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| Montana Administrative Register Notice 37-838 | No. 8 04/27/2018 | |
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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 17, 2018, 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 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 7, 2018, 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 rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
37.85.104 EFFECTIVE DATES OF PROVIDER FEE SCHEDULES FOR MONTANA NON-MEDICAID SERVICES (1) The department adopts and incorporates by reference the fee schedule for the following programs within the Addictive and Mental Disorders Division and Developmental Services Division on the dates stated: (a) Mental health services plan provider reimbursement, as provided in ARM 37.89.125, is effective (b) 72-hour presumptive eligibility for adult-crisis stabilization services reimbursement for services, as provided in ARM 37.89.523, is effective (c) Youth respite care services, as provided in ARM 37.87.2203, is effective (d) Substance use disorder services provider reimbursement, as provided in ARM 37.27.905, is effective (2) remains the same.
AUTH: 53-2-201, 53-6-101, 53-6-113, MCA IMP: 53-2-201, 53-6-101, 53-6-111, MCA
37.85.105 Effective dates, CONVERSION FACTORS, POLICY ADJUSTERS, AND COST-TO-CHARGE RATIOS of Montana Medicaid Provider Fee Schedules (1) remains the same. (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 and Medicaid Services (CMS) of the U.S. Department of Health and Human Services and published at (b) Fee schedules are effective (c) through (g) remain the same. (h) Optometric services receive a (i) remains the same. (j) Reimbursement for vaccines described at ARM 37.86.105 is effective (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) remains the same. (b) The outpatient hospital services fee schedules including: (i) the Outpatient Prospective Payment System (OPPS) fee schedule as published by the Centers for Medicare and Medicaid Services (CMS) in (ii) remains the same. (iii) the Medicaid statewide average outpatient cost-to-charge ratio is (iv) through (e) remain the same. (f) The outpatient drugs reimbursement, dispensing fees range as provided in ARM 37.86.1105(3)(b) is effective (i) for pharmacies with prescription volume between 0 and 39,999, the minimum is (ii) for pharmacies with prescription volume between 40,000 and 69,999, the minimum is (iii) for pharmacies with prescription volume greater than 70,000, the minimum is (g) remains the same. (h) The outpatient drugs reimbursement, vaccine administration fee as provided in ARM 37.86.1105(6), will be $20.68 for the first vaccine and (i) through (k) remain the same. (l) Fee schedules for private duty nursing, nutrition, children's special health services, and orientation and mobility specialists as provided in ARM 37.86.2207(2), are effective (m) and (n) remain the same. (o) The ambulance services fee schedule, as provided in ARM 37.86.2605, is effective (p) The audiology fee schedule, as provided in ARM 37.86.705, is effective (q) The therapy fee schedules for occupational therapists, physical therapists, and speech therapists, as provided in ARM 37.86.610, are effective (r) The optometric fee schedule provided in ARM 37.86.2005, is effective (s) The chiropractic fee schedule, as provided in ARM 37.85.212(2), is effective (t) The lab and imaging fee schedule, as provided in ARM 37.85.212(2) and 37.86.3007, is effective (u) through (w) remain the same. (x) The mobile imaging fee schedule, as provided in ARM 37.85.212, is effective (y) The licensed direct entry midwife fee schedule, as provided in ARM 37.85.212, is effective (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) Home and community-based services for elderly and physically disabled persons fee schedule, as provided in ARM 37.40.1421, is effective (b) through (e) remain the same. (5) The department adopts and incorporates by reference, the fee schedule for the following programs within the Addictive and Mental Disorders Division on the date stated: (a) Mental health center services for adults reimbursement, as provided in ARM 37.88.907, is effective (b) Home and community-based services for adults with severe disabling mental illness, reimbursement, as provided in ARM 37.90.408, is effective (c) Substance use disorder services reimbursement, as provided in ARM 37.27.905, is effective (6) The department adopts and incorporates by reference, the fee schedule for the following programs within the Developmental Services Division, on the date stated: Mental health services for youth, as provided in ARM 37.87.901 in the Medicaid Youth Mental Health Services Fee Schedule, is effective
IMP: 53-2-201, 53-6-101, 53-6-125, 53-6-402, 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) through (c) remain the same. (d) The department computes a base price for long term acute care (e) through (h) remain the same. (2) The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds adopted and effective at ARM 37.85.105. The Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), outlier thresholds, and APR-DRG grouper
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
37.87.903 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, AUTHORIZATION REQUIREMENTS (1) through (6) remain the same. (7) 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 (8) and (9) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113.htm" target="MCA">MCA
37.90.408 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS: REIMBURSEMENT (1) The department adopts and incorporates by reference the Medicaid Home and Community-Based Services for Adults With Severe Disabling Mental Illness Fee Schedule. The provider reimbursement rate for a covered service for Home and Community-Based Services for Adults with Severe Disabling Mental Illness, unless provided otherwise in this rule, is stated in the department's fee schedule as provided in ARM 37.85.105 (a) through (10) remain the same.
