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 amendment of ARM 37.86.805, 37.86.1004, 37.86.1105, 37.86.1506, 37.86.2207, 37.86.2405, and 37.86.2605 pertaining to Medicaid acute services reimbursement and early and periodic screening, diagnostic and treatment (EPSDT)

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT

TO: All Concerned Persons

1. On June 15, 2011, at 1:00 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 June 6, 2011, to advise us of the nature of the accommodation that you need. Please contact Kenneth Mordan, 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:

37.86.805 HEARING AID SERVICES, REIMBURSEMENT (1) The department will pay the lowest of the following for covered hearing aid services and items:

(a) remains the same.

(b) the amount specified for the particular service or item in the department's fee schedule. The department adopts and incorporates by reference the department's Hearing Aid Fee Schedule dated ~~July 2010~~ August 2011. A copy of the department's fee schedule is posted at http://medicaidprovider.hhs.mt.gov and may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951; or

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

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA

37.86.1004 REIMBURSEMENT METHODOLOGY FOR ~~SOURCE~~ RESOURCE BASED RELATIVE VALUE FOR DENTISTS (RVD) (1) For procedures listed in the relative values for dentists scale, reimbursement rates shall be determined using the following methodology:

(a) The fee for a covered service shall be the amount determined by multiplying the relative value unit specified in the relative values for dentists scale by the conversion factor specified in (1)(c). The department adopts and incorporates by reference the Relative Values for Dentists (RVDs) published in ~~2009~~ 2011. The RVDs scale is available for inspection at the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(b) remains the same.

(c) The conversion factor used to determine the Medicaid payment amount for services provided to eligible individuals is ~~$32.75~~ $31.27.

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

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

37.86.1105 OUTPATIENT DRUGS, REIMBURSEMENT (1) through (2)(a) remain the same.

(b) The dispensing fees assigned shall range between a minimum of $2.00 and a maximum of ~~$5.04~~ $4.94.

(3) In-state pharmacy providers that are new to the Montana Medicaid program will be assigned an interim ~~$5.04~~ $4.94 dispensing fee until a dispensing fee questionnaire, as provided in (2), can be completed for six months of operation. At that time, a new dispensing fee will be assigned which will be the lower of the dispensing fee calculated in accordance with (2) for the pharmacy or the ~~$5.04~~ $4.94 dispensing fee. Failure to comply with the six months dispensing fee questionnaire requirement will result in assignment of a dispensing fee of $2.00.

(4) through (7) remain the same.

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

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

37.86.1506 HOME INFUSION THERAPY SERVICES, REIMBURSEMENT

(1) Subject to the requirements of these rules, the Montana Medicaid program will pay for home infusion therapy services on a fee basis, as specified in the department's home infusion therapy services fee schedule. The department adopts and incorporates by reference the Home Infusion Therapy Services Fee Schedule dated ~~July 2010~~ August 2011. A copy of the department's fee schedule is posted at the Montana Medicaid provider web site at

http://medicaidprovider.hhs.mt.gov. A copy of the Home Infusion Therapy Services Fee Schedule may also be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951. The specified fees are on a per day or a per dose basis as specified in the fee schedule. The fees are bundled fees which cover all home infusion therapy services as defined in ARM 37.86.1501.

(2) through (4) remain the same.

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

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

37.86.2207 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES, REIMBURSEMENT (1) remains the same.

(2) Reimbursement for nutrition and private duty nursing services is specified in the department's fee schedule. The department adopts and incorporates by reference the department's private duty nursing services EPSDT Fee Schedule dated ~~July 2010~~ August 2011 and the nutrition EPSDT Fee Schedule dated ~~July 2010~~ August 2011. The fee schedules are posted at http://medicaidprovider.hhs.mt.gov. Reimbursement for outpatient chemical dependency treatment is outlined in ARM 37.27.912. A copy of the Nutrition and Private Duty Nursing Services Fee Schedules 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.

(3) remains the same.

(4) Reimbursements for school-based health related services are specified in the School-Based Health Service Fee Schedule dated ~~January~~ August 2011, which is adopted and incorporated by reference. A copy of the School-Based Health Service Fee Schedule is posted at http://medicaidprovider.hhs.mt.gov. Rates are adjusted to reimburse these services at the federal matching assistance percentage (FMAP) rate.

(5) remains the same.

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

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

37.86.2405 TRANSPORTATION AND PER DIEM, REIMBURSEMENT

(1) remains the same.

(2) The department adopts and incorporates by reference the department's Montana Medicaid Fee Schedule, Personal and Commercial Transportation dated ~~July 2010~~ August 2011 that sets forth the reimbursement rates for transportation, per diem, and other Medicaid services. A copy of the department's fee schedule is posted at the Montana Medicaid provider web site at http://medicaidprovider.hhs.mt.gov. A copy of the fee schedule may also be obtained from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

(3) through (5) remain the same.

