Administrative Rules of the State of Montana

BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

In the matter of the adoption of New Rules I through IV pertaining to implementing the Medicaid rate as the reimbursement rate the State of Montana will pay health care providers for services provided to individuals in the care or custody of the Department of Corrections or the Department of Public Health and Human Services

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NOTICE OF PUBLIC HEARING ON PROPOSED ADOPTION

TO: All Concerned Persons

1. On November 19, 2015, at 9:00 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 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 the Department of Public Health and Human Services no later than 5:00 p.m. on November 12, 2015, 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 PURPOSE (1) The purpose of these rules is to implement 53-6-1312, MCA, which establishes the Medicaid schedule of rates as the reimbursement rates that the State of Montana (State) pays for health care services provided to an individual who does not qualify for Medicaid and is:

(a) in the custody of the Department of Corrections; or

(b) a resident, by commitment or otherwise, of the Montana State Hospital, the Montana Mental Health Nursing Care Center, the Montana Chemical Dependency Center, or the Montana Developmental Center.

(2) The State will process these health care claims through the Department of Public Health and Human Services' Medicaid claims processing agent.

AUTH: 53-6-1318, MCA

IMP: 53-6-1312, MCA

NEW RULE II A PROVIDER MUST ENROLL IN MEDICAID AND ACCEPT THE MEDICAID REIMBURSEMENT RATE TO RECEIVE PAYMENT BY STATE (1) To receive payment from the State for health care services provided to an individual identified in 53-6-1312, MCA, a provider must:

(a) be enrolled as a Montana Medicaid provider;

(b) accept the Montana Medicaid rates as full payment for all health care services; and

(2) A provider who accepts an individual identified in 53-6-1312, MCA, as a patient is agreeing to accept the Medicaid rate as payment in full.

(3) In service settings where an individual identified in 53-6-1312, MCA, is accepted as a patient by a provider who arranges for services by other providers, all providers performing services are deemed to have accepted reimbursement from the State at the Montana Medicaid rates.

(4) A provider may not "balance bill" or seek payment in addition to, or in lieu of, the payment by the State. "Balance bill" means a provider bills the patient, or responsible party, the difference between the amount the state reimburses for services and what the provider chooses to charge.

AUTH: 53-6-1318, MCA

IMP: 53-6-1312, MCA

NEW RULE III PROVIDER REQUIREMENTS (1) Except for the administrative rules listed in (2), the provider requirements of ARM Title 37, chapter 85, subchapter 4, "Provider Requirements," apply to the delivery of health care services provided to an individual identified in 53-6-1312, MCA. For purposes of this subchapter, a reference to "Montana Medicaid" or "Medicaid" in ARM Title 37, chapter 85, subchapter 4 is understood to mean payments made under 53-6-1312, MCA.

(2) The following administrative rules do not apply to providers receiving payment for services provided to an individual identified in 53-6-1312, MCA:

(a) ARM 37.85.407, Third Party Liability;

(b) ARM 37.85.411, Provider Rights;

(d) ARM 37.85.416, Statistical Sampling Audits.

(3) A provider who disputes a payment is entitled to an administrative hearing on the matter according to the procedures of the department responsible for payment. A provider who is aggrieved by a final written decision is entitled to a judicial review of the decision.

AUTH: 53-6-1318, MCA

IMP: 53-6-1312, MCA

NEW RULE IV COST SHARING DOES NOT APPLY (1) The cost sharing requirements of ARM 37.85.204 do not apply to the individuals identified in 53-6-1312, MCA.

AUTH: 53-6-1318, MCA

IMP: 53-6-1312, MCA

4. STATEMENT OF REASONABLE NECESSITY

The Department of Public Health and Human Services (DPHHS) is proposing these rules to implement 53-6-1312, MCA, which the 64th Legislature (2015) enacted as part of the Health and Economic Livelihood Partnership Act (HELP Act), Chapter 368, 2015 Session Laws of Montana. The Department of Corrections (DOC) is adopting and incorporating these rules by reference in a separate rulemaking.

In some circumstances, the State of Montana (State) is obligated to pay for the health care of individuals in the custody of DOC or in the care of DPHHS and residing at the Montana State Hospital, the Montana Mental Health Nursing Care Center, the Montana Chemical Dependency Center, or the Montana Developmental Center. These rules implement the Legislature's decision to set the Medicaid rate as the amount the State will pay for health care provided to individuals identified in 53-6-1312, MCA.

