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Montana Administrative Register Notice 37-518 No. 18   09/23/2010    
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BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

                                                                          STATE OF MONTANA

 

In the matter of the adoption New Rules I through VII, amendment of ARM 37.86.2206, 37.86.2207, 37.87.702, 37.87.703, 37.87.901, and 37.87.903, and repeal of ARM 37.86.2219 and 37.86.2221 pertaining to provider requirements and reimbursement for therapeutic group homes (TGH), therapeutic family care (TFC), and therapeutic foster care (TFOC)

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

 

TO:  All Concerned Persons

 

            1.  On November 3, 2010, at 1:30 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 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 October 25, 2010, 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:

 

            NEW RULE I  THERAPEUTIC GROUP HOME (TGH), PROVIDER REQUIREMENTS  (1) The requirements in this subchapter are in addition to those requirements contained in rules generally applicable to Medicaid providers.

            (2)  Therapeutic group home (TGH) services may be provided only by a facility which is licensed as a TGH by the department in accordance with the provisions of Title 52, chapter 2, part 6, MCA, and found in [New Rules I through IV].

            (3)  TGH services must be provided to a youth in accordance with an individualized treatment plan developed and maintained as specified by licensure requirements and this subchapter.

            (4)  In addition to the clinical records required by TGH licensure rules, the provider must maintain the records required by ARM 37.85.414.

            (5)  As a condition of enrollment in the Montana Medicaid program, TGH providers must pay direct care workers (DCW) a minimum of $8.50 per hour.

            (a)  "Direct care workers (DCW)" means an employee of a Medicaid enrolled provider, who is assigned to work directly with youth or in youth-specific activities for no less than 75% of their hours of employment.  A DCW is primarily responsible for the implementation of the treatment goals of the youth.  DCW does not include professional staff.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, MCA

 

            NEW RULE II  THERAPEUTIC GROUP HOME (TGH), REIMBURSEMENT

            (1)  The reimbursement rate for the therapeutic and rehabilitative portion of TGH or TGH with extraordinary needs aide (ENA) services is the lesser of (1)(a) or (b):

            (a)  the amount specified in the department's Medicaid Mental Health Fee Schedule as adopted in ARM 37.97.901; or

            (b)  the provider's usual and customary charges.

            (2)  The therapeutic and rehabilitative portion of TGH services are therapeutic services defined as follows:

            (a)  "Therapeutic services" means the provision of psychotherapy and rehabilitative remedial services provided by the lead clinical staff acting within the scope of the professional's license or same services provided by an in-training mental health professional in a TGH.  The purpose of these services is for maximum reduction of mental disability and restoration of a youth's best possible functional level, to alleviate the emotional disturbances, reverse or change maladaptive patterns of behavior, and encourage personal growth and development.  A combination of supportive interactions, cognitive therapy, and behavior modification techniques are used to provide therapeutic change for youth in TGH. 

            (3)  TGHs are reimbursed a daily or patient day rate.

            (a)  "Patient day" means a whole 24-hour period that a youth is present and receiving TGH services.  Even though a youth may not be present for a whole 24-hour period, the day of admission is a patient day.  The day of discharge is not a patient day.

            (4)  TGH providers must use the procedure codes designated by the department, per the fee schedule in (1)(a) to be reimbursed for TGH, TGH with ENA, or TGH therapeutic home visit (THV) services.

            (5)  Medicaid will not reimburse for room, board, maintenance, or any other nontherapeutic component of TGH services.

            (6)  Reimbursement will be made to a provider for reserving a TGH bed while the youth is temporarily absent for a THV.  A THV is an opportunity to assess the youth's ability to successfully transition to a less restrictive level of care.  For reimbursement the following criteria must be met:

            (a)  the youth's treatment plan must document the medical need for a THV as part of a therapeutic plan to transition the youth to a less restrictive level of care;

            (b)  the TGH provider clearly documents staff contact and youth achievements or regressions during and following the THV; and

            (c)  the youth is absent from the provider's facility for no more than three patient days per THV, with a maximum of 14 THV patient days per state fiscal year, unless additional days are prior-authorized by the department.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, MCA

 

            NEW RULE III  THERAPEUTIC GROUP HOME (TGH), AUTHORIZATION REQUIREMENTS  (1) The therapeutic and rehabilitative portion of medically necessary TGH service is covered if prior-authorized by the department or its designee according to the provisions of the Children's Mental Health Bureau's (CMHB) Provider Manual and Clinical Guidelines for Utilization Management incorporated in ARM 37.87.903 and this subchapter.  TGH providers are required to abide by the CMHB Provider Manual and Clinical Guidelines for Utilization Management.

            (2)  Medicaid reimbursement is not available for TGH services unless the provider submits to the department or its designee in accordance with this subchapter and the CMHB Provider Manual and Clinical Guidelines for Utilization Management a complete and accurate certificate of need (CON) that certifies the level of care needed for the youth with a serious emotional disturbance (SED).

            (3)  For youth determined Medicaid eligible by the department at the time of admission to the TGH, the CON required under (2) must be:

            (a)  completed, signed, and dated prior to, but no more than 30 days before, admission; and

            (b)  written by a team of health care professionals that has competence in diagnosis and treatment of mental illness, and that has knowledge of the youth's situation, including the youth's psychiatric condition.  The team must include a physician that has competence in diagnosis and treatment of mental illness, preferably in child psychiatry, and a licensed mental health professional.

            (4)  For youth determined Medicaid eligible by the department after admission to or discharge from the TGH, the CON required under (2) is waived.  A retrospective review to determine the medical necessity of the admission to the program and the treatment provided will be completed by the department or its designee at the request of the department, a provider, or the youth's parent or legal guardian.  Request for retrospective review must be:

            (a)  received within 14 days after the eligibility determination for youth determined eligible following admission, but before discharge from the TGH; or

            (b)  received within 90 days after the eligibility determination for youth determined eligible after discharge from the TGH.

