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| Montana Administrative Register Notice 37-503 | No. 7 04/15/2010 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF
TO: All Concerned Persons 1. On May 6, 2010, at 11:00 a.m., the Department of Public Health and Human Services will hold a public hearing in the auditorium of the Department of Public Health and 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 April 27, 2010, to advise us of the nature of the accommodation that you need. Please contact Gwen Knight, Department of Public Health and Human Services, Office of Legal Affairs, 3. The rule as proposed to be adopted provides as follows: RULE I MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, REIMBURSEMENT (1) Medicaid reimbursement for mental health services shall be the lowest of: (a) the provider's actual (submitted) charge for the service; or (b) the rate established in the department's 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 July 1, 2010. A copy of the fee schedule may be obtained from the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 Sanders, (2) The department will not reimburse providers for Medicaid services unless the prior authorization and continued authorization requirements in ARM 37.87.903 are met. (3) 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 Mental Health Plan and Mental Health Services Plan for Youth Services Excluded from Simultaneous Reimbursement (Service Matrix) effective July 1, 2010. A copy of the service matrix may be obtained from the department or at www.mt.medicaid.org. IMP: 53-2-201, 53-6-101, 53-6-111, MCA 4. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined: 37.86.2207 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES, REIMBURSEMENT (1) and (2) remain the same. (3) Reimbursement for the therapeutic portion of therapeutic youth group home 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 [RULE I] and a direct care wage add-on, if applicable; (b) remains the same. (4) 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 (b) remains the same. (5) through (9) remain the same. (10) The department will not reimburse providers for two services that duplicate one another on the same day according to the Medicaid Mental Health Plan and Mental Health Services Plan for Youth Services Excluded from Simultaneous Reimbursement (Service Matrix) adopted in [RULE I].
(11) remains the same. IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA 37.87.733 MENTAL (a) the provider's actual (submitted) charge for the service; or (2) For day treatment services, AUTH: 53-2-201, 53-6-101, 53-6-113, MCA IMP: 53-2-201, 53-6-101, 53-6-111, MCA 37.87.809 TARGETED CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, REIMBURSEMENT (1) through (2)(a) remain the same. (b) the amount specified in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule, adopted at ARM (3) through (5) remain the same. IMP: 53-1-601, 53-1-602, 53-1-603, 53-2-201, MCA 37.87.903 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, AUTHORIZATION REQUIREMENTS (1) Mental health services for a Medicaid youth under the Montana Medicaid program will be reimbursed only if the following requirements are met: (a) remains the same. (b) the department or its designee has determined (i) prior to treatment, (prior authorization); and (ii) when required, (continued authorization). (c) through (2)(b) remain the same. (3) Prior authorization and when required continued authorization by the department or its designee is required for the following services (a) individual or family outpatient therapy services in excess of 24 sessions per state fiscal year, subject to such additional limitations for outpatient therapy services as may be set forth in the Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted at ARM (b) remains the same. (c) all outpatient therapy services (d) (e) therapeutic family care services defined in ARM 37.86.2207; (f) psychiatric residential treatment facility services defined in ARM 37.87.1202; (g) psychiatric hospital and partial psychiatric hospital services defined in ARM 37.86.2901 and 37.86.3001; and (h) as provided for in other rules. (4) The department may waive a requirement for prior authorization or continued authorization when the provider (a) there was a clinical reason why the request for prior authorization or continued authorization could not be made at the required time, and the provider submitted a subsequent authorization request within ten business days; or (b) a timely request for prior authorization or continued authorization was not possible because of a failure or malfunction of the department or its designee's equipment that prevented the transmittal of the request at the required time and the provider submitted a subsequent authorization request within ten business days. (5) The prior authorization or continued authorization requirement shall not be waived except as provided in this rule. (8) and (9) remain the same but are renumbered (7) and (8). IMP: 53-2-201, 53-6-101, 53-6-111, MCA 37.87.2233 MENTAL HEALTH SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE (SED) RESPITE CARE SERVICES, PROVIDER REIMBURSEMENT (1) and (2) remain the same. (4) remains the same. AUTH: 53-2-201, 53-6-101, 53-6-113, MCA IMP: 53-2-201, 53-6-101, 53-6-111, MCA 5. The Department of Public Health and Human Services (the department) is proposing the adoption of New Rule I and the amendment of ARM 37.86.2207, 37.87.733, 37.87.809, 37.87.903, and 37.87.2233 pertaining to