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Montana Administrative Register Notice 37-480 No. 14   07/30/2009    
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BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the adoption of New Rules I through VII, the amendment of ARM 37.79.101, 37.79.102, 37.79.106, 37.79.201, 37.79.202, 37.79.206, 37.79.207, 37.79.208, 37.79.301, 37.79.302, 37.79.303, 37.79.312, 37.79.317, 37.79.325, 37.79.326, 37.79.501, 37.79.503, 37.79.505, 37.79.601, 37.79.602, 37.79.605, 37.79.801, and 37.82.701, and the repeal of 37.79.209 pertaining to implementing the Healthy Montana Kids Plan Act

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NOTICE OF PUBLIC HEARING ON PROPOSED ADOPTION, AMENDMENT, AND REPEAL

 

TO:  All Concerned Persons

 

            1.  On August 20, 2009, at 10:30 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 adoption, 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 Department of Public Health and Human Services no later than 5:00 p.m. on August 11, 2009, to advise us of the nature of the accommodation that you need.  Please contact Rhonda Lesofski, 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 dphhslegal@mt.gov.

 

3.  The rules as proposed to be adopted provide as follows:

 

            RULE I  PROCESS FOR IDENTIFYING AND APPROVING ENROLLMENT PARTNERS  (1)  The following entities are qualified to be enrollment partners:

            (a)  a licensed health care provider;

            (b)  a school district;

            (c )  a community-based organization; and

            (d)  a government agency.

            (2)  The department will consider requests to act as an enrollment partner from other entities and approve requests on a case-by-case basis.

            (3)  A qualified entity becomes an enrollment partner by contacting the department and indicating an interest in becoming an enrollment partner.  The department will notify the entity if it is accepted as an enrollment partner.  The department will provide an enrollment partner with Healthy Montana Kids (HMK) Plan materials and applications.  Enrollment partners must complete department sponsored training and provide application assistance to HMK Plan applicants.

            (4)  The department will maintain a list of the names, addresses, and telephone numbers of its enrollment partners and publish the list on its web site. 

            (5)  Enrollment partners are volunteers who receive no compensation from the state of Montana.  The department has the option of denying or discontinuing enrollment partner status.

 

AUTH:  53-4-1105, MCA

IMP:  53-4-1104, 53-4-1105, MCA

 

            RULE II  ACTIVE ENROLLMENT PROCESS  (1)  The department will promote the HMK Plan through a combination of  traditional marketing methods and social marketing.  The department will develop and maintain an enrollment partner network to encourage, assist, and actively enroll children in the plan.

            (2)  An individual may apply for the HMK Plan coverage group, HMK, or HMK Plus at any time and, if qualified, will be enrolled in the appropriate program.  The department will process applications based upon the date of receipt.  The department will enroll eligible children in the appropriate HMK Plan group based upon the respective program guidelines.  An application can be submitted to the HMK Plan office or any county public assistance office.

 

AUTH:  53-4-1105, MCA

IMP:  53-4-1104, 53-4-1105, MCA

 

            RULE III  MOVEMENT BETWEEN HMK AND HMK PLUS  (1)  The HMK Plan is available to all Montana residents who are 18 years of age or younger and live in households with a combined family income at or below 250% of the 2009 federal poverty level (FPL).  The HMK Plan provides for two coverage groups, HMK and HMK Plus.  The HMK coverage group is available to qualified residents who reside in households with a combined family income between 134% and 250% of the 2009 FPL.  A waiting list may apply to this program.  The HMK Plus coverage group is available to qualified residents who reside in households with a combined family income between 0 and 133% of the 2009 FPL.

            (2)  The HMK and HMK Plus coverage groups provide 12 months continuous coverage.

 

AUTH:  53-4-1105, MCA

IMP:  53-4-1104, 53-4-1105, 53-4-1110, MCA

 

            RULE IV  POINT OF ACCESS  (1)  The department will accept and determine eligibility for all applications for children's health coverage provided by the HMK Plan.  Applications may be submitted directly to the Healthy Montana Kids Plan office or any county office of public assistance (OPA).  The department staff in each location will screen for potential eligibility for the HMK Plan.

            (2)  OPA and HMK Plan staff will coordinate eligibility determination activities and enroll eligible children in the appropriate HMK Plan coverage group, HMK, or HMK Plus.

 

AUTH:  53-4-1105, MCA

IMP:  53-4-1104, 53-4-1105, MCA

 

            RULE V  TRANSITION  (1)  On October 1, 2009, all children currently enrolled in the CHIP and the Medicaid children's programs will transition from CHIP and Medicaid to the HMK Plan.

            (2)  The second transition will take place when current CHIP enrollees from families with income between 100% and 133% of the FPL transition to the CHIP-funded Medicaid expansion program.  The transition will occur at the time of annual reapplication during federal fiscal year 2010 (October 1, 2009 to September 30, 2010).  Approximately 10,000 current CHIP enrollees will be affected by this transition.  The staggered transition will occur throughout the year.

            (a)  For an eligible child in the HMK coverage group there is a 12-month family span.

 

AUTH:  53-4-1105, MCA

IMP:  53-4-1104, 53-4-1105, 53-4-1110, MCA

 

            RULE VI  PROSPECTIVE PAYMENT SYSTEM  FOR FEDERALLY QUALIFIED HEALTH CENTER (FQHC) REIMBURSEMENT  (1)  The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) requires states with separate or combined CHIP programs to pay federally qualified health centers (FQHCs) and rural health centers (RHCs) using the Medicaid outpatient prospective payment system (OPPS) as described in ARM 37.86.4413.  An OPPS rate for the HMK coverage group will be developed by the department.

 

AUTH:  53-4-1105, MCA

IMP:  53-4-1104, 53-4-1105, MCA

 

            RULE VII  OUTREACH EFFORTS  (1)  The department will promote the HMK Plan through a combination of traditional marketing methods, social marketing, the development and maintenance of an enrollment partner network and collaborative efforts with schools, advocacy groups, health care providers, and other community organizations to encourage, assist, and actively enroll children in the plan.  All outreach will include the name HMK Plan on documents associated with the plan including, but not limited to advertising, brochures, applications, and membership cards.

