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| Montana Administrative Register Notice 37-869 | No. 20 10/19/2018 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Concerned Persons
1. On November 8, 2018, at 2:00 p.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 October 28, 2018, to advise us of the nature of the accommodation that you need. Please contact Gwen Knight, 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:
37.27.902 MEDICAID SUBSTANCE USE DISORDER SERVICES: AUTHORIZATION REQUIREMENTS (1) remains the same. (2) In addition to the requirements contained in rule, the department has developed and published the Addictive and Mental Disorders Division Medicaid Services Provider Manual for Substance Use Disorder and Adult Mental Health (Manual), dated
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
37.85.104 EFFECTIVE DATES OF PROVIDER FEE SCHEDULES FOR MONTANA NON-MEDICAID SERVICES (1) The department adopts and incorporates by reference the fee schedule for the following programs within the Addictive and Mental Disorders Division and Developmental Services Division on the dates stated: (a) Mental health services plan provider reimbursement, as provided in ARM 37.89.125, is effective (b) 72-hour presumptive eligibility for adult-crisis stabilization services reimbursement for services, as provided in ARM 37.89.523, is effective (c) remains the same. (d) Substance use disorder services provider reimbursement, as provided in ARM 37.27.905, is effective (2) remains the same.
AUTH: 53-2-201, 53-6-101, 53-6-113, MCA IMP: 53-2-201, 53-6-101, 53-6-111, MCA
37.85.105 Effective dates, CONVERSION FACTORS, POLICY ADJUSTERS, AND COST-TO-CHARGE RATIOS of Montana Medicaid Provider Fee Schedules (1) remains the same. (2) The department adopts and incorporates by reference, the resource-based relative value scale (RBRVS) reimbursement methodology for specific providers as described in ARM 37.85.212 on the date stated. (a) Resource-based relative value scale (RBRVS) means the version of the Medicare resource-based relative value scale contained in the Medicare Physician Fee Schedule adopted by the Centers for Medicare and Medicaid Services (CMS) of the U.S. Department of Health and Human Services and published at 82 Federal Register 219, page 52976 (November 15, 2017) effective January 1, 2018 which is adopted and incorporated by reference. Procedure codes created after January 1, (b) Fee schedules are effective (c) through (h) remain the same. (i) Reimbursement for physician-administered drugs described in ARM 37.86.105 is determined in 42 CFR 414.904 (2016). The department adopts 106% of the Average Sale Price (ASP), effective (j) Reimbursement for vaccines described at ARM 37.86.105 is effective (3) The department adopts and incorporates by reference, the fee schedules for the following programs within the Health Resources Division, on the date stated. (a) The inpatient hospital services fee schedule and inpatient hospital base fee schedule rates including: (i) the APR-DRG fee schedule for inpatient hospitals as provided in ARM 37.86.2907, effective (ii) remains the same. (b) The outpatient hospital services fee schedules including: (i) remains the same. (ii) the conversion factor for outpatient services on or after (iii) and (iv) remain the same. (c) The hearing aid services fee schedule, as provided in ARM 37.86.805, is effective (d) through (j) remain the same. (k) Montana Medicaid adopts and incorporates by reference the Region D Supplier Manual, effective (l) through (q) remain the same. (r) The optometric fee schedule provided in ARM 37.86.2005, is effective (s) remains the same. (t) The lab and imaging fee schedule, as provided in ARM 37.85.212(2) and 37.86.3007, is effective (u) through (w) remain the same. (x) The mobile imaging fee schedule, as provided in ARM 37.85.212, is effective (y) The licensed direct entry midwife fee schedule, as provided in ARM 37.85.212, is effective (z) and (4) remain the same. (5) The department adopts and incorporates by reference, the fee schedule for the following programs within the Addictive and Mental Disorders Division on the date stated: (a) Mental health center services for adults reimbursement, as provided in ARM 37.88.907, is effective (b) Home and community-based services for adults with severe disabling mental illness, reimbursement, as provided in ARM 37.90.408, is effective (c) Substance use disorder services reimbursement, as provided in ARM 37.27.905, is effective (6) remains the same.
IMP: 53-2-201, 53-6-101, 53-6-125, 53-6-402, MCA
37.88.101 MEDICAID MENTAL HEALTH SERVICES FOR ADULTS, AUTHORIZATION REQUIREMENTS (1) remains the same. (2) In addition to the requirements contained in rule, the department has developed and published the Addictive and Mental Disorders Division Medicaid Services Provider Manual for Substance Use Disorder and Adult Mental Health (Manual), dated (3) through (5) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
4. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (department) administers the Montana Medicaid and non-Medicaid programs to provide health care to Montana's qualified low income, elderly, and disabled residents. Medicaid is a public assistance program paid for with state and federal funds appropriated to pay health care providers for the covered medical services they deliver to Medicaid members. Pursuant to 53-6-113(3), MCA, the legislature has delegated authority to the department to set by rule, the reimbursement rates that Medicaid pays to providers for covered services.
