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| Montana Administrative Register Notice 37-765 | No. 14 07/22/2016 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Concerned Persons
1. On August 11, 2016, 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 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 the Department of Public Health and Human Services no later than 5:00 p.m. on August 3, 2016, to advise us of the nature of the accommodation that you need. Please contact Kenneth Mordan, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail [email protected].
3. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
37.85.406 BILLING, REIMBURSEMENT, CLAIMS PROCESSING, AND PAYMENT (1) through (17) remain the same. (18) Except as otherwise provided in the rules of the department which pertain to the method of determining payment rates for claims of recipients members who have Medicare and Medicaid coverage (cross-over claims), the Medicaid allowed amount for Medicare covered services is: (a) for facility based providers who generally bill on the (i) through (21) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-131, 53-6-149, MCA
37.86.2803 ALL HOSPITAL REIMBURSEMENT, COST REPORTING (1) Allowable costs will be determined in accordance with generally accepted accounting principles as defined by the American Institute of Certified Public Accountants. (a) remains the same. (b) For cost report periods occurring on or after May 1, 2010, such definition of allowable costs is further defined in accordance with the Medicare Provider Reimbursement Manual, CMS Publication 15, Form 2552-10, (c) For cost report periods occurring prior to May 1, 2010, such definition of allowable costs is further defined in accordance with the Medicare Provider Reimbursement Manual, CMS Publication 15, Form 2552-96, (d) through (3) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-149, MCA
37.86.2806 COST-BASED HOSPITAL, GENERAL REIMBURSEMENT (1) through (7) remain the same. (8) (a) elective deliveries as set forth in ARM 37.86.2801; and (b) services that are reimbursed at a set rate outside of the CCR.
IMP: 53-2-201, 53-6-101, 53-6-113, MCA
37.86.2907 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, APR-DRG PAYMENT RATE DETERMINATION (1) The department's APR-DRG prospective payment rate for inpatient hospital services is based on the classification of inpatient hospital discharges to APR-DRGs. The provider reimbursement rates for inpatient hospital services, except as otherwise provided in ARM 37.85.206, is stated in the department's APR-DRG fee schedule adopted and effective at ARM 37.85.105. The procedure for determining the APR-DRG prospective payment rate is as follows: (a) and (b) remain the same. (c) The department computes a Montana average base price per case. This base price includes in-state and out-of-state distinct part rehabilitation units (d) The department computes a base price for long term care (LTC) hospitals. The effective date and base rate amount is adopted and effective as provided at ARM 37.85.105. Disproportionate share payments are not included in this price. (d) through (f) remain the same, but are renumbered (e) through (g). (h) Inpatient reimbursement will be calculated at the lesser of the assigned APR-DRG rate or the claim billed charges. (2) The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds adopted and effective at ARM 37.85.105. The Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), outlier thresholds, and APR grouper version
AUTH: 2-4-201, 53-2-201, 53-6-113, MCA IMP: 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
37.86.2916 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, COST OUTLIERS (1) and (2) remain the same. (3) The department determines the outlier reimbursement for cost outliers for all hospitals and distinct part units, entitled to receive cost outlier reimbursement, as follows: (a) computing an estimated cost for the inpatient hospital stay by multiplying the allowed charges for the stay by: (i) the (ii) for non-Center of Excellence out-of-state facilities, their statewide average cost-to-charge ratio; (b) remains the same. (c) multiplying the cost outlier amount by
AUTH: 2-4-201, 53-2-201, 53-6-113, MCA IMP: 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
37.86.4401 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, DEFINITIONS (1) through (7) remain the same. (8) "Health professional" means services furnished by a physician, nurse practitioner (NP), physician assistant (PA), certified nurse-midwife (CNM), clinical psychologist (CP), clinical social worker (CSW), licensed professional counselor (LCPC), and licensed addiction counselor (LAC). (8) through (16) remain the same, but are renumbered (9) through (17).
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
37.86.4412 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, REIMBURSEMENT (1) through (6) remain the same. (7) Approved RHC and FQHC group and education health service payments will be reimbursed separately from their prospective payment at a rate determined by the department. The fee schedule is adopted and effective as provided at ARM 37.85.105.
