BEFORE THE DEPARTMENT OF PUBLIC HEALTH
AND HUMAN SERVICES
OF THE STATE OF MONTANA
TO: All Concerned Persons
1. On November 5, 2021, the Department of Public Health and Human Services (department) published MAR Notice No. 37-963 pertaining to the public hearing on the proposed amendment of the above-stated rules at page 1490 of the 2021 Montana Administrative Register, Issue Number 21. Additionally, on December 10, 2021, the department published an amended notice to MAR Notice No. 37-963 pertaining to a second public hearing on the proposed amendment of the above-stated rules at page 1757 of the 2021 Montana Administrative Register, Issue Number 23.
2. The department has amended the following rules as proposed: ARM 37.87.903, 37.87.1801, 37.87.1802, 37.106.1955, 37.106.1956, 37.106.1960, 37.106.1961, and 37.106.1965.
3. The department has amended the following rule as proposed, but with the following changes from the original proposal, new matter underlined, deleted matter interlined:
37.87.1803 COMPREHENSIVE SCHOOL AND COMMUNITY TREATMENT PROGRAM: REIMBURSEMENT (1) Comprehensive school and community treatment (CSCT) services delivered by a licensed mental health center with an endorsement under ARM 37.106.1955 must be billed under the school district's provider number.
CSCT staff may not bill Medicaid for other mental health center services or outpatient therapy. CSCT staff may only bill Medicaid for CSCT services.
(2) through (8) remain as proposed.
(9) CSCT services rendered to youth attending school in a Montana county with a per capita population of fewer than 6 people per square mile are eligible to receive a frontier community differential of 115% of the current fee schedule, as provided in ARM 37.85.106.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 50-5-103, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
4. The department has thoroughly considered the comments and testimony received. A summary of the comments received, and the department's responses are as follows:
COMMENT #1: Several commenters offered support for the proposed rule amendments and updated Children's Mental Health Medicaid Services Provider Manual (manual) and thanked the department for updating the rate methodology, increasing operational flexibility, and adding care coordination as a billable service, including outcome measurements.
RESPONSE #1: The department thanks providers and stakeholders for this feedback and support, and believes the rule amendments and updated manual will enhance the quality of the Comprehensive School and Community Treatment (CSCT) service provision to youth and families while managing a fiscally sound program.
COMMENT #2: A commenter requested clarification on the billable days per month caps for teams with two or one (therapist) members when schools cannot provide the referrals necessary for a three-person team.
RESPONSE #2: The department clarifies that the CSCT billing caps are 120 service days per month for a CSCT team of one, 240 service days per month for a CSCT team of two, and 360 services days per month for a CSCT team of three.
COMMENT #3: Several commenters expressed concern that given the workforce shortage and the COVID-19 pandemic, the requirement that CSCT staff may not bill for other Medicaid services does not allow providers to fully utilize all available staff to meet the needs of youth and families.
RESPONSE #3: The department agrees with this comment, and has removed this requirement from ARM 37.87.1803(1) and will monitor for quality service delivery when mental health centers are allowed the flexibility of CSCT staff billing for other Medicaid services.
COMMENT #4: A commenter requested clarification if the administrative rule requirement that CSCT staff may not bill Medicaid for other mental health services also includes Healthy Montana Kids (HMK) Extended.
RESPONSE #4: The department clarifies that CSCT has not been, and is not, a covered service by HMK. Providers may bill unbundled services, such as outpatient psychotherapy and community-based psychiatric rehabilitation services for youth enrolled in HMK. The department has removed the restriction of CSCT staff billing for other Medicaid services from ARM 37.87.1803(1) and will monitor for quality service delivery when mental health centers are allowed the flexibility of CSCT staff billing for other Medicaid services.
COMMENT #5: Several commenters raised concern about the intergovernmental transfer process and the guidance received to date.
RESPONSE #5: The purpose of the rule notice is to update the CSCT benefit for Montana Medicaid and authorize an intergovernmental transfer process for funding the state match. The department will continue to work with stakeholders and other state agencies to provide operational guidance. Therefore, the comment is outside the scope of this rulemaking.