 

AUTH:  53-4-1105, MCA

IMP:  53-4-1104, 53-4-1105, MCA

 

            4.  The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:

 

            37.79.101  CHILDREN'S HEALTH INSURANCE PLAN (CHIP) HEALTHY MONTANA KIDS PLAN (HMK)  (1)  The rules in this subchapter implement the Children's Health Insurance program, which is provided through the Children's Health Insurance Plan (CHIP).  CHIP is jointly funded by the federal and state government.  The purpose of CHIP is to provide health care benefits to uninsured individuals under the age of 19 years from low income families who are not eligible for the Montana Medicaid program.  The rules in this subchapter implement the Healthy Montana Kids Plan to provide comprehensive health care coverage to Montana residents who are 18 years of age or younger residing in households with a combined family income at or below 250% of the 2009 federal poverty level (FPL).  There is no resource test, as that term is used in 53-6-113 and 53-6-131, MCA, to qualify to participate in the Healthy Montana Kids Plan.

            (2)  The Healthy Montana Kids Plan has two health care coverage groups, Healthy Montana Kids (HMK) and Healthy Montana Kids Plus (HMK Plus).  The coverage group an applicant is eligible for is determined by the combined family income.

            (a)  Qualified residents residing in households with income at or below 250% of the 2009 FPL but greater than 133% of the 2009 FPL qualify for the HMK coverage group.  The HMK coverage group is a public benefit program administered by the department through a third party administrator.  HMK enrollees have health care coverage to the extent described in this chapter.  HMK providers are members of a provider network reimbursed at rates agreed to by contract.  The provisions of this chapter apply to HMK enrollees.

            (b)  Qualified residents residing in households with income at or below 133% of the 2009 FPL qualify for the HMK Plus coverage group.  The HMK Plus coverage group is the term used to identify the Montana Medicaid program for Montana residents 18 years of age or younger.  HMK Plus enrollees have health care coverage to the extent provided by Montana Medicaid.  HMK Plus providers are reimbursed at Montana Medicaid rates.  The provisions of this chapter and Title 37, chapters 82, 83, 85, 86, and 88 apply to HMK Plus.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, 53-4-1110, MCA

 

            37.79.102  DEFINITIONS  As Definitions as used in this subchapter, unless expressly provided otherwise, the following definitions apply:

            (1)  "Advanced practice registered nurse (APRN)" means a registered professional nurse who has completed educational requirements related to the nurse's specific practice role, in addition to basic nursing education, as specified by the Board of Nursing in ARM Title 8, chapter 32, subchapter 3 who has completed educational requirements related to the nurse's specific practice role, in addition to basic nursing education, as specified by the Board of Nursing pursuant to 37-8-202(5)(a), MCA.

            (2) remains the same.

            (3)  "Applicant" means an individual under the age of 19 years who applied for CHIP the HMK Plan benefits or whose parent or guardian applied for CHIP the HMK Plan benefits on the individual's behalf.

            (4) remains the same.

            (5)  "Benefit year" means the period from October 1st through September 30th of a calendar year.  If an individual is enrolled in CHIP the HMK coverage group after October 1st, the benefit year is the period from the date of enrollment through the following September 30th of the calendar year.

            (6)  "Children's Health Insurance Plan Program (CHIP)" means the Children's Health Insurance Plan Program described in this subchapter and administered by the department under Title 53, chapter 4, part 10, MCA and Title XXI of the Social Security Act.

            (7) through (9)(c) remain the same.

            (10)  "Enrollee" means an individual who is eligible to receive CHIP HMK Plan benefits as determined by the department under this subchapter and is enrolled in the CHIP program the HMK coverage group.  An individual is not an enrollee while on a waiting list or pending issuance of a hearing decision or during any period a hearing officer determines the individual was not eligible for CHIP the HMK coverage group benefits.  The term "enrollee" and "member" are synonymous.

            (11)  "Enrollment partner" means an organization or individual approved by the department to assist in enrolling eligible children in the plan.

            (11) remains the same but is renumbered (12).

            (12) (13)  "Family span" means the 12 month period beginning the first day of the month after an eligibility determination the department receives an application for CHIP HMK coverage group benefits is completed and ending the last day of the 12th month.  Although qualified for CHIP the HMK coverage group benefits, applicants placed on the waiting list may not be enrolled during the entire family span.

            (13) (14)  "Federal poverty level (FPL)" means the poverty income guidelines published in the Federal Register by the U.S. Department of Health and Human Services for 2007 for 2009 for the 48 contiguous states and the District of Columbia as published under the "Annual Update on the HHS Poverty Guidelines" in the Federal Register each year on or about February 15.

            (15) "Federally qualified health center (FQHC)" means an entity that is a federally qualified health center as defined in 42 USC 1396d(l)(2)(B) (2009 Supp.).

            (14) remains the same but is renumbered (16).

            (17)  "Health coverage" means a program administered by the department or a disability insurance plan, referred to in 33-1-207(1)(b), MCA, that provides public health care coverage or private health insurance for children.

            (18)  "Healthy Montana Kids (HMK) Plan" means the two health care coverage groups, Healthy Montana Kids (HMK) and Healthy Montana Kids (HMK) Plus, which pay for covered health care services to qualified individuals until their 19th birthday.  The HMK coverage group was formerly referred to as CHIP and the provisions of Title 53, chapter 4, part 10, MCA apply.  The HMK Plus coverage group is also referred to as children's Medicaid and the provisions of Title 53, chapter 6, MCA apply.

            (15) and (16) remain the same but are renumbered (19) and (20).

            (21)  "Initiative I-155" means the initiative passed by Montana voters in November, 2008, that enacted the HMK Plan Act.

            (17) remains the same but is renumbered (22).

            (18)  "Medicaid screening" means a determination by the department of an individual's potential eligibility to receive Medicaid benefits applying the criteria set forth in ARM Title 37, chapter 82 and certain Medicaid rules which disregard income.

            (19) remains the same but is renumbered (23).

            (20) (24)  "Member" means an individual who is eligible to receive CHIP HMK Plan benefits as determined by the department under this and is enrolled in the CHIP program rule.  An individual is not a member while on a waiting list or pending issuance of a hearing decision or during any period a hearing officer determines the individual was not eligible for CHIP the HMK coverage group benefits.  The term "member" and "enrollee" are synonymous.

            (21) and (22) remain the same but are renumbered (25) and (26).