IMP: 53-6-101, 53-6-111, 53-6-113, MCA
4. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (the department) is proposing amendments to ARM 37.85.406, 37.86.2803, 37.86.2806, 37.86.2907, 37.86.2916, 37.86.4401, and 37.86.4412 regarding claims processing and reimbursement, hospital cost reporting, inpatient hospital reimbursement, rural health clinic and federally qualified health centers. The above rules are being updated to correct dates and claim forms, update reimbursement policies for inpatient APR-DRG hospitals, and update and add new definitions to rural health clinics and federally qualified health centers.
General Billing, Reimbursement, Claims Processing and Payment
In 2005, the National Uniform Billing Committee approved the updated Uniform Bill (UB-04) paper claim and set it as the replacement to the Uniform Bill-92 (UB-92), the department switched to the UB-04 after its creation. The department does not accept the UB-92 claim and is proposing to update the rule to reflect this change.
The following describes the proposed updates to the following rule:
ARM 37.85.406
(18)(a)- Update UB-92 to UB-04.
Fiscal Impact
The changes to the above rule will have no fiscal impact.
All Hospital Reimbursement, Cost Reporting
The department is proposing to remove the dates related to the Medicare Provider Reimbursement Manuals, CMS Publication, Form 2252-10 and 2552-96. These forms have been updated since the last filing of this rule. CMS maintains and updates these forms related to cost reporting for hospitals and requires that hospitals use the most current form.
The following describes the proposed updates to the following rule:
ARM 37.86.2803
(1)(b)- Remove Transmittal 2. The remainder of the section remains the same. (1)(c)- Remove Transmittal 25, last updated April 2011. The remainder of the section remains the same.
Fiscal Impact
The changes to the above rule will have no fiscal impact.
Cost-Based Hospital, General Reimbursement
The department is proposing to exempt services performed in a critical access hospital that are reimbursed at a set rate be excluded from the final cost settlement process. These outpatient services will be reimbursed at the fee schedule rate instead of the facility cost-to-charge ratio. Elective deliveries that do not meet the requirements in ARM 37.86.2801 are already exempt from the final cost settlement process.
The following describes the proposed update of the following rule:
ARM 37.86.2806
(8) – Updated language to cost-based hospital claims that will not be eligible for final reimbursement through cost settlement are as follows: (8)(a) – Updated language to elective deliveries that do not meet the requirements stated in policy in ARM 37.86.2801, will be subject to a 33% reduction in interim reimbursement based on the total claim payment; (8)(b) –added services that are reimbursed at a set rate outside of the cost-to-charge.
Fiscal Impact
The change to the above rule will have no fiscal impact.
Inpatient Hospital Prospective Reimbursement, APR-DRG Hospitals
The department is proposing to update the APR-DRG base rate for long-term care (LTC) hospitals in ARM 37.85.105 effective October 1, 2016. The below rule is being updated to clarify that LTC base rates are separate from other inpatient hospitals. The department is also adding a new lesser of payment methodology for inpatient APR-DRG hospitals. This payment methodology calculates the claim reimbursement at the lesser of the assigned APR-DRG rate or the claim billed charges. The department uses this payment methodology throughout the Medicaid program and is updating the inpatient APR-DRG methodology to maintain program consistency. The department is also updating the APR grouper version used to 33.
The following describes the proposed updates to the following rule:
ARM 37.86.2907
(1)(c)- Remove long-term care facilities. The remainder of the section remains the same. (1)(d)- Add language regarding that the department computes a base price for long-term care hospitals. The adopted fee schedule and effective date is provided in ARM 37.85.105, and that disproportionate share payments are not included in this price (1)(h)- Add language that inpatient reimbursement will be calculated at the lesser of the assigned APR-DRG rate or the claim billed charges. The remainder of section (1) will be renumbered.
(2) Change the APR grouper to version 33 from version 29.
Fiscal Impact
The changes to the above rule will have no fiscal impact. The estimated fiscal impact from the proposed lesser of payment methodology is being rebased to allow for the new proposed long-term care hospital base rate.
