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| Montana Administrative Register Notice 37-636 | No. 8 04/25/2013 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Concerned Persons 1. On May 15, 2013, at 10:00 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 Human Services Building, 111 North Sanders, Helena, Montana, to consider the proposed adoption and 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 May 8, 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 adopted provide as follows: NEW RULE I EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), ORIENTATION AND MOBILITY SPECIALIST SERVICES (1) Orientation and Mobility Specialist Services are those services provided by an individual with: (a) a certification from the Academy for Certification of Vision Rehabilitation and Education Professionals (ACVREP); or (b) a National Orientation and Mobility Certification (NOMC) offered by the National Blindness Professional Certification Board (NBPCB) to Medicaid clients with a diagnosis of a visual impairment. (2) Orientation and Mobility Specialist Services are medically necessary services provided to Medicaid clients whose health conditions cause them to need vision-assisted services. AUTH: 53-2-201, 53-6-101, 53-6-113, MCA IMP: 53-2-201, 53-6-101, 53-6-111, MCA NEW RULE II EFFECTIVE DATES OF PROVIDER FEE SCHEDULES FOR MONTANA NON-MEDICAID SERVICES (1) The department adopts and incorporates by reference the fee schedule for the following programs within the Addictive and Mental Disorders Division and Developmental Services Division on the dates stated: (a) Mental health services plan provider reimbursement, as provided in ARM 37.89.125, is effective July 1, 2013. (b) 72-hour presumptive eligibility for adult-crisis stabilization services reimbursement for services, as provided in ARM 37.89.523, is effective July 1, 2013. (c) Youth respite services reimbursement for services as provided in ARM 37.87.2233, is effective July 1, 2013. (2) Copies of the department's current fee schedules are 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. A description of the method for setting the reimbursement rate and the administrative rules applicable to the covered service is published in the chapter or subchapter of this title regarding that service. AUTH: 53-2-201, 53-6-101, 53-6-113, MCA 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: 37.40.705 HOME HEALTH SERVICES, REIMBURSEMENT (1) Reimbursement fees for home health services are as (2) (a) (b) (c) medical supplies and equipment suitable for use in the home IMP: 53-6-101, 53-6-111, 53-6-131, 53-6-141, MCA 37.40.1105 PERSONAL CARE SERVICES, AGENCY-BASED REIMBURSEMENT (1) Personal care services may be provided up to but not more than 40 hours of attendant service per week per (a) through (c) remain the same. (2)
(3) Personal assistance services include the following: (a) attendant service is a 15-minute unit and means an on-site visit specific to a person; (b) nurse supervision is a 15-minute unit and means an on-site person visit and related activity specific to that person; (c) medical escort is a 15-minute unit and means transportation time and appointment time so the person can access an approved medical appointment; and (d) mileage is a unit of one mile and means reimbursement for mileage when an attendant uses their vehicle to transport a person on an approved shopping trip.
(4) remains the same, but is renumbered (5). AUTH: 53-2-201, 53-6-101, 53-6-113, MCA 37.40.1303 SELF-DIRECTED PERSONAL ASSISTANCE SERVICES, REIMBURSEMENT (1) Self-directed personal assistance services may be provided up to but not more than 40 hours of attendant service per week per (a) through (c) remain the same. (2)
(3) Self-directed personal assistance services include the following: (a) attendant service is a 15-minute unit and means an on-site visit specific to a person; (b) program oversight is a 15-minute unit and means an on-site person visit and related activity specific to that person; (c) medical escort is a 15-minute unit and means transportation time and appointment time so the person can access an approved medical appointment; and (d) mileage is a unit of one mile and means reimbursement for mileage when an attendant uses their vehicle to transport a person on an approved shopping trip.
(4) remains the same, but is renumbered (5). AUTH: 53-6-113, MCA 37.79.102 DEFINITIONS As used in this subchapter, unless expressly provided otherwise, the following definitions apply: (1) through (13) remain the same. (14) "Federal poverty level (FPL)" means the poverty guidelines for (15) through (38) remain the same. AUTH: 53-4-1004, 53-4-1009, 53-4-1105, MCA IMP: 53-4-1003, 53-4-1004, 53-4-1009, 53-4-1103, 53-4-1104, 53-4-1105, 53-4-1108, MCA 37.79.304 SERVICES COVERED (1) The department adopts and incorporates by reference the HMK Evidence of Coverage dated (2) remains the same. AUTH: 53-4-1009, 53-4-1105, MCA IMP: 53-4-1005, 53-4-1109, MCA 37.85.105 Effective dates, CONVERSION FACTORS, POLICY ADJUSTERS, AND COST-TO-CHARGE RATIOS of Montana Medicaid Provider Fee Schedules (1) The Montana Medicaid (2) The department adopts and incorporates by reference, the resource-based relative value scale (RBRVS) reimbursement methodology for specific providers as described in ARM 37.85.212 on the date stated. (a) Resource-based relative value scale (RBRVS) means the version of the Medicare resource-based relative value scale contained in the Medicare Physician Fee Schedule adopted by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services and published at 77 Federal Register 222, 68891 (November 16, 2012), effective January 1, 2013 which is adopted and incorporated by reference. (b) Fee schedules are effective July 1, 2013. The conversion factor for physician services is $31.86. The conversion factor for allied services is $23.11. The conversion factor for mental health services is $22.81. The conversion factor for anesthesia services is $27.55. (c) Policy adjustors are effective July 1, 2013. The maternity policy adjustor is 112%. The family planning policy adjustor is 105%. The psychological testing for youth policy adjustor is 145%. (d) The by-report rate is effective July 1, 2013 and is 46% of the provider's usual and customary charges. (e) The specific percents for modifiers adopted by the department is effective July 1, 2013. (f) Psychiatrists receive a 125% provider rate of reimbursement adjustment to the reimbursement of physicians effective July 1, 2013. (g) Midlevel practitioners receive a 90% provider rate of reimbursement adjustment to the reimbursement of physicians for those services described in ARM 37.86.205(5)(b) effective July 1, 2013. (h) Optometric services receive a 112% provider rate of reimbursement adjustment to the reimbursement for allied services as provided in ARM 37.85.105(2) effective July 1, 2013. (i) Reimbursement for physician administered drugs described at ARM 37.86.105 is determined at 42 CFR 414.904 (2013) and is effective July 1, 2013. (i) the APR-DRG fee schedule for inpatient hospitals as provided in ARM 37.86.2907, effective (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 (b) Outpatient hospital services fee schedule include: (i) the Outpatient Prospective Payment System (OPPS) fee schedule as published by the Centers for Medicare and Medicaid Services (CMS) in 71 Federal Register 226, effective January 1, 2007, and reviewed annually by CMS as required in 42 CFR 419.5 and updated quarterly by the department; (ii) the conversion factor for outpatient services on or after July 1, 2013 is $50.61; (iii) the Medicaid statewide average outpatient cost to charge ratio is 44.5%; and (iv) the bundled composite rate of $267.24 for services provided in an outpatient maintenance dialysis clinic effective on or after July 1, 2013. (c) The hearing aid services fee schedule, as provided in ARM 37.86.805, is effective July 1, 2013. (d) The Relative Values for Dentists, as provided in ARM 37.86.1004, reference published in 2013 resulting in a dental conversion factor of $31.89 is effective July 1, 2013. The dental services covered procedures, the Dental and Denturist Program Provider Manual, as provided in ARM 37.86.1006, is effective July 1, 2013. (e) The outpatient drugs reimbursement, dispensing fees range as provided in ARM 37.86.1105(2)(b) is effective July 1, 2013: (i) a minimum of $2.00 and a maximum of $4.94 for brand-name and nonpreferred generic drugs; (ii) a minimum of $2.00 and a maximum of $6.52 for preferred brand-name and generic drugs and generic drugs not identified on the preferred list; (iii) outpatient drugs reimbursement, compound drug dispensing fee range as provided in ARM 37.86.1105(4), the dispensing fee for each compounded drug will be $12.50, $17.50, or $22.50 based on the level of effort required by the pharmacist, is effective July 1, 2013; (iv) outpatient drugs reimbursement, vaccine administration as provided in ARM 37.86.1105(5), the vaccine administration fee will be $21.32 for the first vaccine and $13.38 for each additional administered vaccine, effective July 1, 2013; and (v) out-of-state providers will be assigned a $3.50 dispensing fee. (f) The home infusion therapy services fee schedule, as provided in ARM 37.86.1506, is effective July 1, 2013. (g) Montana Medicaid adopts and incorporates by reference the Region D Supplier Manual which outlines the Medicare coverage criteria for Medicare covered durable medical equipment, local coverage determinations (LCDs), and national coverage determinations (NCDs) as provided in ARM 37.86.1802, effective July 1, 2013. The prosthetic devices, durable medical equipment, and medical supplies fee schedule, as provided in ARM 37.86.1807, is effective July 1, 2013. (h) The early and periodic screening, diagnostic and treatment (EPSDT) services fee schedules for private duty nursing, nutrition and orientation, and mobility