            (5)  All CONs required under (2) must be actually and personally signed by a minimum of two team members.  Two of the signatures must be:

            (a)  a physician who has competence in diagnosis and treatment of mental illness, preferably child psychiatry, or a board certified/board eligible psychiatrist; and

            (b)  a licensed mental health professional as defined in ARM 37.87.102.  If a signature stamp is used, the team member must actually and personally initial the document over the signature stamp. 

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, MCA

 

            NEW RULE IV  THERAPEUTIC GROUP HOME (TGH), EXTRAORDINARY NEEDS AIDE (ENA) SERVICES, AND AUTHORIZATION REQUIREMENTS

            (1)  Extraordinary needs aide (ENA) services are prior-authorized additional one-to-one, face-to-face, intensive short-term behavior management, and stabilization services provided in the TGH by TGH staff, for youth with serious emotional disturbance (SED).  Short-term generally means 90 days or less.  Additional days may be authorized if the youth continues to meet the criteria specified in (2).

            (2)  ENA services are provided for youth in a TGH who exhibit extreme behaviors that can not be managed by the TGH staffing required by licensure found in ARM Title 37, chapter 97 and who do not require services in a higher level of care.

            (a)  Extreme behaviors need to be current, at least, moderately severe, and consist of documented incidents that are symptoms of the youth's SED.  These behaviors are either frequent in occurrence, at risk of becoming a serious occurrence, and include one or more of the following:

            (i)  harming self or others;

            (ii)  destruction of property; or

            (iii)  a pattern of frequent extreme physical outbursts.

            (3)  To request prior authorization of ENA services, the lead clinical staff (LCS) member must complete the department's ENA request form and document the medical need for such services.  The LCS is defined in the licensure rule found in ARM Title 37, chapter 97.  The form may be obtained from the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, P.O. Box 4210, Helena, MT 59604-4210 or on the department’s web site at www.dphhs.mt.gov/mentalhealth/children/index.shtml.

            (a)  The ENA request form requires a behavior assessment, and a detailed description of the youth's behavior problems including date(s) of occurrence(s), and frequency of behavior problems to justify the number of ENA hours being requested.  The form also requires measurable ENA treatment plan goals and objectives. 

            (b)  If continued prior authorization is requested, a new ENA request form must be completed prior to the end of the authorization period with an updated behavior assessment, plus a description of the behavior problems with new goals and objectives.

            (c)  ENA requests are reviewed and approved on a case-by-case basis by the department or it's designee to determine the medical need for the service and the number of units requested.  One unit of ENA service equals one hour.

            (d)  The dates and frequency of behavior problems must be included on the request form.  If the information on the ENA request form is incomplete, the request will not be reviewed.

            (4)  ENA services must be provided according to measurable goals and objectives identified in the TGH treatment plan.

            (5)  ENA staff are supervised by the TGH LCS.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, MCA

 

            NEW RULE V  THERAPEUTIC FAMILY CARE (TFC) AND THERAPEUTIC FOSTER CARE (TFOC) SERVICES REIMBURSEMENT  (1)  Reimbursement for the therapeutic portion of therapeutic family care (TFC) and therapeutic foster care (TFOC) services is the lesser of (1)(a) or (b):

            (a)  the amount specified in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in ARM 37.87.901; or

            (b)  the provider's usual and customary charges.

            (2)  TFC and TFOC providers must use the procedure codes designated by the department, per the fee schedule in (1)(a) to be reimbursed for TFC, TFOC, and TFOC moderate level THV services.

            (3)  TFC and TFOC providers are reimbursed a daily or patient day rate. Patient day means a whole 24-hour period that a youth is present and receiving TFC or TFOC services.  Even though a youth may not be present for a whole 24-hour period, the day of admission is a patient day.  The day of discharge is not a patient day.

            (4)  Reimbursement will be made to a provider for reserving a moderate level TFOC bed while the youth is temporarily absent for a THV if:

            (a)  the youth's plan of care documents the medical need for THVs as part of a therapeutic plan to transition the youth to a less restrictive level of care;

            (b)  the youth is temporarily absent on a THV;

            (c)  the provider clearly documents staff contact and youth achievements or regressions during and following the THV; and

            (d)  the youth is absent from the moderate level TFOC home for no more than three patient days per THV, unless additional days are authorized by the department.

            (5)  No more than 14 patient days per youth in each state fiscal year will be allowed for moderate level TFOC THVs.

            (6)  Medicaid will not reimburse for room, board, maintenance, or any other nontherapeutic component of TFC or TFOC treatment.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, MCA

 

            NEW RULE VI  THERAPEUTIC FAMILY CARE (TFC) AND THERAPEUTIC FOSTER CARE (TFOC) SERVICES, AUTHORIZATION REQUIREMENTS AND COVERED SERVICES  (1)  The therapeutic and rehabilitative portion of medically necessary TFC and TFOC services is covered if prior-authorized by the department or its designee according to the provisions of the Children's Mental Health Bureau's (CMHB) Provider Manual and Clinical Guidelines for Utilization Management incorporated in ARM 37.87.903 and this subchapter.  TFC and TFOC providers are required to abide by the CMHB Provider Manual and Clinical Guidelines for Utilization Management.

            (2)  Medicaid reimbursement is not available for TFC or TFOC services unless the provider submits to the department or its designee in accordance with this subchapter and the CMHB Provider Manual and Clinical Guidelines for Utilization Management, a complete and accurate CON that certifies the level of care needed for the youth with a serious emotional disturbance (SED).

            (3)  For youth determined Medicaid eligible by the department at the time of admission to TFC or TFOC services, the CON required under (2) must be:

            (a)  completed, signed, and dated prior to, but no more than 30 days before, admission; and

            (b)  written by a team of health care professionals that has competence in diagnosis and treatment of mental illness, and that has knowledge of the youth's situation, including the youth's psychiatric condition.  The team must include a physician that has competence in diagnosis and treatment of mental illness, preferably in child psychiatry, and a licensed mental health professional as defined in ARM 37.87.102.

            (4)  For youth determined Medicaid eligible by the department after admission to or discharge from TFC or TFOC services, the CON required under (2) is waived.  A retrospective review to determine the medical necessity of the admission to the program and the treatment provided will be completed by the department or its designee at the request of the department, a provider or the youth's parent or legal guardian.  Request for retrospective review must be:

            (a)  received within 14 days after the eligibility determination for youth determined eligible following admission, but before discharge from TFC or TFOC services; or

            (b)  received within 90 days after the eligibility determination for youth determined eligible after discharge from TFC or TFOC services.