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

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

37.86.2605 AMBULANCE SERVICES, REIMBURSEMENT (1) remains the same.

(2) The department adopts and incorporates by reference the Montana Medicaid Fee Schedule, Ambulance dated ~~July 2010~~ August 2011. A copy of the fee schedule is posted at the Montana Medicaid provider web site at http://medicaidprovider.hhs.mt.gov. A copy of the department's 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.

(3) and (4) remain the same.

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

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

4. Statement of Reasonable Necessity:

The Montana Medicaid program is administered by the Department of Public Health and Human Services (department) to provide health care to Montana's qualified low income and disabled residents. The program uses state and federal appropriations to pay health care providers for the covered medical services they deliver to their Medicaid patients and clients. The Montana Legislature appropriates the state funds and Montana receives federal funds in proportion to appropriated state funds. The Legislature delegates authority to the department to set the provider reimbursement rates based on the funds appropriated. See 53-6-106(8) and 53-5-113, MCA.

The department is proposing amendments to: ARM 37.86.805 - Hearing Aid Services; ARM 37.86.1004 - Dental Services; ARM 37.86.1105 - Outpatient Drug Services; ARM 37.86.1506 - Home Infusion Therapy; ARM 37.86.2207 - EPSDT Services, Reimbursement; ARM 37.86.2405 - Transportation and Per Diem, Reimbursement; and ARM 37.86.2605 - Air and Ground Licensed Ambulance Services. These proposed amendments establish new Montana Medicaid provider fees as of August 1, 2011, for the listed services.

The proposed amendments give notice that the department will be reducing the reimbursement rates to the identified Medicaid providers by up to 2% beginning on August 1, 2011. These provider rate changes are based on a provider rate increase that went into effect in Fiscal Year (FY) 2010, and was held constant in FY 2011. The 2010 provider rate increase was paid for with one-time-only funding appropriated by the 61st Legislative session meeting in 2009. This one-time-only funding was not included in the budget base for FY 2012 and the funds were not appropriated by the current 62nd Legislative session.

The department considered whether a rate decrease could cause a cost shift to a more expensive service. The department considered the impact of the rate changes on efficiency, economy, quality of care, and access to Medicaid services and concluded that the rates are still sufficient to meet the requirements of 42 USC 1396a (a) (30(A).

In evaluating the reductions needed to live within the legislative appropriation, the department considered the alternatives of eliminating covered services and/or decreasing Medicaid eligibility. The department is unable to decrease eligibility for services after March 23, 2010 and be in compliance with the Medicaid maintenance-of-effort (MOE) requirements of the Patient Protection and Affordable Care Act, PL 111-148, Title II, Sections 2001, et seq. Eliminating optional services was considered and rejected because of the impact on vulnerable Medicaid clients who would lose coverage for services. For these reasons, the department is proposing the following provider rate decreases

ARM 37.86.805

ARM 37.86.805 states the reimbursement rate for providers of hearing aid services.

ARM 37.86. 1004

ARM 37.86.1004 states the reimbursement rate for dental services.

ARM 37.86.1105

ARM 37.86.1105 states the state's maximum dispensing fee for outpatient drug services.

ARM 37.86.1506

ARM 37.86.1506 states the reimbursement rate for home infusion therapy.

ARM 37.86.2207

ARM 37.86.2207 changes the fee schedule date in (2) from July 2010 to August 2011 for private duty nursing services and nutrition, and changes the fee schedule date in (4) from January 2011 to August 2011 for school-based services.

ARM 37.86.2405

ARM 37.86.2405 changes the fee schedule date in (2) from July 2010 to August 2011.

ARM 37.86.2605

ARM 37.86.2605 states the reimbursement rate for air and ground licensed ambulance services.

Fiscal Impact

The estimated federal and state general fund and total cost to the department for the following rule changes are listed below based on the blended Federal Medical Assistance Percentage (FMAP) method of 66.19% Federal Funds, 33.81% State Funds:

SFY 2012 PROGRAM FED STATE TOTAL

37.86.805 Hearing Aid Services ($2,626) ($1,342) ($3,968)

37.86.1004 Dental ($255,773) ($130,649) ($386,422)

37.86.1105 Outpatient Drugs ($70,494) ($36,009) ($106,503)

37.86.1506 Home Infusion ($17,515) ($8,946) ($26,461)

Therapy Services

37.86.2207 EPSDT: Private ($49,198) ($25,130) ($74,328)

Duty Nursing

37.86.2207 EPSDT: Nutrition ($116) ($59) ($175)

37.86.2405 Transportation and ($28,684) ($14,652) ($43,336)

Per Diem

37.86.2605 Ambulance Services ($42,870) ($21,898) ($64,768)

Number of persons / providers effected:

The proposed rule changes could effect an estimated 81,920 Medicaid recipients and the following number of providers listed by program: 48 hearing aid providers; 265 pharmacy providers; 11 home infusion therapy providers; 169 optometric providers; 12 private duty nursing providers; 7 nutrition providers; 229 school-based services providers; 17 transportation providers; 107 ambulance providers.

5. 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: Kenneth Mordan, 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., June 23, 2011.

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

7. 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 5 above or may be made by completing a request form at any rules hearing held by the department.

8. 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.

9. 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 May 16, 2011