Medicaid reimbursement of children's mental health services. The department is proposing a new rule adopting and incorporating the Medicaid and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule (fee schedule) and the Medicaid Mental Health and Mental Health Services Plan for Youth Services Excluded from Simultaneous Reimbursement (service matrix) from the EPSDT in ARM 37.86.2207 into the children's mental health section. The department received requests from providers to organize the children's mental health Medicaid and Mental Health Service Plan rules in one section so they would be easier to find. The department agreed and has already moved many of the children's mental health administrative rules to this new section. Moving the fee schedule and service matrix to ARM Title 37, chapter 87, subchapter 9 would put them with the other children's mental health rules. The department is proposing the following changes to the service matrix so it will be easier to read and understand. The proposed changes are to: (a) specify that moderate level therapeutic family care (Mod TFC) and permanency level therapeutic family care may not be reimbursed on the same day; and (b) specify that no other mental health service on the service matrix will be reimbursed on the same day as psychiatric residential treatment services (PRTF), with the exception of the day of admission and/or discharge. To inform providers of the proposed changes to the service matrix, the service matrix document (with changes indicated in red) will be posted on the Children's Mental Health Bureau's web site at www.dphhs.mt.gov/mentalhealth/children/index.shtml so providers may review and comment on the proposed changes in the rulemaking process. Interested persons without access to the internet may obtain copies from the department by writing the Children's Mental Health Bureau (CMHB), P.O. Box 4210, Helena, MT 59604-4210. CMHB is proposing to change the name of and condense and reorganize for clarity, the 2008 Clinical Management Guidelines in ARM 37.87.903. The new name will be the "Children's Mental Health Bureau's Provider Manual and Clinical Guidelines for Utilization Management" with an effective date of July 1, 2010. The 2008 clinical management guidelines were developed by CMHB with our utilization review contractor, First Health, Inc. The manual and its guidelines are used to make authorization decisions based on clinical criteria to determine whether or not mental health services are medically necessary and reimbursable by the children's mental health Medicaid program. The language incorporating the manual in the administrative rule, would be updated to "adopt and incorporate". This language is consistent with the language in ARM 37.87.901 that "adopts and incorporates" our fee schedule and service matrix. CMHB is proposing minor changes to a few of the chapters. The proposed changes will be posted on the CMHB's web site at www.dphhs.mt.gov/mentalhealth/children/index.shtml so providers may review and comment on the proposed changes. A few more requirements will be added to the PRTF chapter of the manual to require more information about the client's discharge. If the discharge plan does not evolve adequately during a youth's stay in the PRTF, continued authorization for reimbursement will be denied. Discharge planning is already a PRTF requirement and one criteria for continued authorization. However, discharge plans are frequently inadequate to step the youth down to a lower level of care on time. If services upon discharge are not adequately arranged, the likelihood of the youth's success in a community setting is greatly diminished. The PRTF HCBS Waiver chapter of the manual is being updated to reflect waiver amendments regarding the age of youth served and additional counties and services covered. CMHB is proposing to update the therapeutic living chapter of the manual into two separate chapters: one for therapeutic youth group home services and another chapter for therapeutic family care services. Clarification will be added to the therapeutic family care chapter of the manual to indicate permanency level therapeutic family care services will only be authorized in foster care homes and not authorized in biological or postadoption homes. The proposed new rule and amendments are described in detail below. Rule I The Children's Mental Health Fee Schedule and updated service matrix would be adopted and incorporated in Rule I. The fee schedule and service matrix were previously adopted and incorporated in ARM 37.86.2207. This change is being proposed to move all children's mental health rules to the children's mental health section of ARM Title 87, chapter 87. The department previously moved many of the children's mental health rules to this chapter. The CMHB address and division name are also being updated. ARM 37.86.2207 The amendments proposed for this rule would repeal the adoption and incorporation of the Medicaid Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule, (fee schedule) in (3)(a) and of the Medicaid Mental Health and Mental Health Services Plan for Youth Services Excluded from Simultaneous Reimbursement (service matrix) in (10) and move them to the children's mental health section to Rule I. ARM 37.87.733 The department is proposing to move the Children's Mental Health Fee Schedule to Rule I and to update the fee schedule reference in (1)(b) to the new Children's Mental Health Fee Schedule adopted in Rule I. ARM 37.87.809