DPHHS considered the alternative of not adopting rules and proceeding with 53-6-1312, MCA, as self-enacting legislation but decided that adopting rules requiring providers to enroll in Medicaid and providing a method of promptly processing claims was in the best interest of the State and the providers.

DPHHS also considered processing the claims without using the State's Medicaid claims-processing agent because these are claims for health care costs that are paid with state funds only. DPHHS determined that processing claims through the State's Medicaid claims-processing agent would take advantage of economies of scale and be a process familiar to health care providers.

New Rule I

DPHHS is proposing this rule to provide context for the subchapter.

New Rule II

The Legislature established the Medicaid rate as the maximum amount the State will pay for health care provided to individuals identified in 53-6-1312, MCA. DPHHS is proposing to require a health care provider who wants to receive payment from the State to enroll as a Medicaid provider and comply with the requirements of this new subchapter of administrative rules. This will make it possible for the Medicaid claims-processing agent to pay the claims and will simplify the administrative burden for the State and providers.

New Rule II requires a provider who accepts the State payment for some services to accept the State payment rate for all covered services and for all services arranged by the provider. This is necessary for the State to pay the Medicaid rate for all health care services to individuals identified in 53-6-1312, MCA.

New Rule II also prohibits "balance billing." The amount paid by the State will be full payment to the provider. This is necessary to prevent the patient or responsible party from being billed for an amount in addition to the Medicaid rate.

New Rule III

DPHHS is proposing to make the Medicaid provider requirements stated in ARM Title 37, chapter 85, subchapter 4 also applicable to a provider billing the State for health care services to individuals identified in 53-6-1312, MCA, unless the requirement is specifically excluded in New Rule III. Adopting these procedures establishes a consistent method for coding and processing claims that is already familiar to providers and their billing staff and already in place for the State.

The Medicaid provider requirements that will not apply to claims for payment by the State are ARM 37.85.407, Third Party Liability, ARM 37.85.411, Provider Rights, ARM 37.85.415, Medical Assistance Medicaid Payment, and ARM 37.85.416, Statistical Sampling Audits. These Medicaid provisions are not necessary for prompt, efficient claim processing.

DPHHS is also proposing that each department provide an administrative review process for claims disputes because a process for a provider and each department to review and resolve disputes is necessary and the administrative process for Medicaid claims payment does not apply to these claims.

New Rule IV

DPHHS is proposing not to impose cost-sharing requirements. The administrative costs of attempting to collect cost-sharing payments from individuals in the care or custody of the State outweigh any benefits of a cost-sharing program.

Fiscal Impact

DPHHS estimates that Montana State Hospital and the Montana Mental Health Nursing Care Center will experience an approximate 30% savings in the cost of laboratory, outside medical and pharmaceutical costs. The estimated savings for one-half of SFY 2016 is $480,000. The fiscal impact for DOC will be estimated in its rulemaking.

5. The effective date of 53-6-1312, MCA, is contingent upon the Centers for Medicare and Medicaid Services' (CMS) approval of the State's request for a waiver. Under the authority of 2-4-309, MCA, DPHHS is proceeding with this rulemaking with an anticipated effective date of January 1, 2016.

6. Concerned persons may submit their data, views, or arguments either orally or in writing at the hearing. Written data, views, or arguments may also be submitted to: Kenneth Mordan, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail [email protected], and must be received no later than 5:00 p.m., November 27, 2015.

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

8. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request that includes the name,

e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 6 above or may be made by completing a request form at any rules hearing held by the department.

9. An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. The Secretary of State strives to make the electronic copy of the notice conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered. In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems.

10. The bill sponsor contact requirements of 2-4-302, MCA, apply and have been fulfilled. The primary bill sponsor was notified by e-mail on October 9, 2015.

11. With regard to the requirements of 2-4-111, MCA, the DPHHS has determined that the adoption of the above-referenced rules will not significantly and directly impact small businesses.

/s/ Geralyn Driscoll /s/ Richard H. Opper

Geralyn Driscoll, Attorney Richard H. Opper, Director

Rule Reviewer Public Health and Human Services

Certified to the Secretary of State October 19, 2015.