specialists as provided in ARM 37.86.2207(2), is effective July 1, 2013. (i) The transportation and per diem fee schedule, as provided in ARM 37.86.2405, is effective July 1, 2013. (j) The specialized nonemergency medical transportation fee schedule, as provided in ARM 37.86.2505, is effective July 1, 2013. (k) The ambulance services fee schedule, as provided in ARM 37.86.2605, is effective July 1, 2013. (4) The department adopts and incorporates by reference, the fee schedule for the following programs within the Senior and Long Term Care Division on the date stated: (a) Home and community-based services for elderly and physically disabled persons fee schedule, as provided in ARM 37.40.1421, is effective July 1, 2013. (b) Home health services fee schedule, as provided in ARM 37.40.705, is effective July 1, 2013. (c) Personal assistance services fee schedule, as provided in ARM 37.40.1105, is effective July, 2013. (d) Self-directed personal assistance services fee schedule, as provided in ARM 37.40.1303, is effective July 1, 2013. (5) The department adopts and incorporates by reference, the fee schedule for the following programs within the Addictive and Mental Disorders Division on the date stated: (a) Case management services for adults with severe disabling mental illness reimbursement, as provided in ARM 37.86.3515, is effective July 1, 2013. (b) Mental health center services for adults reimbursement, as provided in ARM 37.88.907, is effective July 1, 2013. (c) Home and community-based services for adults with severe disabling mental illness, reimbursement, as provided in ARM 37.90.408, is effective July 1, 2013. (d) Targeted case management services for substance use disorders, reimbursement, as provided in ARM 37.86.4010, is effective July 1, 2013. (6) The department adopts and incorporates by reference, the fee schedule for the following programs within the Developmental Services Division, on the date stated. (a) Mental health services for youth, as provided in ARM 37.87.901 in the Medicaid Youth Mental Health Services Fee Schedule, is effective July 1, 2013. (b) Mental health services for youth, as provided in ARM 37.87.1313 in the 1915(i) HCBS State Plan Program for Youth with Serious Emotional Disturbance Fee Schedule, is effective July 1, 2013. (c) Mental health services for youth, as provided in ARM 37.87.1030 in the 1915(c) HCBS Bridge Waiver for Youth with Serious Emotional Disturbance Fee Schedule, is effective July 1, 2013. IMP: 53-2-201, 53-6-101, 53-6-402, MCA 37.85.212 RESOURCE-BASED RELATIVE VALUE SCALE (RBRVS) REIMBURSEMENT FOR SPECIFIED PROVIDER TYPES (1) For purposes of this rule, the following definitions apply: (a) "Anesthesia units" means time and base units used to compute reimbursement under RBRVS for anesthesia services. Base units are those units as defined by the Medicare program. Time units are 15-minute intervals during which anesthesia is provided. (b) "Conversion factor" means a dollar amount by which the relative value units, or the anesthesia units for anesthesia services, are multiplied in order to establish the RBRVS fee for a service. The effective date and conversion factor amounts are adopted at ARM 37.85.105(2). There are four conversion factor categories: (i) physician services, which applies to the following health care professionals listed in (2): physicians, mid-level practitioners, podiatrists, public health clinics, independent diagnostic testing facilities (IDTF), qualified Medicare beneficiary (QMB) and early and periodic screening, diagnostic and treatment (EPSDT) chiropractors, laboratory and x-ray services, family planning clinics, and dentists providing medical services (ii) allied services, which applies to the following health care professionals listed in (2): physical therapists, occupational therapists, speech therapists, optometrists, opticians, audiologists, (iii) mental health services, which applies to the following health care professionals listed in (2): licensed psychologists, licensed clinical social workers, and licensed professional counselors (iv) anesthesia services, which applies to anesthesia services. (c) through (h) remain the same. (i) "Resource-based relative value scale (RBRVS)" means the (2) Services provided by the following health care professionals will be reimbursed in accordance with the RBRVS methodology set forth in (3): (a) through (r) remain the same. (s) family planning clinics; (t) anesthesia services (u) birth attendants; and (v) EPSDT orientation and mobility specialists. (3) and (4) remain the same. (5) (6) and (7) remain the same. (8) Except for physician administered drugs and vaccine administration as provided in ARM 37.86.105(4), clinical, laboratory services, and anesthesia services, if neither Medicare nor Medicaid sets RVUs or anesthesia units, then reimbursement is by-report. (a) Through the by-report methodology the department reimburses a percent of the provider's usual and customary charges for a procedure code where no fee has been assigned. The percentage is determined by dividing the previous state fiscal year's total Medicaid reimbursement for RBRVS provider covered services by the previous state fiscal year's total Medicaid billings. (b) (9) through (9)(b)(i) remain the same. (ii) the rate established using the by-report methodology; or (A) for purposes of (9)(b) through (9)(b)(iii), the by-report methodology means averaging 50 paid claims for the same code that have been submitted within a 12-month span and then multiplying the average by the amount specified in (8)(b). (iii) remains the same. (10) For anesthesia services the department pays the lower of the following for procedure codes with fees: (a) remains the same. (b) a fee determined by multiplying the anesthesia conversion factor by the applicable anesthesia units, and then multiplying the product by the applicable policy adjustor, if any; or (c) the department pays the lower of the following for procedure codes without fees: (i) remains the same. (ii) the by-report rate. (11) For providers listed at ARM 37.85.212(2) billing for durable medical equipment, prosthetics, orthotics, and medical supplies (DMEPOS), except for the bundled items as provided in (13) (a) remains the same. (b) if there is no fee in (11)(a), the amount determined by multiplying the by-report rate provided in (8)(b) by the billed charges. (12) Subject to the provisions of (12)(a), when billed with a modifier, payment for procedures established under the provisions of (7) is a percentage of the rate established for the procedures. (a) The methodology to determine the specific percent for each modifier is as follows: (i) and (ii) remain the same. (iii) The department's list of the specific percents for the modifiers used by Medicaid (13) remains the same. (14) Providers must bill for services using the procedure codes and modifiers set forth, and according to the definitions contained in the Federal Health Care Administration's Common Procedure Coding System (HCPCS). Information regarding billing codes, modifiers, and HCPCS is available IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-125, MCA 37.86.105 PHYSICIAN SERVICES, REIMBURSEMENT/GENERAL REQUIREMENTS AND MODIFIERS (1) and (2) remain the same. (3) Reimbursement for services of a psychiatrist, except as otherwise provided in this rule, is the lower of: (a) remains the same. (b) to address problems of access to mental health services, subject to funding, mental health services performed by a psychiatrist are reimbursed (4) Reimbursement to physicians for physician-administered drugs which are billed under HCPCS "J" and "Q" codes is made according to the department's fee schedule or the provider's usual and customary charge, whichever is lower. The department's fee schedule is updated at least annually based upon: (a) (b) through (7) remain the same. 37.86.205 MID-LEVEL PRACTITIONER SERVICES, REQUIREMENTS AND REIMBURSEMENT (1) through (4) remain the same. (5) Reimbursement for services, except as otherwise provided in this rule, is the lower of: (a) remains the same. (b) (6) through (10) remain the same. IMP: 53-6-101, MCA 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 (c) and (2) remain the same. IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA 37.86.1004 REIMBURSEMENT METHODOLOGY FOR RESOURCE-BASED RELATIVE VALUE FOR DENTISTS (RVD) (1) remains the same. (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) (b) remains the same. (c) The conversion factor used to determine the Medicaid payment amount for services provided to eligible individuals is IMP: 53-6-101, MCA 37.86.1006 DENTAL SERVICES, COVERED PROCEDURES (1) For purposes of specifying coverage of dental services through the Medicaid program, the department adopts and incorporates by reference the Dental and Denturist Program Provider Manual (2) through (5) remain the same. (6) Full maxillary and full mandibular dentures are a Medicaid covered service. Coverage is limited to one set of dentures every ten years. Only one lifetime exception to the ten-year time period is allowed per (a) and (b) remain the same. (7) Maxillary partial dentures and mandibular partial dentures are a Medicaid covered service. Coverage is limited to one set of partial dentures every five years. Only one lifetime exception to the five-year limit is allowed per (a) and (b) remain the same. (8) The limits on coverage of denture replacement may be exceeded when the department determines that the existing dentures are causing the (a) through (9) remain the same. (10) Orthodontia for (11) Full band orthodontia for (12) and (13) remain the same. (14) Orthodontic treatment not progressing to the extent of the treatment plan because of noncompliance by the (15) through (17) remain the same. 37.86.1105 OUTPATIENT DRUGS, REIMBURSEMENT (1) remains the same. (2) The dispensing fee for filling prescriptions (a) remains the same. (b) The