            (27)  "Outpatient prospective payment system (OPPS)" means the reimbursement method for federally qualified health centers (FQHCs) and Rural Health Centers (RHCs).

            (28)  "Outreach" means efforts which promote the Healthy Montana Kids Plan through a combination of traditional marketing methods, and social marketing.  The department will develop and maintain an enrollment partner network to encourage, assist, and actively enroll children in the program.

            (23) and (24) remain the same but are renumbered (29) and (30).

            (31)  "Rural health clinic (RHC)" means a clinic determined by the secretary of the U.S. Department of Health and Human Service to meet the rural health clinic conditions of certification specified in 42 CFR, part 491, subpart A.

            (25) (32)  "Serious emotional disturbance (SED)" means the criteria stated in ARM 37.87.303 means a designation determined by qualified department staff and based on social history and clinical information in the form of a psychological assessment with DSM-IV diagnosis, completed by a licensed psychologist, social worker, or professional counselor, that a youth is seriously emotionally disturbed according to the definition set forth in ARM 37.86.3702(2).

            (26) (33)  "State employee" means a person, including the CHIP HMK applicant, employed on a permanent basis by the state of Montana.

            (27) (34)  "Third party administrator (TPA)" means an entity with a certificate of registration to conduct business in Montana in accordance with 33-17-603, MCA, or an entity licensed as a health service corporation.  The CHIP program department may contract for TPA services including but not limited to claims processing, maintaining an adequate network of participating providers, coordination and continuation of care, health education, notices, quality assurance, reporting, case management services, and customer service.

            (28) remains the same but is renumbered (35).

            (29) (36)  "Waiting list" means a list of applicants who have been determined eligible for CHIP the HMK coverage group but who are not enrolled because funds are not available.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.106  ELECTRONIC APPLICATIONS AND SIGNATURES  (1)  The CHIP program HMK Plan will accept electronic applications and signatures.  Electronic signatures are allowed in compliance with the requirements of ARM Title 30, chapter 18, subchapters 106, 117, and 122 to the extent those provisions are not inconsistent with this subchapter.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.201 ELIGIBILITY  (1)  An applicant may be eligible for covered services under CHIP the HMK coverage group if:

            (a) and (b) remain the same.

            (c)  the family of which the applicant is a member has annual family income, without regard to other family resources, at or below 175% 250% of the federal poverty level (FPL);

            (d) through (f) remain the same.

            (g)  the applicant is not an inpatient in an institution for mental disease on the date of initial application or reapplication; the date of any redetermination of eligibility; and

            (h)  the applicant does not have or has not had creditable health insurance coverage as defined in 42 USC 300gg(c) 30 days for three months prior to becoming eligible for CHIP the HMK coverage group.  This 30 day period shall three month period does not apply if the parent or guardian providing the insurance:

      (i)  dies;

      (ii)  is fired terminated or laid off;

      (iii)  can no longer work due to a disability;

      (iv)  has a lapse in insurance coverage due to new employment; or

      (v)  has an employer who does not offer dependent coverage.

      (v)  had insurance coverage that ended because the stepparent, who provided the coverage, and the parent divorced;

            (vi)  had coverage through the Insure Montana Program;

            (vii)  had coverage through the Medicaid Health Insurance Premium Payment (HIPP) program; or

            (viii)  paid more than 50% of the insurance premium.

            (i)  the applicant or the applicant's parent is not eligible for health insurance coverage under the state of Montana Employee's Health Insurance Plan; and

            (j)  the applicant is not eligible or potentially eligible for Medicaid coverage as determined by the department.

            (2)  An applicant who is eligible for health benefits coverage under the Montana Employee's Health Insurance Plan or the Montana University System Employees Health Insurance Plan is not eligible for HMK coverage.

            (3)  An applicant who is eligible or potentially eligible for Medicaid as determined by the department is not eligible for the HMK coverage group.

            (4)  The department must verify an applicant's citizenship or qualified alien status before an otherwise eligible applicant is enrolled.

            (2) (5)  Family income information for all family members must be included on the signed and dated application must be verified to determine eligibility.

            (a)  Family income includes may include one or more of the following:

            (i)  the income of both parents if the child resides with both parents;

            (ii)  the income of the custodial parent with whom the child resides the majority of the year, including any child support received for the child, if the child resides with one parent in a single parent household:

(A)  If the custodial parent with whom the child resides the majority of the year has remarried, the stepparent's income is imputed to the custodial parent with whom the child resides the majority of the year.

            (B)  The income of individuals under the age of 19 who live in the household but do not attend school is imputed to the custodial parent with whom the child resides the majority of the year.

            (b)  Family income does not include:

            (i)  money received from assets drawn down such as withdrawals from a savings account, an annuity, or from the sale of a house or a car;

            (ii)  gifts, loans, one-time insurance payments, or lump sum compensation for an injury;

            (iii)  the first $2,000 of an enrolled tribal member's per capita payment;

            (iv)  the first $2,000 of an enrolled tribal member's tribal land income;

            (v)  the interest earned on (2)(b)(iv) (2)(b)(iii) and (v) (iv);

            (vi)  earned income which is excluded and dependent care expenses which are deducted from income under the state Medicaid poverty programs for children HMK Plus coverage group;

            (vii) through (d) remain the same.

            (3) (6)  An applicant whose CHIP HMK coverage group enrollment ended because his or her parent was activated into military service and who was insured through Tri-care, which is the insurance available to active duty and retired military families during the parent's military activation period, is not subject to the 30 day minimum three month waiting period for previous creditable health insurance and will be enrolled in CHIP the HMK coverage group if he or she continues to be eligible for CHIP the HMK coverage group.  Upon notification that the parent was deactivated and the applicant loses Tri-care coverage, the applicant may be re-enrolled:

            (a)  the month after CHIP HMK Plan is notified, if the family has an open family span; or

            (b)  the month after a completed application is received and the applicant requalifies for CHIP benefits, if the family does not have an open family span HMK coverage group.

            (4) (7)  Applicants eligible to receive services from the Indian Health Services (IHS) program administered by the United States Department of Health and Human Services are eligible for CHIP the HMK coverage group if they meet the criteria specified in this subchapter.