            (5)  All CONs required under (2) must actually and personally be signed by a minimum of two team members.  Two of the signatures must be:

            (a)  a physician who has competence in diagnosis and treatment of mental illness, preferably child psychiatry, or a board-certified/board-eligible psychiatrist and;

            (b)  a licensed mental health professional.  If a signature stamp is used, the team member must actually and personally initial the document over the signature stamp. 

            (6)  The therapeutic portion of moderate level TFC or TFOC, as defined in ARM Title 37, chapters 37 and 97, is covered if provided by a TFOC agency licensed by and contracted with the department to provide moderate level TFC or TFOC services.

            (7)  The therapeutic portion of permanency TFOC treatment, as defined in ARM Title 37, chapters 37 and 97, is covered if provided by a TFOC agency licensed by and contracted with the department to provide permanency TFOC services.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, MCA

 

            NEW RULE VII  THERAPEUTIC FAMILY CARE (TFC) AND THERAPEUTIC FOSTER CARE (TFOC) SERVICES, DEFINITION OF PERMANENCY TFOC TREATAMENT  (1)  Permanency TFOC treatment is an intensive level of treatment for youth in a therapeutic foster family placement which is permanent and includes:

            (a)  individual, family, and group therapies;

            (b)  clinical supervision provided by a licensed psychologist on a 1:20 ratio;

            (c)  a treatment manager who is a masters or bachelors level social worker with three years experience, on a 1:6 ratio;

            (d)  therapeutic aide services averaging at least ten hours per week;

            (e)  respite care at least one weekend per month; and

            (f)  additional specialized training for families.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, MCA

 

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

 

            37.86.2206  EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), MEDICAL AND OTHER SERVICES

            (1) remains the same.

            (2)  In addition to the services generally available to Medicaid recipients, the following services are available to EPSDT eligible persons:

            (a) through (d) remain the same.

            (e)  the therapeutic portion of medically necessary therapeutic youth group home (TGH) treatment as provided in ARM 37.86.2219 Title 37, chapter 87;

            (f)  the therapeutic portion of medically necessary therapeutic family care (TFC) and therapeutic foster care (TFOC) treatment as provided in ARM 37.86.2221 [New Rule VI]; and

            (g)  school-based health related services as provided in ARM 37.86.2230.

            (3)  Requests for prior authorization must be made in writing to the Department of Public Health and Human Services, Addictive and Mental Disorders Division, Mental Health Program, 555 Fuller Avenue, P.O. Box 202905, Helena, MT 59620-2905, or to the department's designee.  The therapeutic portion of TGH, TFC, and TFOC must be prior-authorized by the department or their designee before services are provided.

            (a)  Review of authorization requests by the department or its designee will be made consistent with Children's Mental Health Bureau's (CMHB) Provider Manual and Clinical Guidelines for Utilization Management dated December 1, 2010 adopted in ARM 37.87.903.  A copy of the CMHB Provider Manual and Clinical Guidelines for Utilization Management can be obtained from the department by a request in writing to the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 Sanders, PO Box 4210, Helena MT 59604-4210.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.86.2207  EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT (EPSDT) SERVICES, REIMBURSEMENT  (1) through (2) remain the same.

            (3)  Reimbursement for the therapeutic portion of therapeutic youth group home treatment services is the lesser of:

            (a)  the amount specified in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in ARM 37.87.901 and a direct care wage add-on, if applicable; or

            (b)  the provider's usual and customary charges (billed charges).

            (4)  Reimbursement for the therapeutic portion of therapeutic family care treatment services is the lesser of:

            (a)  the amount specified in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in ARM 37.87.901 and a direct care wage add-on if, applicable; or

            (b)  the provider's usual and customary charges (billed charges).

            (5)  For purposes of (3) and (4), "patient day" means a whole 24-hour period that a person is present and receiving therapeutic youth group home or therapeutic family care services.  Even though a person may not be present for a whole 24-hour period, the day of admission is a patient day.  The day of discharge is not a patient day.

            (6)  Reimbursement will be made to a provider for reserving a therapeutic youth group home or therapeutic youth family care (other than permanency therapeutic family care) bed while the recipient is temporarily absent for a therapeutic home visit if:

            (a)  the recipient's plan of care documents the medical need for therapeutic home visits as part of a therapeutic plan to transition the recipient to a less restrictive level of care;

            (b)  the recipient is temporarily absent on a therapeutic home visit;

            (c)  the provider clearly documents staff contact and recipient achievements or regressions during and following the therapeutic home visit; and

            (d)  the recipient is absent from the provider's facility for no more than three patient days per therapeutic home visit, unless additional days are authorized by the department.

            (7)  No more than 14 patient days per recipient in each state fiscal year will be allowed for therapeutic home visits.

            (8) and (9) remain the same but are renumbered (3) and (4).

            (10)  The department will not reimburse providers for two services that duplicate one another on the same day according to the Medicaid Mental Health Plan and Mental Health Services Plan for Youth Services Excluded from Simultaneous Reimbursement (Service Matrix) adopted in ARM 37.87.901.

            (11) remains the same but is renumbered (5).

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.87.702  MENTAL HEALTH CENTER SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE (SED), DEFINITIONS  For purposes of this subchapter, the following definitions apply:

            (1)  "Community-based psychiatric rehabilitation and support (CBPRS)" means rehabilitation services provided in home, school, and community settings for youth with serious emotional disturbance (SED) who are at risk of out of home or residential placement.  CBPRS services are provided for a short period of time, generally 90 days or less, to improve or restore the youth's functioning in one or more of the spheres identified in the SED definition in ARM 37.87.303.  Services are provided by trained mental health personnel under the supervision of a licensed mental health professional and according to a rehabilitation plan.

            (2) remains the same.