IMP: 53-6-402, MCA
4. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (department) administers the Montana Medicaid and non-Medicaid programs 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. Pursuant to 53-6-113(3), MCA, the legislature has delegated authority to the department to set by rule, the reimbursement rates that Medicaid pays to providers for covered services.
Although not all rule changes encompassed in this rulemaking pertain to Resource-based Relative Value Scale (RBRVS) Methodology, this methodology relates to a significant portion of this rulemaking. Medicaid proposes to revise fee schedules, effective dates, rates, and references to incorporate the annual relative value unit (RVU) updates from the Centers for Medicare and Medicaid Services (CMS). ARM 37.85.105 contains the references to Medicaid′s fee schedules, effective dates, conversion factors, provider rates percentages, and rates for services provided through Medicaid, effective July 1, 2018.
Resource-Based Relative Value Scale (RBRVS) Methodology Summary
Many Medicaid providers′ rates are established through the resource-based relative value scale (RBRVS) model. RBRVS is used nationwide by most health plans, including Medicare and Medicaid. The RVU component of RBRVS is revised annually by CMS and the American Medical Association. The department amends ARM 37.85.105 annually to adopt current RVUs. An RVU is a numerical value assigned to each medical procedure. RVUs are based on physician work, practice expense, and malpractice insurance expenses, and express the relative effort and expense expended to provide one procedure compared with another. RVUs are added for new procedures and the RVUs of particular procedures may increase or decrease from year to year.
Conversion factor (CF) means a dollar amount by which RVUs are multiplied to establish the RBRVS fee for a service. The department annually calculates CF for physician services, allied services, mental health services, and anesthesia services. These CFs are calculated by dividing the Montana Legislature′s appropriation for Medicaid services during the upcoming SFY by the total units of health care expressed, as total RVUs, which are estimated to be provided during the upcoming state fiscal year (SFY). The resulting quotient is the conversion factor. The RVU for a procedure multiplied by the CF is the fee paid for the procedure. In SFY 2018, the CFs for allied, mental health, and anesthesia services were calculated in this manner. Pursuant to ARM 37.85.212(6), the department has the authority to achieve budget neutrality by adjusting conversion factors to ensure that the expenditure of appropriations does not exceed available revenue.
There are four divisions within the department that are proposing amendments in this rulemaking. They are the Addictive and Mental Disorders Division (AMDD); the Children′s Mental Health Bureau (CMHB) of the Developmental Services Division; the Health Resources Division (HRD); and the Senior and Long Term Care Division (SLTC). Each division′s statement of reasonable necessity appears below.
ARM 37.85.104
The Addictive and Mental Disorders Division proposes amending ARM 37.85.104(1)(a), (b), and (d) to change from January 1, 2018, to July 1, 2018, the effective date of the fee schedules for reimbursement for mental health services plan, 72-hour presumptive eligibility for adult-crisis stabilization services, and substance use disorder services. The department proposes this to incorporate by reference the new fee schedules to implement the cost neutral rates set by Medicaid′s RBRVS reimbursement for psychologists, social workers, and professional counselors. The proposed amendment removes a reference to interactive psychotherapy which no longer exists according to the CPT Manual. In the July 1, 2018, fee schedules, the department is also amending the limit column and removing the management column for general housekeeping purposes.
The Children′s Mental Health Bureau is proposing to amend ARM 37.85.104(1)(c) to incorporate by reference the new fee schedules to implement the cost neutral rates set by RBRVS reimbursement psychologists, social workers, and professional counselors. The proposed amendment removes a reference to interactive psychotherapy which no longer exists according to the American Medical Association Current Procedural Terminology (CPT®) manual.
ARM 37.85.105
The AMDD proposes to remove overnight supports and companion services from the 1915(c) Home and Community-based Services (HCBS) Severe Disabling Mental Illness (SDMI) Waiver fee schedule effective July 1, 2018. CMS approved adding overnight supports and companion services to the 1915(c) HCBS SDMI Waiver on October 11, 2016, and both were added to the 1915(c) HCBS SDMI Waiver Fee schedule effective July 1, 2017. Since being added, overnight supports has never been used and companion services has been used only minimally. The department has submitted to CMS an amendment to the 1915(c) HCBS SDMI Waiver proposing to remove these services starting July 1, 2018. Rules were never approved for either service, so there are no corresponding rule numbers.
