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| Montana Administrative Register Notice 37-757 | No. 12 06/17/2016 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Concerned Persons
1. On July 7, 2016, at 11:00 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 June 29, 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:
37.85.105 Effective dates, CONVERSION FACTORS, POLICY ADJUSTERS, AND COST-TO-CHARGE RATIOS of Montana Medicaid Provider Fee Schedules (1) and (2) remain the same. (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 (ii) the Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), outlier thresholds, and APR grouper version (b) through (e) remain the same. (f) The outpatient drugs reimbursement, dispensing fees range as provided in ARM 37.86.1105 (i) for pharmacies with prescription volume between 0 and 39,999, the minimum is $2.00 and the maximum is $14.77; (ii) for pharmacies with prescription volume between 40,000 and 69,999, the minimum is $2.00 and the maximum is $11.51; or (iii) for pharmacies with prescription volume greater than 70,000, the minimum is $2.00 and the maximum is $10.51. (g) The outpatient drugs reimbursement, compound drug dispensing fee range as provided in ARM 37.86.1105 (h) The outpatient drugs reimbursement, vaccine administration fee as provided in ARM 37.86.1105 (i) The out-of-state providers will be assigned a $3.50 dispensing fee. (j) The outpatient drugs reimbursement, unit dose prescriptions fee as provided in ARM 37.86.1105 (k) through (6) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-402 MCA
37.86.1105 OUTPATIENT DRUGS, REIMBURSEMENT (1) and (2) remain the same. (3) The dispensing fee for filling prescriptions is determined for each pharmacy provider annually. (a) The dispensing fee is based on the pharmacy's average cost of filling prescriptions and prescription volume. The average cost of filling a prescription is based on the direct and indirect costs that can be allocated to the cost of the prescription department and that of filling a prescription, as determined from the Montana Dispensing Fee Questionnaire. The prescription volume of a provider is determined using the information provided on the annual Montana Dispensing Fee Questionnaire. A provider's failure to submit, upon request, the dispensing fee questionnaire properly completed results in the assignment of the minimum dispensing fee offered. A copy of the Montana Dispensing Fee Questionnaire is available upon request from the department. (b) and (c) remain the same. (4) In-state pharmacy providers that are new to the Montana Medicaid program are assigned the maximum dispensing fee in (5) through (12) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-113, MCA
4. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (department) is proposing amendments to ARM 37.85.105 and 37.86.1105.
Proposed changes for Pharmacy
Montana Medicaid is proposing changes to the professional dispensing fee structure. This change will shift from a professional dispensing fee that is based on drug status and will move to a structure determined by prescription volume.
Montana Medicaid will modify ARM 37.85.105 to outline the new tiered professional dispensing fee based on prescription volume. In addition, ARM 37.86.1105 will be modified to state that the prescription volume disclosed on the Montana Dispensing Fee Questionnaire is used to determine the appropriate dispensing fee for pharmacy providers.
This rule change is required to set up a professional dispensing fee structure that accounts for the varying cost to dispense seen for pharmacy providers. The yearly dispensing fee questionnaire shows a difference in the cost to dispense when store volume is taken into consideration.
Montana Medicaid utilized the dispensing fee questionnaire completed by pharmacy providers to analyze a tiered professional dispensing fee based on prescription volume. It was determined that three volume-based bands were appropriate to accommodate the prescription volumes of our Montana pharmacy providers. With the prescription volume bands established, Montana Medicaid utilized the calculated cost to dispense of the stores to determine the average cost to dispense for stores within their assigned bands.
42 CFR Part 447 Medicaid Program; Covered Outpatient Drugs; Final Rule requires Medicaid states to analyze and implement appropriate professional dispensing fees. Proposed for Inpatient Hospitals
ARM 37.85.105 contains the references to Montana Medicaid's fee schedules, effective dates, conversation factors, provider rate percentages, and rates for services. ARM 37.85.105(1) through 37.85.105(3) are the sections that are applicable to the services provided through the Health Resources Division (HRD).
HRD will be updating the Inpatient Hospital APR-DRG fee schedule effective date and the APR grouper version effective October 1, 2016.
The following describes in detail the changes that will be made to ARM 37.85.105:
(3)(a)(i): Revise the effective date regarding the APR-DRG (inpatient hospital) fee schedule to October 1, 2016.
(3)(a)(ii): Revise the effective date regarding the APR-DRG Table of Weights and Thresholds to October 1, 2016. Update the APR-DRG grouper version from version 32 to version 33.
It is necessary for the department to provide these updates to reflect the most current information regarding the inpatient hospital fee schedule effective date and APR grouper version.
Fiscal Impact
In notices of proposed amendment MAR Notice No. 37-745 and MAR Notice No. 37-746, the department proposed changes to its method for calculating outpatient pharmacy reimbursement. Federal law requires the changes. Montana Medicaid is eliminating the estimated acquisition cost reimbursement methodology for calculating drug ingredient reimbursement. Instead, it is revising its dispensing fee structure and paying a drug ingredient reimbursement amount set as close to actual acquisition costs as possible.
In MAR Notice No. 37-745 and 37-746 (MAR 37-745 and 37-746), the department is not adopting the proposed language in MAR 37-745 regarding dispensing fees. Instead, it is proposing a three-tiered professional dispensing fee model based on prescription volume in this notice. These rule amendments are proposed to have a retroactive effective date of July 1, 2016. The administrative cost reported in MAR 37-745 and 37-746 does not change. The cost savings associated with MAR 37-746 and this notice will remain the same at $4.3 million.
Hospital Change
The revision to the grouper version for inpatient hospitals is expected to be budget neutral.
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: 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., July 15, 2016.
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. 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.
9. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
10. 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.
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/ 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 June 6, 2016. |
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].
