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| Montana Administrative Register Notice 37-893 | No. 21 11/08/2019 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Concerned Persons
1. On December 3, 2019, at 1:00 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 adoption and 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 November 26, 2019, 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 rule as proposed to be adopted provides as follows:
NEW RULE I OUTPATIENT HOSPITAL REIMBURSEMENT, OUTPATIENT HOSPITAL REIMBURSEMENT ADJUSTOR (1) The outpatient hospital reimbursement adjustor (HRA) payment is payable to a PPS hospital or critical access hospital, as those terms are defined in 50-5-101, MCA, that provides outpatient hospital services. Eligibility to receive the outpatient HRA is based on a hospital's year-end reimbursement status. (2) An individual hospital's outpatient HRA payment will be based upon total hospital Medicaid outpatient charges and will be computed as follows: HRA = (J ÷ D) x P. (a) "HRA" represents the calculated hospital specific outpatient HRA payment. (b) "J" equals the total outpatient hospital charges billed to Medicaid by the hospital for which the payment is calculated. (c) "D" equals the total outpatient hospital charges billed to Medicaid by all hospitals eligible to receive an outpatient HRA payment. (d) "P" equals the distributable revenue generated by the outpatient hospital utilization fee plus applicable federal financial participation. (3) Data sources for the department to determine which hospitals meet the criteria to receive an outpatient HRA payment and the amount of the payment may include, but are not limited to: (a) the Montana Hospital Association (MHA) database; (b) the Medicaid paid claims database for the most recent calendar year; (c) filed or settled cost reports; and (d) reports from the Licensure Bureau of the Quality Assurance Division. (4) Eligibility evaluations, payment calculations, and payments will be made annually. (5) The Montana State Hospital or a hospital or facility operated by the state, a political subdivision of the state, the United States, or an Indian Tribe or any facility authorized under the Indian Health Care Improvement Act are not eligible for the HRA payment.
AUTH: 2-4-201, 53-2-201, 53-6-113, MCA IMP: 2-4-201, 53-2-201, 53-6-101, 53-6-113, 53-6-149, MCA
4. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
37.86.2901 INPATIENT HOSPITAL SERVICES, DEFINITIONS (1) through (27) remain the same. (28) "Inpatient hospital utilization fee" means the utilization fee collected by the Department of Revenue as provided in 15-66-102, MCA. (28) through (47) remain the same but are renumbered (29) through (48).
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, 53-6-149, MCA
37.86.2928 INPATIENT HOSPITAL REIMBURSEMENT, HOSPITAL REIMBURSEMENT ADJUSTOR (1) (2) Revenue generated from the inpatient hospital utilization fee plus applicable federal financial participation (FFP) is utilized to calculate the following supplemental payments: (a) the continuity of care payment described in ARM 37.87.1224; (b) Part 1 of the HRA; and (c) Part 2 of the HRA. (a) For the purposes of calculating Part 1 of the HRA, the following apply: (i) through (iii) remain the same. (iv) "P" equals the total amount to be paid via Part 1 of the HRA. "P" consists of a state-paid amount plus the applicable federal financial participation (FFP). The portion of "P" that is paid by the state will equal the amount of revenue generated by Montana's inpatient hospital utilization fee, less all (A) 4% of the total revenue generated by the inpatient hospital utilization fee, which will be expended as match for continuity of care adjustor payments, as provided in ARM 37.87.1224; and (B) 8% of the total revenue generated by the inpatient hospital utilization fee, which will be expended as match for Part 2 of the HRA, as provided in (a) For the purposes of calculating Part 2 of the HRA, the following apply: (i) through (iii) remain the same. (iv) "P" equals the total amount to be paid via Part 2 of the HRA. "P" will be 8% of the total revenue generated by Montana's inpatient hospital utilization fee plus applicable FFP.
