BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.86.3401, 37.86.3402, 37.86.3405, 37.86.3410, 37.86.3415, 37.86.3901, 37.86.3902, 37.86.3905, 37.86.3906, and 37.86.3910 and the repeal of ARM 37.86.3411, 37.86.3801, 37.86.3805, 37.86.3806, 37.86.3810, and 37.86.3811 pertaining to targeted case management

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT AND REPEAL

 

TO: All Concerned Persons

 

            1. On August 10, 2017, at 3:30 p.m., the Department of Public Health and Human Services will hold a public hearing in Room 207 of the Department of Public Health and Human Services Building, 111 North Sanders, Helena, Montana, to consider the proposed amendment and repeal 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 July 26, 2017, 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 provides as follows, new matter underlined, deleted matter interlined:

 

            37.86.3401 TARGETED CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, DEFINITIONS The definitions of targeted case management services for high risk pregnant women are as follows:

            (1) "Assessment" means an evaluation to identify a client's physical, medical, nutritional, psychosocial, developmental, and educational status to determine if the person meets the "high risk" criteria. This is an ongoing process updated at each contact.

            (2) "Care coordination and referral" means helping a client to access services by establishing and maintaining a referral process for needed and appropriate services and avoiding duplication of services.

            (3) (1)  "Case planning" "Care plan" means preparing a written service plan that reflects a client's needs and the resources available to meet those needs in a coordinated and integrated fashion. a specific written plan that is based on the information collected through the comprehensive assessment and periodic reassessment that:

            (a) specifies the goals and actions to address the medical, social, educational, and other services needed by the member;

            (b) includes activities such as ensuring the active participation of the member, and working with the member and others to develop those goals; and

            (c) identifies a course of action to respond to the assessed needs of the member.

(2) "Comprehensive Assessment and Periodic Reassessment" means an evaluation to identify a member's need for any medical, educational, social, or other services. These assessment activities include:

            (a) taking a member's history;

            (b) identifying the member's needs and completing the related documentation; and

            (c) gathering information from other sources to form a complete assessment of the member.

            (4) (3)  "Monitoring and follow-up activity" means regular contacts to encourage cooperation and resolve problems which may create barriers to services and assuring that a client receives services as indicated in the service plan. activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the member's needs. The activities may be with the member, family members, service providers, or other entities or individuals and may be conducted as frequently as necessary. Monitoring may be furnished through face-to-face visits, telephone calls, and telemedicine services.

            (4) "Paraprofessional" means a person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional.

            (5) "Referral" means activities that help link the member with medical, social, or educational providers, and other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan.

            (6) "Targeted case management" means services that assist a member to access needed medical, social, or other resources and services by establishing and maintaining a referral process for needed and appropriate services and avoiding duplication of services.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3402  TARGETED CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, ELIGIBILITY (1) A person member is eligible for targeted case management as a high risk pregnant woman if:

            (a) remains the same.

            (b) the person's member's pregnancy outcome is considered to be at high risk as determined by the case manager.

            (2) A pregnancy is of high risk if the person member:

            (a) and (b) remain the same.

            (c) abuses alcohol, tobacco, or drugs;

            (c) (d)  or has someone in the person's member's immediate environment who abuses alcohol, tobacco, or drugs;

            (d) remains the same, but is renumbered (e).

            (e) (f)  is homeless; or

            (g) has had greater than three residences during pregnancy; or

            (f) (h)  demonstrates an inability to obtain necessary resources and services and the person member meets three of the following criteria. The person:

            (i) has a history of physical or sexual abuse;

            (ii) has no support system or involvement of a spouse or other supporting person;

            (iii) has two or more children under age five has not had a dental cleaning in the last year;

            (iv) is not educated beyond the 12th grade level or does not have a GED;

            (v) and (vi) remain the same.

            (vii) is a refugee or a migrant worker;

            (viii) is age 18 or 19; or

            (ix) is over the age of 35; or

            (ix) remains the same, but is renumbered (x).

            (3) The member is not eligible for targeted case management services if enrolled in a Medicaid Patient Centered Medical Home (PCMH) program, Comprehensive Primary Care Plus (CPC+), or Health Improvement Program (HIP).

            (3) (4)  Targeted Ccase management services may be delivered to the client member, if Medicaid eligibility continues, until the last day of the month in which occurs the 60th day following the end of the pregnancy.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3405 TARGETED CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, COVERAGE (1) Reimbursable targeted case management services for high risk pregnant women are:

            (a) comprehensive assessment and periodic reassessment;

            (b) case care plan development;

            (c) remains the same.

