BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.87.102, 37.87.901, 37.87.903, 37.87.1303, 37.87.1313; and the repeal of ARM 37.87.723 pertaining to the revision of authorization requirements for Medicaid Mental Health Services for Youth

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT AND REPEAL

 

TO: All Concerned Persons

 

          1. On August 19, 2015, at 10:00 a.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 August 12, 2015, 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 provide as follows, new matter underlined, deleted matter interlined:

 

          37.87.102 Mental Health SERVICES (MHS) for YOUTH with serious emotional disturbance (SED), Definitions As used in this chapter, the following terms apply:

          (1) "Accredited secondary school" means a secondary school located in the state of Montana accredited in accordance with Montana Board of Public Education standards for secondary education or the Northwest Accreditation Commission.

          (2) "Licensed health care professional" means:

          (a) a licensed physician;

          (b) a physician assistant-certified; or

          (c) an advanced practice registered nurse who is authorized to prescribe medication within the scope of the license.

          (3) through (5) remain the same, but are renumbered (1) through (3).

          (6) "Outpatient therapy services" means the provision of psychotherapy and related services by a licensed mental health professional acting within the scope of the professional's license.

          (7) through (10) remain the same, but are renumbered (4) through (7).

(11) (8)  "Youth" means, for Medicaid services, a person 17 years of age and younger or a person who is up to 20 years of age and is enrolled in an accredited secondary school with the exception for PRTF services, a person 17 years of age or younger.  A youth may receive Psychiatric Residential Treatment Facility services through the age of 17.

 

AUTH: 53-2-201, 53-6-113, 53-21-703, MCA

IMP: 53-1-601, 53-1-602, 53-1-603, 53-2-201, 53-21-201, 53-21-202, 53-21-701, 53-21-702, MCA

 

          37.87.901 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, REIMBURSEMENT (1) remains the same.

          (2) For services for which Medicare does not specify Relative Value Unit (RVU) as provided in ARM 37.87.212 37.85.212, the department determines the Medicaid fee for children's mental health services as follows:

          (a) and (b) remain the same.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, MCA

 

          37.87.903 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, AUTHORIZATION REQUIREMENTS (1) remains the same.

          (2) Medicaid mental health services for youth requiring approval prior to treatment, prior authorization, or continued stay authorization will be reimbursed only if the following requirements are met:

          (a) the youth has been determined to have a serious emotional disturbance defined in the Children's Mental Health Bureau, Medicaid Services Provider Manual adopted and incorporated by reference in (8), which has been verified by the department or designee; or

          (b) through (7) remain the same.

          (8) In addition to the requirements contained in rule, the department has developed and published a provider manual entitled Children's Mental Health Bureau, Medicaid Services Provider Manual (Manual), dated September 19, 2014 October 1, 2015, for the purpose of utilization management. The department adopts and incorporates by reference the Children's Mental Health Bureau, Medicaid Services Provider Manual, dated September 19, 2014 October 1, 2015. A copy of the manual may be obtained from the department by a request in writing to the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210 or at www.dphhs.mt.gov/publications/index.shtml#cmh http://dphhs.mt.gov/dsd/CMB/Manuals.aspx.

          (9) and (10) remain the same.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, MCA

 

          37.87.1303 HOME AND COMMUNITY-BASED 1915(c) SERVICES BRIDGE WAIVER FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: FEDERAL AUTHORIZATION AND AUTHORITY OF STATE TO ADMINISTER PROGRAM

          (1) In 2007, the U.S. Department of Health and Human Services (HHS) provided a grant to the Montana Department of Public Health and Human Services (department), under Section 6063 of the Deficit Reduction Act of 2005, to foster the establishment of a home and community-based (HCBS) Psychiatric Residential Treatment Facility (PRTF) Demonstration waiver program (HCBS PRTF waiver), approved by the Centers of Medicare and Medicaid Services (CMS). The purpose of the HCBS PRTF waiver was to avoid admitting youth with serious emotional disturbance into psychiatric residential treatment facilities. The HCBS PRTF waiver authority ends ended September 30, 2012.

          (2) The Centers for Medicare and Medicaid Services (CMS) is allowing allowed Montana the opportunity to continue to provide 1915(c) HCBS waiver services authorized by section 6063(b)(2) of the Deficit Reduction Act of 2005, only with respect to youth already enrolled in the existing HCBS PRTF waiver program on the termination date of that program and only for the duration of their current eligibility as established under these rules. These youth may continue to receive services through the 1915(c) HCBS bridge waiver, in accordance with these rules and the agreement with CMS, for the continued delivery of home and community services.