dispensing fees assigned (3) remains the same. (4) The department (a) Prescription claims for compound drugs (b) remains the same. (c) Reimbursement for each drug component (d) remains the same. (e) The department will reimburse pharmacies a compound-drug dispensing fee as provided in ARM 37.85.105(3) in lieu of the dispensing fee stated in (2). Prior authorization (g) through (i) remain the same, but are renumbered (f) through (h). (5) The department will reimburse pharmacies a vaccine administration fee as provided in ARM 37.85.105(3) in lieu of the dispensing fee stated in (2) for any covered vaccine as allowed by the Montana Pharmacy Practice Act, 37-7-101, MCA. (a) for institutions participating in the state contract for pharmacy services, the rates agreed to in that contract. Such reimbursement (b) for institutions not participating in the state contract for pharmacy services, the actual cost of the drug and dispensing fee. Such reimbursement IMP: 53-2-201, 53-6-101, 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 (2) For home infusion therapy services also reimbursed for the (3) Covered drugs prepared and administered as part of a (4) remains the same. 37.86.1802 PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, GENERAL REQUIREMENTS (1) remains the same. (2) Reimbursement for prosthetic devices, durable medical equipment, and medical supplies (a) The prescription must indicate the diagnosis, the medical necessity, and projected length of need for prosthetic devices, durable medical equipment, and medical supplies. The original prescription must be retained in accordance with the requirements of ARM 37.85.414. Prescriptions may be transmitted by an authorized provider to the durable medical equipment provider by electronic means or pursuant to an oral prescription made by an individual practitioner and promptly reduced to hard copy by the durable medical equipment provider containing all information required. Prescriptions for durable medical equipment, prosthetics, and orthotics (DMEPOS) (i) Prescriptions for oxygen (b) Subject to the provisions of (3), medical necessity for oxygen is determined in accordance with the Medicare criteria outlined in the Medicare Durable Medical Equipment Regional Carrier (DMERC) Region D Supplier Manual, (c) remains the same. (d) A statement of medical necessity for the rental of durable medical equipment, excluding oxygen equipment, (e) No more than one month's medical supplies may be provided to a Medicaid (f) remains the same. (g) (3) Providers of oxygen to (4) and (5) remain the same. (6) The following items are not reimbursable by the program: (a) through (f) remain the same. (g) any delivery, mailing or shipping fees, or other costs of transporting the item to the (h) through (7) remain the same. IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA 37.86.1807 PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, FEE SCHEDULE (1) remains the same. (2) Prosthetic devices, durable medical equipment, and medical supplies (3) The department's DMEPOS Fee Schedule for items other than those billed under generic or miscellaneous codes as described in (1) (a) remains the same. (b) Except as provided in (4), for all items for which no Medicare allowable fee is available, the department's fee schedule amount (i) and (ii) remain the same. (4) The department's DMEPOS Fee Schedule, referred to in ARM 37.86.1807(2), for items billed under generic or miscellaneous codes as described in (1) IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA 37.86.2005 OPTOMETRIC SERVICES, REIMBURSEMENT (1) Subject to the requirements of this rule, the Montana Medicaid (a) and (a)(i) remain the same. (ii) to address problems of access to optometric services, subject to funding, up to AUTH: 53-6-113, MCA IMP: 53-6-101, 53-6-113, 53-6-141, MCA 37.86.2206 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), MEDICAL AND OTHER SERVICES (1) remains the same. (2) In addition to the services generally available to Medicaid (a) through (d) remain the same. (e) (g) orientation and mobility specialist services as provided in [NEW RULE I]. IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA 37.86.2207 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES, REIMBURSEMENT (1) Reimbursement for an EPSDT service, except as otherwise provided in this rule, is the lowest of the following: (a) and (b) remain the same. (c) the department's Medicaid Mental Health Fee Schedule (d) remains the same. (2) Reimbursement for nutrition, (3) remains the same. (4) Reimbursements for school-based health related services are specified in the School-Based Health Service Fee Schedule. IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA 37.86.2230 EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), SCHOOL-BASED HEALTH RELATED SERVICES (1) remains the same. (2) School-based health related services may include: (a) through (i) remain the same. (j) comprehensive school and community treatment; (k) specialized transportation; and (l) orientation and mobility specialist services. (3) through (5) remain the same. IMP: 53-2-201, 53-6-101, 53-6-111, 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 (3) through (5) remain the same. IMP: 53-6-101, 53-6-113, 53-6-141, MCA 37.86.2505 SPECIALIZED NONEMERGENCY MEDICAL TRANSPORTATION, REIMBURSEMENT (1) remains the same. (2) The department adopts and incorporates by reference the department's fee schedule IMP: 53-6-101, 53-6-113, 53-6-141, 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 (3) For items and services for which no fee has been set in the department's fee schedule referred to in (2), reimbursement will be based on the by-report method and rate specified in ARM (a) through (b)(iii) remain the same. (4) The department may reimburse providers for ambulance services to transport patients to and from out-of-state facilities at negotiated fees where the department or its designee in its discretion determines that the in-state reimbursement rates are inadequate to assure that the IMP: 53-6-101, 53-6-113, 53-6-141, MCA 37.86.3020 OUTPATIENT HOSPITAL SERVICES, OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) METHODOLOGY, AMBULATORY PAYMENT CLASSIFICATION (1) Outpatient hospital or birthing center services that are not provided by critical access hospitals will be reimbursed on a rate-per-service basis using the Outpatient Prospective Payment System (OPPS) schedules. The provider reimbursement rates for outpatient hospital services is stated in the department's Outpatient Prospective Payment System (OPPS) Fee Schedule as provided in ARM 37.85.105(3). Under this system, Medicaid payment for outpatient services included in the OPPS is made at a predetermined, specific rate. These outpatient services are classified according to a list of APCs published annually in the Code of Federal Regulations (CFR). The rates for OPPS are determined as follows: (a) The department uses a conversion factor for each APC group as defined in ARM 37.86.3001(5). (b) through (d) remain the same. (e) If the OPPS does not assign a Medicare fee or APC for a particular procedure code, a Medicaid fee will be assigned in accordance with the resource-based relative value scale (RBRVS) methodology found at ARM 37.85.212. If there is not a Medicaid fee, the service will be reimbursed at hospital-specific outpatient cost-to-charge ratio as in ARM 37.86.2803. Birthing centers and out-of-state hospitals will be reimbursed the statewide outpatient cost-to-charge ratio: (i) (f) through (h) remain the same. (2) The department adopts and incorporates by reference the OPPS Schedules published by the Centers for Medicare and Medicaid Services (CMS) IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA 37.86.3515 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, REIMBURSEMENT (1) and (2) remain the same. (3) The department adopts and incorporates by reference the department's fee schedule (4) remains the same. IMP: 53-2-201, 53-6-101, 53-6-113, MCA 37.86.4010 TARGETED CASE MANAGEMENT SERVICES FOR SUBSTANCE USE DISORDERS, REIMBURSEMENT (1) and (2) remain the same. (3) The provider reimbursement rate for case management services for substance use disorders is stated in the department's fee schedule provided in ARM 37.85.105(5). (3) and (4) remain the same, but are renumbered (4) and (5). IMP: 53-2-201, 53-6-101, 53-6-113, MCA 37.86.4205 DIALYSIS CLINICS FOR END STAGE RENAL DISEASE, REIMBURSEMENT (1) Reimbursement for outpatient maintenance dialysis and other related services provided in a AUTH: 53-6-113, MCA IMP: 53-6-101, MCA 37.87.901 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, REIMBURSEMENT (1) Medicaid reimbursement for mental health services shall be the lowest of: (a) remains the same. (b) the rate established in the department's fee schedule. IMP: 53-2-201, 53-6-101, 53-6-113, MCA 37.87.1303 HOME AND COMMUNITY-BASED 1915(c) SERVICES BRIDGE WAIVER FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: FEDERAL AUTHORIZATION AND AUTHORITY OF STATE TO ADMINISTER PROGRAM (1) through (3) remain the same. (4) The 1915(c) home and community-based bridge waiver services for youth with serious emotional disturbance must be delivered in accordance with the requirements and limitations of the Home and Community-Based Services Bridge Waiver for Youth with Serious Emotional Disturbance Policy Manual dated (5) The department adopts and incorporates by reference the 1915(c) HCBS Bridge Waiver for Youth with Serious Emotional Disturbance Policy Manual, dated July 1, 2013. A copy of the manual may be obtained from the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 Sanders, P.O. Box 4210, Helena, MT 59604 or at http://www.dphhs.mt.gov/mentalhealth/children/. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1313 1915(i) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN PROGRAM FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: FEDERAL AUTHORIZATION AND AUTHORITY OF STATE TO ADMINISTER PROGRAM (1) through (3) remain the same. (4) The 1915(i) home and community-based services state plan program for youth with serious emotional disturbance must be delivered in accordance with the requirements and limitations of the 1915(i) HCBS State Plan Program for Youth with Serious Emotional Disturbance Policy Manual dated (5) The department adopts and incorporates by reference the 1915(i) HCBS State Plan Program for Youth with Serious Emotional Disturbance Policy Manual, dated July 1, 2013. A copy of the manual may be obtained from the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 Sanders, P.O. Box 4210, Helena, MT 59604 or at http://www.dphhs.mt.gov/mentalhealth/children/. AUTH: 53-6-113, MCA IMP: 53-6-101, MCA 37.87.1314 1915(i) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN PROGRAM FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: REIMBURSEMENT (1) remains the same. (2) Program services are reimbursed at the lower of the following: (a) remains the same. (b) (3) and (4) remain the same. AUTH: 53-6-113, MCA IMP: 53-6-101, MCA 37.87.1333 HOME AND COMMUNITY-BASED 1915(c) SERVICES BRIDGE WAIVER FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: REIMBURSEMENT (1) Services available through the program are reimbursed as provided in this rule. (2) Program services are reimbursed at the lower of the following: (a) remains the same. (b) (3) and (4) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.2233 MENTAL HEALTH SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE (SED) RESPITE CARE SERVICES, PROVIDER REIMBURSEMENT (1) Respite care services are non-Medicaid funded services except for youth with SED enrolled in the (2) remains the same. (3) Reimbursement for respite care services is as provided in the department's Medicaid fee schedule, as adopted in ARM (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 37.88.907 MENTAL HEALTH CENTER SERVICES FOR ADULTS, REIMBURSEMENT (1) The department adopts and incorporates by reference the Medicaid Adult Mental Health and the Adult Mental Health Services Plan fee schedule (a) and (b) remain the same. (2) The provider reimbursement rate for a covered service for mental health centers is stated in the department's fee schedule adopted and effective at ARM 37.85.105(5). These fees are calculated based on: (a) the biennial legislative appropriation; and (b) the estimated demand for covered services during the biennium. (2) through (6) remain the same, but are renumbered (3) through (7). IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA 37.89.125 MENTAL HEALTH SERVICES PLAN, PROVIDER REIMBURSEMENT (1) remains the same. (a) For services covered under the plan, reimbursement under the plan is subject to the same requirements, restrictions, limitations, rates, fees and other provisions that would apply to the service if it were provided to a Medicaid (i) through (5) remain the same. (6) The provider reimbursement rate for services under the Mental Health Services Plan is stated in the department's fee schedule as provided in [NEW RULE II]. These fees are calculated based on: (a) the biennial legislative appropriation; and (b) the estimated demand for covered demand for covered services during the biennium. AUTH: 53-2-201, 53-6-113, 53-21-703, MCA IMP: 53-1-601, 53-2-201, 53-6-101, 53-6-116, 53-6-701, 53-6-705, 53-21-202, 53-21-702, MCA 37.89.523 72-HOUR PRESUMPTIVE ELIGIBILITY FOR ADULT CRISIS STABILIZATION SERVICES: REIMBURSEMENT FOR SERVICES (1) The department adopts and incorporates by reference the Medicaid 72-Hour Presumptive Eligibility Crisis Stabilization Services fee schedule dated August 2011. A copy of the department's fee schedule is posted at the Montana Medicaid provider web site at www.dphhs.mt.gov/amdd/services/index.shtml. A copy may be obtained from the Department of Public Health and Human Services, Addictive and Mental Disorders Division, PO Box 202905, Helena, MT 59620-2951. Reimbursement for services delivered under this subchapter will be the amounts listed in the fee schedule. The provider reimbursement rate for 72-Hour Presumptive Eligibility Crisis Stabilization Services is stated in the department's fee schedule as provided in [New Rule II]. These fees are calculated based on: (a) the biennial legislative appropriation; and (b) the estimated demand for covered services during the biennium. (2) remains the same. IMP: 53-6-101, MCA 37.90.408 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS: REIMBURSEMENT (1) The department adopts and incorporates by reference the Medicaid Home and Community-Based Services for Adults With Severe Disabling Mental Illness (a) the biennial legislative appropriation; and (b) the estimated demand of covered services during the biennium. (2) through (8) remain the same. (9) No copayment is imposed on services provided through the program but (10) Reimbursement is not available for the provision of services to other members of a person's household or family unless specifically provided for in these rules. IMP: 53-6-402, MCA 5. STATEMENT OF REASONABLE NECESSITY The Department of Public Health and Human Services (the department) is adopting New Rule I pertaining to the addition of a new service for Orientation and Mobility (O and M) to the existing Early and Periodic Screening, Diagnosis and Treatment (EPSDT) services. New Rule II is also being proposed and will contain the fee incorporation by reference for fee schedules for the Addictive and Mental Disorders Division and the Developmental Services Division. These fee schedules are for non-Medicaid funded services. The department is proposing to amend the following: ARM 37.40.705, 37.40.1105, 37.40.1303, 37.79.102, 37.79.304, 37.85.105, 37.85.212, 37.86.105, 37.86.205, 37.86.805, 37.86.1004, 37.86.1006, 37.86.1105, 37.86.1506, 37.86.1802, 37.86.1807, 37.86.2005, 37.86.2206, 37.86.2207, 37.86.2230, 37.86.2405, 37.86.2505, 37.86.2605, 37.86.3020, 37.86.3515, 37.86.4010, 37.86.4205 37.87.901, 37.87.1303, 37.87.1313, 37.87.1314, 37.87.1333, 37.87.2233, 37.88.907, 37.89.125, 37.89.523, and 37.90.408 pertaining to the implementation of new rates within the Montana Medicaid's fee schedules. This proposed rulemaking continues the process of reorganizing all administrative rules containing information about the incorporation by reference of all Medicaid rates and fee schedules into one administrative rule. This rulemaking combines four of the department's division's administrative rules into one rule that will help providers of services to obtain information about the department's many fee schedules in one place. The four divisions whose rules are incorporated together are the Health Resources Division, Senior and Long Term Care Division, Addictive and Mental Disorders Division, and the Developmental Services Division. Each of the division's administrative rule changes are described below and broken down by each division. A fiscal impact is included with each of the division's statement of reasonable necessity. The department is proposing to change the term "recipient" or "consumer" throughout these proposed rule amendments to "person" to be consistent with other department rules. STATEMENT OF REASONABLE NECESSITY ORIENTATION AND MOBILITY SPECIALIST SERVICES New Rule I New Rule I is being proposed to add the services of an Orientation and Mobility Specialist Services to the list of services covered under EPSDT in accordance with 53-6-101(4)(q), MCA. A new fee schedule for Orientation and Mobility Specialist Services along with a provider manual for training and future reference has been developed. The department has determined such services to be necessary for blind and low-vision persons. New Rule II The department is proposing New Rule II to include those fee schedules that are for non-Medicaid services. Two fee schedules are being added for the Addictive and Mental Disorders Division and one for the Developmental Services Division. ARM 37.86.2206 The department is amending this rule to include a service of the Orientation and Mobility Specialist Services with existing services made available to EPSDT clients. ARM 37.86.2230 The department is amending this rule to include a service of the Orientation and Mobility Specialist with the existing services made available in the School-Based Health Related Services. Two new codes will be included in the School-Based Fee Schedule and the Orientation and Mobility Specialist service will be included in the School-Based Provider Manual along with others in Coverage of Specific Services. There is no fiscal impact to the Montana Medicaid Program because Montana Medicaid would cover this service under EPSDT regulations as medically necessary. The alternative to the proposed amendments would be to make no changes to the existing rules. The department recognizes Orientation and Mobility Specialist services are medically necessary and covered under EPSDT. These rules will enable the department to reimburse and track services once defined in rule. STATEMENT OF REASONABLE NECESSITY HEALTH RESOURCES DIVISION The Department of Public Health and Human Services (the department) is proposing amendments to ARM 37.86.3020, outpatient hospital services, regarding a 2% increase in Medicaid fees to providers. This increase is mandated by House Bill 2 (HB2) of the 63rd Montana Legislature. The proposed rule amendments also address a 2% decrease in Medicare funding as estimated by the Congressional Budget Office (CBO) due to the federal sequestration effective March 1, 2013. Many services provided through the Medicaid program utilize reimbursement methodology which is established by Medicare. Because Medicaid follows many of the Medicare fee schedules, this decrease in Medicare funding will have a negative effect upon reimbursement to Medicaid providers and the state Medicaid budget. This decrease in Medicare funding