            (d) monitoring and follow up.

            (2) Face-to-face comprehensive assessments must occur at least monthly during the pregnancy.

            (3) Two post-partum reassessments must occur after delivery prior to the last day of the month in which the 60th day following delivery occurs.

            (4) Monitoring must include at least one annual monitoring to determine if the following conditions are met:

            (a) services are being furnished in accordance with the member's care plan;

            (b) services in the care plan are adequate; and

            (c) changes in the needs or status of the member are reflected in the care plan.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3410 TARGETED CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, PROVIDER REQUIREMENTS (1) remains the same.

            (2) To be qualified as a provider of targeted case management services for high risk pregnant women, an entity enrolled Montana Medicaid provider must:

            (a) remains the same.

            (b) meet the requirements in (3) through (7) (8);

            (c) have knowledge and experience in the delivery of home and community services to high risk pregnant women;

            (d) remains the same.

            (e) have developed collaborative working relationships with health care and other agencies in the area to be served.

            (3) A targeted case management provider must use an interdisciplinary team that includes members from the professions of nursing, social work, and nutrition.

            (a) The professional requirements for these professionals are the following:

            (i) nursing must be provided by a licensed registered professional nurse who has a current Montana license and is either:

            (A) a registered nurse with a bachelor of science degree in nursing, including whose education includes course work in public health; or

            (B) a certified nurse practitioner with two years experience in the care of families;

            (ii) social work must be provided by a social worker with a masters or bachelors degree in behavioral sciences or related field with one year experience in community social services or public health. A social worker with a masters in social work (MSW), masters in counseling, or a bachelors in social work (BSW) with two years experience in community social services or public health is preferred; and

            (ii) social work must be provided by one of the following:

            (A) a clinical social worker with a master's in social work (MSW), who has a current Montana license;

            (B) a master's level counselor (LCPC), who has a current Montana license; or

            (C) a bachelor's in social work (BSW) with two years' experience in community social services or public health; and

            (iii) remains the same.

            (b) The department must be notified within 30 days regarding any staff changes or updates.

            (b) (c)  To accommodate special agency and geographic needs and circumstances, exceptions to the staffing requirements, including the use of paraprofessionals, may be allowed if approved by the department. If the targeted case management team includes a paraprofessional, that individual must have a minimum of an associate's degree in behavioral sciences or a related field with two years of closely related work experience, and complete a state-sponsored training for paraprofessional targeted case managers.  Qualifying experience may be substituted, year for year, for education.

            (4) The targeted case management provider must be able to provide the services of at least one of the professional disciplines listed in (3) directly. The other disciplines may be provided through subcontracts.

            (5) Where services are provided through a subcontractor, the subcontract must be submitted to the department or designee for review and approval.

            (6) (5)  A targeted case management provider must:

            (a) remains the same.

            (b) deliver prenatal care coordination services appropriate to the individual client's member's level of need;

            (c) respond promptly to requests and referrals for targeted case management clients members;

            (d) remains the same.

            (e) schedule services to accommodate the client's member's situation;

            (f) inform clients members regarding whom and when to call for pregnancy emergencies;

            (g) remains the same.

            (h) assure that ongoing communication and coordination of client member care occurs within the targeted case management team and with the client's member's medical prenatal care provider;

            (i) provide services in a home, setting in addition to office, or clinic settings., with telephone contacts as appropriate; Home visiting, particularly by the community health nurse, is an integral part of targeted case management;

            (j) have a system for handling client member grievances; and

            (k) maintain an adequate and confidential client records system. All services provided directly or through a subcontractor must be documented in this system.

            (7) (6)  A case manager providing services for a targeted case management provider must have knowledge of:

            (a) knowledge of:

            (i) (a) federal, state, and local programs for children and pregnant women such as Title V programs, WIC, immunizations, perinatal health care, handicapped children's services, family planning, genetic services, hepatitis B screening, kids count (EPSDT), etc. and other healthcare related programs in Montana;

            (ii) (b) individual health care plan development and evaluation;

            (iii) (c) community health care systems and resources; and

            (iv) (d) nationally recognized perinatal and child health care standards;.