            (3)  "In-training mental health professional services" are services provided under the supervision of a licensed mental health professional by an individual who has completed all academic requirements for licensure as a psychologist, clinical social worker, or licensed professional counselor and is in the process of completing the supervised experience requirement for licensure, in accordance with ARM Title 24, chapters 189 and 219.

            (4) through (11) remain the same.

 

AUTH:  53-2-201, 53-6-101, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, MCA

 

            37.87.703  MENTAL HEALTH CENTER SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE (SED), COVERED SERVICES  (1)  Mental health center services for youth with serious emotional disturbance include:

            (a)  Community-based psychiatric rehabilitation and support (CBPRS) services:

            (i)  are provided on a face-to-face basis primarily with a youth, or and may also include consultation services provided on a face-to-face basis with family members, teachers, employers, or other key individuals in the youth's life when such contacts are clearly necessary to meet goals established in the youth's individual rehabilitation treatment plan;

            (ii)  may only be provided when the youth is receiving other mental health services; have as their purpose:

            (A)  the maximum attainment of mental functioning;

            (B)  the minimization or elimination of deterioration in mental functional status; and

            (C)  the maintenance of mental health functional status of a youth.

            (iii)  must be require prior authorized authorization by the department or its designee to be when provided for a youth in the PRTF waiver during day treatment program hours; in comprehensive school and community treatment programs, day treatment, partial hospitalization, therapeutic group home facilities, therapeutic foster homes, therapeutic family homes, or other residential facilities in accordance with all of the following: 

            (A)  youth with extraordinary behavioral needs whose behaviors have not resulted in criminal or status offenses may be eligible for community-based psychiatric rehabilitation and support;

            (B)  proposed services must be reviewed on a case-by-case basis by the department or its designee to determine the medical necessity and number of units authorized as defined in (1)(a)(ii); and

            (C)  sufficient documentation supporting the medical necessity for the additional services must be provided by the requestor.

            (iv)  do not require prior authorization when provided on the same day as CSCT, Day Tx, or partial hospital services, if CBPRS is provided before or after program hours.  Documentation of CBPRS must include time in and time out to show that CBPRS was not provided during program hours; excludes the following services except as provided in (1)(a)(iii):

            (A)  interventions provided in a hospital, skilled nursing facility, intermediate nursing facility, or psychiatric residential treatment facility;

            (B)  case planning activities, including but not limited to, attending meetings, completing paperwork and other documentation requirements, and traveling to and from the youth's home, or other location;

            (C)  therapeutic interventions by licensed mental health professionals, regardless of the location of the service;

            (D)  activities that are purely recreational in nature;

            (E)  services provided within the school classroom that are educational, including but not limited to educational aides;

            (F)  habilitation services; and

            (G)  services within day treatment, therapeutic group home, therapeutic foster home, therapeutic family home, or other residential facilities solely for the purpose of staff safety.

            (v)  are not allowed when the service to be provided is:

            (A)  during day treatment program hours unless the youth is in the PRTF waiver and CBPRS services are prior-authorized;

            (B)  during CSCT or partial hospital program hours;

            (C)  provided by a licensed mental health professional;

            (D)  for the purpose of habilitation, academic instruction, recreation, vocational, or pre-vocational training;

            (E)  in a shelter care facility, therapeutic group home, hospital, psychiatric residential treatment facility, or other residential facilities;

            (F)  case planning activities such as attending meetings, completing paperwork, and other documentation requirements or travel time; and

            (G)  solely for the purpose of safety.

            (vi)  may not exceed the following limits for group:

            (A)  up to a maximum of two hours per day;

            (B)  up to a maximum of eight youth per group; and

            (C)  up to a staff ratio of four youth to one staff.

            (b) and (c) remain the same.

            (d)  In-training mental health professional services as defined in ARM 37.87.702.  Such services must be supervised by a Services are subject to the same requirements that apply to licensed mental health professionals in the same field, and, other than licensure, the services are subject to the same requirements that apply to licensed mental health professionals.

            (e)  Outpatient therapy services such as provided according to an individualized treatment plans and includes:

            (i)  psychotherapy and related services provided in accordance with the current edition of the American Medical Association's Current Procedural Terminology, Professional Edition, and codes approved by the department.  The department adopts and incorporates by reference this manual; by a mental health professional acting within the scope of the professional's license; and

            (ii)  family therapy, provided with or without the youth present, directed at the eligible youth's mental health needs and their impact on the family dynamics; and if medically necessary for the treatment of the Medicaid eligible youth who is involved in the family therapy:

            (A)  family therapy may be provided with or without the Medicaid eligible youth present;

            (B)  adequate documentation must be present to document the direct benefit to the Medicaid eligible youth in accordance with the treatment plan;

            (C) (iii)  individual and family therapy are targeted at reducing or eliminating symptoms or behaviors related to a youth's mental health diagnosis as specified in the treatment plan;.

            (D)  the mental health professional is required to develop and implement a treatment plan for the youth and family; and

            (E)  individual therapy includes diagnostic interviews where testing instruments are not used.

            (f)  Targeted case management services as defined in ARM 37.87.802 in accordance with Title 37, chapter 86, subchapter 37.

            (g)  Mental health professional services, which include the professional component of physician or psychiatrist services covered in ARM 37.86.101, 37.86.104, and 37.86.105:  provided according to mental health center licensing requirements as part of mental health center services. 

            (i)  Mental health professional services are subject to the following limitations:

            (i) (A)  To the extent otherwise permitted by applicable Medicaid rules, such mental health professional services may be billed by the mental health center either as mental health center services or by the mental health professional under the applicable Medicaid category of service, but may not be billed as both mental health center services and mental health professional services.

            (ii) (B)  Mental health professional services may be covered and reimbursed by Medicaid only if the mental health professional is enrolled as a provider and the services are provided according to the Medicaid rules and requirements applicable to the mental health professional's category of service and within the scope of practice, including but not limited to medication management.

            (iii)  Mental health center services covered by the Medicaid program include the medical director component of a physician's services to a mental health center, but do not include the professional component of physician services covered in ARM 37.86.101, 37.86.104, and 37.86.105.  The professional component of physician services may be billed according to the provisions of (1)(g)(i) or ARM 37.86.101, 37.86.104, and 37.86.105.

