37.85.105    EFFECTIVE DATES, CONVERSION FACTORS, POLICY ADJUSTERS, AND COST-TO-CHARGE RATIOS OF MONTANA MEDICAID PROVIDER FEE SCHEDULES

(1) The Montana Medicaid Program establishes provider reimbursement rates for medically necessary, covered services based on the estimated demand for services and the legislative appropriation and federal matching funds. Provider reimbursement rates are stated in fee schedules for covered services applicable to the identified Medicaid program. New rates are established by revising the identified program's fee schedule and adopting the new fees as of the stated effective date of the schedule. Copies of the department's current fee schedules are posted at http://medicaidprovider.mt.gov. A description of the method for setting the reimbursement rate and the administrative rules applicable to the covered service are published in the chapter or subchapter of this title regarding that service. The department will make periodic updates, as necessary, to the fee schedules noted in this rule to include new procedure codes and applicable rates and to remove terminated procedure codes.

(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 & Medicaid Services (CMS) of the U.S. Department of Health and Human Services and published at 87 Federal Register 69404 (Nov. 18, 2022), effective January 1, 2023, which is adopted and incorporated by reference. Procedure codes created after January 1, 2023, will be reimbursed using the relative value units from the Medicare Physician Fee Schedule in place at the time the procedure code is created.

(b) Fee schedules are effective July 1, 2023. The conversion factor for physician services is $44.32. The conversion factor for allied services is $26.13. The conversion factor for mental health services is $22.67. The conversion factor for anesthesia services is $32.04.

(c) Policy adjustors are effective July 1, 2023. The maternity policy adjustor is 100%. The family planning policy adjustor is 105%. The psychological testing policy adjustor is 200%. The psychological testing policy adjustor applies only to psychologists.

(d) The BCBA/BCBA-D services policy adjuster is 115.8%, effective July 1, 2021.

(e) The payment-to-charge ratio is effective July 1, 2023, and is 46.8% of the provider's usual and customary charges.

(f) The specific percentages for modifiers adopted by the department are effective July 1, 2016.

(g) Psychiatrists receive a 112% provider rate of reimbursement adjustment to the reimbursement of physicians effective July 1, 2016.

(h) Midlevel practitioners receive a 90% provider rate of reimbursement adjustment to the reimbursement of physicians for those services described in ARM 37.86.205(5)(b), effective July 1, 2016.

(i) Optometric services receive a 115.50% provider rate of reimbursement adjustment to the reimbursement for allied services, as provided in ARM 37.85.105(2), effective July 1, 2023.

(j) Reimbursement for physician-administered drugs described in ARM 37.86.105 is determined pursuant to 42 U.S.C. 1395w-3a.

(k) Reimbursement for vaccines described at ARM 37.86.105 is effective July 1, 2020.

(3) The department adopts, and incorporates by reference, the fee schedule 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 October 1, 2023; and

(ii) the Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), outlier thresholds, and APR grouper version 40.0, contained in the APR-DRG Table of Weights and Thresholds, effective October 1, 2023. The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds effective October 1, 2023.

(b) The outpatient hospital services fee schedules including:

(i) the Outpatient Prospective Payment System (OPPS) fee schedule as published by the CMS in 87 Federal Register 71748 (Nov. 23, 2022), effective January 1, 2023, and reviewed annually by CMS, as required in 42 CFR 419.50 and as updated by the department;

(ii) the conversion factor for outpatient services on or after July 1, 2023 is $58.39;

(iii) the Medicaid statewide average outpatient cost-to-charge ratio is 48.95%; and

(iv) the bundled composite rate of $271.02 for services provided in an outpatient maintenance dialysis clinic effective on or after July 1, 2023.

(c) The hearing aid services fee schedule, as provided in ARM 37.86.805, is effective July 1, 2023.

(d) The Relative Values for Dentists, as provided in ARM 37.86.1004, reference published in 2023 resulting in a dental conversion factor of $36.90 and fee schedule is effective July 1, 2023.

(e) The Dental and Denturist Program Provider Manual, as provided in ARM 37.86.1006, is effective July 1, 2023.

