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| Montana Administrative Register Notice 37-750 | No. 8 04/22/2016 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Concerned Persons
1. On May 12, 2016, at 9:30 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 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 May 5, 2016, 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:
37.85.406 BILLING, REIMBURSEMENT, CLAIMS PROCESSING, AND PAYMENT (1) through (17) remain the same. (18) Except as otherwise provided in the rules of the department which pertain to the method of determining payment rates for claims of recipients members who have Medicare and Medicaid coverage (cross-over claims), the Medicaid allowed amount for Medicare covered services is: (a) for facility based providers who generally bill on the (i) through (21) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-131, 53-6-149, MCA
37.86.2803 ALL HOSPITAL REIMBURSEMENT, COST REPORTING (1) Allowable costs will be determined in accordance with generally accepted accounting principles as defined by the American Institute of Certified Public Accountants. (a) remains the same. (b) For cost report periods occurring on or after May 1, 2010, such definition of allowable costs is further defined in accordance with the Medicare Provider Reimbursement Manual, CMS Publication 15, Form 2552-10, (c) For cost report periods occurring prior to May 1, 2010, such definition of allowable costs is further defined in accordance with the Medicare Provider Reimbursement Manual, CMS Publication 15, Form 2552-96, (d) through (3) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-149, MCA
37.86.2907 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, APR-DRG PAYMENT RATE DETERMINATION (1) The department's APR-DRG prospective payment rate for inpatient hospital services is based on the classification of inpatient hospital discharges to APR-DRGs. The provider reimbursement rates for inpatient hospital services, except as otherwise provided in ARM 37.85.206, is stated in the department's APR-DRG fee schedule adopted and effective at ARM 37.85.105. The procedure for determining the APR-DRG prospective payment rate is as follows: (a) and (b) remain the same. (c) The department computes a Montana average base price per case. This base price includes in-state and out-of-state distinct part rehabilitation units (d) The department computes a base price for long-term care (LTC) facilities. The effective date and base-rate amount are adopted and effective as provided at ARM 37.85.105. Disproportionate share payments are not included in this price. (d) through (f) remain the same, but are renumbered (e) through (g). (h) Inpatient reimbursement will be calculated at the lessor of the assigned APR-DRG rate or the claim billed charges. (2) The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds
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, MCA
37.86.2916 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, COST OUTLIERS (1) and (2) remain the same. (3) The department determines the outlier reimbursement for cost outliers for all hospitals and distinct part units, entitled to receive cost outlier reimbursement, as follows: (a) computing an estimated cost for the inpatient hospital stay by multiplying the allowed charges for the stay by the statewide facility-specific average PPS cost-to-charge ratio as set forth in ARM 37.86.2905; all out-of-state facilities, except Center of Excellence facilities, will use their statewide average cost-to-charge ratio; (b) remains the same. (c) multiplying the cost outlier amount by
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, MCA
37.86.4401 RURAL HEALTH CLINICS AND FEDERALLY QUALIFIED HEALTH CENTERS, DEFINITIONS (1) and (2) remain the same. (3) "Crossover claim" means a claim for services provided to (4) "Federally qualified health center (FQHC)" means an entity which is a federally qualified health center as defined in 42 USC 1396d(l)(2)(B) (2016). (5) "FQHC core services" means the FQHC ambulatory services defined in 42 USC 1396d(l)(2)(A) and described in 42 USC 1395x(aa)(1). (6) and (7) remain the same. (8) "Health professional" means a physician, nurse practitioner (NP), physician assistant (PA), certified nurse-midwife (CNM), clinical psychologist (CP), clinical social worker (CSW), licensed professional counselor (LCPC), or licensed addiction counselor (LAC). (8) through (16) remain the same, but are renumbered (9) through (17).