is not expected to impact services to Montana Medicaid members. In addition, language will be added incorporating fee schedules, dates, conversion factors, percentages, and rates for services provided through the Health Resources Division (HRD) under one reimbursement rule (ARM 37.85.105) rather than having separate reimbursement rules for each service. These services include outpatient hospital, physician, pharmacy, HMK, and acute services. It is necessary for the department to incorporate these services under one rule to organize and streamline the process of updating fee schedules, dates, conversion factors, percentages, and rates pertaining to each service as necessary. STATEMENT OF REASONABLE NECESSITY – HEALTHY MONTANA KIDS (HMK) The department incorporated by reference into Administrative Rules of Montana the HMK Evidence of Coverage effective October 1, 2012. The HMK Evidence of Coverage describes the health care benefits available to HMK coverage group enrollees. HMK is proposing to revise the effective date regarding the Evidence of Coverage referenced in ARM 37.79.304. Out-of-state medical services for HMK members are provided through the third party administrator's (TPA) Blue Card Program, and the language for the Blue Card Program must be approved by the Blue Cross Blue Shield Association. HMK's TPA is Blue Cross Blue Shield of Montana (BCBSMT) and they are part of the BCBS Association. Upon implementation of HMK (formerly CHIP) in 1999 the department purchased insurance policies for members through BCBSMT. The current language in the HMK Evidence of Coverage applies to a fully insured product. Effective October 1, 2007, HMK transitioned from a fully insured product to a publicly funded product and Blue Card Program language in the HMK Evidence of Coverage has not been updated to address this change. BCBSMT requested updated Blue Card Program language in the HMK Evidence of Coverage. In addition, HMK is proposing an update to information regarding the "Federal Poverty Level" (FPL) to include the current effective date and current reference to the federal register. This rule change is required by program policy to follow the current version of the FPL guidelines when determining eligibility for program participants. The definition of FPL changes when FPL is updated in the Federal Register (usually on an annual basis). New 2013 FPL levels impact all applicants for Healthy Montana Kids because the designated income levels are higher than the previous year, thereby allowing more applicants access to coverage. The following describes the purpose of the proposed rule amendments pertaining to HMK: ARM 37.79.304
Regarding the Healthy Montana Kids Program, the effective date that references the program's Evidence of Coverage will be updated. This proposed change is necessary to align these administrative rules with current HMK policy. ARM 37.79.102 The effective date for the FPL and the reference to the Federal Register will be updated. Since member eligibility is determined using the FPL as updated in the Federal Register, it is necessary to update the rule to reflect the most current FPL within the most current reference to the Federal Register. The proposed rule amendments regarding the Healthy Montana Kids Program will have no fiscal impact on members or providers. STATEMENT OF REASONABLE NECESSITY – HOSPITAL SERVICES
The following describes the purpose of the proposed rule amendments pertaining to hospital services: ARM 37.85.105 The effective date regarding the inpatient hospital fee schedule, inpatient hospital base rates, and the bundled composite rate for dialysis clinics will be revised to July 1, 2013. In addition, language will be added incorporating fee schedules, dates, conversion factors, percentages, and rates for services provided through the Health Resources Division (HRD) under one reimbursement rule, ARM 37.85.105. It is necessary for the department to incorporate these services under one rule to organize and streamline the process of updating fee schedules, dates, conversion factors, percentages, and rates pertaining to each service as necessary. The fiscal impact and number of providers affected can be found within the "fiscal impact" section of this document. ARM 37.86.3020 The outpatient conversion factor regarding the ambulatory payment classifications (APC) fee schedule will be removed from the rule as well as the statewide average cost-to-charge ratio. Language will be added that indicates this conversion factor and ratio is adopted and effective in ARM 37.85.105. This proposed change is necessary to organize the information deleted from ARM 37.86.3020 into one rule and to provide a reference to ARM 37.85.105 where this information can now be found. This is part of the department's continuing reorganization of its rules to make them easier to use. ARM 37.86.4205 The effective date and bundled rate regarding dialysis clinics will be removed. Language will be added which indicates that the effective date and bundled rate is effective and provided in ARM 37.85.105. This proposed change is necessary to organize the information deleted from ARM 37.86.4205 into one rule and provide a reference to ARM 37.85.105 where this information can now be found. STATEMENT OF REASONABLE NECESSITY – ACUTE SERVICES
The Acute Services Bureau is also proposing to add the ability to reimburse Orientation and Mobility (O and M) Specialists under the EPSDT program. Administrative rules for the O and M specialty establishing the service under EPSDT and school-based services have been included in this proposed rule. The following describes the purpose of the proposed rule amendments pertaining to Acute Services: ARM 37.85.105 The effective date regarding the acute services fee schedule will be revised to July 1, 2013. In addition, language will be added incorporating fee schedules, dates, conversion factors, percentages, and rates for services provided through the Health Resources Division (HRD) under one reimbursement rule, ARM 37.85.105. It is necessary for the department to incorporate these services under one rule to organize and streamline the process of updating fee schedules, dates, conversion factors, percentages, and rates pertaining to each service as necessary. The fiscal impact and number of providers affected can be found within the "fiscal impact" section of this document. ARM 37.86.805 The department is amending this rule by removing the fee schedule date and directing the reader to ARM 37.85.105. ARM 37.86.1004 The department is amending this rule by removing the date the Relative Values for Dentists (RVDs) is published and adding language that indicates this date is adopted and effective as provided at ARM 37.85.105. This amendment also removes the conversion factor used to determine the Medicaid payment amount for dental services and adds language that indicates this conversion factor is adopted and effective as provided at ARM 37.85.105. ARM 37.86.1006 The department is amending this rule by removing the effective date regarding the Dental and Denturist Program Provider Manual and adding language that indicates this date is adopted and effective as provided at ARM 37.85.105. ARM 37.86.1105 The department is amending this rule by removing the dispensing fee for outpatient drugs in (b)(i) and (b)(ii) and adding language that indicates these fees are adopted and effective as provided at ARM 37.85.105. This amendment removes the dispensing fee for compound drugs and adds language that indicates prior authorization is required for compound drug dispensing fees over the minimum provided at ARM 37.85.105. This amendment also removes the dispensing fee for compound drugs and adds language that indicates these fees are adopted and effective as provided at ARM 37.85.105. New language has been added to address the vaccine administration fee and indicates these fees are adopted and effective as provided at ARM 37.85.105. ARM 37.86.1506 The department is amending this rule by removing the date regarding the home infusion therapy services fee schedule and adds language that indicates this date is adopted and effective as provided at ARM 37.85.105. ARM 37.86.1802 The department is amending this rule by removing the publish dates for the various Medicare local and national coverage determinations, supplier manuals, and policy articles and adds language that indicates these publication are adopted and effective as provided in ARM 37.85.105.
ARM 37.86.1807 The department is amending this rule by removing the date regarding the durable medical equipment and medical supplies fee schedule and adds language that indicates this date is adopted and effective as provided at ARM 37.85.105. ARM 37.86.2005 The department is amending this rule by removing the percentage regarding reimbursement for allied services and adding language that indicates this percentage is adopted and effective as provided at ARM 37.85.105.
ARM 37.86.2207 The department is amending this rule by removing the dates regarding the department's private duty nursing services EPSDT fee schedule and the nutrition EPSDT fee schedule and add language that indicates these dates are adopted and effective as provided at ARM 37.85.105. Language will be added regarding a new orientation and mobility EPSDT fee schedule and language is added to indicate this fee schedule is adopted and effective as provided at ARM 37.85.105. ARM 37.86.2405 The department is amending this rule by removing the date regarding the Personal and Commercial Transportation Fee Schedule and adding language that indicates this date is adopted and effective as provided at ARM 37.85.105. ARM 37.86.2505 The department is amending this rule by removing the date regarding the Specialized Nonemergency Medical Transportation Services Fee Schedule and adds language that indicates this date is adopted and effective as provided at ARM 37.85.105.