(f) The outpatient drugs reimbursement dispensing fees range as provided in ARM 37.86.1105(3)(b), is effective July 1, 2023:

(i) for pharmacies with prescription volume between 0 and 39,999, the minimum is $5.11 and the maximum is $16.36;

(ii) for pharmacies with prescription volume between 40,000 and 69,999, the minimum is $5.11 and the maximum is $14.16; or

(iii) for pharmacies with prescription volume greater than or equal to 70,000, the minimum is $5.11 and the maximum is $11.98.

(g) The outpatient drugs reimbursement compound drug dispensing fee range, as provided in ARM 37.86.1105(5), will be $12.50, $17.50, or $22.50, based on the level of effort required by the pharmacist, effective July 1, 2013.

(h) The outpatient drugs reimbursement vaccine administration fee, as provided in ARM 37.86.1105(6), will be $21.32 for the first vaccine and $18.65 for each additional vaccine administered on the same date of service, effective July 1, 2023.

(i) The outpatient drugs reimbursement, unit dose prescriptions fee as provided in ARM 37.86.1105(10), will be $0.75 per pharmacy-packaged unit dose medication, effective November 1, 2013.

(j) The home infusion therapy services fee schedule, as provided in ARM 37.86.1506, is effective July 1, 2023.

(k) Montana Medicaid adopts and incorporates by reference the Region D Supplier Manual, effective October 1, 2023, which outlines the Medicare coverage criteria for Medicare covered durable medical equipment, local coverage determinations (LCDs), and national coverage determinations (NCDs), as provided in ARM 37.86.1802, effective October 1, 2023. The prosthetic devices, durable medical equipment, and medical supplies fee schedule, as provided in ARM 37.86.1807, is effective October 1, 2023.

(l) The nutrition services fee schedule, as provided in ARM 37.86.2207(2), is effective July 1, 2023.

(m) The children's special health services fee schedule, as provided in ARM 37.86.2207(2), is effective July 1, 2019.

(n) The orientation and mobility specialist services fee schedule, as provided in ARM 37.86.2207(2), is effective July 1, 2023.

(o) The transportation and per diem fee schedule, as provided in ARM 37.86.2405, is effective July 1, 2023.

(p) The specialized nonemergency medical transportation fee schedule, as provided in ARM 37.86.2505, is effective July 1, 2023.

(q) The ambulance services fee schedule, as provided in ARM 37.86.2605, is effective July 1, 2023.

(r) The audiology fee schedule, as provided in ARM 37.86.705, is effective July 1, 2023.

(s) The therapy fee schedules for occupational therapists, physical therapists, and speech therapists, as provided in ARM 37.86.610, are effective July 1, 2023.

(t) The optometric services fee schedule, as provided in ARM 37.86.2005, is effective July 1, 2023.

(u) The chiropractic fee schedule, as provided in ARM 37.85.212(2), is effective July 1, 2023.

(v) The lab and imaging services fee schedule, as provided in ARM 37.85.212(2) and 37.86.3007, is effective July 1, 2023.

(w) The Targeted Case Management for Children and Youth with Special Health Care Needs fee schedule, as provided in ARM 37.86.3910, is effective July 1, 2023.

(x) The Targeted Case Management for High Risk Pregnant Women fee schedule, as provided in ARM 37.86.3415, is effective July 1, 2023.

(y) The mobile imaging services fee schedule, as provided in ARM 37.85.212, is effective July 1, 2023.

(z) The licensed direct-entry midwife fee schedule, as provided in ARM 37.85.212, is effective July 1, 2023.

(aa) The private duty nursing services fee schedule, as provided in ARM 37.86.2207(2), is effective July 1, 2023.

(4) The department adopts and incorporates by reference, the fee schedule for the following programs within the Senior and Long Term Care Division on the date stated:

(a) The Big Sky Waiver home and community-based services for elderly and physically disabled persons fee schedule, as provided in ARM 37.40.1421, is effective July 1, 2023.