COMMENT #6: A commenter requests that the department rewrite the rule to allow care coordination to be billed without the requirement to provide two core services per week.
RESPONSE #6: The department disagrees with this comment and will not rewrite the rule to allow care coordination to be billed without the requirement to provide two core services. The department added care coordination to address concerns that CSCT providers were performing unbillable care coordination. While care coordination is important for youth and their families, the department requires direct care therapeutic interventions such as individual, group, and family psychotherapy, psychiatric rehabilitation, and crisis response to be provided within the same week as care coordination is billed to ensure that the program's focus is on improving the youth's functional level by facilitating the development of skills related to exhibiting appropriate behaviors in the school, home, and community settings.
COMMENT #7: Two commenters requested clarification on billing for summer programming and the proposed daily rate. One commenter would like the department to consider an increase of 1.5 times the daily rate for longer durations. The other commenter asked the department to amend the rule to allow for CSCT teams to either provide CSCT or unbundle services during summer months and bill other Medicaid services.
RESPONSE #7: The department disagrees with the commenters, and did not increase the daily rate for longer durations. In order to convert the reimbursement unit from a 15-minute unit to a daily per encounter rate, the department did the following: compiled three years of historical utilization data on CSCT, including total encounters and total 15-minute billed units, calculated the average number of 15-minute units per encounter based on historical data for calendar year 2019 (5.6) and 2020 (6.0), adjusted the average units per encounter based on projected utilization, multiplied the historical 15-minute unit rate by the projected units per encounter, and applied an adjustment for inflation. The historical utilization data included data from the summer months and the average 15-minute unit per encounter included longer durations in the summer months. Additionally, the resulting daily rate aligned with the daily rate that was included in a proposal received from CSCT providers. The department maintained the requirement in ARM 37.106.1956(1)(i) for CSCT to be available twelve continuous months per year and provided four days per week at a minimum in the summer months. Unbundling services to bill other Medicaid services would not comply with this requirement.
COMMENT #8: A commenter requested clarification on if new provider team numbers will be issued for teams rather than schools in situations where one team of three provides services to two schools.
RESPONSE #8: The department clarifies that provider team numbers will be issued to the team providing the CSCT services rather than issue provider team numbers by the school in which services are provided.
COMMENT #9: A commenter recommended amending the data collection process by working with the department to design a tool that better collects useful data.
RESPONSE #9: The department disagrees with this comment and will not amend the data collection process. The proposed data collection tool was created by the department with input from mental health centers providing the data for Targeted Case Management (TCM) for Youth with Serious Emotional Disturbances (SED). The department believes that provider input has been captured on this tool and that there is value in collecting the same measurements across services. Mental health centers are welcome to collect any outcome measurements that the agency is interested in, and the department welcomes this information to inform future policy.
COMMENT #10: A commenter proposes to amend the proposed amendment to reduce the number of school coordination meetings to "at least three times per year."
RESPONSE #10: The department disagrees with this comment, and did not change the proposed amendment to reduce the number of school coordination meetings to "at least three times per year." The department believes that quarterly meetings with school administration are the appropriate minimum number of annual meetings and the updated rules will allow for flexibilities that align with typical school calendars by requiring the school coordination meetings to occur four times per year rather than every ninety days.
COMMENT #11: A commenter requested clarification on how youth in crisis should be incorporated into the CSCT billing structure and there could be a separate crisis rate that is used during a child/family crisis. The commenter noted that working with one child in crisis can take considerable time and impact the time available for other youth within the program.
RESPONSE #11: The department disagrees with this comment and will not add a separate crisis rate to be used during a child/family crisis. The department notes that crisis response services have always been a component of CSCT. Crisis response services are included in the proposed daily bundled rate for CSCT which was based on three years of historical utilization, including units billed for crisis response.
COMMENT #12: Several commenters requested clarification on how the prior authorization process will work for CSCT and Home Support Services (HSS) and if there will be an administrative burden as there are with other programs. The commenters felt that it would be beneficial during the workforce shortage to streamline or remove CSCT and HSS prior authorizations. Commenters also inquired when the two programs should be offered concurrently as they are both intensive programs for families
RESPONSE #12: The department agrees with the commenters and removed the requirement in the CSCT and HSS sections of the manual for prior authorization for CSCT and HSS to be provided concurrently. This change was made to reduce administrative burden for mental health centers and to increase access to services for youth with SED.
