BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.87.1202, 37.87.1210, 37.87.1214, 37.87.1217, and 37.87.1223 and the repeal of ARM 37.87.1222, pertaining to psychiatric residential treatment facility (PRTF) services

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NOTICE OF AMENDMENT AND REPEAL

 

TO: All Concerned Persons

 

1. On October 31, 2013, the Department of Public Health and Human Services published MAR Notice No. 37-653 pertaining to the public hearing on the proposed amendment and repeal of the above-stated rules at page 1948 of the 2013 Montana Administrative Register, Issue Number 20.

 

2. The department has amended ARM 37.87.1202, 37.87.1210, and 37.87.1214 as proposed. The department has repealed ARM 37.87.1222 as proposed.

 

3. The department has amended the following rules as proposed, but with the following changes from the original proposal, new matter underlined, deleted matter interlined:

 

            37.87.1217 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES, TREATMENT REQUIREMENTS (1) through (5) remain as proposed.

            (6) The plan of care and discharge plan for the youth must be reviewed at least every 30 days at the multidisciplinary treatment team meeting, and more frequently if there is a significant change in the condition of the youth. The parent or legal representative of the youth must be invited to participate in these meetings, and given adequate notice to participate. Adequate notice means generally a week unless the condition of the youth dictates otherwise. At a minimum the following must be discussed, if applicable to the needs of the youth:

            (a) through (10) remain as proposed.

 

AUTH:    53-2-201, 53-6-113, MCA

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

 

            37.87.1223 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES, REIMBURSEMENT (1) through (7) remain as proposed.

            (8) The bundled per diem rate for out-of-state PRTFs does not include the following services, which are separately reimbursable by the Medicaid program for enrolled providers:

            (a) remains as proposed.

            (b) adult mental health center evaluations a clinical intake assessment by a licensed mental health center, with an endorsement to provide adult services, for transition age youth 17 to 18, to determine whether or not they have a severe and disabling mental illness and if they qualify for adult mental health services and have a severe and disabling mental illness; and

            (c) through (12) remain as proposed.

            (13) Notice of the admission and discharge dates for the youth must be submitted to the department or its designee the day of admission or discharge. The department may impose a $200 $100 charge against the facility for each instance where the department does not receive timely notification.

 

AUTH: 53-2-201, 53-6-113, MCA

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

 

4. The department has thoroughly considered the comments and testimony received. A summary of the comments received and the department's responses are as follows:

 

COMMENT #1: One commenter expressed concern regarding the removal of care coordination as a reimbursed ancillary service. The commenter stated they expect that there will be more out-of-state referrals based on this decision. The commenter also stated that they did, in fact, utilize care coordination so questioned the department's reasoning for removing the service option.

RESPONSE #1: The department is currently seeking federal guidance regarding this issue. In order to provide accurate and reliable information the department will further address this issue once a federal response has been received.

 

COMMENT #2: Several commenters requested the department to reconsider the decision to not require assessment or treatment services for substance use disorder. The commenters stated it is counter to efforts to expand the availability of co-occurring mental health and substance use disorder services. Furthermore, the commenters stated it was an extremely helpful treatment.

RESPONSE #2: Providing substance disorder screening, assessment, and treatment is optional and not mandatory. The department took the opportunity to reimburse psychiatric residential treatment facilities (PRTFs) for chemical dependency assessment and treatment services when PRTFs were responsible to reimburse for ancillary services youth received while in their facilities. The Children's Mental Health Bureau (CMHB) does not reimburse for substance use disorder treatment; Addictive and Mental Disorders Division (AMDD) does when the provider is state approved and under contract.

 

COMMENT #3: A few commenters stated the requirement of using Montana - Child and Adolescent Needs and Strengths (MT-CANS) is an additional and unfunded requirement and places a burden on current staff.

RESPONSE #3: Requiring the use of a department-approved functional assessment is not new; the requirement was adopted in administrative rule February 20, 2013, with an effective date of July 1, 2013, to allow time for implementation of the assessment.  The department determined that after initial staff training, the assessments take a minimal amount of time to complete.  Also, the department has developed an electronic Montana CANS System (MCS) that is designed for ease of access, to collect MT-CANS assessments, and to return the resulting MT-CANS data back to the providers which helps to inform treatment decision planning.

COMMENT #4: One commenter stated that in ARM 37.87.1217(6)(f), the discussion areas listed, while relevant, are too inclusive as they may or may not apply to the individual youth.

RESPONSE #4:    The department agrees with the commenter. The list included in ARM 37.87.1217(6)(f) may not apply to the condition of all youth. Therefore, the department will add language to allow for more flexibility to address the individualized need of each youth.

COMMENT #5: One commenter requested clarification regarding ARM 37.87.1223(5) and (6) regarding the direct care wage. The commenter specifically asked if the per diem rate that went into effect July 1, 2013, will now be considered to include direct care wages.

