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| Montana Administrative Register Notice 37-736 | No. 15 08/04/2017 | |
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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 24, 2017, 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 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 August 9, 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 adopted provide as follows:
NEW RULE I MEDICAID SUBSTANCE USE DISORDER SERVICES: PURPOSE (1) The purpose of rules contained in this subchapter is to establish standards for the coverage and reimbursement of substance use disorder services under the Montana Medicaid Program.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, MCA
NEW RULE II MEDICAID SUBSTANCE USE DISORDER SERVICES: GENERAL REQUIREMENTS (1) General Medicaid provider requirements found in ARM 37.85.104 through 37.85.1125 are applicable to all Medicaid substance use disorder services. (2) HELP Medicaid requirements found in ARM 37.84.101 through ARM 37.84.115 are applicable to all Medicaid substance use disorder services. (3) Medicaid substance use disorder services include: (a) screening and assessment; (b) individual therapy; (c) group therapy; (d) family therapy; (e) multiple-family group therapy; (f) targeted case management for substance use disorders as defined in ARM 37.86.3301 through 37.86.3306 and ARM 37.86.4001 through 37.86.4010; (g) nonhospital inpatient substance use disorder detoxification; (h) nonhospital inpatient substance use disorder residential treatment; and (i) nonhospital inpatient substance use disorder residential day treatment. (4) All services must be delivered by facilities or programs approved by the department.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, MCA
NEW RULE III MEDICAID SUBSTANCE USE DISORDER SERVICES: REIMBURSEMENT (1) Medicaid substance use disorder programs must bill for services using procedure codes, modifiers, and definitions contained in the: (a) Centers for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Code System (HCPCS); and (b) American Medical Association's (AMA) Current Procedural Terminology (CPT) Codes. (2) Subject to requirements of this rule, the Medicaid substance use disorder program pays the lower of the following for Medicaid eligible members: (a) the Medicaid substance use disorder program's usual and customary charge for services; (b) the reimbursement methodologies described in ARM 37.85.212; or (c) for items or services where no Resource Based Relative Value (RBRVS) or Medicare fee is available, the department's fee schedule. (3) The allowable Medicaid substance use disorder procedure billing codes and department fee schedules are available at the department's website located at http://medicaidprovider.mt.gov/ and incorporated by reference at ARM 37.85.105. AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, MCA
NEW RULE IV MEDICAID SUBSTANCE USE DISORDERS SERVICES: TREATMENT REQUIREMENTS (1) All Medicaid substance use disorder services must be determined medically necessary by a licensed health care professional within the scope of their Montana professional license. (2) Medical necessity includes documentation to support: (a) an appropriate level of care placement for service based upon the American Society of Addiction Medicine (ASAM) Criteria, Third Edition; Copyright 2013 by the American Society of Addiction Medicine, Inc.; http://www.asam.org/publications/the-asam-criteria/text/; and (b) an International Classification of Diseases – Revision 10 Clinical Modification (ICD-10-CM) diagnosis of a substance use disorder. (3) All services except assessment services must be based upon a treatment plan established with the member.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, MCA
4. The department proposes to repeal the following rules:
37.27.901 CHEMICAL DEPENDENCY AND ABUSE TREATMENT SERVICES: REHABILITATION OPTION 32 is found on page 37-6089 of the Administrative Rules of Montana.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA
37.27.904 CHEMICAL DEPENDENCY AND ABUSE TREATMENT SERVICES: GENERAL REQUIREMENTS is found on page 37-6093 of the Administrative Rules of Montana.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA
37.27.907 CHEMICAL DEPENDENCY BUREAU MEDICAID SUBSTANCE DEPENDENCY AND ABUSE TREATMENT SERVICES: REHABILITATION OPTION 32, FINANCIAL ELIGIBILITY is found on page 37-6097 of the Administrative Rules of Montana.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA
37.27.908 CHEMICAL DEPENDENCY AND ABUSE TREATMENT SERVICES: BILLING PROCEDURE FOR CONSULTATIONS WITH PARENTS is found on page 37-6098 of the Administrative Rules of Montana.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA
37.27.912 ENROLLMENT OF MEDICAID PROVIDERS OF SUBSTANCE DEPENDENCY AND ABUSE TREATMENT SERVICES is found on page 37-6105 of the Administrative Rules of Montana.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA
37.27.916 CHEMICAL DEPENDENCY AND ABUSE TREATMENT SERVICES: INPATIENT FREE STANDING TREATMENT REQUIREMENTS is found on page 37-6109 of the Administrative Rules of Montana.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA
37.27.920 CHEMICAL DEPENDENCY AND ABUSE TREATMENT SERVICES: OUTPATIENT TREATMENT, REQUIREMENTS is found on page 37-6113 of the Administrative Rules of Montana.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA
37.27.921 CHEMICAL DEPENDENCY AND ABUSE TREATMENT SERVICES: CERTAIN OUTPATIENT SERVICES, REQUIREMENTS is found on page 37-6114 of the Administrative Rules of Montana.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA
37.27.926 CHEMICAL DEPENDENCY AND ABUSE TREATMENT SERVICES: DAY TREATMENT, REQUIREMENTS is found on page 37-6121 of the Administrative Rules of Montana.
AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, 53-24-215, MCA
5. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (department) proposes to adopt New Rules I through IV and repeal ARM 37.27.901, 37.27.904, 37.27.907, 37.27.908, 37.27.912, 37.27.916, 37.27.920, 37.27.921, and 37.27.926.
In the 2015 Legislative Session, the 64th Montana Legislature passed Senate Bill 405 (SB405), which implemented Medicaid expansion in Montana under the federal Affordable Care Act, or "ACA." In implementing Medicaid expansion, 42 USC 18022(b) and 45 CFR 156.110 require that the department adhere to specific standards for Essential Health Benefits (EHB). 42 USC 18022(b)(1)(A) through (J) and 45 CFR 156.110(a)(1-10) identify ten categories of EHB services in which the department is required to provide treatment services and reimbursement equal in scope to any other illness. Coverage for Medicaid substance use disorder services is one of the ten identified categories. Pursuant to 42 USC 18022(b)(1)(A) through (J), EHB standards must be defined in a manner that:
(A) reflects appropriate balance among the ten statutory EHB categories;
(B) is not designed in such a way as to discriminate based on age, disability, or expected length of life;
(C) takes into account the health care needs of diverse segments of the population; and
(D) does not allow denials of EHB based on age, life expectancy, or disability.
Current administrative rules for Medicaid substance use disorder services contain language that fails to meet these requirements by limiting services to adults; requiring prior authorization for indicated procedures; indicating limitations of provider enrollment to those who are under contract with the department; and referencing treatment protocols, diagnosis, and care placement information that is outdated. This proposed rulemaking is intended to correct these deficiencies.
The department proposes updating the terminology of "chemical dependency" to "substance use disorders" in all new rules and justification as the term "chemical dependency" is antiquated language.
NEW RULE I
The department proposes this New Rule I to set forth the purpose of subchapter 9.
NEW RULE II
The department proposes by (1) of this new rule to identify the general Medicaid provider requirements set forth in ARM 37.85.104 through ARM 37.85.1125 as applying to all Medicaid substance use disorder services to ensure providers are aware of the general Medicaid requirements that must be followed under this program.
The department proposes by (2) of this new rule to inform providers that the HELP Medicaid requirements as set forth in ARM 37.85.104 and 37.85.1125 apply to Medicaid substance use disorders services.
The department proposes by (3) of this new rule to expand the definition of Medicaid substance use disorder services formally found in ARM 37.27.901(1) to include the following additional services in the term "Medicaid substance use disorder services" pursuant to the requirements of 42 USC 18022(b)(1)(A) through (J):
(a) New Rule II(3)(a) "screening" as a payable service to allow providers to screen Medicaid members to determine whether a full assessment is medically appropriate;
(b) New Rule II(3)(f) "targeted case management for substance use disorder services" and referring to the general Medicaid targeted case management rules set forth in ARM 37.86.3301 through 37.86.3306 and to the specific Medicaid targeted case management for substance use disorders rules set forth in ARM 37.86.4001 through 37.86.4010 to ensure treatment providers of substance use disorders are aware of and follow the correct administrative rules for targeted case management;
(c) New Rule II(3)(g) "detoxification" as a payable service in a nonhospital inpatient substance use disorders treatment center given that many provide detoxification services for the first few days of an inpatient stay; and
(d) New Rule II(3)(h) and (i), "nonhospital" in the description of inpatient substance use disorders services (residential treatment and residential day treatment) to clarify that providers may only bill for such services under subchapter 9 if they are provided in a nonhospital setting.
The department proposes by (4) of this new rule to inform providers of the type of facility certification required to bill for Medicaid substance use disorders services.
NEW RULE III
The department proposes by (1) of this new rule to require substance use disorder treatment programs to use procedure codes, modifiers, and definitions in the Centers for Medicare and Medicaid Services' (CMS) Healthcare Common Procedure Code System (HCPCS) and the American Medical Association's (AMA) Current Procedural Terminology (CPT) Codes when billing for services.
The department proposes by (2) of this new rule to outline the three reimbursement rates considered in processing Medicaid payment and the hierarchy used to determine the lower cost reimbursement rate.