          (3) In accordance with the state and federal statutes and rules generally governing the provision of Medicaid-funded home and community-based services and federal-state agreements specifically governing the provision of the Medicaid-funded home and community-based services to be delivered through this program, and within the fiscal limitations of the funding appropriated and available for the program, the department may determine within its discretion the following features of the program:

          (a) through (d) remain the same.

          (i) Only those youth who were already enrolled in the HCBS PRTF waiver for youth with serious emotional disturbance on September 30, 2012 are eligible to be enrolled in the HCBS bridge waiver for youth with serious emotional disturbance.

          (e) and (f) remain the same.

          (4) Only those youth who were already enrolled in the HCBS PRTF waiver for youth with serious emotional disturbance on September 30, 2012, through the duration of their current eligibility, as established under these rules, are eligible to enroll in the HCBS bridge waiver for youth with serious emotional disturbance.

          (4) (5)  The 1915(c) home and community-based bridge waiver services for youth with serious emotional disturbance must be delivered in accordance with the requirements and limitations of the Home and Community-Based Services Bridge Waiver for Youth with Serious Emotional Disturbance Policy Manual dated July 1, 2013 October 1, 2015.

          (5) (6) The department adopts and incorporates by reference the 1915(c) HCBS Bridge Waiver for Youth with Serious Emotional Disturbance Policy Manual, dated July 1, 2013 October 1, 2015. A copy of the manual may be obtained from the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604 or at http://www.dphhs.mt.gov/mentalhealth/children/ http://dphhs.mt.gov/dsd/CMB/Manuals.aspx.

 

AUTH: 53-2-201, 53-6-113, 53-6-402, MCA

IMP: 53-6-402, MCA

 

          37.87.1313 1915(i) HOME AND COMMUNITY-BASED SERVICES (HCBS) STATE PLAN PROGRAM FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: FEDERAL AUTHORIZATION AND AUTHORITY OF STATE TO ADMINISTER PROGRAM (1) through (3) remain the same.

          (4) The 1915(i) home and community-based services state plan program for youth with serious emotional disturbance must be delivered in accordance with the requirements and limitations of the 1915(i) HCBS State Plan Program for Youth with Serious Emotional Disturbance Policy Manual dated December 13, 2013 October 1, 2015.

          (5) The department adopts and incorporates by reference the 1915(i) HCBS State Plan Program for Youth with Serious Emotional Disturbance Policy Manual, dated December 13, 2013 October 1, 2015. A copy of the manual may be obtained from the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604 or at http://www.dphhs.mt.gov/mentalhealth/children/ http://dphhs.mt.gov/dsd/CMB/Manuals.aspx.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

          4. The department proposes to repeal the following rule:

 

          37.87.723 MENTAL HEALTH CENTER SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE (SED), PROVIDER REQUIREMENTS found on page 37-21339 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-101, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, MCA

 

          5. STATEMENT OF REASONABLE NECESSITY

 

The Department of Public Health and Human Services, Children's Mental Health Bureau (the department) proposes to amend ARM 37.87.102, 37.87.901 37.87.903, 37.87.1303, and 37.87.1313. The department is proposing the repeal of ARM 37.87.723. These rules specify provider participation, utilization review, and program requirements and define the basis and procedure the department will use to pay children's Medicaid mental health services. The proposed rulemaking is the result of feedback received by the department from providers, the department's required periodic review of its administrative rules and is a continuation of the Children's Mental Health Bureau's efforts to incorporate certain regulations, program policies, and procedures into the Children's Mental Health Bureau Medicaid Services Provider Manual (Manual), which is adopted and incorporated by reference in ARM 37.87.903.

 

Specifically, the department proposes the following amendments:

 

ARM 37.87.102:

 

Move definitions from this rule into the definition section of the Manual, remove the definition of "Outpatient Therapy" as redundant, and amend the definition of "Youth" to provide consistency in the language between the definition of "youth" and the proposed language for Serious Emotional Disturbance (SED) criteria. These "housekeeping" amendments are necessary because they continue an intentional process to move defining terms into the Manual, and provide a concise reference, which is consistent with departmental goals for improved rule writing and clear and understandable policy manuals.

 

ARM 37.87.901:

 

Amending the ARM reference in (2) from ARM 37.87.212 to 37.85.212. This amendment is necessary to correct a typographical error in the rule number. 