            (5) (8)  Applicants who are losing Medicaid HMK Plus coverage or who were denied Medicaid HMK Plus coverage for a reason other than the family withdrew their application or failed to comply with Medicaid HMK Plus requirements will be referred to CHIP the HMK coverage group via an electronic report.  CHIP The HMK coverage group eligibility will be determined and applicants will be enrolled in CHIP the HMK coverage group or placed on the CHIP HMK coverage group's waiting list.

            (6) remains the same but is renumbered (9).

            (7) (10)  CHIP The HMK coverage group benefits do not start until the applicant is enrolled even though the applicant may have been determined eligible for CHIP the HMK coverage group prior to the date of enrollment.

            (8) (11)  CHIP The HMK coverage group eligibility is redetermined within one year after the initial eligibility period, and annually thereafter.  A renewal application must be completed, signed, dated, and returned by a specified date for purposes of eligibility redetermination.  Prior eligibility for CHIP HMK does not guarantee continued eligibility or enrollment in CHIP.

            (9) (12)  CHIP The HMK coverage group eligibility and benefits are not an entitlement.  If funding is insufficient, the department may reduce enrollment numbers or reduce eligibility to a lower percentage of the federal poverty level to limit the number of individuals who are eligible to participate.

            (10) (13)  A determination of CHIP the HMK coverage group eligibility will be completed within 20 working 45 calendar days after receipt of a complete application.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.202  NONQUALIFYING APPLICANTS  (1)  Applicants determined by the department to be eligible for Medicaid through a Medicaid determination process are the HMK Plus coverage group are eligible to receive the HMK Plus coverage group benefits but not eligible to receive CHIP the HMK coverage group benefits.

            (2)  Applicants determined by the department to be potentially eligible for Medicaid during the CHIP eligibility determination process will be referred to their local office of public assistance for a determination of Medicaid eligibility.

            (3) (2)  Applicants who are themselves eligible or who have a parent who is eligible for state employee or the Montana University System employee insurance benefits are not eligible for CHIP the HMK coverage group.

            (4) (3)  Applicants who apply for CHIP benefits while they are patients in an institution for mental disease (IMD) shall not be enrolled in CHIP until they are discharged from the IMD.  A CHIP enrollee who becomes a patient in an IMD shall not lose CHIP benefits solely because the enrollee is a patient in an IMD Applicants who are patients in an institution for mental diseases on the date of initial application or any redetermination of eligibility are not eligible for the HMK coverage group (42 CFR 457.310).

            (5) (4)  Applicants who are incarcerated cannot be enrolled in CHIP the HMK coverage group.

            (6) (5)  Applicants who are not eligible for CHIP HMK coverage group benefits because their family income exceeds the CHIP HMK coverage group income guideline for the family size will be referred to other health care programs for children, as appropriate.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.206  ELIGIBILITY REDETERMINATION, NOTICE OF CHANGES

            (1)  Eligibility determinations shall be effective for a period of 12 months unless one or more of the following changes occurs:

            (a) remains the same.

            (b)  the enrollee moves, does not notify CHIP the department of the new address and CHIP the department is unable to locate the enrollee;

            (c) through (e) remain the same.

            (f)  the enrollee or the enrollee's parent becomes eligible for state employee or the Montana University System employee benefits before the expiration of the 12 month eligibility period;

            (g) remains the same.

            (h)  the enrollee becomes eligible for Medicaid HMK Plus.

            (2) remains the same.

            (3)  A CHIP HMK renewal application must be completed and CHIP eligibility redetermined every 12 months.  If the renewal application is not returned before CHIP the HMK coverage group enrollment is scheduled to end, benefits will terminate.  A new application may be completed at a later date but, if the children are determined eligible, they may be placed on the waiting list if one exists.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.207  TERMINATION OF ELIGIBILITY AND GUARDIAN LIABILITY

            (1)  CHIP The HMK coverage group eligibility terminates immediately upon:

            (a) and (b) remain the same.

            (2)  CHIP The HMK coverage group eligibility terminates at the end of the month the department becomes aware:

            (a) remains the same.

            (b)  the parent or guardian or enrollee becomes eligible for state employee or Montana University System employee insurance benefits;

            (c) remains the same.

            (d)  the enrollee is determined eligible for Medicaid HMK Plus;

            (e) and (f) remain the same.

            (g)  the applicant has moved without providing a new address and CHIP the department is unable to locate the applicant; or

            (h) through (4) remain the same.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.208  PROVISIONAL BENEFITS, DETERMINATION OF ELIGIBILITY, AND APPLICATIONS FOR CHIP HMK   (1)  Provisional CHIP HMK coverage group benefits may be extended to enrollees who would otherwise lose health care coverage while awaiting a Medicaid an HMK Plus determination.  Provisional coverage may be extended to enrollees who:

            (a)  submit a completed CHIP HMK Plan renewal application before their CHIP HMK coverage group benefits are scheduled to end;

            (b)  have been determined potentially eligible for Medicaid HMK Plus coverage; and

            (c)  are awaiting a Medicaid an HMK Plus eligibility determination.

            (2)  A determination of CHIP HMK Plan eligibility will be completed within 20 45 working days after receipt of a complete application.

            (3)  Applications for applicants who appear to be Medicaid eligible will be forwarded to the appropriate county office of public assistance for a Medicaid eligibility determination within 20 working days after receipt of a complete application.

            (a) (3)  Applicants who are denied Medicaid HMK Plus coverage for failure to comply with Medicaid HMK Plus eligibility requirements:

            (i) (a)  are not eligible for CHIP the HMK coverage group benefits; and

            (ii) (b)  will not have their application referred to other health care resources.

            (b) (4)  CHIP HMK coverage group applications will be processed for those applicants who subsequently provide information which would preclude them from Medicaid HMK Plus eligibility.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.301  COVERED BENEFITS  (1) through (3) remain the same.

            (4)  Access to information through a 24-hour call-in service, commonly referred to as a "nurse advice line", is a covered benefit for HMK Plan members. 

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.302  COVERAGE LIMITATIONS  (1) and (2) remain the same.

            (3)  Covered benefits shall be provided to an enrollee who is receiving inpatient hospital benefits up to and including the 11th day after the effective date of losing CHIP benefits.