COMMENT #13: A commenter recommended that the proposed frontier rate be based on the school district location and not the youth's residence. The commenter stated that it would be challenging to have clean agreements/processes with the schools. An unforeseen impact of this frontier versus non-frontier rate is that frontier schools are required to pay more for the same service and the frontier schools feel this is unequitable.
RESPONSE #13: The department agrees with the commenter and has revised the manual to provide the frontier rate county to be based on the location of the school district rather than the county where the youth resides to simplify CSCT contracts and billing. This change has been added to the CSCT section of the manual.
COMMENT #14: A commenter requested that the compliance date to begin using the CASII be moved to August 2022 to allow for training of staff not already using CASII. The commenter stated they are in complete agreement with using the CASII outcome measurement tool for CSCT. The commenter also noted that agencies already using CASII for other programs such as TCM and HSS, could provide the data prior to August 2022 for DPHHS and the legislature oversight.
RESPONSE #14: The department agrees with this change, and has revised the requirement in the CSCT section of the manual to start administering CASII or ECSII effective August 1, 2022, to allow additional time for training of CSCT staff in the CASII.
COMMENT #15: A commenter raised concerns that the department is proposing that 75% of HSS must be provided in the home or community. The commenter stated that it appears to be an additional, unnecessary restriction of HSS, meaning only 25% is allowable in a school setting. The commenter stated that there are many schools across the state that do not have CSCT but have a need for a youth to have HSS and that HSS is intended to meet the need in the school, home, and community. The commenter added that this rule change would limit the support and the autonomy of the youth's individualized treatment plan based on clinical/medical necessity to determine where the intervention/service is most needed.
RESPONSE #15: The department agrees with this comment, and has included school in its definition of community in the manual. The department has updated the HSS section of the manual to clarify that 75% of HSS must be provided in the home, school, or community.
COMMENT #16: A commenter requested that prior authorization based on team size be removed from the manual leaving the limit at 360 billable days per month. The commenter stated that, as written, they thought this will lead to providers providing unbillable services with the new 30 minutes equals one billable day methodology.
RESPONSE #16: The department disagrees with this comment, and will maintain the prior authorization based on team size as proposed. These limits are intended to maintain the level of service intensity of CSCT. Using an average month of 20 school days, 120 billable days per team member allows for each team member to serve six youth for at least 30 minutes, which the department believes to be an appropriate caseload. Allowing for one team member to bill for 360 days per month would incentivize higher caseloads and less intense services.
COMMENT #17: A commenter inquired when prior authorizations will be required when the number of team members changes within a month.
RESPONSE #17: The department clarifies that prior authorization is required for a CSCT team of one to provide over 120 service days per month or for a CSCT team of two to provide over 240 service days per month. If the number of team members changes within a month, and the provider anticipates providing over the 120 service days per month per team member limits, the department requests that a prior authorization form be submitted when the change occurs. The prior authorization form will include more details on the process and will be located on the Montana Healthcare Programs Provider Information website and on the Children's Mental Health Bureau website.
COMMENT #18: A commenter stated that the HSS section of the manual states: "The requirements outlined in (b) and (c) above are waived for the warm discharge hand-off period, during the warm discharge hand-off period the provider must meet all other requirements and have weekly contact with the family to be eligible for Medicaid reimbursement." The commenter added that there is no (b) and (c) above to reference and that the section above has numbers instead of letters.
RESPONSE #18: The department appreciates the commenter bringing this to our attention, and it has been corrected in the HSS section of the manual.
5. The department intends to apply changes related to outcome measurements in ARM 37.106.1961 effective March 1, 2022. All other referenced rule amendments are effective retroactively to October 1, 2021. A retroactive application of the proposed rule amendments does not result in a negative impact to any affected party.
/s/ Aleea Sharp /s/ Adam Meier
Aleea Sharp Adam Meier, Director
Rule Reviewer Public Health and Human Services
Certified to the Secretary of State January 18, 2022.