 

ARM 37.87.903:

 

Updating the effective date of the Manual as a result of proposed amendments to the Manual. The proposed Manual revisions, effective October 1, 2015, are described as follows:

 

Chapter 1- Introduction, Overview, and Definitions

 

• Removal of all information regarding the rationale for the changes to the Manual version that became effective September 19, 2014. The department has deemed the removal of this information necessary as it is not relevant to this proposed Manual revision.
• In the Overview section, update the web site of the claims instructions to the most current address.
• Addition of a Definitions section for the Manual to relocate and consolidate into one location all the terms that are defined in the Manual, which improves navigability of the Manual.

 

Chapter 2- CANS-MT, Coordination, Discharge

 

Montana Child and Adolescents Needs and Strengths Functional Assessment Subchapter

 

• The definitions for CANS-MT and Montana CANS System (MCS) are removed from this section and relocated into the proposed definitions section of the Manual. The department has deemed this change necessary to provide one point of reference for definitions within the Manual to improve navigability of the Manual.
• The language regarding trained staff requirements in section (3) has been revised and renumbered as (1). This amendment is necessary to clarify that providers must have staff that are trained and certified as CANS-MT users, in addition to the provider.
• Section (4), referring to time frame requirements which were put in place during the initial phase of implementing the CANS-MT, has been removed. The amendment is necessary because these time frames have passed and are no longer relevant.
• The CANS-MT admissions, update, and discharge assessment requirements for youth that are transferring services, as well as being provided concurrent services, have been revised. This section is renumbered from (5) to (2). This amendment is necessary based upon provider feedback that the requirements were unclear.
• Section (6) is renumbered to (3) and additional guidance is given concerning the addition of the provider's CANS-MT administrator into the MCS. This amendment attempts to resolve questions the department received from providers assigning their provider administrator roles in the MCS.
• Additional requirements for the coordination and use of the MCS have been added as (5), (6) and (7) as further guidance for the assignment of primary provider and secondary provider in the MCS when there is more than one provider serving a youth and the roles of the primary and secondary providers. This amendment is necessary with the implementation of the MCS to avoid confusion and facilitate communication between providers.
• In the closing paragraph, the term "encourages" has been revised to "recommends" and a statement added which identifies the CANS-MT's intended purpose. The department has deemed these changes necessary to describe better departmental expectations for providers in order to avoid confusion.
• The link to the Children's Mental Health Bureau CAN-MT web site has been updated to the most current web site address.

 

Coordination of Services Provided Concurrently Subchapter

 

• Remove language from the section's introductory paragraph regarding habilitation services because Children's Mental Health Bureau Services are rehabilitative rather than habilitative services. This terminology is out of date with industry practices and does not apply to the content of this Manual in its current state.
• Add language in subsection (1) to describe more specifically provider requirements when providing community services concurrently with other providers or services. These changes are the result of provider feedback to clarify that coordination of services must happen even with providers and services which are outside the array of the services provided through the Children's Mental Health Bureau.
• Add section (7), which references ARM 37.85.406 as the rule giving authority to the department to recover payment. The department added this reference to ensure providers are aware of this rule when coordinating potentially duplicative services. 

 

Discharge from Services Subchapter

 

• Strike the entire first paragraph of this section and add this identical language under the heading "Discharge after a Denial". The intent of this amendment is to place the information where it is applicable and make this information easier for providers to locate.
• Add language to the first paragraph which describes the purpose for the Discharge Notification form and the process for submitting the Discharge Notification form to the department or its designee. The department also proposes to remove the table identifying discharge notification form requirements for each service and relocate that identical language for each service into the respective sections of the Manual applicable to that service. This amendment is the result of the periodic review of the Manual and feedback from providers and is necessary to avoid meeting this service requirement.

 

Chapter 3 – Clinical Guidelines and Services

 

Prompted by the upcoming transition from International Statistical Classification of Diseases and Related Health Problems (ICD) ICD-9 to ICD-10, the department took the opportunity to review the existing covered diagnoses and functional impairment requirements included in the SED criteria for accuracy and application to the population CMHB serves. The department proposes to amend the functional impairment criteria so that it applies from ages 0 to the age of 18 rather than having two separate age-dependent sets of functional impairment requirements. The department also proposes the following amendments to the list of covered diagnoses:

 

Diagnoses that were removed are as follows:

• Sexual disorders; 302.2, 302.3, 302.4, 302.82, 302.83, 302.84, 302.89. 
• Gender identity disorder has been replaced with gender dysphoria in adolescents (F64.1 or 302.85), gender dysphoria in children (F64.2 or 302.6) and other specified gender dysphoria (F64.8 and 302.6).