            (4) (3)  A newborn of a CHIP an HMK coverage group enrollee shall have all medically necessary benefits covered by the CHIP HMK coverage group program for 31 days after the newborn's date of live birth.  Coverage for the newborn shall begin the day of live birth, without regard to whether the newborn is hospitalized on the date of coverage.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.303  BENEFITS NOT COVERED  (1)  In addition to any exclusions noted elsewhere in these rules, the following services are not covered benefits:

            (a) through (g) remain the same.

            (h)  biofeedback and neurofeedback;

            (i) through (x) remain the same.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.312  PRESCRIPTION DRUG BENEFITS  (1) through (4) remain the same.

            (5)  The CHIP HMK coverage group program shall use the Medicaid formulary if the program chooses to employ a formulary.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.317  CHEMICAL DEPENDENCY BENEFITS  (1) remains the same.

            (2)  The combined benefit for inpatient and outpatient treatment for alcoholism and drug addiction, excluding costs for medical detoxification, is subject to a maximum benefit of $6,000 in a 12-month period.  Inpatient benefits are limited to a The lifetime inpatient maximum benefit of is $12,000.  After If the inpatient lifetime maximum benefit has been is met, the annual outpatient benefit may be is reduced to $2,000. 

            (3)  Benefits for medical detoxification treatment will be paid the same as any illness and are not subject to the annual and lifetime limits stated above.

            (3) remains the same but is renumbered (4).

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.325  AUDIOLOGY BENEFITS  (1) and (2) remain the same.

            (3)  Hearing aides aids are not a covered benefit and prior authorization is required.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.326  DENTAL BENEFITS  (1) through (2) remain the same.

            (3)  The following procedures are not a benefit of the CHIP HMK coverage group Dental Program:

            (a) through (e) remain the same.

            (4)  Providers must comply with all applicable state and federal statutes, rules and regulations, including the United States Code governing CHIP the HMK Plan and all applicable Montana statutes and rules governing licensure and certification.

            (5)  Enrollees with significant dental needs beyond those covered in the basic dental plan may, with prior authorization, receive additional services through the CHIP HMK coverage group Extended Dental Plan (EDP).  The EDP program is dependent on legislative appropriation for the program.

            (a)  A CHIP HMK coverage group enrollee determined eligible for extended dental benefits may receive additional services in the benefit year.  The maximum EDP payment to all dental providers for an enrollee's additional dental services is $1000 per benefit year.

            (b) through (6) remain the same.

            (7)  For purposes of applying the provisions of any Medicaid rule as required by this subchapter, references in the Medicaid rule to "Medicaid" or the "Montana Medicaid program" or similar references shall be deemed to apply to CHIP the HMK Plan as the context permits.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.501  COST SHARING PROVISIONS  (1)  Except as provided in (2) and (3), the parent or guardian of each CHIP HMK coverage group enrollee whose family income is greater than 100% of the federal poverty level must pay to the provider of service the following copayments not to exceed the cost of service:

            (a) through (3) remain the same.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.503  ENROLLMENT  (1)  The CHIP program HMK coverage group will accept without restriction eligible applicants in the order in which they are received for enrollment until the maximum enrollment, at which time eligible applicants will be put on a waiting list and will be enrolled when spaces become available.  Applicants come off the waiting list and are enrolled based on the date they were determined eligible.

            (2)  The enrollment date will always be the first day of the enrollment month.  An applicant eligible child will be enrolled the later of:

            (a)  the month after the applicant is determined eligible the first of the month following the month the application is received if the family is determined eligible; or

            (b)  the month funding is sufficient to enroll the applicant from the waiting list.

            (3)  The CHIP program HMK coverage group will:

            (a)  provide each enrollee with a handbook of information about CHIP the program including a summary of benefits; and

            (b) remains the same.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1007, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.505  DISENROLLMENT  (1)  Participation in CHIP the HMK coverage group is voluntary and an enrollee may withdraw from the program at any time.

            (a)  CHIP HMK coverage group benefits may be terminated for good cause if the enrollee, parent, or guardian has violated rules adopted by the Montana Commissioner of Insurance for enrollment with an insurer.

            (b) remains the same.

            (2)  Disenrollment takes effect, at the earliest, the first day of the month after the department receives the request for disenrollment, but no later than the first day of the second calendar month after the request for disenrollment is received.  The enrollee remains enrolled in CHIP the HMK coverage group and the CHIP HMK coverage group program is responsible for benefits covered under the contract until the effective date of disenrollment, which is always the first day of a month.

            (3) remains the same.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.601  CONTRACT FOR TPA SERVICES  (1)  The department may contract as it determines appropriate and in conformity with state and federal procurement law for services to administer the HMK coverage group enter into a contract with an entity with a certificate of authority issued by the Montana Commissioner of Insurance to provide third party administration specified in these rules.

            (2)  A third party administrator may not in any manner hold an enrollee, parent, or guardian responsible for the debts of the third party administrator.

            (3)  The department may contract with a vendor to purchase eyeglasses under a volume purchase contract.

            (4)  The department may contract with individual dentists to provide dental benefits as specified in ARM 37.79.326.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.602  PROVISION OF BENEFITS  (1)  The CHIP program department may impose the following requirements in the provision of benefits:

            (a) through (d) remain the same.

            (2)  An enrollee must use the CHIP program's or the TPA's HMK coverage group's TPA participating providers unless:

            (a)  the CHIP program department authorizes a nonparticipating provider to provide a service; or

            (b) remains the same.

            (3)  The TPA and participating providers must provide covered benefits as listed in this subchapter to enrollees in the same manner as those benefits are provided to non-CHIP members any child who is not enrolled in the HMK Plan.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.605  PARTICIPATING PROVIDERS  (1) through (4) remain the same.

            (5)  In addition to the cost sharing provisions outlined in ARM 37.79.501, participating providers may bill the enrollee, parent, or guardian for services provided to a CHIP HMK coverage group enrollee, which are not covered benefits.

            (6) through (6)(b) remain the same.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.801  GRIEVANCE AND APPEAL PROCEDURES  (1) remains the same.

            (2)  Except when CHIP the HMK coverage group eligibility has been denied, an enrollee, parent, or guardian must exhaust the third party administrator's grievance procedure before appeal of the matter may be made to the department.

            (3)  An applicant, parent, or guardian aggrieved by a denial, suspension, or termination of CHIP the HMK coverage group eligibility or an enrollee, parent, or guardian aggrieved by a final grievance decision of a third party administrator, including but not limited to a reduction or denial of benefits, may request a fair hearing in accordance with ARM 37.5.304, 37.5.313, 37.5.322, 37.5.325, 37.5.328, 37.5.334, and 37.5.337. 

