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 37.85.105, 37.86.2803, 37.86.2901, 37.86.2907, and 37.86.2928, pertaining to Medicaid inpatient hospital services

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NOTICE OF PROPOSED AMENDMENT

TO: All Concerned Persons

1. On March 20, 2013, at 2:30 p.m., the Department of Public Health and Human Services will hold a public hearing in Room 207 of the Department of Public Health and Human Services Building, 111 North Sanders, at 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 March 13, 2013, 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:

37.85.105 Effective dates of Montana Medicaid Provider Fee Schedules (1) remains the same.

(2) The department adopts and incorporates by reference, the fee schedule for the following programs on the date stated:

(a) remains the same.

(b) inpatient hospital services fee schedule and inpatient hospital base rates to include:

(i) the APR-DRG fee schedule for inpatient hospitals, as provided in ARM 37.86.2907, is effective April 1, 2013;

(ii) the Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), outlier thresholds, and APR grouper version 29 are contained in the APR-DRG Table of Weights and Thresholds effective April 1, 2013. The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds, effective April 1, 2013.

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

IMP: 53-2-201, 53-6-101, 53-6-402, MCA

37.86.2803 ALL HOSPITAL REIMBURSEMENT, COST REPORTING

(1) and (2) remain the same.

(3) All hospitals reimbursed under ARM 37.86.2806, 37.86.2905, 37.86.2907, 37.86.2912, 37.86.2916, 37.86.2918, 37.86.2920, 37.86.2924, 37.86.2925, 37.86.2928, 37.86.2943, 37.86.2947, 37.86.3005, 37.86.3006, 37.86.3007, 37.86.3009, 37.86.3014, 37.86.3016, 37.86.3018, 37.86.3020, 37.86.3022, 37.86.3025, 37.86.3037, or 37.86.3109 or must file the cost report with the Montana Medicare intermediary and the department on or before the last day of the fifth calendar month following the close of the period covered by the report. For fiscal periods ending on a day other than the last day of the month, cost reports are due 150 days after the last day of the cost reporting period.

(a) remains the same.

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

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-149, MCA

37.86.2901 INPATIENT HOSPITAL SERVICES, DEFINITIONS (1) through (21) remain the same.

(22) "Hospital Acquired Condition (HAC)" means a condition that occurs during an inpatient hospital stay and results in a high cost or high volume of care or both; results in a claim being assigned to a diagnosis related group (DRG) that has a higher payment when present as a secondary diagnosis; and could have reasonably been prevented through the application of evidence-based guidelines as defined in Section 5001(c) of the Deficit Reduction Act of 2005.

(22) through (31) remain the same, but are renumbered (23) through (32).

(33) "Present on Admission (POA)" means conditions that are present at the time a medical order for an inpatient admission occurs.

(32) through (43) remain the same, but are renumbered (34) through (45).

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

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, 53-6-149, MCA

37.86.2907 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, APR-DRG PAYMENT RATE DETERMINATION (1) The department's APR-DRG prospective payment rate for inpatient hospital services is based on the classification of inpatient hospital discharges to APR-DRGs. The provider reimbursement rates for inpatient hospital services, except as otherwise provided in ARM 37.85.206, is stated in the department's APR-DRG fee schedule adopted and effective at ARM 37.85.105. The procedure for determining the APR-DRG prospective payment rate is as follows:

(a) and (b) remain the same.

(c) The department computes a Montana average base price per case. This base price includes in-state and out-of-state distinct part rehabilitation units and long term care (LTC) facilities. ~~Effective~~ ~~April 1, 2012~~ ~~the average base price, including capital expenses, is~~ ~~$4,630~~. The effective date and base rate amount is adopted and effective as provided at ARM 37.85.105. Disproportionate share payments are not included in this price.

~~(i)~~(d) ~~The average base price for Center of Excellence hospitals, including capital expenses, is~~ ~~$7,725~~. The department computes a base price for Center of Excellence hospitals. The effective date and base rate amount is adopted and effective as provided at ARM 37.85.105. Disproportionate share payments are not included in this price.

(d) and (e) remain the same, but are renumbered (e) and (f).