Addictive & Mental Disorders Division (AMDD)
The department proposes to amend these rules to incorporate a new edition of the Addictive and Mental Disorders Division Medicaid Services Provider Manual for Substance Use Disorder and Adult Mental Health (Manual), effective January 1, 2019, which includes the following manual changes to clarify policy language, and to revise the concurrent services sections in the services as described below.
Section 1 - Utilization Management:
Revise the language under "Authorization" in the "Determinations" section to reflect that an authorization indicates that the utilization review resulted in approval of provider requested services or service units as deemed medically necessary up to the maximum number of allowed days as stated for each service requiring authorization.
Section 2 - Medicaid Adult Mental Health Services:
Revise the concurrent services lists as follows (removed services means the service is allowed concurrently, added services means the service is not allowed concurrently): 1) Add Community-Based Psychiatric Rehabilitation and Supports (CBPRS) to Crisis Stabilization Program. 2) Remove Dialectical Behavioral Therapy (DBT) and Illness Management and Recovery (IMR) from Adult Group Home (AGH). 3) Remove Crisis Stabilization Program from DBT. 4) Remove Intensive Community-Based Rehabilitation (ICBR) and Crisis Stabilization Program from Mental Health Out Patient (OP) Therapy. 5) Added language to clarify that CBPRS may not be provided during PHP program hours. 6) Remove ICBR, Crisis Stabilization Program, and DBT from IMR. 7) Remove Crisis Stabilization Program from Targeted Case Management (TCM).
Section 3 - Medicaid Substance Use Disorder (SUD) Services, SUD Medically Monitored Intensive Inpatient (ASAM 3.7) Adult / SUD Medically Monitored High Intensity Inpatient (ASAM 3.7) Adolescent:
Revise the definition language in Section 3 to remove the language pertaining to the maximum number of beds in the facility. This is necessary because the Patients and Communities Act, if signed into law, may modify the provision of reimbursement for Institutions for Mental Disease (IMD), which may affect the number of beds a facility may have and still receive reimbursement.
ARM 37.85.104(1) and 37.85.105(5)
The department is proposing to amend ARM 37.85.104(1) and 37.85.105(5) to update the AMDD Medicaid and non-Medicaid fee schedules effective dates to January 1, 2019, as follows:
Substance Use Disorder Fee Schedules:
ARM 37.85.104(1)(d) - Add "HF" modifier to CPT 90832, 90834, 90837, 90853 to reflect required billing information for the Substance Abuse Management System (SAMS) under the Block Grant for contracted State-Approved Substance Use Disorder Treatment Providers. This update is in conjunction with a May 9, 2018 Provider Notice which clarifies the use of the HF modifier.
ARM 37.85.105(5)(c) - Remove CPT codes subject to the resource-based relative value scale (RBRVS) reimbursement methodology for specific providers as described in this rule and add the language: State approved Chemical Dependency providers may bill applicable CPT codes within the scope of their practice, subject to licensure provisions and state approval. State approved Chemical Dependency Providers bill using standard CPT procedure codes and are reimbursed according to the Department's RBRVS system. Please refer to https://medicaidprovider.mt.gov/." This amendment is necessary to make the AMDD behavioral health fee schedules consistent.
Severe Disabling Mental Illness (SDMI) Waiver fee schedule:
ARM 37.85.105(5)(b) - Amend the AMDD SDMI Waiver fee schedule to remove the following services pursuant to the approved 10/1/18 waiver amendment:
(1) S5116 Overnight Support; and (2) S5135 Companion Services.
Medicaid Mental Health Individuals 18 years of age and older Fee Schedule:
ARM 37.85.105(5)(a) - Update the "Limit" column to reflect unit limits in place for certain services as described in the manual. The limits require a provider to receive prior authorization for the provision of services over the defined limits. These revisions do not affect current reimbursement or applicable billing practices.
72 Hour Presumptive Eligibility Program for Crisis Stabilization, Individuals 18 years of age and Older Fee Schedule:
ARM 37.85.104(1)(b) - Update the "Limit" column to reflect unit limits in place for certain services as described in the manual. The limits require a provider to receive prior authorization for the provision of services over the defined limits. These revisions do not affect current reimbursement or applicable billing practices.
Mental Health Services Plan Individuals 18 years of age and Older Fee Schedule:
ARM 37.85.104(1)(a) - Update the "Limit" column to reflect unit limits in place for certain services as described in the manual. The limits require a provider to receive prior authorization for the provision of services over the defined limits. These revisions do not affect current reimbursement or applicable billing practices.
Health Resources Division (HRD)
The Department of Public Health and Human Services (department) is proposing to amend ARM 37.85.105, to update the effective dates of Medicaid fee schedules to January 1, 2019.
The rule amendments are necessary so that the Montana Medicaid Program can adopt updates to procedure codes that the federal Medicare program will enact in January 2019. The federal Medicare program's updates include new code additions, code deletions, and changes to existing code descriptions. Medicare enacts routine updates every January, and Montana Medicaid, which uses Medicare procedure codes for billing, must adopt the changes for the state program.