 

AUTH:  53-2-201, 53-6-101, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, MCA

 

            37.87.901  MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, REIMBURSEMENT  (1)  Medicaid reimbursement for mental health services shall be the lowest of:

            (a) remains the same.

            (b)  the rate established in the department's fee schedule.  The department adopts and incorporates by reference the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule dated July November 1, 2010.  A copy of the fee schedule may be obtained from the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 Sanders, P.O. Box 4210, Helena, MT  59604 or at www.mt.medicaid.org.

            (2) remains the same.

            (3)  The department will not reimburse providers for two services that duplicate one another on the same day.  The department adopts and incorporates by reference the Medicaid Mental Health Plan and Mental Health Services Plan for Youth Services Excluded from Simultaneous Reimbursement (Service Matrix) effective July December 1, 2010.  A copy of the service matrix may be obtained from the department or at www.mt.medicaid.org.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, MCA

 

            37.87.903  MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, AUTHORIZATION REQUIREMENTS  (1) through (2)(b) remain the same.

            (3)  Prior authorization and when required continued authorization by the department or its designee is required for the following services:

            (a) through (c) remain the same.

            (d)  therapeutic youth group home services defined ARM 37.86.2207 and extraordinary needs aide services in accordance with [New Rules I through IV];

            (e)  therapeutic family care (TFC) and therapeutic foster care (TFOC) services defined in ARM 37.86.2207 in accordance with [New Rules V through VII] and ARM Title 37, chapter 51;

            (f) through (h) remain the same.

            (4)  The department may waive a requirement for prior authorization or continued authorization when the provider submits documentation that:

            (a) remains the same.

            (b)  a timely request for prior authorization or continued authorization was not possible because of a failure or malfunction of the department department's or its designee's equipment that prevented the transmittal of the request at the required time and the provider submitted a subsequent authorization request within ten business days.

            (5) remains the same.

            (6)  Review of authorization requests by the department or its designee will be made with consideration of the department's clinical management guidelines.  The department adopts and incorporates by reference the Children's Mental Health Bureau's Provider Manual and Clinical Guidelines for Utilization Management dated July December 1, 2010.  A copy of the manual can be obtained from the department by a request in writing to the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210 or at www.dphhs.mt.gov/mentalhealth/children/index.shtml.

            (7) and (8) remain the same.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, 53-6-113.htm" target="MCA">MCA

 

            5.  The department proposes to repeal the following rules:

 

            37.86.2219  EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), THERAPEUTIC YOUTH GROUP HOME SERVICES, is found on page 37-20321 of the Administrative Rules of Montana.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.86.2221  EARLY AND PERIODIC SCREENING, DIAGNOSTIC AND TREATMENT SERVICES (EPSDT), THERAPEUTIC FAMILY CARE TREATMENT SERVICES, is found on page 3737-20325 of the Administrative Rules of Montana.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:  53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            6.  The Department of Public Health and Human Services (the department) is proposing the adoption of New Rules I through VII, amendment of ARM 37.86.2206, 37.86.2207, 37.87.702, 37.87.703, 37.87.901, and 37. 87.903, and repeal of ARM 37.86.2219 and 37.86.2221 pertaining to provider requirements and reimbursement for therapeutic group homes (TGH), therapeutic family care (TFC), and therapeutic foster care (TFOC) services.

 

The department is amending and repealing the TGH rules in the Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT) rules, ARM 37.86.2207 and 37.86.2219 and proposing to modify and move the provider requirements, reimbursement and authorization requirements into the Children's Mental Health section of ARM Title 37, chapter 87 and in New Rules I through IV.  

 

A new service is being proposed in New Rule IV to replace the use of community based psychiatric rehabilitation and support (CBPRS) for difficult-to-serve youth in a TGH, called extraordinary needs aide (ENA) services.  ENA services, when prior-authorized, will be reimbursed at a lower rate than CBPRS.  Please see New Rule IV for fiscal impact.  In the proposed TGH rules, there will be only one level of TGH service instead of three.

 

The department is repealing and amending the TFC rules in the EPSDT rules, ARM 37.86.2207 and 37.86.2221 and proposing to move them into the Children's Mental Health in New Rules V, VI, and VII.  The department is proposing to separate TFC from therapeutic foster care (TFOC) by assigning separate modifiers to each service, so that the department can manage the two services separately.  Currently TFC and TFOC use the same modifiers for reimbursement.  No significant changes are being made to the TFC rules other than using separate modifiers for family versus foster care and not allowing outpatient therapy services for youth receiving permanency level TFOC services.  Not allowing outpatient therapy with permanency level TFOC will be indicated on the service matrix.  The department sees no alternative for these changes because they are needed for proper management of Medicaid services.  There will be a limited fiscal impact to the permanency level TFOC providers also providing outpatient therapy to the same family.  Permanency level TFOC already requires individual, group, and family therapy in rule.  There will not be a fiscal impact for moving the TFC rules to New Rules V, VI, and VII.

 

The department is proposing to amend the definition of CBPRS and add certain criteria for group CBPRS in ARM 37.87.703.  The group CBPRS criteria will limit the hours that may be billed per day, group size, and the youth-to-staff ratio.  Limits are being set to control the significant utilization growth in this service in the last three years.  The total amount for individual and group CBPRS for state fiscal year (SFY) 2008 was $2,397,307 for 1,270 youth served.  For SFY 2009, the cost was $3,501,588 for 1,519 youth served, and the total amount for SFY 2010 to date is already $3,855,099 for 1,583 youth served.  These changes will have a financial impact on providers.  Please see ARM 37.87.703 below for information on the fiscal impact.