            (b) (7)  A case manager providing services for a targeted case management provider must have the ability to:

            (i) interpret medical findings;

            (ii) (a)  develop an individual case management care plan based on an assessment of a client's member's health, nutritional and psychosocial status, and personal and community resources;

            (iii) (b)  inform a client member regarding health conditions and implications of risk factors;

            (iv) (c)  encourage a client's member's responsibility for health care;

            (v) remains the same, but is renumbered (d).

            (vi) (e)  coordinate access to multiple agency services to the benefit of the client member; and

            (vii) (f)  evaluate a client's member's progress in obtaining appropriate medical care and other needed services.

            (8) Providers must maintain case records that meet the maintenance of records and auditing guidelines set forth in ARM 37.85.414 and that document for all members receiving targeted case management the following:

            (a) the name of the member;

            (b) the dates of the targeted case management services;

            (c) the name of the provider agency and the person providing the services;

            (d) the nature, content, and units of the targeted case management services received and whether goals specified in the care plan have been achieved;

            (e) whether the member has declined services in the care plan;

            (f) the need for, occurrences of, and coordination with other targeted case managers;

            (g) a timeline for obtaining needed services; and

            (h) a timeline for reevaluation of the plan.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3415 TARGETED CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, REIMBURSEMENT (1) Case Targeted case management services for high risk pregnant women provided on or after January 1, 1996 are reimbursed at the lower of the following:

            (a) the provider's customary charge to the general public for the service; or

            (b) $6.00 for each 15 minutes of service the department's current fee schedule under ARM 37.85.105.

            (2) Case management services for high risk pregnant women provided prior to January 1, 1996 are reimbursed, in accordance with (2)(a) through (2)(d), for the allowable costs of providing case management services to eligible Medicaid recipients.

            (a) The amount of reimbursement due a provider will be determined retrospectively by the department based upon the reporting period cost report required under ARM 37.86.3411. An overpayment or underpayment for the reporting period is calculated by finding the difference between the total of the incurred allowable costs reported and the total of the interim payments received by the provider. The department will notify the provider in writing of any overpayment or underpayment determination.

            (b) The department will establish interim rates for each service. An interim rate will be determined for a fiscal year by dividing the estimated total allowable costs on a statewide basis for the service during the fiscal year by estimated total of service units to be delivered on a statewide basis during that fiscal year.

            (i) The department may, but is not required to, review and adjust the interim rates established during the reporting period to assure that interim payments approximate allowable costs for case management services if:

            (A) there is a significant change in the utilization of case management services;

            (B) the incurred allowable costs vary materially from the estimated allowable costs; or

            (C) the department in its discretion determines that other circumstances warrant an adjustment.

            (c) No cost shall be allowable unless the department determines that it has been incurred and that it is reasonable and necessarily related to the provision of case management services. Profit is not an allowable cost.

            (d) Reimbursement shall not exceed the provider's customary charge to the general public for the service.

            (2) The following activities may not be billed as targeted case management and are not reimbursable as a unit of targeted case management:

            (a) outreach to the member or member's representative;

            (b) application activities related to Medicaid services or eligibility;

            (c) direct medical services, including counseling or the transportation or escort of members;

            (d) duplicate payments that are made to providers under Medicaid or other program authorities;

            (e) writing, recording, or entering case notes for the member's files;

            (f) travel to and from member activities;

            (g) coordination of the investigation of any suspected abuse, neglect, or exploitation cases; and

            (h) any service less than eight minutes duration if it is the only service provided that day.

            (3) Targeted case management services are not separately billable for members enrolled in a Medicaid Patient Centered Medical Home (PCMH) program, Comprehensive Primary Care Plus (CPC+), or Health Improvement Program.

            (4) All targeted case management services must meet the guidelines of medical necessity set forth in ARM 37.85.410.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3901 TARGETED CASE MANAGEMENT SERVICES FOR CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS, DEFINITIONS The definitions of targeted case management services for children and youth with special health care needs are as follows:

            (1) "Assessment" means an evaluation of a child's physical, medical, nutritional, psychological, social, developmental, and educational status in the context of the child's caretakers to determine if the child meets the "at risk" criteria stated in ARM 37.86.3902 or if the child has diagnosed special health care needs, and to document the child's needs for resources and services.