Inpatient Hospital Prospective Reimbursement, Cost Outliers
The APR-DRG payment methodology uses a calculation by multiplying the allowed charges for the inpatient stay by cost-to-charge ratio. The current methodology in ARM states that the department will use the statewide average Prospective Payment System (PPS) cost-to-charge ratio set forth in ARM 37.86.2905. In July of 2015, the department changed the methodology to use the facility-specific average PPS cost-to-charge ratio for in-state facilities and Centers of Excellence facilities. Out-of-state facilities, that are not Centers of Excellence, use their statewide average cost-to-charge ratio. The below rule is being updated to reflect this change. These changes were incorporated into ARM 37.85.105 effective July 1, 2015, the changes to the below rule are to clarify the methodology used in the adopted APR-DRG fee schedule.
The department is also updating the cost outlier amount from 60 percent to 50 percent. The cost outlier amount is used to establish the marginal cost outlier payment for the hospital stay.
The following describes the proposed updates to the following rule:
ARM 37.86.2916
(3)(a)- Update the language to state the use of the facility-specific PPS cost-to-charge ratio for in-state and Center of Excellence facilities. For out-of-state, non-Center of Excellence facilities, update the language to state that they will use their statewide average PPS cost-to-charge ratio. (3)(c)- Change to cost outlier amount from 60% to 50%.
Fiscal Impact
The changes to the above rule will have no fiscal impact in the aggregate. Hospitals will receive less reimbursement for cost outliers and charge cap. This decrease will be offset in the aggregate by the base price increase to the APR-DRG.
Rural Health Clinics and Federally Qualified Health Centers, Definitions
Health professional and licensed addiction counselor (LAC) were added as definitions.
ARM 37.86.4401
(8)- Added "Health professional" means services furnished by physician, nurse practitioner (NP), physician assistant (PA), certified nurse-midwife (CNM), clinical psychologist (CP), clinical social worker (CSW), licensed professional counselor (LCPC), and licensed addiction counselor (LAC).
The remainder of the definitions will be renumbered.
Fiscal Impact
The addition of licensed addiction counselors to the allowed core service providers could increase the number of visits at these clinics. The estimated total fiscal impact for state fiscal year 2017 would be $157,481.
Rural Health Clinics and Federally Qualified Health Centers, Reimbursement
The department may provide payment for approved FQHC and RHC group and education health services on October 1, 2016. Group and education health service(s) payments will be paid separately from the prospective payment system (PPS) at a paid rate determined by the department. The methodology used will be based on either the Montana RBRVS or outpatient prospective payment system (OPPS) hospital methodology.
ARM 37.86.4412
(7) – add approved RHC and FQHC group and education health service(s) payments will be reimbursed separately from their prospective payment at a rate determined by the department. The fee schedule is adopted and effective as provided at ARM 37.85.105.
Fiscal Impact
The addition of group and education health services could increase the number of visits at these clinics. The estimated total fiscal impact for state fiscal year 2017 would be $32,174.
5. These rule amendments are proposed to be effective October 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., August 19, 2016.
7. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing.
8. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 6 above or may be made by completing a request form at any rules hearing held by the department.
9. An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. The Secretary of State strives to make the electronic copy of the notice conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered. In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems.
10. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
11. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment of the above-referenced rules will not significantly and directly impact small businesses.
12. Section 53-6-196, MCA, requires that the department, when adopting by rule proposed changes in the delivery of services funded with Medicaid monies, make a determination of whether the principal reasons and rationale for the rule can be assessed by performance-based measures and, if the requirement is applicable, the method of such measurement. The statute provides that the requirement is not applicable if the rule is for the implementation of rate increases or of federal law.
The department has determined that the proposed program changes presented in this notice are appropriate for performance-based measurement and therefore are subject to the performance-based measures requirement of 53-6-196, MCA. The department will measure access to long-term care hospitals, Centers of Excellence, and licensed addiction counselors (LAC).
/s/ Brenda K. Elias /s/ Richard H. Opper Brenda K. Elias Richard H. Opper, Director Rule Reviewer Public Health and Human Services
Certified to the Secretary of State July 11, 2016.
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A directory of state agencies is available online at http://www.mt.gov/govt/agencylisting.asp.
For questions about the organization of the ARM or this web site, contact [email protected].