 

The department is updating the Medicaid Mental Health and Mental Health Services Plan Individuals Under 18 Years of Age Fee Schedule (fee schedule), the Medicaid Mental Health Plan and Mental Health Services Plan (MHSP) for Youth Services Excluded from Simultaneous Reimbursement (service matrix) in ARM 37.87.901, and the Children's Mental Health's (CMHB) Provider Manual and Clinical Guidelines for Utilization Management in ARM 37.87.903 to reflect the proposed rule changes.  One change will be to not allow outpatient therapy on the same day as TGH services.  This change will be on the service matrix, but will not take effect until each TGH complies with the new licensure rules that increase the standards for the therapy provided by TGH staff.  The department's Licensure Bureau is establishing a time period to comply with the increased standards for therapy.  Some TGHs will be in compliance with the new requirements before other TGHs.  Another change will eliminate the use of CBPRS during program hours for youth in day treatment (day tx), comprehensive school and community treatment (CSCT), partial hospital programs, and TGHs.  A new service, ENA, has been developed to replace CBPRS for youth in a TGH and day treatment.  TFC services are being separated into family care and foster care in rule and on the service matrix.  Outpatient therapy will not be allowed for youth in permanency level TFOC on the service matrix to align with the permanency level TFOC rules.

 

The department does not see an alternative to these changes because they are necessary for proper Medicaid and budget management. The fiscal impact for specific rule changes are addressed in their respective sections below.

 

The TGH and TFC clinical management guidelines in the EPSDT rules are being repealed because the clinical guidelines are already in the CMHB Provider Manual and Clinical Guidelines for Utilization Management.  To have the guidelines in both places would be redundant.  The TGH clinical guidelines will be revised, to reflect one level instead of three levels of service, and to include ENA authorization  requirements.  The TFC clinical guidelines will be revised and separate TFC from TFOC to distinguish foster care from family care services. 

 

The department received a recommendation from providers and provider organizations that having the Children's Mental Health Medicaid and Mental Health Service Plan administrative rules in one location would be less confusing than the current location within EPSDT rules.  The alternative was to leave the TGH and TFC rules in ARM Title 37, chapter 86 and not consolidate children's mental health rules in one chapter.  The department agrees with provider recommendations and has proposed new rules accordingly.  There is no fiscal impact to these changes.

 

New Rule I

 

TGH provider requirements regarding licensure as a condition of participation were moved to New Rule I from ARM 37.86.2219, which is being repealed.  A reference was added to New Rule I for clarity that TGHs have to meet requirements applicable to all Medicaid providers.  The definition of direct care worker and the current minimum wage requirement of $8.50 an hour was added.

 

The department intends to move all of the children's mental health rules to ARM Title 37, chapter 87 so providers can find them more easily.

 

New Rule II

 

TGH reimbursement and THV requirements were moved to New Rule II from ARM 37.86.2207.  The term "rehabilitative", along with a definition of "therapeutic services", are being added to New Rule II to clarify department reimbursement requirements for TGH services.  CMHB Medicaid reimburses providers for rehabilitative and therapeutic services.  TGH providers must use procedure codes designated by the department on the fee schedule to be reimbursed for TGH, TGH with ENA and TGH THV services.  The department does not see a practical alternative to clarifying TGH services requirements. 

 

New Rule III

 

The prior authorization (PA) and CON requirements for TGH services were moved to New Rule III.  The TGH PA and CON requirements were in ARM 37.86.2219 that is being repealed so that all the children's mental health rules are in one place.  The TGH clinical management guidelines in ARM 37.86.2207 were repealed and will not be moved to New Rule III because they are in CMHB Provider Manual and Clinical Guidelines for Utilization Management.  The department does not see an alternative to these rule changes.  No controversy or fiscal impact is expected as a result of these rule changes.

 

New Rule IV

 

A new service called Extraordinary Needs Aide or ENA is defined and being proposed in New Rule IV.  ENA services, when prior-authorized, would allow all TGHs to add a one-to-one staff person for extremely difficult to serve SED youth.  Prior authorization requirements for ENA services are defined in proposed New Rule IV.

 

CBPRS services were used to add one-to-one staff services  for extremely difficult to serve youth until a new service could be developed, and the TGH rule could be updated.  The department does not believe that using CBPRS aides in a TGH has been cost effective.  CBPRS is a mental health center service and cannot be provided by all TGH providers.  After reviewing the cost reports completed by the TGH providers in SFY 2009, the department is proposing to reimburse ENA services at $14.56 for each one-hour unit based on labor costs.

 

The methodology for the rate of $14.56 per unit (1 hour) was calculated by using:  a base rate of $9.50, plus benefits calculated at 25% (state rate used in grant applications), plus an administrative cost of 22.59% (median percentage from TGH Cost Study for the fiscal year ending June 30, 2008).

 

The fiscal impact of this rule change for TGH providers will come from lowering the one-to-one staffing reimbursement rate from the higher CBPRS rate to the lower ENA rate.  Reimbursement for CBPRS for SFY 2008 was $443,400 for 15 youth, at $6.49 per 15 minute unit.  Use of the ENA service instead of CBPRS in TGHs is expected to decrease department expenditures.  If the number of youth receiving ENA services in SFY 2010 doubled, 30 youth would be served at a cost of $314,496. 

 

Fourteen TGH providers would be affected by this change.  Approximately 515 youth received TGHs services in SFY 2008. The department does not expect youth receiving TGH services to see a change in their benefits due to this change.  The department does not see an alternative to developing this more cost effective ENA service.  This rule is expected to be controversial due to a lower rate and stricter criteria for prior authorization of ENA services.

 

New Rule V

 

The TFC reimbursement and TFC THV requirements were moved to New Rule V and repealed from ARM 37.86.2207.  TFC is separated from TFOC to identify and manage each service better.  TFC and TFOC providers must use the procedure codes designated by the department on its fee schedule.  Rule V clarifies that reimbursement for reserving a bed while the youth is on a THV is only available in moderate level TFOC.  Permanency level TFOC is provided in a permanent foster home and moderate level TFC is provided in the youth's biological or adoptive home.  The proposed changes are necessary and the department does not see an alternative.  No controversy is expected as a result of these changes.  There is no fiscal impact with these rule changes.

 

New Rule VI

 

The PA and CON requirements for TFC services are moved to New Rule VI.  The TFC PA and CON requirements were in ARM 37.86.2221 that is being repealed so all the children's mental health rules will be in one place.  The TFC clinical management guidelines in ARM 37.86.2221 were repealed and will not be moved to New Rule VI because they are in the CMHB Provider Manual and Clinical Guidelines for Utilization Management.