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, 53-6-149, MCA
37.86.2940 INPATIENT HOSPITAL REIMBURSEMENT ADJUSTOR (HRA), DATA SOURCES (1) (2) Data sources for the department to determine which hospitals meet the criteria to receive (a) through (c) remain the same. (d) reports from the (3) remains the same. (4) The Montana State Hospital
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, 53-6-149, MCA
37.86.3001 OUTPATIENT HOSPITAL SERVICES, DEFINITIONS (1) through (16) remain the same. (17) "Outpatient hospital reimbursement adjustor (HRA)" means a payment to a Montana PPS hospital or critical access hospital as specified in [New Rule I]. (17) remains the same but is renumbered (18). (19) "Outpatient hospital utilization fee" means the utilization fee collected by the Department of Revenue as provided in 15-66-102, MCA. (18) remains the same but is renumbered (20). (21) "Outpatient revenue" means the gross revenue from a hospital's charges for services provided on an outpatient basis. Charges for professional services provided as part of an outpatient treatment are not included. (19) remains the same but is renumbered (22). (23) "Prospective payment system (PPS) hospital" means a hospital reimbursed pursuant to the diagnosis related group (DRG) system. DRG hospitals are classified as such by the Centers for Medicare and Medicaid Services (CMS) in accordance with 42 CFR part 412. (20) through (23) remains the same but are renumbered (24) through (27).
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
37.87.1224 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES, CONTINUITY OF CARE PAYMENT (1) Hospital-based psychiatric residential treatment facilities as defined in ARM 37.87.1207 qualify for a continuity of care payment. (a) remains the same. (b) The amount will be determined by the department according to the following formula: CCA=[M/D]*P: (i) through (iii) remain the same. (iv) "P" is the total amount available for distribution via the continuity of care payments. P equals 4% of the revenue generated by the Montana inpatient hospital utilization fee, plus federal financial participation. (2) The number of Medicaid days
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
5. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (department) administers the Montana Medicaid and non-Medicaid program 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.
The purpose of the proposed rule amendments is to: (1) implement House Bill 658, passed by the 2019 legislature, which requires the department to establish an outpatient hospital reimbursement adjustor (HRA) supplemental payment for PPS hospitals and critical access hospitals in Montana; (2) modify the exclusion criteria for the HRA supplemental payments; (3) update definitions for inpatient and outpatient hospitals; (4) update the claim data parameters for the Continuity of Care payment calculations; and (5) clarify the difference between Part 1 and Part 2 of the HRA payments generated from the inpatient hospital utilization fee.
NEW RULE I
House Bill (HB) 658 enacted an outpatient hospital utilization fee for hospitals to pay a percentage of the outpatient revenue. Eligible hospitals pay a 0.9% fee on hospital outpatient revenue. A portion of the revenue collected by the Department of Revenue for the outpatient utilization fee will be used to provide the state matching funds used in a new outpatient HRA payment.
New Rule I is reasonably necessary to enact the requirements of HB 658 which includes the following:
Inpatient and Outpatient Hospital Definitions
The department proposes to add definitions for "outpatient hospital utilization fee," "hospital reimbursement adjustor," "outpatient hospital revenue," and "inpatient hospital utilization fee." These definitions will support the proposed rules to implement the supplemental payment rules for outpatient revenue and differentiate the inpatient hospital utilization fee from the outpatient hospital utilization fee.
Continuity of Care
The department proposes to amend ARM 37.87.1224 to utilize paid claims data for the most recent calendar year, instead of the calendar year ending 12 months prior to the Continuity of Care payment calculation. The reasonable necessity for this change is to align it with the data qualifications for the HRA payments.
Clarify Inpatient Hospital Reimbursement Adjustor Payments
The department proposes to amend ARM 37.86.2928 to clarify language outlining HRA Part 1 and Part 2 of the hospital reimbursement adjustor generated from the inpatient hospital utilization fee. In addition, the rule is proposed to change the reference of hospital utilization fee to inpatient hospital utilization fee to distinguish it from the newly enacted outpatient hospital utilization fee, and remove language no longer applicable to data utilized for calculating payment for a facility not in operation for two full calendar years.
Fiscal Impact
The state fiscal impact, shown above, is funded from the outpatient hospital utilization fee.
The department intends these rule amendments to be effective January 1, 2020.
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: 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., December 6, 2019.
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, apply and have been fulfilled. The primary bill sponsor was notified by U.S. mail on October 28, 2019.
10. With regard to the requirements of 2-4-111, MCA, the department has determined that the adoption and amendment 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 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 29, 2019.
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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].