ARM 37.85.105(2)
The department is proposing to adopt new Medicare codes that are effective on January 1, 2019. This will allow the department to update Medicare fees, additions, deletions, or changes to procedure codes when Medicare releases and updates their fee schedule.
ARM 37.85.105(2)(b)
The department is proposing to amend the effective date for RBRVS fee schedules from July 1, 2018, as revised and labeled "version 2," to January 1, 2019. This will allow the department to update Medicare fees, additions, deletions, or changes to procedure codes when Medicare releases and updates their fee schedule.
ARM 37.85.105(2)(i)
The department is proposing to amend the effective date for Average Sale Price from January 1, 2018 to January 1, 2019. This will allow the department to update Medicare fees, additions, deletions, or changes to procedure codes when Medicare releases and updates their fee schedule.
ARM 37.85.105(2)(j)
The department is proposing to add the fee schedule for vaccines and provide an effective date of January 1, 2019. This will allow the department to update Centers for Disease Control and Prevention (CDC) fees when they update their fee schedule.
ARM 37.85.105(3)(a)(i)
The department is proposing to increase the inpatient hospital base rate for general hospitals by 5%, a change from $5,154 to $5,425 effective date of January 1, 2019. This does not apply to the base rate for Center for Excellence (CoE) hospitals, as the CoE rates were not reduced. This change restores a reduction implemented in state fiscal year (SFY) 2018 via MAR Notice No. 37-828.
ARM 37.85.105(3)(b)(ii)
The department is proposing to increase the outpatient conversion factor by 10%, a change from $50.98 to $56.64 with an effective date of January 1, 2019. This change restores a reduction implemented in state fiscal year via MAR Notice No. 37-828.
ARM 37.85.105(3)(c)
The department is proposing to amend the effective date for the hearing aid services fee schedule from July 1, 2018 to January 1, 2019. This will allow the department to update Medicare fees, additions, deletions, or changes to procedure codes when Medicare releases and updates their fee schedule.
ARM 37.85.105(3)(k)
The department is proposing to amend the effective date of the Region D Supplier Manual from July 1, 2018 to January 1, 2019. The department is amending the effective date of local coverage determinations (LCDs), national coverage determinations (NCDs) as provided in ARM 37.86.1802 from July 1, 2018 to January 1, 2019. The department is also prosing to amend the effective dates for the durable medical equipment fee schedule from July 1, 2018 to January 1, 2019 by adopting the Calendar Year 2019 Medicare Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) fee schedule. This will allow the department to update Medicare fees, additions, deletions, or changes to procedure codes when Medicare releases and updates their fee schedule.
ARM 37.85.105(3)(r)
The department is proposing to amend the effective date for the optometric fee schedule from July 1, 2018, as revised and labeled "version 2," to January 1, 2019. This will allow the department to update Medicare fees, additions, deletions, or changes to procedures codes when Medicare releases and updates their fee schedule.
ARM 37.85.105(3)(t)
The department is proposing to amend the effective date for the lab and imaging fee schedule from July 1, 2018, as revised and labeled "version 2" to January 1, 2019. This will allow the department to update Medicare fees, additions, deletions, or changes to procedure codes when Medicare releases and updates their fee schedule.
ARM 37.85.105(3)(x)
The department is proposing to amend the effective date for the mobile imaging fee schedule from July 1 2018, as revised and labeled "version 2" to January 1, 2019. This will allow the department to update Medicare fees, additions, deletions, or changes to procedure codes when Medicare releases and updates their fee schedule.
ARM 37.85.105(3)(y)
The department is proposing to amend the effective date for the licensed direct entry midwives fee schedule from July 1, 2018, as revised and labeled "version 2" to January 1, 2019. This will allow the department to update Medicare fees, additions, deletions, or changes to procedure codes when Medicare releases and updates their fee schedule.
AMDD Fiscal Impact
There is no fiscal impact pertaining to the amendments in ARM 37.27.902, 37.85.104(1)(a), (b), and (d), and 37.85.105(5)(a), (b), and (c). There is no fiscal impact pertaining to the amendments in the AMDD, Medicaid Services Provider Manual.
HRD Fiscal Impact
The following table displays the provider groups affected, the number of providers by type, and the fiscal impact to State general funds for State Fiscal Year (SFY) 2019 and SFY 2020 for the proposed amendments.
5. 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: Gwen Knight, 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 16, 2018.
6. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing.
7. 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 5 above or may be made by completing a request form at any rules hearing held by the department.
8. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
9. 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.
10. 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 not appropriate for performance-based measurement and therefore are not subject to the performance-based measures requirement of 53-6-196, MCA.
/s/ Brenda K. Elias /s/ Sheila Hogan Brenda K. Elias Sheila Hogan, Director Rule Reviewer Public Health and Human Services
Certified to the Secretary of State October 9, 2018.
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