 

TFOC has been separated from TFC to allow the department to distinguish between those two services on claims.  No substantive changes have been made in the TFC and TFOC services or clinical guidelines.  TFC and TFOC rules will be revised at a later date.  The proposed changes are necessary and the department does not see an alternative.  There is no fiscal impact with these rule changes.

 

New Rule VII

 

The department is proposing a definition of permanency TFOC treatment in this new rule.  Placing the definition in a new rule will make it easier for the department and the public to find and interpret.  No substantive changes are intended.

 

ARM 37.86.2206

 

The department is moving the TGH and TFC ARM 37.86.2206(2) to new TGH and TFC rule numbers in [New Rules I through VII].  TFC is listed as family and foster care in ARM 37.86.2206(2).  The department is rewording the prior authorization language in ARM 37.86.2206(3) and  referencing the department's CMHB Provider Manual and Clinical Guidelines for Utilization Management used for authorizing children's mental health services.  The department is also amending the address in ARM 37.86.2206(3) by taking out Addictive and Mental Disorders Division and replacing it with the CMHB address.  Most of the children's mental health rules are already in ARM Title 37, chapter 87.  The proposed changes are necessary and the department intends no substantive changes due to the rule reorganization.  No fiscal impact will occur as a result of these rule changes.  

 

ARM 37.86.2207

 

The department is proposing to strike all references to TGH services and TFC in this rule because they are being moved to the Children's Mental Health section of ARM Title 37, chapter 87.  The service matrix reference in ARM 37.86.2207(10) is being repealed because the TGH and TFC references are being repealed as well.  It is already in the children’s mental health section of ARM Title 37, chapter 87.  No controversy is expected as a result of these rule changes, and there is no fiscal impact with these proposed rule changes.

 

ARM 37.86.2219

 

The department is proposing to repeal ARM 37.86.2219.  The prior authorization requirements in that section will be moved to the new TGH section of the Children's Mental Health ARM Title 37, chapter 87.  The requirement that TGH services need to be ordered by a physician or licensed mental health professional will not move, as it is redundant and already required for the certificate of need (CON) which in turn is referred to in the CMHB Provider Manual and Clinical Guidelines for Utilization Management.  The intensive, campus-based, and moderate levels of TGH will not move to the new TGH rule because only one level of TGH is being proposed.  This change is being proposed to simplify TGH licensure and Medicaid requirements.  The licensing and Medicaid requirements in the proposed rules were developed collaboratively with the Licensure Bureau to be consistent. Costs associated with providing TGH services, such as room and board, that are not reimbursed by Medicaid will also be repealed in this ARM and moved to the TGH ARM Title 37, chapter 87.

 

The TGH clinical management guidelines in this rule are being repealed because they are already in the Children's Mental Health's (CMHB) Provider Manual and Clinical Guidelines for Utilization Management.  To have them in all three places would be redundant.  New TGH clinical guidelines are being proposed in an updated version of the CMHB Provider Manual and Clinical Guidelines for Utilization Management .  The new TGH clinical guidelines will reflect one instead of three levels of TGH service and ENA authorization requirements.

 

The campus-based TGH daily rate was changed on October 1, 2007 to the higher Intensive TGH daily rate of $171.69.  There are no moderate TGHs at this time.  All TGHs receive the highest TGH rate.  For state fiscal year (SFY) 2010, the daily TGH rate is $183.98.  The proposed changes are necessary to maintain youth access and the department does not see an alternative to making this change.  No overall impact is expected as a result of these rule changes.

 

ARM 37.86.2221

 

The department is proposing to repeal ARM 37.86.2221.  The TFC prior authorization requirements will be moved to the new TFC section of the children's mental health ARM Title 37, chapter 87.  The requirement that TFC services need to be ordered by a physician or licensed mental health professional will be removed, as it is redundant and already required for the CON which is described in the CMHB Provider Manual and Clinical Guidelines for Utilization Management.  The TFC clinical management guidelines in this rule are being repealed because they too are already in the CMHB Provider Manual and Clinical Guidelines for Utilization Management and to have them in both places would be redundant.  TFC and TFOC will be separated and will have different procedure codes and modifiers.  The department does not see any alternative to these changes, and there is no expected fiscal impact. 

 

ARM 37.87.702

 

The department is proposing to change the CBPRS definition in ARM 37.87.702(1) because of significant utilization growth and budget constraints.  CBPRS is a rehabilitative service.  The department believes it should be provided for a short period of time to improve the youth's functioning in one or more sphere as defined in the SED definition at ARM 37.87.303.  The change proposes youth receiving CBPRS must be at risk for out of home or residential care placement.

 

The department is proposing to add ARM Title 24, chapters 189 and 219 to ARM 37.87.702(3), referencing the licensure requirements for psychologists, social workers, and professional counselors for clarity.  The proposed changes are necessary to avoid confusion and the department does not see a practical alternative.  No controversy or fiscal impact is expected as a result of these rule changes.

 

ARM 37.87.703

 

The department is also proposing to change CBPRS covered services in ARM 37.87.703(1)(a) because of significant utilization growth and budget constraints.  CBPRS covered services are being reorganized and renumbered in this rule for clarity.  CBPRS is not a stand-alone service and may only be provided in conjunction with other mental health services in ARM 37.87.703(1)(a)(ii).

 

CBPRS may be provided during day treatment program hours for youth participating in the PRTF waiver if authorized by the department in ARM 37.87.703(1)(a)(iii), because youth participating in the waiver may require a higher level of service to be successful in the community.

 

Prior authorization for CBPRS on the same day as CSCT, day treatment and partial hospital programs will not be required in ARM 37.87.703(1)(a)(iv), if CBPRS is provided before or after program hours, and is verified in the case documentation. 

 

The department is proposing CBPRS not be provided during program hours concurrent with CSCT, day treatment and partial hospital programs in ARM 37.87.703(1)(a)(v), because these programs are reimbursed at a bundled rate and are required to be intensive.  The medical necessity requirements for CBPRS are being repealed because CBPRS during the other program hours will no longer be allowed.  The CBPRS chapter of the CMHB Provider Manual and Clinical Guidelines for Utilization Management will be revised to reflect these changes.