 

Diagnoses that were added are as follows:

• schizophreniform disorder (F20.81, 295.40);
• disruptive mood dysregulation disorder (F34.8 and   296.99);
• avoidant/restrictive food intake disorder (F50.8 and 307.59);
• panic disorder (F41.0 and 300.01).

 

Services Subchapter

 

Acute Inpatient Hospital Section

 

• Certificate of Need - remove doctor and mid-level physician references and revise to only physician in the Certificate of Need section. The department has deemed this change necessary to clarify this requirement for providers and provide for consistency between the Manual and the Code of Federal Regulations (CFR).
• Prior Authorization - remove the prior authorization requirements as a prior authorization is no longer required for this service.
• Required Forms – move the time frame requirements for submission of Discharge Notification Form from a table containing all form submission deadlines to this specific section.
• Additional information - remove the statement from the Manual regarding Acute Inpatient Hospital Services compliance with the CFR because it is already in the CFR.

 

Psychiatric Residential Treatment Facility (PRTF) Section

 

• Definition - Add a statement to the definition of PRTF describing that a youth must meet Serious Emotional Disturbance Criteria (SED) to receive PRTF services. The department has deemed this change necessary to clarify this requirement for providers and provide for consistency between the Manual and the Code of Federal Regulations (CFR).
• Prior authorization - add requirements for admission to an out-of-state PRTF and remove these requirements from the additional information section. The department has deemed these changes necessary to be more specific in the definition and to provide one location within the PRTF section of the Manual for prior authorization information, providing clarification for providers.
• Service Requirements (Introduction) – specify that it is a requirement for a PRTF to be in compliance with all state and federal regulations in order to provide service. This change is necessary to clarify this requirement for providers and provide for consistency between the Manual and the CFR.
• Service Requirements (1) - add the requirement for a physician to perform an evaluation within 24 hours of the admission of a youth. This change is necessary to align the content of the Manual with the CFR.

• Service Requirements (2) - clarify the requirement for a provider's treatment team to involve a youth's legal representatives unless it is clinically inappropriate or otherwise not feasible. This change is necessary based on provider feedback to the department that this requirement was unclear.
• Service Requirements (4) - move language from ARM 37.87.1217, as described in pending MAR Notice No. 37-715 and add the word "minimum" to the medication amount required at discharge. This amendment is necessary to continue moving service requirements into the Manual. Additionally, the department desires to provide clarification to PRTFs regarding medication amounts after the department determined some providers were dispensing medication the youth was prescribed at the PRTF because of a misunderstanding that the seven-day supply of medication was a maximum not the minimum.
• Service Requirements (7) - clarify the requirement for written notification to a school district of credits earned by a youth who is discharging from a PRTF. This amendment is necessary, based on feedback received from providers and schools that there is ambiguity of communication in this area of the continuum of care.
• Required Forms - Add a reporting deadline requirement for submission of discharge notification forms to increase providers' reporting compliance. This new requirement is necessary because the department has not specified the need for the timely preparation and submission of required discharge notification forms.
• Information - remove the PRTF Denial Letter form as a required form. This is necessary because the department has discontinued this self-imposed process to require denial letters from the three in-state PRTFs prior to a youth being eligible for out of state PRTF placement because after further review, the process was non-functional.
• Information - add the requirement for seeking an eligibility determination from the department's developmental disability program when providing care to youth with SED and DD. This language is being moved into the Manual from ARM 37.87.1217, as a part of MAR Notice No. 37-715, in order to facilitate continuity of care, increase likelihood of access to services, and increase provider understanding of the requirement.

 

PRTF - Assessment Services (PRFT-AS) Section

 

• Definitions - Add a definition for PRTF-AS, which is necessary in order to differentiate this type of service provided by a PRTF from other PRTF services.
• Service requirements section - add a statement of requirement that a PRTF must comply with all state and federal regulations. The department has deemed this change necessary to clarify this requirement for providers and provide for consistency between the Manual and the Code of Federal Regulations (CFR).
• Service Requirements - specify the requirement for written notification to a school district of credits earned by a youth who is discharging from a PRTF. This amendment is necessary, based on feedback received from providers and schools that there is ambiguity of communication in this area of the continuum of care.