            (2) (1)  "Case Care plan" means a specific written, individualized, family-centered, culturally competent and coordinated case management service plan reflecting a child's needs and strengths. The plan provides goals of intervention, objectives, activities in context of the child's caregivers, and the resources and services available to meet the child's needs in a coordinated and integrated fashion. plan that is based on the information collected through the comprehensive assessment and periodic reassessment process that:

            (a) specifies the goals and actions to address the medical, social, educational, and other services needed by the child;

            (b) includes activities such as ensuring the active participation of the child and child's caregiver and working with the child and others to develop those goals; and

            (c) identifies a course of action to respond to the assessed needs of the child.

            (3) "Care coordination and referral" means assisting a child and child's caregivers to access resources and services, including children's special health services, specialty clinics, other needed services, and to establish and maintain eligibility for services other than medicaid. For those children for whom the developmental disabilities family education and support services program (DDFESS) retains lead status, care coordination activities are determined at the community level.

            (2) "Comprehensive assessment and periodic reassessment" means an evaluation to identify a child's need for any medical, educational, social, or other services. These assessment activities include:

            (a) taking a child's history;

            (b) identifying the child's needs and completing the related documentation; and

            (c) gathering information from other sources to form a complete assessment of the child.

            (4) "Developmental disabilities family education and support services (DDFESS)" means the developmental disabilities family education and support services program comprised of the federally authorized and funded Part H services, state funded family education and support services.

            (5) (3)  "Monitoring and follow-up activity" means regular contacts through ongoing home visitation and other means to assure appropriateness of services provided to the child and the child's caregivers, to identify and address concerns which may create barriers to services, and to assure the receipt of services as indicated in the case plan. Health and medical services for children served by DDFESS may be monitored by the children with special health care needs. Program monitoring functions include:

            (a) utilizing information obtained from assessments of the child/family's needs and status; and

            (b) modifying the case management service plan as needed in coordination with all involved providers in order to promote positive outcomes for a child and the child's caregivers. activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the child's needs. The activities may be with the child, family members, service providers, or other entities or individuals and may be conducted as frequently as necessary. Monitoring may be furnished through face-to-face visits, telephone calls, and telemedicine services.

            (4) "Paraprofessional" means a person to whom a particular aspect of a professional task is delegated but who is not licensed to practice as a fully qualified professional.

            (5) "Referral" means activities that help link the child or child's caregiver with medical, social, or educational providers, and other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the care plan.

            (6) "Targeted case management" means services that assist a child and a child's caregivers to access needed medical, social, or other resources and services by establishing and maintaining a referral process for needed and appropriate services and avoiding duplication of services.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3902 TARGETED CASE MANAGEMENT SERVICES FOR CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS, ELIGIBILITY  (1) A child is eligible for targeted case management services for children and youth with special health care needs if:

            (a) the child is receiving Medicaid or is presumptively eligible for Medicaid;

            (a) (b)  the child:

            (i) through (iii) remain the same.

            (b) (c)  the child is born to a woman who received targeted case management services as a high risk pregnant woman.

            (2) For a child who is eligible for developmental disabilities Part H services or for developmental disabilities family and educational support general fund services and who is eligible for children with special health care needs case management, the developmental disabilities services program provides lead case management. For a child with case management services from both the developmental disabilities program and the children's special health care needs program, the case management services provided by children with special health care needs case management providers are limited to the coordination of health and medical activities only. Children with special health care needs case management providers must incorporate the health and medical care plan within the individual family service plan and provide services in accordance with ARM 37.34.601, 37.34.602, 37.34.604, 37.34.605, 37.34.609, 37.34.612 through 37.34.616, 37.34.621, 37.34.622, 37.34.2101, 37.34.2102, 37.34.2106, 37.34.2107, 37.34.2111 and 37.34.2112. Under these circumstances, children with special health care needs case management providers may bill medicaid for health and medical case management activities only.

            (2) The member is not eligible for targeted case management services if enrolled in a Medicaid Patient Centered Medical Home (PCMH) program, Comprehensive Primary Care Plus (CPC+), or Health Improvement Program (HIP).

            (3)  Initial assessment of children covered by these special health care needs targeted case management services may occur in the hospital following the infant's birth. This assessment must be followed by a referral to appropriate service providers in the community. Assessments by all professionals will be accepted, shared, and integrated into planning for all children covered by these services.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3905 TARGETED CASE MANAGEMENT SERVICES FOR CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS, COVERAGE  (1) The following services are reimbursable targeted case management services for children and youth with special health care needs:

            (a) comprehensive assessment and periodic reassessment;

            (b) case planning care plan development;

            (c) care coordination and referral for other services; and

            (d) monitoring and follow up.