            (4) and (5) remain the same.

 

AUTH:  53-4-1009, MCA

IMP:  53-4-1003, MCA

 

            37.82.701  GROUPS COVERED, NONINSTITUTIONALIZED FAMILIES AND CHILDREN  (1)  Medicaid will be provided to:

            (a) through (d)(i) remain the same.

            (e)  a pregnant woman whose pregnancy has been verified, whose family income does not exceed 133% of the federal poverty guidelines, and whose countable resources do not exceed $3,000.  This coverage group is known as the "pregnancy group";

            (i) remains the same.

            (ii)  newborn children are continuously eligible through the month of their first birthday, provided they continue to reside with their mother in Montana and she would continue to be eligible for assistance if she were still pregnant.  This coverage group is known as the "automatic newborn assistance child-newborn group";

            (f) through (g)(i) remain the same.

            (h)  a child who has attained age six but has not yet reached age 19, whose family income does not exceed 100% 133% of the federal poverty guidelines and whose countable resources do not exceed $15,000.  This coverage group is known as the "child-age six to 19 group" "Healthy Montana Kids (HMK) Plus" group.  There is no resource test for this coverage group;

            (i)  a child through the month of the sixth birthday whose family income does not exceed 133% of the federal poverty guidelines and whose countable resources do not exceed $15,000; this group is known as the "child-under age six group";

            (j) through (o)(ii) remain the same but are renumbered (i) through (n)(ii).

            (2) and (3) remain the same.

 

AUTH:  53-4-212, 53-4-1105, 53-6-113, MCA

IMP:  53-4-231, 53-4-1104, 53-4-1105, 53-6-101, 53-6-131, 53-6-134, MCA

 

            5.  The department proposes to repeal the following rule:

 

            37.79.209  ELIGIBILITY VERIFICATION REVIEWS, is found on page 37-17614 of the Administrative Rules of Montana.

 

AUTH:  53-4-1009, MCA

IMP:  53-4-1004, MCA

 

            6.  The Department of Public Health and Human Services (the department) is proposing to adopt new Rules I, II, III, IV, V, VI, and VII, the amendment of ARM 37.79.101, 37.79.102, 37.79.106, 37.79.201, 37.79.202, 37.79.206, 37.79.207, 37.79.208, 37.79.301, 37.79.302, 37.79.303, 37.79.312, 37.79.317, 37.79.325, 37.79.326, 37.79.501, 37.79.503, 37.79.505, 37.79.601, 37.79.602, 37.79.605, 37.79.801, and 37.82.701, and the repeal of 37.79.209 pertaining to the Healthy Montana Kids Plan Act, which expands eligibility for the Children's Health Insurance Program (CHIP) and the Montana Medicaid program.  The department administers both Montana Medicaid and CHIP. 

 

Montana Medicaid is a program administered by the department that pays for medical assistance to qualified low income Montana residents.  Montana and the federal government jointly fund the program.  Montana pays providers for service delivered to eligible individuals enrolled in the Medicaid program.

 

CHIP is a program administered by the department to provide health care to children who are not eligible for health care services under the Montana Medicaid program.  The department currently operates CHIP as a self funded insurance program that makes direct payment to providers for service delivered to eligible enrollees.  The department contracts with a third party administrator (TPA) to maintain a provider network and pay claims.  Provider rates are generally set as a percentage of the TPA's rate schedule.  Like Medicaid, the CHIP program is jointly funded by Montana and federal taxpayers.

 

The department is proposing these amendments to implement the changes in Montana Medicaid and CHIP that result from Initiative 155 as implemented in House Bill 2 (HB 2) of the 2009 Legislature and Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law 111-3.

 

In November, 2008, the Montana voters approved Initiative 155 that enacted the Healthy Montana Kids (HMK) Plan Act.  The Healthy Montana Kids Plan Act is now codified at Title 53, chapter 4, part 11, MCA.  Congress also enacted significant changes in the CHIP program in CHIPRA.  Both acts require significant changes in the programs that will be implemented in phases.

 

As of October 1, 2009, the department intends to have the following HMK Plan Act requirements implemented: create an administrative single point of access for the HMK Plan within the department, use the name "Healthy Montana Kids" to the extent permitted by federal law, transition current CHIP and Medicaid enrollees on October 1, 2009 to the HMK Plan, increase the income limit for the HMK coverage group from 175% to 250% of the federal poverty level, increase the income limit for HMK Plus from 100% of FPL to 133% of FPL, eliminate the Medicaid resource limits for children, change the time period a child must be without creditable health insurance coverage from one month to three months, and provide a new combined application for HMK and HMK Plus, expand access to the HMK Plan through enrollment partners and implement outreach efforts.

 

At a later date the department will adopt rules to implement provisions applicable to section 125 plans, premium assistance and presumptive eligibility.

 

CHIPRA requirements regarding documentation of status as a citizen or qualified resident will be implemented October 1, 2009.  In phase two a rate for the outpatient prospective payment system (OPPS) for federally qualified health centers (FQHC) and rural health centers (RHC) will be developed.  A similar payment system already applies to HMK Plus.  In phase two the department will address mental health parity, substance abuse benefits and dental benefits.  These changes will be made after federal regulatory guidelines are provided.

 

RULE I

 

The HMK Act directs the department to use interested organizations and individuals assistance to enroll eligible children in the HMK Plan.  This rule establishes a framework for identifying and approving enrollment partners.  The HMK Plan uses enrollment partners for efficient and effective outreach to provide health care to eligible children.

 

RULE II

 

The HMK Act directs the department to create and define an active enrollment process.  This rule states how the department will promote the HMK Plan.  The department's goal is to encourage and assist families to obtain medically necessary health care and actively enroll eligible children in the HMK Plan.

 

RULE III

 

The HMK Plan Act directs the department to promote seamless movement between the two coverage groups, HMK and HMK Plus.  The two coverage groups have some basic differences that are statutory.  For example, different income thresholds apply, the HMK coverage group may have a waiting list but HMK Plus coverage may not, HMK Plus has more extensive coverage and there are different provider rates of reimbursement for each coverage group.  Both coverage groups eligibility will be determined on a 12-month basis.  An enrollee in HMK Plus will remain eligible for HMK Plus coverage throughout his or her 12-month continuous eligibility period.  An enrollee in the HMK coverage group will have the option of applying for HMK Plus coverage.