 

Vocational and pre-vocational training activities have been added to the list of services not allowed for CBPRS in ARM 37.87.703(1)(a)(v).

 

The department is limiting the number of hours group CBPRS can be provided, the number of youth allowed per group, and setting a staff to youth ratio in ARM 37.87.703(1)(a)(vi).

 

The supervision requirements for in-training mental health professionals in (1)(d) are being changed to be consistent with the definition of in-training mental health professional in ARM 37.87.702 that references their professional licensing requirements.  The professional licensing requirements address who needs to provide the supervision for them.

 

Outpatient therapy services in ARM 37.87.703(1)(e) are being revised to require psychotherapy services be provided in accordance with the current version of the American Medical Association's Current Procedural Terminology (AMA CPT) Professional Edition.  The AMA CPT will be adopted instead of having an incomplete list of requirements for outpatient therapy.  The department uses the terms outpatient therapy and psychotherapy interchangeably, as provided in the definition of outpatient therapy in ARM 37.87.102.

 

Some of the documentation requirements for outpatient therapy services in ARM 37.87.703(1)(e) are being repealed because they are already covered in other rules applicable to all Medicaid providers.

 

The covered physician services in ARM 37.87.703(1)(g) under mental health professional services were rewritten for clarity.  The professional component of physician and psychiatrist services are covered according to the rules and limitations referenced for all mental health professionals.

 

The department expects some fiscal impact with the CBPRS rule changes.  There was a 68% increase in group CBPRS from SFY 2008 to SFY 2009, from $76,171 to $127,767, and a 45% increase in individual CBPRS for the same period from $2,321,136 to $3,373,820.  Data is incomplete for SFY 2010, but the CMHB anticipates an increase in CBPRS utilization for SFY 2010.  Group and individual CBPRS expenses as of June 30, 2010 are $116,111 and $3,738,988, respectively.  The unique count of youth served for SFY 2008 was 1,270; for SFY 2009 it was 1,519; and so far for SFY 2010 it is 1,583.

 

ARM 37.87.901

 

The department is updating both the Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule (fee schedule) in ARM 37.87.901(1)(b) and the Medicaid Mental Health Plan and Mental Health Services Plan for Youth Excluded from Simultaneous Reimbursement (service matrix) in ARM 37.87.901(3) to reflect the proposed rule changes.

 

The following changes have been made to the fee schedule incorporated in ARM 37.87.901(1)(b).  The TGH intensive, moderate and campus based levels have been eliminated to leave one level of TGH.  (There are currently no moderate level TGHs, the intensive and campus based levels are reimbursed the same amount.)  ENA services are added to the fee schedule with a UD modifier and a proposed rate of $14.56 per hour.

 

The new procedure code for moderate level TFC is H2020, to distinguish it from TFOC.  Moderate and permanency level TFOC have been added with their own modifiers, HR and HE respectively.  Moderate TFC therapeutic home leave (THV) was changed to moderate level TFOC THV, because moderate level TFC is provided in the youth's biological or adoptive home.  Permanency level TFC is changed to permanency level TFOC.  Permanency level may only be provided in TFOC.  The TFC changes are necessary to enable CMHB to distinguish family care from foster care services.  The department does not see any practical management alternative.  There is no fiscal impact expected from the TFC proposed changes.

 

The following changes have been made to the service matrix incorporated in ARM 37.87.901(3).  Moderate level TFOC, permanency level TFOC and ENA services have been added.

 

CBPRS will be taken off the service matrix, but a note on the matrix will let providers know they need to refer to the CBPRS rules to see when CBPRS services can be reimbursed.  There are too many different CBPRS scenarios to address them all adequately on the service matrix.

 

ENA services will be reimbursed on the same day as TGH services, when prior-authorized.  ENA is a 1:1 service specifically for youth in a TGH, provided by TGH staff.  ENA services may also be reimbursed for youth in a TGH during day treatment program hours, when prior-authorized.

 

Outpatient therapy will not be reimbursed on the same day as TGH services when the TGH becomes compliant with the new licensure rule which requires higher standards for therapy provided in the TGH.  The new licensure rules will allow TGHs time to comply with higher standards of care.

 

Outpatient therapy will not be reimbursed on the same day as permanency level  TFOC.  This change is being made on the service matrix to be consistent with the permanency level TFOC rule that already requires individual, group, and family therapy to be provided.

 

The department is making the following procedure code and modifier changes on the service matrix:

 

The department will remove the intensive, moderate, and campus levels and use procedure code S5145 for TGH.

 

For ENA the department will add procedure code and modifier S5145 UD.

 

For moderate level TFC it will remove procedure code and modifier S5145 HR and use procedure code H2020.

 

For moderate level TFOC the department will add procedure code and modifier S5145 HR.

 

The term permanency TFC will be changed to permanency TFOC.

 

There will be some financial impact as a result of these changes.  The department paid $212,566 for outpatient therapy for 3,502 youth in TGH and $632,460 for outpatient therapy for 10,774 youth in TFC in SFY 2010 to date.  The department sees this rule change as necessary. 

 

ARM 37.87.903

 

The department is adding TGH, TGH with ENA, TFC and TFOC services to the list of services in ARM 37.87.903 (3)(d) that require prior authorization.  The CMHB Provider Manual and Clinical Guidelines for Utilization Management effective date in ARM 37.87.903(6) is being changed to November 1, 2010, to identify the update authorization requirements for TGH, ENA, TFC, TFOC, and CBPRS services.  No significant changes are being made to the TFC and TFOC clinical guidelines.  These changes are necessary if the proposed rules amendments are adopted and the department does not expect a fiscal impact.  The fiscal impact of ENA services are addressed under New Rule IV. 

 

            7.  The department intends the rule amendments to be applied effective December 1, 2010.

 

            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., November 5, 2010.

 

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/  John Koch                                                /s/  Anna Whiting Sorrell                              

Rule Reviewer                                               Anna Whiting Sorrell, Director

                                                                        Public Health and Human Services

           

Certified to the Secretary of State September 13, 2010.

 

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