The department is proposing to move the Children's Mental Health Fee Schedule to Rule I and to update the fee schedule reference in (2)(b) to the new fee schedule in Rule I. The CMHB address is being deleted because the information would be transferred to Rule I under this proposal. ARM 37.87.903 The department is proposing more specific language regarding authorization requirements including prior and continued authorizations in this rule. Both prior and continued authorizations are needed before a service is provided to a Medicaid recipient. The purpose of prior and continued authorization is to determine whether the service is medically necessary or continues to be medically necessary. The department's authorization requirements have not changed. The rule is being updated to make it easier to read and understand. The language in (3)(c) is changed to be consistent with the language in the service matrix. Both this rule and the service matrix do not allow Comprehensive School and Community Treatment and outpatient therapy services to be reimbursed if provided on the same day unless outpatient therapy is priorly authorized. The department also proposes to add additional services to (3) that require prior and continued authorization for reimbursement: therapeutic youth group home, therapeutic family care, psychiatric residential treatment facility, psychiatric hospital and partial hospital programs. The department's authorization requirements have not changed. The rule is being updated to make it easier to read and understand. The department is also proposing to amend the language in (4) as to when the department may waive a requirement for prior authorization or continued authorization of a service. If a clinical reason exists preventing the authorization request from being made timely, and a subsequent authorization request is made within ten business days and states the clinical reason the authorization request was made late, the timely authorization request requirement may be waived. The rule language is also being updated to specify that the department may waive an authorization requirement when a continued authority request is submitted late due to a failure or malfunction of the department's or designee's equipment and not the provider's equipment. The department's 2008 clinical management guidelines would be updated to the July 1, 2010 version and renamed the "Children's Mental Health Bureau's Provider Manual and Clinical Guidelines for Utilization Management" as part of the department's ongoing effort to make its rules easier to read and understand. The language is also being updated to "adopt and incorporate" this manual to be consistent with the language in Rule I that adopts and incorporates the department's Children's Mental Health Fee Schedule and Service Matrix. The department is proposing to condense and reorganize the manual for clarity. Minor changes will be made to a few of the chapters. The proposed changes will be posted on the CMHB's web site at www.dphhs.mt.gov/mentalhealth.children/index.shtml. Minimal requirements will be added to the PRTF chapter of the manual to require more information about the client's discharge plan. If the discharge plan does not evolve adequately during a youth's stay in the PRTF, continued authorization for reimbursement will be denied. Discharge planning is already a PRTF requirement and one criteria for continued authorization; however, discharge plans are frequently inadequate to step the youth down to a lower level of care. If services upon discharge are not adequately arranged, the likelihood of the youth's success in a community setting is greatly diminished. The PRTF HCBS Waiver chapter is being updated to reflect waiver amendments regarding age of youth served and additional counties and services covered. The following language will be added to the admission criteria for waiver services: "In lieu of waiver services the youth would regress and require institutionalization or inpatient hospital services in the community". CMHB is proposing to update the therapeutic living chapter into two separate chapters: one for therapeutic youth group home services and another chapter for therapeutic family care services. Clarification will be added to the therapeutic family care chapter to indicate permanency level therapeutic family care services will only be authorized in foster care homes and not authorized in biological or postadoption homes. The CMHB address and division name in (7) is being updated because the CMHB moved from the Health Resource Division to the Disability Services Division on July 1, 2009, and was subsequently renamed the Developmental Services Division. 6. The department proposes that the adoption of New Rule I and proposed rule changes to be applied effective July 1, 2010. 7. 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: Gwen Knight, 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 13, 2010. 8. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing. 9. 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 7 above or may be made by completing a request form at any rules hearing held by the department. 10. 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. 11. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
/s/ John Koch /s/ Anna Whiting Sorrell Rule Reviewer Anna Whiting Sorrell, Director Public Health and Human Services Certified to the Secretary of State April 5, 2010
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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].