 

Partial Hospital Services (PHP) Section

 

• Service Requirements - clarify the requirement for a provider's treatment team to involve a youth's legal representatives unless it is clinically inappropriate or otherwise not feasible. This change is necessary based on provider feedback to the department that the use of the term "pre-admission caregivers" was not specific enough. 
• Service Requirements - further amendments to this section are proposed and necessary as "housekeeping," are a result of the department's periodic review of its rules, and are consistent with departmental goals for improved rule writing and clear and understandable policy manuals.

 

Therapeutic Group Home (TGH) Section

 

• Prior Authorization - add a prior authorization (PA) requirement and specify the process for requesting a PA. Due to a loss of funding for the utilization review contract, the department discontinued the PA requirement, effective November 2013. Since the discontinuation, the department received feedback from providers that PAs are preferred for initial stays to ensure the department concurs with a provider when a youth meets the medical necessity and admission criteria for TGH services prior to receiving such services, in order to negate a risk of take back upon a retroactive review. To correct this PA issue, the department determined it necessary to create an internal process for utilization review and, in response to the provider feedback, desires to reinstate a PA review process.
• Prior Authorization - provide clarification that a provider may only request a continued stay between 5 and 10 business days prior to the expected discharge date of a youth. The department received feedback from providers who stated that it was unclear that a continued stay would be denied if submitted earlier than 10 business days prior to the discharge of a youth.
• Prior Authorization - update the turnaround time for the psychiatrist review and determination from two to four days. The department is bringing additional utilization review responsibilities in house and as such the turnaround time must be kept reasonable in order for the bureau to meet the deadlines.
• Further amendments to the section are proposed and necessary as "housekeeping," are a result of the department's periodic review of its rules, and are consistent with departmental goals for improved rule writing and clear and understandable policy manuals.

 

Home Support Services (HSS) Section

 

• Prior Authorization - remove information pertaining to the "grandfather date" for the lifetime limit of services a youth may receive. This amendment is necessary because the date referenced is no longer applicable for the department's processing of claims.
• Prior Authorization - add information regarding how claims are processed for the U.S. Department of Health and Human Services (HHS). Because Medicaid allows 365 days in which to file a clean claim, providers need to be aware that claims are paid first come first served regardless of the date of service.

• Continued Stay Criteria - modify continued stay criteria to provide that the Children's Mental Health Bureau clinical team will complete reviews for continued stay requests so providers are informed of where to send a continued stay request.
• Continued Stay Criteria - amend continued stay criteria to remove the requirement that a youth must still meet admission criteria and add criteria more applicable to a continued stay. These amendments were determined necessary upon review by the department that a youth having completed 365 days of HSS services should reflect improvement from when the youth first began to receive services, rendering the admission criteria null for continued stays.
• Continued Stay Review - specify the time frame for submission of a continued stay request. This new requirement is necessary because the department received feedback from providers that the department has not adequately specified the need for the timely preparation and submission of these requests.

 

Outpatient Therapy (OP) Section

 

• Admission Criteria - add the requirement that a youth must be at least two years of age in order to receive OP. Upon review by the department, it was determined that OP is not appropriate for a youth who has communication skills below the level of a two year old.
• Service Requirements - add a service requirement that family therapy with a youth under the age of 8 must include education and support for the family on how to respond to the needs of the youth, manage their own emotional state, and build secure attachment. The department determined through provider practices and utilization review that the addition of this specification is necessary to ensure the OP services provided primarily support the mental health of the youth.

 

Targeted Case Management (TCM) Section

 

• Medical Necessity Criteria - amend the medical necessity criteria to ensure that youth mental health TCM includes the need for at least one other mental health service. The department contends the amendment is necessary to fix a possible scenario where, as currently policy provides, a youth could receive TCM without having a mental health need for TCM.

 

Therapeutic Home Visits (THV) Section

 

• Prior Authorization - add request deadlines for when a THV may be requested. The amendment is necessary because utilization reviews by the department have shown that guidelines surrounding the request deadlines for the request for a PA were lacking from this subsection of the Manual.

 

Extraordinary Needs Aide (ENA) Section

 

• Service Requirement - clarify that ENA may not be used to supplant the staffing requirements of ARM 37.97.903 upon the request of the Surveillance and Utilization Review unit (SURS). In the course of completing TGH audits, SURS identified this as an area of rule that was unclear and it could not audit to this requirement.