            (2) Monitoring must be at least once annually to determine if the following conditions are being met:

            (a) services are being furnished in accordance with the child's care plan;

            (b) services in the care plan are adequate; and

            (c) changes in the needs or status of the child are reflected in the care plan.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3906 TARGETED CASE MANAGEMENT SERVICES FOR CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS, PROVIDER REQUIREMENTS (1) remains the same.

            (2) To be qualified as a provider of targeted case management services for children and youth with special health care needs, an entity enrolled Montana Medicaid provider must:

            (a) be a provider of public health nursing or social work services;

            (b) be approved by the department's health policy and services division;

            (c) have knowledge and experience in the delivery of home and community services to children with special health care needs;

            (d) demonstrate an understanding of service coordination for young children up to 18 years of age;

            (e) have developed collaborative working relationships with health care and other providers in the area to be served;

            (f) have access to multi-disciplinary providers; and

            (g) have on file with the department's health policy and services division, a signed collaborative agreement with community providers of services for children with special health care needs that includes at a minimum:

            (i) public health nursing;

            (ii) social work;

            (iii) nutrition;

            (iv) primary care providers;

            (v) subspecialty providers;

            (vi) dental providers;

            (vii) Part H early intervention providers;

            (viii) paraprofessional home visitor program; and

            (ix) others deemed appropriate by the contractor.

            (a) be approved by the department;

            (b) meet the requirements in (3) through (8);

            (c) have knowledge and experience in the delivery of home and community services to children and youth with special health care needs;

            (d) demonstrate an understanding of service coordination for children up to 18 years of age; and

            (e) have developed collaborative working relationships with health care and other providers in the area to be served.

            (3) Requirements for professional public health providers include:

            (a) for a registered nurse:  a minimum of a bachelor's degree in nursing including course work in public health; and

            (b) for a social worker: a master's or bachelor's degree in behavioral sciences or related field with one year experience in community social services or public health.

            (3) A targeted case management provider must use an interdisciplinary team that includes members from the professions of nursing, social work, and nutrition.

            (a) The professional requirements are the following:

            (i) nursing must be provided by a registered nurse, who has a current Montana license and is either:

            (A) a registered nurse whose education includes course work in public health; or

            (B) a certified nurse practitioner;

            (ii) social work must be provided by one of the following:

            (A) clinical social worker with a master's in social work (MSW), who has a current Montana license;

            (B) master's level counselor (LCPC), who has a current Montana license; or

            (C) bachelor's in social work (BSW) with two years' experience in community social services or public health; and

            (iii) nutrition services must be provided by a registered dietitian who is licensed as a nutritionist in Montana and has one-year experience in public health or maternal-child health.

            (b) The department must be notified within 30 days regarding any staff changes or updates.

            (c) To accommodate special agency and geographic needs and circumstances, exceptions to the staffing requirements, including the use of paraprofessionals, may be allowed if approved by the department. If the targeted case management team includes a paraprofessional, that individual must have a minimum of an associate's degree in behavioral sciences or a related field with two years of closely related work experience, and complete a state-sponsored training for paraprofessional targeted case managers. Qualifying experience may be substituted, year for year, for education.

            (4) The targeted case management provider must be able to directly provide services of at least one of the professional disciplines listed in (3) of this rule. The other disciplines may be provided through subcontracts. Where services are provided through a subcontractor, the subcontract must be submitted to the department or designee for review and approval.

            (5)  A targeted case management provider must:

            (a) conduct activities to inform the target population and health care and social service providers in the geographic area to be served of its services for youth and children with special health care needs;

            (a) (b)  deliver care coordination targeted case management services appropriate to the child and caregiver's level of need;

            (b) through (e) remain the same, but are renumbered (c) through (f).

            (g) establish working relationships with medical providers, community agencies, and other appropriate organizations;

            (f) (h)  assure ongoing communication and coordination of the child's care occurs within the targeted case management team and among the child's care providers;

            (g) (i)  provide services primarily in the a home, setting and additionally in office, or clinic settings with telephone contacts as appropriate.; Home visiting, particularly by the public health nurse, is an integral part of targeted case management for children with special health care needs. To accommodate unusual circumstances or the safety of home visitors, exceptions to home visiting as the primary location of service delivery may be allowed and should be documented in the child's case record;

            (h) remains the same, but is renumbered (j).