 

RULE IV

 

The HMK Act directs the department to provide a single point of access for the HMK Plan.  The department interprets this to mean that it must have a single application process that applies to both programs.  Montana residents will have multiple opportunities to apply for the HMK Plan but the application process will be uniform across the state and apply to both the HMK and HMK Plus coverage groups.

 

RULE V

 

This rule transition applies during the period from October 1, 2009 to September 30, 2010.  The rule describes the schedule the department will follow to implement the HMK Plan.  CHIP currently provides a 12-month continuous eligibility period that begins the first of the month after eligibility is determined.  All CHIP enrollees will transfer into the HMK coverage group on October 1, 2009.  At the time of the annual enrollment redetermination, the enrollee may be determined eligible for either the HMK or the HMK Plus coverage group.  An individual enrolled in HMK coverage who is eligible for HMK Plus coverage may enroll in HMK Plus anytime.

 

RULE VI

 

CHIPRA requires states to pay FQHCs and RHCs using an OPPS.  OPPS currently applies to Montana Medicaid payments for FQHCs and RHCs.  The department will develop a OPPS rate for HMK coverage group.

 

RULE VII

 

The HMK Plan Act requires the department to adopt rules to encourage enrollment partners to actively enroll as many eligible, uninsured children as possible.  This rule describes how the department intends to carry out that directive by actively encouraging program participation.

 

ARM 37.79.101

 

CHIP provides health care coverage to children up to the age of 19 with family income greater than the amount that qualifies for Medicaid benefits but less than or equal to 175% of the FPL.  The HMK Plan Act expanded the eligibility guidelines of the former CHIP program to 250% of FPL.

 

The Act also allowed for the expansion of Medicaid coverage up to 185% of FPL.  The Legislature determined that Medicaid should be expanded to 133% of FPL.  Children and young adults living in households with income between 100 and 133% of FPL formerly were not eligible for Medicaid but were eligible for CHIP.

 

The HMK Plan Act directed the department to include and coordinate health coverage for enrollees in CHIP and Montana Medicaid and, to the extent possible, use the name Healthy Montana Kids.  To carry out this direction the department has identified two coverage groups within the Healthy Montana Kids (HMK) Plan, Healthy Montana Kids (HMK), and Healthy Montana Kids Plus (HMK Plus).  Generally, HMK refers to the program that was formerly known as CHIP and HMK Plus refers to the Montana Medicaid program for qualified individuals up to their 19th birthday.

 

There are differences in the two coverage groups.  The HMK Plus coverage group generally provides enrollees more extensive coverage and the HMK coverage group's provider rates are generally higher than the HMK Plus provider rates.

 

ARM 37.79.102

 

This rule is a definition section.  It is being amended to include or change definitions of terms applicable from the HMK and HMK Plus.

 

ARM 37.79.106, 37.79.206, 37.79.207, 37.79.312, 37.79.326, 37.79.501, 37.79.503, 37.79.505, 37.79.602, 37.79.605, and 37.79.801

 

There are no substantive amendments to these rules.  The rules are amended to change references from the acronym CHIP to HMK.

 

ARM 37.79.201

 

The amendments to this rule extend the current 30-day insurance delay period after creditable coverage ends to a three month waiting period, as provided by 53-4-1004(1)(c), and amend or add exceptions to the delay period.  The amendments also make the rule consistent with the federal requirements stated in 42 CFR 457.310 regarding who can qualify as a "targeted low income child", establish an income verification requirement and expand the time allowed for processing applications.  The HMK Act raised the combined family income limit for the program from 175% of the federal poverty level to 250% of the federal poverty level.  This change is being made throughout these rules to be consistent with the Act.  There are also edits throughout the rule to replace the term "CHIP" with "HMK" or "HMK coverage group".

 

Insurance delay period and exceptions.  Prior to the passage of I-155, 53-4-1004(1)(c), MCA, stated "To be considered eligible for the program, a child . . . may not already be covered by private insurance that offers creditable coverage, as defined in 42 USC 300gg(c)" I-155 added the phrase "for three months prior to enrollment in the program or since birth, whichever period is less."  The department had implemented the pre I-155 language of 53-4-1004(1)(c) by adopting a 30-day insurance delay period with exceptions necessary to avoid irrational or arbitrary results. 

 

The department is proposing to amend some of the exceptions to the insurance delay period.  Current exception (1)(h)(v) is struck because it is unnecessary.  If a parent's employer did not offer dependent coverage the applicant did not have creditable coverage and the insurance delay period did not apply.  New exceptions (1)(h)(v) and (viii) are proposed to avoid irrational results from the application of the delay period.  Without these exceptions, to be eligible for HMK coverage an otherwise qualified child who had had creditable coverage would have to be uninsured for three months if the child's parent and step parent divorced.  A child would also be ineligible if the parent had paid for the majority of the cost of the insurance premium.  A child whose parent or step parent had never provided coverage, however, would not have delayed coverage.  There is no rational basis for this disparity and it would result in situations where previously insured children had no health care coverage, which is contrary to the intent of the HMK Act. 

 

The department has the authority, pursuant to 53-4-1004(3), to adopt rules governing eligibility, including financial standards and criteria for income and resources.  The department is proposing an exception to the insurance delay period when a parent paid more than 50% of the premium because the department understands the intent of the three month waiting period to have been to avoid substitution of coverage, also referred to as "crowd out".  This proposal implements the intent of the initiative and seeks to avoid irrational results.

 

New exceptions (1)(h)(vi) and (vii) are being added to make HMK and HMK Plus transitions seamless and to accurately state current practice.  

 

Targeted low income child.  Amendments are proposed to accurately state current law, which is that inpatients in an "institution for mental disease" (a term from 42 CFR 457.310), employees of state government and employees of the state university system are not eligible for the HMK coverage group regardless of income level.  The amendments are necessary for compliance with current federal regulations regarding CHIP and do not represent a change in practice under the HMK Act.

 

Income verification.  Currently, the CHIP program does not require an applicant to verify reported income but Montana Medicaid does.  The HMK Plan requires consistent program administration between HMK and HMK Plus coverage groups and the department decided that requiring income verification was appropriate.