The department is proposing to amend ARM 37.85.105 to incorporate by reference the new fee schedules to implement the cost neutral rates set by RBRVS reimbursement psychologists, social workers, and professional counselors. The proposed amendment removes a reference to interactive psychotherapy which no longer exists according to the American Medical Association Current Procedural Terminology (CPT®) manual. The department is proposing to amend ARM 37.87.903 to require prior authorization of partial hospital for youth with a serious emotional disturbance (SED) beginning July 1, 2018, and is removing the requirement that youth must be at least two years of age to receive outpatient therapy, to be retroactively effective November 1, 2017.
ARM 37.85.105(2)(a)
The Health Resources Division is proposing amendments to citations in ARM 37.85.105(2)(a) that refer to the most recently published Federal Register update for RBRVS and update the effective date to January 1, 2018.
ARM 37.85.105(2)(b)
Pursuant to ARM 37.85.212(6), the department has the authority to achieve budget neutrality by adjusting conversion factors to ensure that the expenditure of appropriations does not exceed available revenue.
The CF for licensed physicians is set by 53-6-125, MCA, and is calculated in accordance with 20-9-326, MCA. For the physician services CF, the department achieved budget neutrality decreasing the existing CF of $36.53 by 0.94% to offset changes to RVUs or Geographic Practice Cost Indices (GPCIs), resulting in a CF of $36.19. With budget neutrality achieved, the department then applied a reduction of 0.5% to $36.19, which resulted in a CF of $36.01. The 0.5% reduction is necessary because in January 2018, the department applied a 1% increase to the physician services conversion factor and implemented the increase over six months instead of the usual 12-month period to satisfy the increase provided in 53-6-125, MCA. Finally, the department applied the legislatively mandated 1.87% increase to $36.01, resulting in the proposed physician CF of $36.68.
The allied services CF is used for reimbursement across multiple provider types. The proposed CF for allied services was reduced to compensate for the increase in RVUs. The allied services CF was decreased from $24.29 to $22.96 in order to achieve budget neutrality and ensure that expenditure of appropriations does not exceed available revenue.
ARM 37.85.105(2)(h)
Because the allied services CF was reduced to compensate for the increase in RVUs and because optometric RVUs did not increase at the rate of other providers, the Health Resources Division proposes to increase the optometric rate of reimbursement adjustment from 112% to 117% to compensate for the discrepancy.
ARM 37.85.105(2)(j)
The Health Resources Division proposes to amend ARM 37.85.105(2)(i) to adjust the effective date to July 1, 2018, for the vaccines fee schedule, which has been revised pursuant to the proposed revised physician services CF.
ARM 37.85.105(3)
The Health Resources Division proposes to amend ARM 37.85.105(3)(b)(i), to correctly cite the Federal Register reference for Outpatient Prospective Payment System (OPPS) fee schedule to Volume 82, Issue 217, page 52356 (November 13, 2017).
The Health Resources Division proposes amending ARM 37.85105(3)(b)(iii) to update the Medicaid statewide average outpatient cost-to-charge ratio from 39.91% to 37.30%. The most recent, in-state audited cost reports were used to calculate this percentage.
The Health Resources Division proposes amendments to ARM 37.85.105(3)(f)(i), (ii), and (iii), to revise the minimum dispensing fee amount to reflect the lowest calculated cost to dispense from $3.41 to $2.75, effective July 1, 2018, as required by CMS. This change is required to ensure compliance with Montana Medicaid′s State Plan.
The Health Resources Division proposes amending ARM 37.85.105(3)(h) to revise the outpatient drugs reimbursement, vaccine administration fee as provided in ARM 37.86.1105(6), from $12.61 to $13.42 for each additional administered vaccine effective July 1, 2018. The vaccine administration fees are being changed to reflect the current rate which was calculated to reflect the proposed conversion factors proposed in (2) of ARM 37.85.105, and explained above.
The Health Resources Division proposes amending ARM 37.85.105(3)(l) through (3)(y), to update the effective date for fee schedules, which have been revised to reflect revisions made by CMS to the average sales price for drugs, and to the RVUs for medical procedures multiplied by the revised conversion factors proposed in (2) of ARM 37.85.105.
ARM 37.85.105(4)
The Senior and Long Term Care Division proposes amending ARM 37.85.105(4)(a) to remove the billing code for independence advisor services from the fee schedule and make it unusable for billing purposes. This billing code is no longer necessary because the only independence advisor service provider has given notice it will no longer provide such services. Department staff will be providing independence advisor services, and members have been transitioned to the state staff.