            (i) (k)  maintain an adequate and confidential client record system. All services provided must be documented in this system.

            (6)  A targeted case manager must have knowledge of:

            (a) federal, state and local programs for children and youth such as WIC, immunizations, perinatal health care, children's special health care needs services, family planning, genetic services, hepatitis B screening, EPSDT, Montana Milestones (Part C Early Interventions), DDFESS, and other health care related programs in Montana;

            (b) and (c) remain the same.

            (d) nationally recognized early childhood health care and well child health supervision standards.

            (7)  A targeted case manager must have the ability to:

            (a) interpret medical findings;

            (b) (a)  develop or participate in the development of an individual case management care plan based on assessment of a child's health, nutritional and psychosocial status, and personal and community resources;

            (c) through (f) remain the same, but are renumbered (b) through (e).

            (g) (f)  evaluate a child's and the child's caregiver's success progress in obtaining appropriate medical care and other needed services.

            (8) Providers must maintain case records that meet the maintenance of records and auditing guidelines set forth in ARM 37.85.414 and that document, for all members receiving targeted case management, the following:

            (a) the name of the member;

            (b) the dates of the targeted case management services;

            (c) the name of the provider agency and the person providing the services;

            (d) the nature, content, and units of the targeted case management services received, and whether goals specified in the care plan have been achieved;

            (e) whether the member has declined services in the care plan;

            (f) the need for, and occurrences of, coordination with other targeted case managers;

            (g) a timeline for obtaining needed services; and

            (h) a timeline for reevaluation of the plan.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3910 TARGETED CASE MANAGEMENT SERVICES FOR CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS, REIMBURSEMENT (1) Case Targeted case management services for children and youth with special health care needs are reimbursed at the lower of the following:

            (a) remains the same.

            (b) $10.00 for each 15 minutes of service the department's current fee schedule under ARM 37.85.105.

            (2) No cost shall be allowable unless the department determines that it has been incurred and that it is reasonable and necessarily related to the provision of case management services. Profit is not an allowable cost.

            (2) The following activities may not be billed as targeted case management and are not reimbursable as a unit of targeted case management:

            (a) outreach to the child or child's caregiver(s);

            (b) application activities related to Medicaid services or eligibility;

            (c) direct medical services, including counseling or the transportation or escort of members;

            (d) duplicate payments that are made to providers under Medicaid or other program authorities;

            (e) writing, recording, or entering case notes for the member's files;

            (f) travel to and from member activities;

            (g) coordination of the investigation of any suspected abuse, neglect, or exploitation cases; and

            (h) any service less than eight minutes duration if it is the only service provided that day.

            (3) Targeted case management services are not separately billable for members enrolled in a Medicaid Patient Centered Medical Home (PCMH) program, Comprehensive Primary Care Plus (CPC+), or Health Improvement Program.

            (4) All targeted case management services must meet the guidelines of medical necessity set forth in ARM 37.85.410.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

4. The department proposes to repeal the following rules:

 

            37.86.3411 CASE MANAGEMENT SERVICES FOR HIGH RISK PREGNANT WOMEN, FINANCIAL RECORDS, AND REPORTING found on page 37-20604 of the Administrative Rules of Montana.

 

AUTH: 53-6-113, MCA

IMP: 2-4-201, 53-2-201, 53-2-606, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.86.3801 CASE MANAGEMENT SERVICES FOR CHILDREN AT RISK OF ABUSE AND NEGLECT, DEFINITIONS found on page 37-20745 of the Administrative Rules of Montana.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3805 CASE MANAGEMENT SERVICES FOR CHILDREN AT RISK OF ABUSE AND NEGLECT, COVERAGE found on page 37-20749 of the Administrative Rules of Montana.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3806 MEDICAID REIMBURSED CASE MANAGEMENT SERVICES FOR CHILDREN AT RISK OF ABUSE AND NEGLECT, ELIGIBILITY found on page 37-20749 of the Administrative Rules of Montana.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3810 MEDICAID REIMBURSED CASE MANAGEMENT SERVICES FOR CHILDREN AT RISK OF ABUSE AND NEGLECT, PROVIDER REQUIREMENTS found on page 37-20755 of the Administrative Rules of Montana.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.86.3811 MEDICAID REIMBURSED CASE MANAGEMENT SERVICES FOR CHILDREN AT RISK OF ABUSE AND NEGLECT, REIMBURSEMENT found on page 37-20756 of the Administrative Rules of Montana.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            5. STATEMENT OF REASONABLE NECESSITY

 

The Department of Public Health and Human Services (department) is proposing to amend ARM 37.86.3401, 37.86.3402, 37.86.3405, 37.86.3410, 37.86.3415, 37.86.3901, 37.86.3902, 37.86.3905, 37.86.3906, and 37.86.3910 and repeal ARM 37.86.3411, 37.86.3801, 37.86.3805, 37.86.3806, 37.86.3810, and 37.86.3811 regarding targeted case management.