(2) The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds adopted and effective at ARM 37.85.105. The Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), outlier thresholds, and APR grouper version 29 are contained in the APR-DRG Table of Weights and Thresholds ~~(effective April 1, 2012)~~ which are adopted and effective as provided at ARM 37.85.105 and published by the department. ~~The department adopts and incorporates by reference the~~ ~~APR-DRG Table of Weights and Thresholds (effective April 1, 2012).~~ Copies 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.

AUTH: 2-4-201, 53-2-201, 53-6-113, MCA

IMP: 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

37.86.2928 INPATIENT HOSPITAL REIMBURSEMENT, HOSPITAL REIMBURSEMENT ADJUSTOR (1) and (2) remain the same.

(3) Part 2 of the ~~IRA~~ HRA payment will be based upon total hospital Medicaid charges, and will be computed as follows: HRA2 = (I ÷ D) x P.

(a) through (c) remain the same.

AUTH: 2-4-201, 53-2-201, 53-6-113, MCA

IMP: 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-149, MCA

4. STATEMENT OF REASONABLE NECESSITY

The Department of Public Health and Human Services (the department) is proposing amendments to ARM 37.85.105, 37.86.2803, 37.86.2901, 37.86.2907, and 37.86.2928, regarding Medicaid Inpatient Hospital Services. The following describes the purpose of the proposed rule amendments and necessity pertaining to each rule:

ARM 37.85.105

In (2)(b), language would be added to clarify that: (1) the inpatient hospital fee schedule, (2) both inpatient hospital base rates, and (3) the APR-DRG Table of Weights and Thresholds which include effective dates and base rate amounts, are listed within ARM 37.85.105 and would be adopted and incorporated by reference. This proposed addition is necessary as access to this information will be considerably easier for providers and department personnel and provides a legal reference for the rule.

ARM 37.86.2803

In (1), the CMS publication 15 (Medicare Provider Reimbursement Manual), Form 2552-10, would be updated to the current transmittal number of "3". This update is necessary to ensure that the department and providers are utilizing the most current federal publication.

A typographical error in (3) would be corrected to provide clarity and accuracy within the rule.

ARM 37.86.2901

In (22), the term "Hospital Acquired Condition" (HAC) would be added to the list of definitions. This is necessary to provide clarity to the term as it pertains to inpatient hospital services.

In (33), the term "Present on Admission" (POA) would be added to the list of definitions. This is necessary to provide clarity to the term as it pertains to inpatient hospital services.

ARM 37.86.2907

The proposed amendment would add to (1) language which clarifies that the provider reimbursement rates for inpatient hospital services, except as otherwise provided in ARM 37.85.206, as stated in the department's APR-DRG fee schedule adopted and effective as provided at ARM 37.85.105. This proposed change is necessary as access to this information will be considerably easier for providers and department personnel and provides a legal reference for the rule.

In (1)(c), the reference to the Montana average base rate amount and the effective year would be removed. Reference to ARM 37.85.105 would be added which is where the base rate amount and effective date will be recorded. This proposed change is necessary as access to this information will be considerably easier for providers and department personnel.

In (1)(c)(i), the reference to the Center of Excellence average base rate amount and the effective year would be removed. Reference to ARM 37.85.105 would be added which is where the base rate amount and effective date will be recorded. This proposed change is necessary as access to this information will be considerably easier for providers and department personnel.

In (2), language would be added to clarify that the department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds and the APR grouper version adopted and effective at ARM 37.85.105. This proposed change is necessary to provide the current effective date as to when the APR-DRG weights and measures and the grouper are reviewed and to provide a legal reference for the rule.

ARM 37.86.2928

There is a typographical error in (3) where the acronym "IRA" is listed.

This would be corrected to "HRA" which is consistent with the information pertained in the rule.

FISCAL IMPACT

The proposed amendments to the stated rules regarding inpatient hospital services will not have any fiscal impact on the Medicaid budget for state fiscal year (SFY) 2014. Current hospital base rates would remain the same having a budget neutral effect. The proposed changes would affect approximately 372 inpatient hospital providers both in and out of state. Services provided to Medicaid clients would not be affected.

5. The department intends to apply these rules retroactively to April 1, 2013. A retroactive application of the proposed rules does not result in a negative impact to any affected party.

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: 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., March 28, 2013.

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/ John Koch /s/ Richard H. Opper

John Koch Richard H. Opper, Director

Rule Reviewer Public Health and Human Services

Certified to the Secretary of State February 19, 2013.