ARM 37.86.2605 The department is amending this rule by removing the date regarding the ambulance fee schedule and adding language that indicates this date is adopted and effective as provided at ARM 37.85.105. These changes are necessary to update the fee schedule dates in rule; to provide for the two percent provider rate increase appropriated in HB2 and update reimbursement rules to reflect current policy. In addition, federal sequestration will reduce Medicare funding by 2% as estimated by the Congressional Budget Office (CBO). The Medicaid Durable Medical Equipment Program reimburses providers 100% of the Medicare Region D allowable fee as stated in ARM 37.86.1807(3). Some Medicaid Durable Medical Equipment fees will be reduced as a result of the Medicare competitive bidding for diabetic supplies as authorized in Section 1847 of the Social Security Act and Section 636(b) of the American Taxpayer Relief Act of 2012 (ATRA). Fiscal Impact The estimated general fund cost to the Acute Services Bureau for the following rule changes are listed below for State Fiscal Year 2014: ARM 37.86.805 Hearing Aid Services; $1,052 ARM 37.86.1004 and 37.86.1006 Dental Services; $153,684 ARM 37.86.1105 Outpatient Drugs; $38,739 ARM 37.86.1506 Home Infusion Therapy Services; $5,129 ARM 37.86.1807 Durable Medical Equipment; ($101,235) Federal Sequestration ARM 37.86.1807 Durable Medical Equipment; ($26,428) competitive bidding for diabetic supplies ARM 37.86.2207 EPSDT: Private Duty Nursing; $27,742 ARM 37.86.2207 EPSDT: Nutrition; $72 ARM 37.86.2405 Transportation and Per Diem; $19,822 ARM 37.86.2505 Specialized Nonemergency Transportation; $356 ARM 37.86.2605 Ambulance Services; $17,961 ARM 37.86.2005 Optometric (costs are included in 37.85.212) The changes to ARM 37.86.2207 EPSDT O & M Services are expected to have no fiscal impact to the department and no material effects on Medicaid persons or Medicaid providers. Additional information regarding the fiscal impact and number of providers affected can be found within the "fiscal impact" section of this document. STATEMENT OF REASONABLE NECESSITY – PHYSICIAN SERVICES
The Department of Public Health and Human Services (the department) is proposing amendments to ARM 37.85.212, 37.86.105, and 37.86.205. These rules implement Montana Medicaid's resource-based relative value scale (RBRVS) reimbursement method for specified provider types. Montana Medicaid uses the RBRVS rate system to calculate the fees Montana Medicaid pays to 20 types of health care professionals. The Montana Medicaid Program is administered by the department to provide health care to Montana's qualified low income and disabled residents (hereinafter "Medicaid members"). It is a public program paid for with state and federal funds appropriated to pay health care providers (hereinafter "Medicaid providers") for the covered medical services they deliver to Medicaid members. The Legislature delegates authority to the department to set the reimbursement rates Montana pays Medicaid providers for Medicaid covered services. See 53-6-101(8) and 53-6-113, MCA. RBRVS is used nationwide by most health plans, including Medicare and Medicaid. The relative value unit component of RBRVS is revised annually by the Centers for Medicare and Medicaid Services (CMS) and the American Medical Association. The department annually proposes to amend ARM 37.85.212(1)(i) to adopt current relative value units (RVUs). An RVU is a numerical value assigned to each medical procedure. RVUs are based on physician work, practice expense, and malpractice insurance expenses and express the relative effort and expense expended to provide one procedure compared with another. RVUs are added for new procedures and the RVUs of particular procedures may increase or decrease from year to year. The department annually calculates conversion factors for physician services, allied services, mental health services, and anesthesia services. These conversion factors are calculated by dividing the Montana Legislature's appropriation for Medicaid member's health care during the upcoming State Fiscal Year (SFY) by the estimated total units of health care, expressed as total RVUs paid, to be provided during the upcoming SFY. The resulting quotient is the conversion factor. The RVU for a procedure multiplied by the conversion factor is the fee paid for the procedure. The conversion factor for licensed physicians is further set by 53-6-124 through 53-6-127, MCA, and the fees paid are funded by legislative appropriations. The proposed rule amendments address a 2% decrease in Medicare funding as estimated by the Congressional Budget Office (CBO) due to the federal sequestration effective March 1, 2013 for a limited number of fees paid to physicians and mid-level providers. The physician services conversion factor will increase 3.7% due to the increase in the consumer price index for medical services as directed by 53-6-125, MCA and an additional increase of 2% as directed by HB2. HB2 also directs a 2% provider increase for allied services, mental health services, and anesthesia services. The conversion factor amounts for physician services, allied services, mental health services, and anesthesia services will be determined by modeling data. The "by-report" percentage is determined by dividing the amount that is reimbursed for services by the amount billed for the services. For SFY 2014 the department will determine the by-report percentage by modeling. ARM 37.85.105 Proposed amendments to this rule contain the Resource-Based Relative Value Scale (RBRVS) conversion factors and by-report percentage. Modeling has not concluded to determine SFY 2014 amounts. For purposes of this notice we have included rates presently in effect for SFY 2013. The department will continue modeling and file an amended proposed notice by May 13, 2013 with proposed amounts for SFY 2014 that will be effective July 1, 2013. Interested parties will have an opportunity to comment on the proposed amounts for SFY 2014. ARM 37.86.105(4) addresses the reimbursement of physician administered drugs. The department follows the reimbursement methodology used by Medicare for many physician administered drugs. The amendment allows the department to update the fees for these drugs by using the most current information provided by Medicare. The Affordable Care Act requires state Medicaid agencies to reimburse birth attendants separately. The department adopted rule information at ARM 37.86.1201 to define birth attendants effective January 1, 2013. The RBRVS rule will be amended to add them to the list of providers reimbursed using the RBRVS reimbursement methodology. Some, but not all, modifier information was housed within ARM 37.85.212. All modifier information is housed in the physician provider manual. Modifier information in rule will not be maintained within ARM 37.85.212 and will therefore be removed. Citation, date, and fee schedule information formerly contained in ARM 37.85.212, 37.86.105, and 37.86.205 will be moved to ARM 37.85.105. Fiscal Impact HOUSE BILL (HB) 2 The proposed amendments as mandated in House Bill 2 (HB2) to the above-mentioned rules regarding services provided through the Health Resources Division will increase the Medicaid budget by 2% for State Fiscal Year (SFY) 2014. The following amounts are the budget figures reflecting this 2% increase: SFY 2014 Acute Services $822,000 Hospital Services $2,221,081 Clinic Services $42,529 Indian Health Pharmacy $3,780 Physician/Mid-level Services $993,587 Breast and Cervical $90,590 Acute Pharmacy $114,855 Totals $4,650,249 This increase in Medicaid funding will have a positive impact upon 372 hospitals; 36 hearing aid dispensers; 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; 379 dental providers; 8,337 physicians; 2,045 mid-level practitioners; 65 podiatrists; 43 public health clinics; 19 Independent Diagnostic Testing Facilities(IDTF) providers; 116 lab and x-ray providers; and 14 family planning clinics. This increase in funding will aide in providing Medicaid services for 108,572 members within Montana. MEDICARE BUDGET REDUCTIONS The following Medicaid budget amounts reflect the impact of a 2% reduction in Medicare fees for SFY 2014 and SFY 2015 should the federal sequestration remain in effect: SFY 2014 SFY 2015 Hospital Outpatient Services ($777,087) ($816,796) Physician/Mid-level Services ($164,240) ($167,525) Acute Services ($101,359) ($101,509) Totals ($1,042,686) ($1,085,830) This decrease in Medicare funding due to the federal sequestration will have a negative effect upon the Medicaid budget and may be adverse to 372 outpatient hospital providers; 8,337 physicians; 2,045 mid-level providers; 526 durable medical equipment providers; 36 hearing aid dispensers; 178 optometrists; and 26 optician providers. Services to Montana Medicaid members will not be affected. MEDICARE FEE REDUCTIONS (Competitive Bidding) The following Medicaid budget amounts reflect the impact of the reduction in Medicare fees due to the Medicare competitive bidding for diabetic supplies for state fiscal year (SFY) 2014 and (SFY) 2015: SFY 2014 Durable Medical Equipment Program ($26,428) This decrease in fees for diabetic supplies due to the Medicare competitive bidding for diabetic supplies will have a negative effect upon the Medicaid budget and may be adverse to 526 durable medical equipment providers. This decrease in Medicare funding is not expected to impact services to Montana Medicaid members. STATEMENT OF REASONABLE NECESSITY- ADDICTIVE AND MENTAL DISORDERS DIVISION The Department of Public Health and Human Services (the department) is proposing amendments to ARM 37.86.3515, 37.88.907, 37.89.125, 37.89.523, 37.90.408, and 37.86.4010, regarding a 2% increase in Medicaid fees to providers. HB2 of the 2013 Montana Legislature mandates this increase. In addition, language is added to incorporate fee schedules and dates for services provided through the Addictive and Mental Disorders Division (AMDD) under one reimbursement rule (ARM 37.85.105) rather than having separate references to fee schedules. It is necessary for the department to incorporate these services under one rule to organize and streamline the process of updating fee schedules, dates and rates pertaining to each service as necessary. ARM 37.86.3515 The department is proposing to remove the date of the fee schedule and add a reference to the fee schedule in ARM 37.85.105. ARM 37.88.907 The department is proposing to remove the date of the fee schedule and add a reference to the fee schedule in ARM 37.85.105. ARM 37.89.125 The department is proposing to add language incorporating and adoption of the fee schedule in NEW RULE II and adding language for the calculation of fee methodology. ARM 37.89.523 The department is proposing to remove the date of fee schedule and add language to adopt the fee schedule in ARM 37.85.105 and adding language on the calculation of fee methodology. ARM 37.90.408 The department is proposing to remove date of the fee schedule and add language incorporating and adoption of the fee schedule in ARM 37.85.105 and adding language on the calculation of fee methodology. ARM 37.86.4010