ARM 37.85.105(5)(a), (b), and (c)
The Addictive and Mental Disorders Division proposes amending ARM 37.85.105(5)(a) through (5)(c) to change from January 1, 2018, to July 1, 2018, the effective date of the fee schedules for Medicaid mental health center services for adults, home and community-based services for adults with severe disabling mental illness, and substance use disorder services. The department proposes this to incorporate by reference the new fee schedules to implement the cost neutral rates set by Medicaid′s RBRVS reimbursement for psychologists, social workers, and professional counselors.
The proposed amendment removes a reference to interactive psychotherapy which no longer exists according to the CPT manual. In the July 1, 2018 fee schedules, the department is also amending the limit column and removing the management column for general housekeeping purposes.
ARM 37.85.105(6)
The Children′s Mental Health Bureau is proposing to amend ARM 37.85.105(6) to incorporate by reference the new fee schedules to implement the cost neutral rates set by Medicaid′s resource-based relative value scale (RBRVS) reimbursement for psychologists, social workers, and professional counselors. The department proposes to update the fee schedule date from March 1, 2018, to July 1, 2018.
It is necessary for the department to incorporate new assigned relative values to implement references rates set by Medicaid′s RBRVS reimbursement for psychologists, social workers, and professional counselors. RBRVS methodology is located in ARM 37.85.212 and is revised annually.
The Children′s Mental Health Bureau is proposing to amend the Youth Mental Health Services Fee Schedule, which is amended to remove a reference to interactive psychotherapy which no longer exists according to the American Medical Association Current Procedural Terminology (CPT®) manual. This is necessary to ensure the most current mental health procedures are billed.
The remaining proposed amendments in ARM 37.85.105(3) relate to changing to July 1, 2018, the effective date for fee schedules, which have been revised to reflect revisions made by CMS to the RVUs for medical procedures multiplied by the revised conversion factors proposed in ARM 37.85.105(2), and explained above.
ARM 37.86.2907
The reasons for the proposed changes are to align language in this rule with the Medicaid State Plan. Terminology has been added for clarification. These changes are housekeeping and do not have any impact on programs.
ARM 37.87.903
The department proposes to amend the CMHB Medicaid Services Provider Manual (Manual) and update the effective date from March 1, 2018, to July 1, 2018, to add prior authorization requirements of partial hospital for youth with a serious emotional disturbance to manage costs and avoid paying for services that are not medically necessary.
In addition, CMHB is proposing amendments to the proposed revisions to the Manual, beginning July 1, 2018, and removing the requirement that youth must be at least two years of age to receive outpatient therapy, retroactively effective November 1, 2017. This proposed amendment is necessary because CMHB had determined that youth under two years of age must have access to medically necessary mental health services.
In SFY 2015, the year prior to the rule and Manual change disallowing outpatient therapies for clients under the age of two years, there were $43,793 in outpatient therapies and assessments provided to Medicaid clients under the age of two. The payment system was not altered to deny claims for this new rule or limit, and therefore, many providers billed and have been paid for services after the rule was in effect. In SFY 2016, the year of the rule and Manual change, there were $34,731 in expenditures paid for outpatient therapies and assessments provided to Medicaid clients under the age of two. In SFY 2017, the amount of payments made for outpatient therapies and assessments to-date for clients under the age of 24 months is slightly less than SFY 2016, but since providers have 365 days to bill for services, the annual expenditures for SFY 2017 are not complete, but are estimated to be similar to SFY 2016.
ARM 37.90.408
The Addictive and Mental Disorders Division is proposing to amend ARM 37.90.408 to correct a reference to the department′s fee schedule provided in ARM 37.85.105. The department corrects the reference from (6) to (5)(b).
Fiscal Impact
Addictive and Mental Disorders Division
Updating the fee schedules for the Medicaid and non-Medicaid programs within the AMDD related to the updates to the (RBRVS) is presumed to have no fiscal impact.
Updating the rule reference in ARM 37.90.408 has no fiscal impact.
Children′s Mental Health Bureau
Updating youth mental health outpatient services′ (RBRVS) is presumed to have no fiscal impact.
Requiring prior authorization of partial hospital has the following fiscal impact.
Health Resources Division
The following table displays the number of providers affected by the amended fee schedules, effective dates, conversion factors, provider rate percentages, and rates for services, as well as the fiscal impact to State general funds for SF2019 based on the proposed amendments.
The proposed rule is estimated to affect 271,283 Medicaid members. In addition, it will impact the provider populations outlined in the tables above.
Senior and Long Term Care Division
There is no fiscal impact.
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: 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., May 25, 2018.
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. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
9. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment of the above-references rules will not significantly and directly impact small businesses.
10. 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/ Francis X. Clinch /s/ Marie Matthews for Director Francis X. Clinch Sheila Hogan, Director Rule Reviewer Public Health and Human Services
Certified to the Secretary of State April 17, 2018.
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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].