 

Expand the time allowed for processing applications.  The current rule requires a CHIP eligibility determination to be made within 30 working days.  The amendment extends that period to 45 calendar days.  Allowing approximately two additional weeks is necessary because of the income verification requirement.

 

ARM 37.79.202 and 37.79.207

 

The changes in these rules are necessary to comply with federal requirements for financial participation.  Family members of an employee of the state's university system are not eligible for the CHIP (the HMK coverage group) group regardless of income pursuant to 42 USC 1397.  A person who is a patient in an institution for mental disease on the date of initial application or any redetermination of eligibility (42 CFR 457.310(2)(ii)) is also not eligible.  Both of these are federal requirements and are not a change in current practice.  The rule is being amended to correctly state current practice.

 

ARM 37.79.208

 

The department is proposing to change the days allowed for processing applications from 20 working days to 45 calendar days.  This allows sufficient time to process the HMK Plan application and obtain citizenship and income verification.  These changes improve program integrity and consistent administration between the HMK and HMK Plus coverage groups.

 

ARM 37.79.209

 

ARM 37.79.209 is being repealed because income verification will be required for both the HMK and HMK Plus.  This change is necessary to have a uniform application process for both coverage groups.  Income verification is currently required for Montana Medicaid.

 

ARM 37.79.301

 

This rule change is necessary because HMK is adding a benefit.  HMK will be adding access by telephone to a nurse who will help assess symptoms and direct members to the appropriate level of care.

 

ARM 37.79.302

 

The department is proposing to strike ARM 37.79.302(3).  In October, 2006 CHIP became a fully self-insured program but continued to allow for inpatient hospital benefit extension.  In federal fiscal year (FFY) 2008 24 CHIP enrollees received inpatient hospitalization benefit extension.  The department reviewed standard insurance industry practice and found that this coverage benefit is not a standard practice.  This proposed amendment is implemented as a cost-savings measure.

 

ARM 37.79.303

 

Neurofeedback is added to the list of benefits not covered.  This amendment is for clarity only and is not a change in policy.  Neurofeedback is a type of biofeedback, and has never been a covered benefit.

 

ARM 37.79.317

 

The amendments to this rule are necessary for clarity.  The rule changes are not intended to have substantive impact because the new language states CHIP's current practice regarding chemical dependency benefits.  There is currently an annual limit of $6,000 for medically necessary in and outpatient chemical dependency treatment.  There is also a $12,000 lifetime limit on inpatient benefits but the program will allow up to $2,000 per year of medically necessary outpatient treatment after the lifetime inpatient benefit has been attained.  The rule as currently worded is confusing.

 

ARM 37.79.325

 

The proposed amendment will expand HMK coverage to include medically necessary hearing aids with prior authorization.  Inclusion of the benefit meets a critical need for hearing impaired children and is not estimated to be costly to the program.

 

ARM 37.79.503

 

The effective date of enrollment is changed so eligible children will have HMK coverage beginning the month after the application is received in either the HMK office or an office of public assistance.  Currently, children are enrolled the first of the month after their eligibility is determined. This change will reduce the time a child is without health coverage since it is the application date, rather than the eligibility determination date, which determines the enrollment date.

 

ARM 37.79.601

 

The amendment clarifies the extent of the department's authority to contract for services related to the HMK coverage group.  The title of this rule was Contract for Third Party Administration.  HMK does currently contract for third party administrative services but it can, and does, contract for a number of services related to HMK.  For example, the department contracts with a vendor to purchase eyeglasses and also contracts with individual dentists.  The department intends to contract with a nurse advice line for a 24-hour, seven days a week access to health information.  The current rule gives the erroneous impression that all contracts are listed in rule, which is not correct and is not required by the Montana Administrative Procedures Act.

 

ARM 37.82.701

 

ARM 37.82.701 describes the noninstitutionalized families and children's groups covered by Medicaid.  The department is proposing to amend this rule to expand eligibility for Medicaid for children through age 18 to 133% of the federal poverty level.  These children will now be eligible for health care coverage through Medicaid, to be known as Healthy Montana Kids Plus (HMK Plus).  There will be no resource test applied for children in HMK Plus.

 

I-155 set the income maximum for participation in HMK Plus at 185% of the federal poverty level and allows the department to establish lower maximum income levels to the extent necessary to maximize federal matching funds.  The department considered the range of income allowed by statute and chose 133% to be consistent with the current maximum income for children age zero to six to keep siblings together and to operate the program within the funding appropriated by the Legislature for the 2009-2011 biennium.

 

The rule for newborn coverage is amended as a result of the CHIPRA enactment.  States can no longer require that the newborn lives with the mother to be continuously eligible through the month of their first birthday.  Instead, the newborn must only be a resident of the state.

 

Fiscal Impact

 

It is estimated that that 29,978 additional enrollees will be eligible for HMK.  The annual impact of this will be $14,112,556 in FY 2010 and $14,819,024 in state special revenue funds. The impact will be $47,157,483 in FY 2010 and $50,148,202 in FY 2011 in federal funds.

 

It is estimated 10,000 current CHIP enrollees who were not eligible for Medicaid will become eligible for the CHIP-funded/Medicaid Expansion program.  These enrollees will receive the expanded benefit coverage of the HMK Plus coverage group. Cost sharing (copayments) will not be required.  The provider reimbursement rate for services to these enrollees will change from the current CHIP rate to the Medicaid rate, which will result in a net decrease in provider reimbursement.  There are approximately 6,000 Medicaid providers.

 

            7.  The department intends the rule amendments to be applied effective October 1, 2009.  In the event the rules are amended retroactively no negative impact is anticipated.

 

            8.  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: Rhonda Lesofski, 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 dphhslegal@mt.gov, and must be received no later than 5:00 p.m., August 27, 2009.

 

9.  The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing.

 

10.  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 8 above or may be made by completing a request form at any rules hearing held by the department.

 

11.  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.

 

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

 

 

 

 

/s/  Geralyn Driscoll                                       /s/  Laurie Lamson for                                  

Rule Reviewer                                               Anna Whiting Sorrell, Director

                                                                        Public Health and Human Services

           

Certified to the Secretary of State July 20, 2009.

 

 

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