 

In November 2015, the Centers for Medicare and Medicaid Services (CMS) approved an update to the high-risk pregnancy and children and youth with special health care needs state plan in November of 2015. The state plan amendment updated the definitions pertaining to targeted case management and the services required by the provider. The proposed rule updates are to match the state plan agreement and to specify eligible individuals and allowed services.

 

All of the following rules were updated to change the word "client" to "member."

 

Targeted Case Management for High-Risk Pregnant Women

 

The following describes proposed rule amendments to the following rules pertaining to high-risk pregnant women targeted case management:

 

The title of all of the below rules were updated to be targeted case management for high-risk pregnant women.

 

ARM 37.86.3401

 

Update the definitions to match the new definitions in the state plan agreement that was approved by CMS.

 

ARM 37.86.3402

 

Update the list of members eligible for high-risk pregnancy targeted case management to match the requirements listed in the CMS-approved state plan.

 

ARM 37.86.3405

 

Update the reimbursable services to match the services within the CMS-approved state plan.

 

ARM 37.86.3410

 

Update the provider requirements to match the state plan and specify the requirements for the interdisciplinary team.

 

ARM 37.86.3411

 

Repeal this entire rule as financial records and reporting requirements for Medicaid providers is adequately covered in ARM 37.85.414.

 

ARM 37.86.3415

 

Remove information regarding the reimbursement methodology prior to 1996, and remove the specific rate of reimbursement as this is now done through ARM 37.85.105. Add information regarding nonreimbursable services to match the services within the state plan.

 

Fiscal Impact

 

There is no fiscal impact to the above rule amendments.

 

Children and Youth with Special Health Care Needs Targeted Case Management

 

The following describes proposed rule amendments to the following rules pertaining to children and youth with special health care needs targeted case management:

 

The titles of all the below rules were updated to state targeted case management for children and youth with special health care needs.

 

ARM 37.86.3901

 

Update the definitions to match the new definitions within the CMS-approved state plan agreement.

 

ARM 37.86.3902

 

Update the list of members eligible for children and youth with special health care needs targeted case management to match the requirements listed in the state plan and to add clarification for providers.

 

ARM 37.86.3905

 

Specify and amend the covered targeted case management services to match the state plan.

 

ARM 37.86.3906

 

Update the provider requirements to match the state plan and specify the requirements for the interdisciplinary team.

 

ARM 37.86.3910

 

Remove the specific rate of reimbursement as this is now done through ARM 37.85.105. Add information regarding nonreimbursable activities to match the state plan.

 

Fiscal Impact

 

There is no fiscal impact to the above rule amendments.

 

ARM 37.86.3801, 37.86.3805, 37.86.3806, 37.86.3810, and 37.86.3811

 

These rules are all proposed to be repealed as this program no longer exists.

 

Fiscal Impact

 

There is no fiscal impact to repealing the above rules.

 

            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 18, 2017.

 

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. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.

 

10. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment and repeal of the above-referenced rules will not significantly and directly impact small businesses.

 

11. 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 amendments to the "High Risk Pregnancy" and "Children and Youth with Special Health Care Needs" Targeted Case Management rules are intended to increase the number of providers offering these health care services. Pursuant to 53-6-196, MCA, the department will measure the rule amendments' intended outcomes over a 9-month period of time. The department will compare the total number of Targeted Case Management providers enrolled with the department prior to the effective date of the rule amendments and compare that number to the total number of enrolled Targeted Case Management providers after the rule amendments have been in effect for 9 months.

 

 

 

/s/ Brenda K. Elias                                       /s/ Laura Smith for                          

Brenda K. Elias, Attorney                            Sheila Hogan, Director

Rule Reviewer                                             Public Health and Human Services

 

 

Certified to the Secretary of State July 10, 2017.