The department proposes by (3) of this new rule to indicate where providers of substance use disorder services can find the allowable Medicaid procedure codes, the associated fee schedules, and Medicaid program information to bill for substance use disorder services. The reference to ARM 37.85.105 is included in this section because this is the administrative rule that contains the fee schedules.
NEW RULE IV
The department proposes by (1) of this new rule to set forth the requirement from the Affordable Care Act (ACA) that the determination of whether substance use disorder services are medically necessary must be made by licensed health care providers acting within the scope of their Montana professional license.
The department proposes by (2) of this new rule to define information necessary to support a diagnosis of "medical necessity" for substance use disorder services.
The department proposes by (3) of this new rule to set forth the requirement that all substance use disorder services other than assessment services be based upon a treatment plan established with the member.
Repeal of ARM 37.27.901, 37.27.904, 37.27.907, 37.27.908. 37.27.912, 37.27.916, 37.27.920, 37.27.921, and 37.27.926
ARM 37.27.901
The requirements under these rules are no longer applicable for the substance abuse disorder rule services. The information regarding the Medicaid provider fee schedules has been moved to New Rule III.
The department proposes repealing ARM 37.27.901 because it no longer reflects the identification or implementation of substance use disorder services under the Montana Medicaid program. The list of treatment services is being moved to New Rule II(3) and expanded to reflect current law.
ARM 37.27.904
The department proposes repealing ARM 37.27.904 because it no longer reflects the general service requirements for substance use disorder services under the Montana Medicaid program, which is set forth in New Rule III. Language regarding treatment planning set forth in ARM 37.27.904(2) is being moved to New Rule IV(3).
ARM 37.27.907
The department proposes repealing ARM 37.27.907 because the information in the rule concerning substance use disorder providers' determination of Medicaid member eligibility no longer applies. Substance use disorder providers no longer determine Medicaid member eligibility.
ARM 37.27.908
The department proposes repealing ARM 37.27.908(1) and (2), which no longer reflect billing and reimbursement procedures. New Rule IV reflects the current procedures regarding reimbursement substance use disorders services.
ARM 37.27.912 The department proposes repealing ARM 37.27.912 because the information in the rule concerning requirements for Medicaid substance use disorder provider enrollment is found in the proposed language for ARM 37.27.904, and the information in the rule concerning where the manual may be obtained is antiquated as all Medicaid provider manuals are found online on the Medicaid Provider Portal, https://medicaidprovider.mt.gov/.
ARM 37.27.916
The department proposes repealing ARM 37.27.916 because the Montana Medicaid program no longer requires the age limitation and prior authorization requirements set forth in the rule for inpatient substance use disorder, and because the diagnosis and placement information in this rule is found in the proposed language for New Rule IV.
ARM 37.27.920
The department proposes repealing ARM 37.27.920 as the information listed a level of care for treatment services and not services. Clarification of services covered are found in the proposed language for New Rule II.
ARM 37.27.921
The department proposes repealing ARM 37.27.921 as the information is found in the proposed language for New Rule IV.
ARM 37.27.926 The department proposes repealing ARM 37.27.926 as the Montana Medicaid program no longer requires the age limitation and prior authorization requirements set forth in the rule for inpatient substance use disorder day treatment.
Summarize the approach that was taken.
Current Medicaid substance use disorder rules were reviewed and compared to the proposed Blue Cross Blue Shield of Montana "Blue Dimensions Group Plan" for comparability of services available. Specific services and requirement differences were identified. This information was used to propose changes to current rules for Medicaid substance use disorder services listed above.
FISCAL IMPACT
The proposed new rules will increase benefits for eligible individuals under the Medicaid benefit package. The proposed new rules allowing nonhospital inpatient and day-treatment services to be billed under Medicaid for adults ages 21 years and older will have the following estimated annual fiscal impact:
Total number of individuals served for SFY2018 and SFY2019 will be 1,302.
The above numbers do not take into account a projected number of individuals who apply for Medicaid Expansion and are deemed Standard Medicaid eligible.
6. The department intends the proposed rule amendments to be applied effective October 1, 2017.
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., September 1, 2017.
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. 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 July 24, 2017.
11. With regard to the requirements of 2-4-111, MCA, the department has determined that the adoption and repeal of the above-referenced rules will significantly and directly impact small businesses by increasing possible revenue generated by the additional covered services. Projected revenues are those indicated under the fiscal impact statement.
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.
13. 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 following matrix presents the department's intended performance monitoring scheme.
/s/ Francis X. Clinch /s/ Marie Matthews for Francis X. Clinch, Attorney Sheila Hogan, Director Rule Reviewer Public Health and Human Services
Certified to the Secretary of State July 24, 2017.
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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].