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) is proposing amendments to ARM 37.85.406, 37.86.2803, 37.86.2907, 37.86.2916, and 37.86.4401 regarding claims processing and reimbursement, hospital cost reporting, inpatient hospital reimbursement, rural health clinic, and federally qualified health centers. These rules are being updated to correct dates and claim forms, update reimbursement policies for inpatient APR-DRG hospitals, and update and add new definitions applicable to rural health clinics and federally qualified health centers.
37.85.406(18)(a)
In 2005, the National Uniform Billing Committee approved the updated Uniform Bill (UB-04) paper claim as the replacement to the Uniform Bill-92 (UB-92). The department no longer accepts the UB-92 claim and is proposing to update the rule to reflect this change.
Fiscal Impact
The changes to this rule will have no fiscal impact.
The department is proposing to remove the dates related to the Centers for Medicare and Medicaid (CMS) publications, Form 2252-10 and Form 2552-96. These publications and forms have been updated since the last filing of this rule. The department is adopting the current versions that CMS maintains and updates related to cost reporting for hospitals.
Fiscal Impact
The changes to this rule will have no fiscal impact.
The department is proposing to amend the APR-DRG base rate for long-term care (LTC) hospitals in ARM 37.85.105 effective July 1, 2016. ARM 37.86.2907 is being updated to clarify that LTC base rates are separate from other inpatient hospitals.
The department is adding a new methodology for inpatient APR-DRG hospitals. This payment methodology calculates the claim reimbursement at the lessor of the assigned APR-DRG rate or the claim billed charges. The department uses this payment methodology throughout the Medicaid program and is updating the inpatient APR-DRG methodology to maintain program consistency.
The department is also updating the APR grouper version used to 33.
Fiscal Impact
The changes to this rule will have no fiscal impact. The fiscal impact for the changes to the LTC hospital-base rate is in the updates to ARM 37.85.105 found in MAR Notice No. 37-745.
The APR-DRG payment methodology multiplies the allowed charges for the inpatient stay by the cost-to-charge ratio. The current methodology in administrative rules states that the department will use the statewide average Prospective Payment System (PPS) cost-to-charge ratio set forth in ARM 37.86.2905. In July of 2015, the department changed the methodology to use the facility-specific average PPS cost-to-charge ratio for in-state facilities and Centers of Excellence facilities. Out-of-state facilities, that are not Centers of Excellence, use their statewide average cost-to-charge ratio. ARM 37.86.2916 is being updated to reflect this change.
The department is reducing the marginal percentage from 60% to 50% for the cost outlier payment for hospital stays. This change is necessary because 60% results in outlier payments going to out-of-state hospitals at a disproportionate amount. The reduction to 50% will not lower the percentage of the DRG payment going to the outlier pool.
Fiscal Impact
The changes to this rule will have no fiscal impact. Savings from these changes will be incorporated back into the base rate that hospitals receive.
The language within the definitions for rural health clinics (RHC) and federally qualified health centers (FQHC) was updated to reflect the federal statute 42 CFR 1396d and to remove duplicate information.
A new definition, health professional, was added. This definition was added to clarify the allowed core service providers allowed to bill within an FQHC or RHC. Any clinic that wants to bill services for one of the allowed health professionals must have that profession within their scope of service. Licensed addiction counselors (LAC) are being added to the allowed core service providers. If a clinic plans to include an LAC in their clinic services, they must complete a scope of service change.
Fiscal Impact
The only proposed change to the above rule that has a fiscal impact is the addition of licensed addiction counselors to the allowed core service providers. The addition of LACs could increase the number of visits at these clinics. The estimated total fiscal impact for state fiscal year 2017 would be $157,481.
5. The department intends to adopt these rule amendments effective July 1, 2016.
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., May 20, 2016.
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 of the above-referenced rules will not significantly and directly impact small businesses.
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.
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. The changes proposed are primarily rate and language changes that do not lend themselves to performance-based measurement.
/s/ Geralyn Driscoll /s/ Richard H. Opper Geralyn Driscoll, Attorney Richard H. Opper, Director Rule Reviewer Public Health and Human Services
Certified to the Secretary of State April 11, 2016.
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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].
