatment plan. COMMENT #9: Why did the department choose to use the 15 minute billing increment when the Centers for Medicare and Medicaid Services (CMS) have withdrawn regulations requiring its use? RESPONSE #9: The use of a 15 minute unit for case management is not a change in
COMMENT #10: We recommend the entire section of ARM 37.86.3515 pertaining to reimbursement be deleted. RESPONSE #10: The department agrees and has deleted ARM 37.86.3515(c), (d), and (e) from the final rule.
COMMENT #11: It is not practical to require that each recipient have only one case manager. Services are sometimes necessary when a case manager is away for training, sick leave, or vacation. Another case manager should be permitted to provide services temporarily. RESPONSE #11: The department agrees and has amended ARM 37.86.3506(9) to use the term "case management provider" in accordance with federal regulations. This means that an individual will have one case manager but the individual can access another case manager from the provider agency if necessary. COMMENT #12: Please clarify Rule I(1)(a) (37.86.3503), pertaining to severe disabling mental illness (SDMI) that would recognize hospitalization only at Montana State Hospital (MSH). It is our understanding that RESPONSE #12: Recent legislation is permissive of short term care in local hospitals in lieu of involuntary admission to MSH. However, this legislation does not affect the proposed changes to the definition of SDMI. COMMENT #13: We support adding post traumatic stress disorder (PTSD) and suicidal ideation and behavior to the SDMI definition. RESPONSE #13: The department agrees that these are needed additions to the definition and appreciates the commenter's support of the change. COMMENT #14: Please clarify what is meant by self-harm. RESPONSE #14: Self-harm means intentional self-injury. This can include a number of different behaviors such as cutting or burning, intentionally taking an overdose of pills, or head banging. It does not include such things as smoking, drinking, or anorexia which may also be harmful.
COMMENT #15: We are concerned that the definition of suicidality may not be adequate. RESPONSE #15: The department believes the definition is adequate for the determination of SDMI. If an individual does not meet the criteria for SDMI, the individual may still receive outpatient psychotherapy, medication management, and services under the 72-Hour Presumptive Eligibility Program for Crisis Stabilization. COMMENT #16: We recommend several changes to the list of covered diagnoses. Please check 293.01, 296.32, and 296.24 for typographical errors. Please add 206.90. Please eliminate 294.0 and 204.8. RESPONSE #16: Several diagnostic codes were omitted in error and have been added to the final rule. An examination of billing records for the past year does not support the suggestion that 206.90 be added to the list, as it was never billed, nor that 294.0 and 204.8 be removed, as they were billed a number of times.
COMMENT #17: Case managers should be allowed to bill for assisting clients with Medicaid, SSI applications, and social security hearings. We are concerned that under the proposed changes, clients would not be able to get help with forms and applications. RESPONSE #17: The department agrees and has deleted proposed ARM 37.86.3505(4)(c) that would have excluded Medicaid determination and redetermination from the definition of case management. COMMENT #18: Under the proposed changes to ARM 37.86.3506(3), will the department disallow billing if a case manager accompanies a client to a medical appointment to provide information to the doctor? RESPONSE #18: No. The department will allow billing for this activity because the recipient is receiving a case management service (assessment or care plan development with the doctor, therapist, etc.) and a medical service. COMMENT #19: We have concerns about the brokerage model for delivery of case management services in rural settings and about the restriction of direct service delivery to this population. Please clarify the case manager's role and the billing of other services by persons employed as case managers. RESPONSE #19: The department agrees that the service array in rural settings must meet the needs of consumers. The adult mental health services program is working with licensing program managers to address these concerns. COMMENT #20: We propose the addition of language defining core areas of case management. RESPONSE #20: The department appreciates the suggested additions, but the details contained in the proposal are too specific for administrative rule. COMMENT #21: We propose language changes related to free choice of providers. RESPONSE #21: The department appreciates the suggested changes, but the suggested language is less detailed than is required for administrative rule. COMMENT #22: The medical necessity rule does not need to be duplicated in the rules pertaining to case management services for adults with SDMI and should be deleted. RESPONSE #22: Many people who are new to the mental health system have experienced difficulty finding the rule for medically necessary service in the general Medicaid chapter (ARM Title 37, chapter 82). Therefore, the department has chosen to repeat the standards for the convenience of the public. COMMENT #23: Consumers value the trusting relationships they have with their case managers, especially when they have little to no family support. We are concerned people will end up in crisis or in institutions without case management. RESPONSE #23: The department understands and appreciates that consumers value the services they receive from their case managers. Case management is not being eliminated by these changes. These rules pertain to activities that may be billed as case management services. Some activities that case managers previously provided in the course of case management must now be billed as other activities. COMMENT #24: We are concerned that the department may choose to limit the number of qualified case management services providers or contract exclusively with one case management services provider. RESPONSE #24: It is the department's intent to encourage freedom of choice, not to limit choice of a case management provider for adults with SDMI. ARM 37.86.3515(2) is not new language or an addition to the rule.
COMMENT #25: Under the proposed change to ARM 37.86.3515(2), pertaining to designation of a single case management services provider, would a provider have to serve a larger or smaller area? RESPONSE #25: Not necessarily. It is the department's intent to encourage freedom of choice, not to limit the choice of adults with SDMI. ARM 37.86.3515(2) is not new language or an addition to this rule. COMMENT #26: Please clarify the proposed changes pertaining to the frequency with which reassessment and case plan review must be completed. RESPONSE #26: In order to be consistent with other rules of the department, the final rule has been amended to say that reassessment and review of a specific care plan as provided at ARM 37.86.3505(1)(a) and (b) must occur at least once every 90 days. COMMENT #27: Please explain why the term "intensive case management" was changed to "case management" in the proposed rules. RESPONSE #27: The term "intensive case management" was changed to provide consistency in language among all targeted case management services provided under Montana Medicaid. COMMENT #28: If rules are applied retroactively, how will it affect the way providers are audited? RESPONSE #28: The definition of case management services has been available to providers since 2006 and the department believes that providers have been working toward meeting the standards adopted in this notice. The policy of the department is to audit based on the date rules are in place, so providers can expect to be audited based on the date the changes were retroactively effective. COMMENT #29: How will First Health Services of Montana, the department's utilization review contractor, address a noncovered diagnosis when suicidal thoughts or behavior, or involuntary hospitalization at MSH are met? RESPONSE #29: First Health Services of Montana has been advised of the updated definition of SDMI and will contact the provider if prior authorization for services is requested for an individual with a noncovered diagnosis. COMMENT #30: Does this set of rules apply to the mental health services plan (MHSP)? RESPONSE #30: As amended, ARM 37.86.3501, 37.86.3505, and 37.86.3506 include the mental health services plan, COMMENT #31: Please clarify the department's policy pertaining to billing case management services for the last 60 days transitioning from an institution. Change this to require involvement by a case manager from admission and travel to the facility. RESPONSE #31: The department concluded that the proposed policy was not feasible under current eligibility rules and withdraws it. COMMENT #32: Does 72-hour presumptive eligibility apply to case management services? RESPONSE #32: Case management is not billable when an individual is covered by 72-hour presumptive eligibility. 5. The department intends for the adoption and amendment of these rules to be applied retroactively to July 1, 2009. A retroactive application of the proposed rules does not result in a negative impact on providers or consumers. /s/ John Koch /s/ Anna Whiting Sorrell Rule Reviewer Anna Whiting Sorrell, Director Public Health and Human Services Certified to the Secretary of State February 1, 2010.
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