The department is proposing to add language incorporating the fee schedule under ARM 37.85.105. Fiscal Impact The proposed amendments as mandated in HB2 to the above mentioned rules regarding services provided through the Addictive and Mental Disorders Division will increase the Medicaid and Mental Health Services Plan (MHSP) budget by 2% for FY 2014. The following are the budget figures reflecting this 2% increase: FY 2014 Mental Health Centers $384,140 Chemical Dependency Case Management $2,961 Mental Health Case Management $182,371 SDMI HCBS Waiver Program $75,600 72-Hour Presumptive $28,827 Mental Health Services Plan (MHSP) $133,789 Total $807,688 The increase in funding will have a positive impact on the providers of mental health centers, mental health waiver providers, mental health and chemical dependency providers, MHSP, and 72-Hour Presumptive Crisis Stabilization providers. STATEMENT OF REASONABLE NECESSITY- SENIOR AND LONG-TERM CARE DIVISION ARM 37.40.1105, 37.40.1303, and 37.85.105 These amendments to the existing Personal Assistance Service (PAS) and Self- Directed Personal Assistance Service (SDPAS) reimbursement rules are necessary to remove the current reimbursement rates listed in ARM 37.40.1105 and 37.40.1303 and incorporate them by reference through a fee schedule dated July 1, 2013, for PAS and SDPAS reimbursement in ARM 37.85.105. The PAS and SDPAS rules will no longer list a specific dollar amount or rate of reimbursement; rather, it will reference the fee schedule that will be published on the department's web site, effective July1, 2013. This rule change will make it more efficient to update future rules by the incorporation of the fee schedule when changes occur in funding levels appropriated for these programs. Additions will also be made to the rule to define services included in the reimbursement for PAS and SDPAS program, such as, mileage, program oversight, and medical escort. The Department of Public Health and Human Services (the department) is proposing amendments to ARM 37.40.1105, 37.40.1303, and 37.85.105 pertaining to reimbursement for Medicaid PAS and SDPAS providers. The fee schedule will be updated to implement the anticipated 2% provider rate increase in these Medicaid funded programs effective July 1, 2013 for fiscal year 2014. This increase is mandated by HB2 of the 63rd Montana Legislature. The department does not have available, at this time, all of the information that will be necessary to establish final rates for PAS and SDPAS providers effective July 1, 2013. The final rates that will be set will be dependent on the final funding levels authorized by the 63rd Legislature, as well as other factors. The department will provide fee schedules to all providers in advance of the rule for verification purposes and in order to facilitate comments when rate information becomes available. These schedules will incorporate legislatively appropriated funding levels currently estimated at a 2% provider rate increase. The department is revising its process of changing provider reimbursement rates in administrative rule. It intends to adopt fee schedules effective as of a stated date in one rule. This is not a substantive change in the rate-setting process. It is a procedural change to simplify notices of rate changes and to compile a centralized list of fees schedules that a reader can reference. This change is reasonably necessary to improve public access to provider rates, make the Medicaid rate-setting process and the rates established by rule easier to understand, and reduce the costs associated with publication of revised provider rates. The department has considered the alternative of continuing the current process for publication of rate changes and intends to evaluate the efficacy of the current process and this change before applying this revision to all rate rules. The department has determined these rates are consistent with efficiency, economy, and quality of care. These rates are sufficient to enlist enough providers so that care and services under the Montana Medicaid program are available to the extent that such care and services are available to the general population in the geographic area. The department administers the Montana Medicaid program to provide health care to Montana's qualified low income and disabled residents. It is a public program paid for with state and federal funds appropriated to pay health care providers for the covered medical services they deliver to Medicaid clients. The Legislature delegates authority to the department to set the reimbursement rates Montana pays Medicaid providers for Medicaid clients' covered services. See 53-6-106(8) and 53-5-113, MCA. Fiscal Impact The proposed amendments as mandated in HB2 to the above mentioned rules regarding services provided through the Senior and Long Term Care Division will increase the provider rates by 2%. The Legislature in HB2 has appropriated $737,268 in total funds for SFY 2014, effective July 1, 2013 for these rate increases. This funding will impact all Medicaid personal assistance and self-directed personal assistance persons and providers. The anticipated number of persons who will receive personal assistance and self-directed personal assistance services in FY 2014 is approximately 3,500. ARM 37.85.105 The Department of Public Health and Human Services (the department) is proposing amendments to ARM 37.85.105 pertaining to reimbursement for Medicaid home and community-based services (HCBS) for the elderly and physically disabled persons. The department has revised its process of changing provider reimbursement rates in administrative rule for the HCBS waiver services. It intends to adopt fee schedules effective as of a stated date in one rule. The purpose of the proposed rule amendments is to update the effective date of the fee schedule that is published on the department's web site, effective July 1, 2013 to take into consideration the provider rate increase funding, expected to be implemented for SFY 2014. The fee schedule will be updated to implement the anticipated 2% provider rate increase in this Medicaid funded program effective July 1, 2013. This increase is mandated by HB2 of the 63rd Montana Legislature. The department does not have available, at this time, all of the information that will be necessary to establish final payment rates for home and community-based waiver services providers effective July 1, 2013. The final rates that will be set will be dependent on the funding levels authorized by the 63rd Legislature, as well as other factors. The department will provide fee schedules to all providers in advance of the rule for verification purposes and in order to facilitate comments when rate information becomes available. These schedules will incorporate legislatively appropriated funding levels currently estimated at a 2% provider rate increase. The department has determined these rates are consistent with efficiency, economy, and quality of care. These rates are sufficient to enlist enough providers so that care and services under the Montana Medicaid Program are available to the extent that such care and services are available to the general population in the geographic area. The department administers the Montana Medicaid Program to provide health care to Montana's qualified low income and disabled residents. It is a public program paid for with state and federal funds appropriated to pay health care providers for the covered medical services they deliver to Medicaid clients. The Legislature delegates authority to the department to set the reimbursement rates Montana pays Medicaid providers for Medicaid clients' covered services. See 53-6-106(8) and 53-5-113, MCA. Fiscal Impact The proposed amendments as mandated in HB2 to the above-mentioned rules regarding services provided through the Senior and Long Term Care Division will increase the provider rates by 2%. The Legislature in HB 2 has appropriated $731,529 in total funds for SFY 2014, effective July 1, 2013 for these rate increases. Persons and providers will be impacted by the Medicaid home and community-based services for elderly and physically disabled persons waiver. The anticipated number of persons who will receive waiver services in FY 2014 is approximately 2,600. The proposed rule change for Home Health Services is for the purpose of removing the current reimbursement rates listed in ARM 37.40.705 for Home Health Services and incorporating by reference a fee schedule dated July 1, 2013 for Home Health Services Reimbursement into ARM 37.85.105. The home health rule will no longer list a specific dollar amount or rate of reimbursement; rather, it will reference the fee schedule that will be adopted by the department and published on the department's web site, effective July 1, 2013. This incorporation by reference will make it more efficient to update future rules