RESPONSE #5: The July 1, 2013, PRTF per diem rate does not include direct care wages.

 

COMMENT #6: One commenter asked if in ARM 37.87.1223(6)(d)(ii), the PRTF physician would order the services provided or if they would be required to direct the actual service.  Additionally, the commenter would like to know if in (6)(d)(iii) the provider would be required to enter into an arrangement with a qualified Medicaid provider or if the Medicaid provider would provide the service and charge Montana Medicaid directly for the services.

RESPONSE #6: Yes, the PRTF physician orders the ancillary service provided but is not required to direct the actual service. Yes, the Montana Medicaid qualified provider provides the ancillary service and bills the Montana Medicaid Program directly for the service.

 

COMMENT #7:  One commenter asked the department how the direct care wage will be added and to explain the options, "through contract with the Department or in the bundled per diem rate."

RESPONSE #7: The proposed language in ARM 37.87.1223(5)(a) is not new; it was moved when ARM 37.87.1222 was repealed. The rule was previously changed in anticipation of adding the direct care wage funds to the PRTF bundled per diem rate. The direct care wage add-on is currently reimbursed through a contract with the department. Providers report to the department, on a quarterly basis, the number of Montana Medicaid youth served and their current number of direct care staff.

The department has not made a final decision on whether or not to add the direct care wage add-on to the bundled PRTF per diem rate and specific methodology to do so has not been established.

COMMENT #8: A few commenters requested the department allow in-training practitioners with clinical supervision be added as allowable providers within the bundled per diem rate.

RESPONSE #8: Services provided by licensed psychologists, clinical social workers, and professional counselors are included in both the in-state and out-of-state PRTF bundled per diem rates. This rule does not exclude PRTFs from employing in-training practitioners. The intent of the rule is that the licensed professionals listed cannot bill for their professional services separately, they are built into the bundled per diem rate.

COMMENT #9: A few commenters requested that targeted case management (TCM) also be allowed for discharge planning from an in-state PRTF. A few commenters stated that due to the demographics of Montana, some in-state PRTFs could be further from the home of the youth than an out-of-state PRTF.

RESPONSE #9: The department is currently seeking federal guidance regarding this issue. In order to provide accurate and reliable information the department will further address this issue once a federal response has been received.

 

COMMENT #10:  A few commenters stated in ARM 37.87.1223(13) that they prefer that penalties not be charged and that improving the process and addressing the problems is a better solution. However, the commenter also stated they appreciate that the department lowered the fine down from the original proposed amount of $500.

RESPONSE #10: It is not the department's intent to create an adversarial relationship with providers. The department will maintain the current $100 charge while researching and considering other solutions. However, due to the consequences when this requirement is not adhered to, the department needs to stress the importance of submitting timely and accurate admission and discharge dates to the department or their designee.

COMMENT #11:  One commenter noted that it may be infeasible for a licensed mental health center to complete a clinical intake assessment, especially on out-of-state youth, due to the fact it must be completed in person. The commenter also offered alternative terminology from "adult mental health center" to "licensed mental health center" and "clinical intake assessment" rather than "evaluation" in order to remain consistent with the terminology currently used in adult mental health.

RESPONSE #11: The department agrees with the commenter regarding the terminology and will make the suggested changes with the addition that the licensed mental health center must be endorsed to provide adult services.

The department understands the youth must be present in order to complete the clinical intake assessment and with out-of-state youth that may not always be an option.  There are options available to provide this service to youth in both in-state and out-of-state PRTFs.  Per ARM 37.88.605(6), services through interactive video are considered face-to-face and are reimbursed in the same fashion. Also, some youth do come back in-state for therapeutic home visits at which time it may be feasible to schedule an in-person assessment. Another option would be for the clinician to go to the PRTF to administer the assessment when it is feasible to do so.

COMMENT #12: One commenter requested clarification regarding how the CANS assessments should be administered now that the electronic Montana CANS System (MCS) is operational. The commenter articulated that using the MCS would provide valuable opportunity to collect and assess information that would be beneficial for both the department and providers.

RESPONSE #12: The department agrees with the commenter; however, rather than adding this requirement into this rule set, the department will consider adding the use of the MCS to future rulemaking as it applies to more than just the PRTF rules.

 

            5. The department intends to adopt these rule amendments and repeal effective December 31, 2013, except for ARM 37.87.1223(5)(a) which is retroactively effective to July 1, 2013. A retroactive application of (5)(a) does not result in a negative impact to any affected party.

 

 

/s/ Cary B. Lund                                           /s/ Richard H. Opper                                  

Cary B. Lund                                                Richard H. Opper, Director

Rule Reviewer                                               Public Health and Human Services

           

Certified to the Secretary of State December 16, 2013