 

Chapter 4 - Determinations

 

The department proposes minor "housekeeping" amendments regarding procedural matters for a technical denial even though the definition of technical denial has been moved to the definitions section. The department contends the amendments are necessary for procedural clarity and are consistent with departmental goals for improved rule writing and clear and understandable policy manuals.

 

Chapter 5 - Appeals

 

The department proposes amending this chapter to improve the department's explanation of administrative review timelines, fair hearings process, and to clarify affected parties' rights. The need for a proposed improved explanation came after the department's review of this technical subject matter, which can be difficult to understand by those who believe they have received an adverse determination by the department. The proposed changes are consistent with departmental goals for improved rule writing and clear and understandable policy manuals.

 

Chapter 6 - Reviews

 

The department proposes to add language to specify what a provider must submit in order to request a retrospective review. The department has deemed this change necessary to clarify this requirement for providers and provide for consistency between the Manual and the Code of Federal Regulations (CFR).

 

ARM 37.87.1303:

 

The department proposes amending obsolete waiver background language from (1) and (2) and a date reference of the "Home and Community-Based Services Bridge Waiver for Youth with Serious Emotional Disturbance Policy Manual, dated July 1, 2013." These amendments are necessary because the date-specific language describing the history of the waiver is obsolete and removal of Appendix A from this manual, which lists the current SED criteria, is necessary for the upcoming transition from ICD-9/DSM-IV to ICD-10/DSM-V. Additionally, the department proposes amending the internet link to the manual. Due to a reconfiguration of the department's web site, the Uniform Resource Locator (URL) address listed for the Manual is no longer valid.

 

ARM 37.87.1313:

 

The department proposes amending the version date of the "1915(i) HCBS Bridge Waiver for Youth with Serious Emotional Disturbance Policy Manual, dated July 1, 2013." This amendment is necessary to remove Appendix A, which lists the current SED criteria, from this manual due to the transition from ICD-9/DSM-IV to ICD-10/DSM-V. Additionally, the department proposes amending the link to the manual. Due to a reconfiguration of the department's web site, the Uniform Resource Locator (URL) address listed for the Manual is no longer valid.

 

ARM 37.87.723:

 

The department proposes to repeal ARM 37.87.723 as Mental Health Center Services provider requirements are located in the administrative rules pertaining to licensure and it is unnecessary to repeat those requirements here.

 

FISCAL IMPACT

 

The provider manual incorporates a new definition of serious emotional disturbance (SED) that uses new ICD-10 diagnosis codes. The new definition mostly updates the old ICD-9 diagnosis codes with the associated new ICD-10 code. However, the new SED definition has a few new diagnosis codes added, while some codes are removed from the prior definition. Those diagnosis codes added include: panic disorder, disruptive mood dysregulation disorder (dysthymia), and avoidance/restrictive food intake disorder. Conversely, the new manual language removes most sexual disorder diagnosis codes from the prior SED definition.

 

There is some risk that the ICD-10 mapping and new diagnosis codes could increase the number of clients that meet the SED definition and increase SED related expenditures. It is unknown if providers will adjust diagnosis coding and claims submission that could result in a fiscal impact. Any fiscal impact is unquantifiable at this time, but is not expected to be substantial.

 

The manual includes the addition of prior authorization (PA) for initial Therapeutic Group Home (TGH) stays. The initial stay authorization is for up to 180 days. Prior to this change, a continued stay prior authorization is required after 120 days, equating to a potential 60 day increase for initial stays.

 

Based on historical utilization review information, it is anticipated that approximately 60 initial stays will be denied and expenditures will decline by approximately $500,000 per year. As an offset, there are approximately 100 continued stays that are denied per year where the number of days in the initial stay service could increase by 60 days (180 days is new initial stay period – 120 days current). The additional 60 days is anticipated to increase costs by nearly $500,000 per year. The net estimated impact is near neutral.  

 

Inpatient stays were required to have a pass-through PA prior to the new language in the manual. It is not anticipated that removing the PA requirement will impact hospital stays.

 

          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 27, 2015.

 

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. An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register.  The Secretary of State strives to make the electronic copy of the notice conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered.  In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems.

 

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

 

11. 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.

 

 

/s/ Cary B. Lund                                    /s/ Richard H. Opper                            

Cary B. Lund, Attorney                          Richard H. Opper, Director

Rule Reviewer                                       Public Health and Human Services

 

 

Certified to the Secretary of State July 20, 2015.