when changes occur in funding levels appropriated for this program. The Department of Public Health and Human Services (the department) is proposing amendments to ARM 37.40.705 and 37.85.105 pertaining to reimbursement for Medicaid home health services. The purpose of the proposed rule amendments is to update and set provider rates to take into consideration the provider rate increase funding, expected to be implemented July 1, 2013. The fee schedule will be updated to implement the anticipated 2% provider rate increase in this Medicaid funded program effective July 1, 2013 for FY 2014. This increase is mandated by HB2 of the 63rd Montana Legislature. The department does not have available, at this time, all of the information that will be necessary to establish final payment rates for home health providers effective July 1, 2013. The final rates that will be set will be dependent on the funding levels authorized by the 63rd Legislature, as well as other factors. The department will provide fee schedules to all providers in advance of the rule for verification purposes and in order to facilitate comments when rate information becomes available. These schedules will incorporate legislatively appropriated funding levels currently estimated at a 2% provider rate increase. The department is revising its process of changing provider reimbursement rates in administrative rule. It intends to adopt fee schedules effective as of a stated date in one rule. This is not a substantive change in the rate-setting process. It is a procedural change to simplify notices of rate changes and to compile a centralized list of fees schedules that a reader can reference. This change is reasonably necessary to improve public access to provider rates, make the Medicaid rate-setting process and the rates established by rule easier to understand, and reduce the costs associated with publication of revised provider rates. The department has considered the alternative of continuing the current process for publication of rate changes and intends to evaluate the efficacy of the current process and this change before applying this revision to all rate rules. The department has determined these rates are consistent with efficiency, economy, and quality of care. These rates are sufficient to enlist enough providers so that care and services under the Montana Medicaid Program are available to the extent that such care and services are available to the general population in the geographic area. The department administers the Montana Medicaid Program to provide health care to Montana's qualified low income and disabled residents. It is a public assistance program paid for with state and federal funds appropriated to pay health care providers for the covered medical services they deliver to Medicaid clients. The Legislature delegates authority to the department to set the reimbursement rates Montana pays Medicaid providers for Medicaid clients' covered services. See 53-6-106(8) and 53-5-113, MCA. Fiscal Impact The proposed amendments as mandated in HB2 to the above-mentioned rules regarding services provided through the Senior and Long Term Care Division will increase the provider rates by 2%. The Legislature in HB2 has appropriated $6,525 in total funds for SFY 2014, effective July 1, 2013 for these rate increases. This funding will impact all Medicaid home health persons and home health providers who utilize this service. The anticipated number of persons who will receive home health services in FY 2014 is approximately 400. STATEMENT OF REASONABLE NECESSITY- DEVELOPMENTAL SERVICES DIVISION - CHILDREN'S MENTAL HEALTH BUREAU The Department of Public Health and Human Services (the department) is proposing to amend ARM 37.86.2206, 37.86.2207, 37.87.901, 37.87.1303, 37.87.1313, 37.87.1314, 37.87.1333, and 37.87.2233 regarding a 2% increase in Medicaid fees to providers. HB2 of the 2013 Montana Legislature mandates this increase. In addition, language is deleted from ARM 37.87.901 and added to ARM 37.85.105, which incorporates the Medicaid Youth Mental Health Services Fee Schedule dated July 1, 2013, consistent with other Medicaid programs. It is necessary for the department to incorporate these services under one rule to organize and streamline the process of updating fee schedules, dates, and rates pertaining to each service as necessary. ARM 37.87.105
The department is proposing to amend this rule for youth services. The policy adjuster for psychological testing codes is 145%. This change is necessary to be consistent with the current payment system. The psychological policy adjuster has been in effect since SFY 2010. ARM 37.87.901
The department is proposing to amend this rule by deleting language from ARM 37.87.901 and adding it to ARM 37.85.105 which incorporates the Medicaid Youth Mental Health Services Fee Schedule dated July 1, 2013 so it will be consistent with other Medicaid programs. It is necessary for the department to incorporate these services under one rule to organize and streamline the process of updating fee schedules, dates, and rates pertaining to each service as necessary.
ARM 37.86.2206 The department is proposing to amend this rule to add mental health services for youth and refers to the children's mental health section of rule for requirements. Prior authorization requirements are already referenced in ARM Title 37, chapter 87 and were removed from ARM 37.87.2206 which contained inaccurate or incomplete information regarding children's mental health services. This is necessary to clarify children's mental health services covered by Medicaid. ARM 37.86.2207 The Department of Public Health and Human Services (the department) is proposing to amend this rule. The proposed changes add a reference to the department fee schedule found in ARM 37.85.105 to be consistent with other Medicaid programs. ARM 37.87.2233
The Department of Public Health and Human Services (the department) is proposing to amend this rule to add a reference to the new fee schedule rule, NEW RULE II, which contains non-Medicaid fee schedules to be consistent with other department non-Medicaid programs. ARM 37.87.1303 and 37.87.1333 The Children's Mental Health Bureau received an opportunity to continue to provide the 1915(c) Home and Community-Based (HCBS) Psychiatric Residential Treatment Facility (PRTF) Waiver, effective October 1, 2012, for children who were already enrolled in the HCBS PRTF waiver that ended September 30, 2012. The department is proposing to amend the rule to relocate the adoption and incorporation of the 1915(c) HCBS Bridge Waiver for Youth with Serious Emotional Disturbance Policy Manual, dated October 1, 2012, from ARM 37.87.1333 to ARM 37.87.1303. The proposed rule change for the 1915(c) HCBS Bridge Waiver for Youth with Serious Emotional Disturbance is also for the purpose of removing the current fee schedule in Appendix A of the manual and renaming the fee schedule the 1915(c) HCBS Bridge Waiver for Youth with Serious Emotional Disturbance Fee Schedule and incorporating it by reference, dated July 1, 2013, into ARM 37.85.105. The 1915(c) HCBS Bridge Waiver rule and manual will no longer list a specific dollar amount or rate of reimbursement; rather, they will reference the fee schedule that will be adopted by the department and published on the department's web site, effective July 1, 2013. The proposed fee schedule will take into consideration the anticipated provider rate increase funding expected to be implemented for State Fiscal Year (SFY) 2014, mandated by HB2 by the 63rd Montana Legislature. This incorporation by reference will make it more efficient to update future rules when changes occur in funding levels appropriated for this program. ARM 37.87.1313 and 37.87.1314 Children's Mental Health Bureau submitted a 1915(i) Home and Community-Based (HCBS) state plan amendment which became effective January 1, 2013. The department is proposing to amend the rule language in order to relocate the adoption and incorporation of the 1915(i) HCBS State Plan Program for Youth with Serious Emotional Disturbance Policy Manual, dated January 1, 2013 (manual) from ARM 37.87.1314 to ARM 37.87.1313. The proposed rule change for the 1915(i) HCBS State Plan Program for Youth with Serious Emotional Disturbance is also for the purpose of removing the current fee schedule in Appendix A of the manual and renaming the fee schedule the 1915(i) HCBS State Plan Program for Youth with Serious Emotional Disturbance Fee Schedule and incorporating it by reference dated July 1, 2013 into ARM 37.85.105. The 1915(i) HCBS State Plan Program rule and manual will no longer list a specific dollar amount or rate of reimbursement; rather, they will reference the fee schedule that will be adopted by the department and published on the department's web site, effective July 1, 2013. The proposed fee schedule will take into consideration the anticipated 2% provider rate increase funding, expected to be implemented for state fiscal year 2014, mandated by HB2 of the 63rd Montana Legislature. This incorporation by reference will make it more efficient to update future rules when changes occur in funding levels appropriated for this program. Fiscal Impact The proposed amendments as mandated in HB2 to the above proposed rules regarding services provided through the Children's Mental Health Bureau will increase the provider rates. The Legislature in HB2 has appropriated $1,857,927 in total funds for SFY 2014, effective July 1, 2013. This funding will impact about 14,000 youth served by children's mental health Medicaid. 6. The department intends to adopt these rules effective July 1, 2013. 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: 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., May 23, 2013. 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/ Richard H. Opper John Koch Richard H. Opper, Director Rule Reviewer Public Health and Human Services Certified to the Secretary of State April 15, 2013.
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