(b) The home health services fee schedule, as provided in ARM 37.40.705, is effective July 1, 2023.

(c) The personal assistance services fee schedule, as provided in ARM 37.40.1135, is effective July 1, 2023.

(d) The self-directed personal assistance services fee schedule, as provided in ARM 37.40.1135, is effective July 1, 2023.

(e) The community first choice services fee schedule, as provided in ARM 37.40.1026, is effective July 1, 2023.

(5) The department adopts and incorporates by reference, the fee schedule for the following programs within the Behavioral Health and Developmental Disabilities Division on the date stated:

(a) The mental health center services for adults fee schedule, as provided in ARM 37.88.907, is effective July 1, 2023.

(b) The home and community-based services for adults with severe disabling mental illness fee schedule, as provided in ARM 37.90.408, is effective July 1, 2023.

(c) The substance use disorder services fee schedule, as provided in ARM 37.27.905, is effective July 1, 2023.

(6) For the Behavioral Health and Developmental Disabilities Division, the department adopts and incorporates by reference the Medicaid youth mental health services fee schedule, as provided in ARM 37.87.901, effective July 1, 2023.

History: 53-2-201, 53-6-113, MCA; IMP, 53-2-201, 53-6-101, 53-6-125, 53-6-402, MCA; NEW, 2011 MAR p. 1713, Eff. 8/26/11; AMD, 2013 MAR p. 686, Eff. 4/26/13; AMD, 2013 MAR p. 1111, Eff. 7/1/13; AMD, 2013 MAR p. 2151, Eff. 11/15/13; AMD, 2014 MAR p. 506, Eff. 3/14/14; AMD, 2014 MAR p. 1402, Eff. 7/1/14; AMD, 2014 MAR p. 2168, Eff. 9/19/14; AMD, 2015 MAR p. 26, Eff. 1/16/15; AMD, 2015 MAR p. 822, Eff. 7/1/15; AMD, 2015 MAR p. 1911, Eff. 10/30/15; AMD, 2016 MAR p. 151, Eff. 1/23/16; AMD, 2016 MAR p. 1058, Eff. 7/1/16; AMD, 2016 MAR p. 1462, Eff. 10/1/16; AMD, 2016 MAR p. 2431, Eff. 1/1/17; AMD, 2017 MAR p. 2287, Eff. 1/1/18; AMD, 2017 MAR p. 2443, Eff. 1/1/18; AMD, 2018 MAR p. 458, Eff. 3/1/18; AMD, 2018 MAR p. 1116, Eff. 7/1/18; AMD, 2018 MAR p. 1612, Eff. 8/11/18; AMD, 2018 MAR p. 2057, Eff. 10/20/18; AMD, 2018 MAR p. 2409, Eff. 1/1/19; AMD, 2019 MAR p. 343, Eff. 4/1/19; AMD, 2019 MAR p. 1061, Eff. 7/6/19; AMD, 2019 MAR p. 1640, Eff. 10/1/19; AMD, 2019 MAR p. 2252, Eff. 12/7/19; AMD, 2020 MAR p. 91, Eff. 1/18/20; AMD, 2020 MAR p. 1158, Eff. 7/1/20; AMD, 2020 MAR p. 1740, Eff. 10/1/20; AMD, 2021 MAR p. 180, Eff. 2/13/21; AMD, 2021 MAR p. 1324, Eff. 10/9/21; AMD, 2021 MAR p. 1683, Eff. 11/20/21; AMD, 2021 MAR p. 1927, Eff. 12/24/21; AMD, 2022 MAR p. 241, Eff. 2/12/22; AMD, 2022 MAR p. 695, Eff. 5/14/22; AMD, 2022 MAR p. 1078, Eff. 7/1/22; AMD, 2022 MAR p. 1914, Eff. 9/24/22; AMD, 2023 MAR p. 181, Eff. 2/25/23; AMD, 2023 MAR p. 482, Eff. 5/27/23; AMD, 2023 MAR p. 1563, Eff. 9/9/23; AMD, 2024 MAR p. 615, Eff. 3/23/24.