HOME    SEARCH    ABOUT US    CONTACT US    HELP   
           
Montana Administrative Register Notice 37-525 No. 24   12/23/2010    
Prev Next

 

BEFORE THE Department of Public

health and human services of the

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.81.304, 37.86.1005, 37.86.1006, 37.86.1101, 37.86.1105, 37.86.1802, 37.86.1807, and 37.86.2207 and repeal of ARM 37.83.812 pertaining to Big Sky RX benefit, Medicaid dental services, outpatient drugs, prescriptions for durable medical equipment, prosthetics, and orthotics (DMEPOS), early and periodic screening, diagnostic and treatment (EPSDT), and qualified Medicare beneficiaries chiropractic services

)

)

)

)

)

)

)

)

)
)
)
)
)

NOTICE OF AMENDMENT AND REPEAL

 

TO: All Concerned Persons

 

1. On October 28, 2010 the Department of Public Health and Human Services published MAR Notice No. 37-525 pertaining to the proposed amendment and repeal of the above-stated rules at page 2528 of the 2010 Montana Administrative Register, Issue Number 20.

 

2. The department has amended and repealed the above-stated rules as proposed.

 

3. The department has thoroughly considered the comments and testimony received. A summary of the comments received and the department's responses are as follows:

 

COMMENT #1: One practicing dentist commented on the proposed changes to the payment methodology for orthodontia services. The commenter suggests the department continue with full prepayment for all services. Monthly invoicing is problematic with patients going on and off Medicaid often and monthly billing is costly to the dental office.

 

RESPONSE #1: The department does not agree. The new payment methodology for orthodontia procedure codes is possible due to the publishing of an established unit value for such codes. In the past there were no published unit values for orthodontic procedure codes, necessitating the payment "by report" methodology. The department, by removing references to payment details for orthodontia is making it consistent with the payment methodology of all other dental procedure codes: fee-for-service. If the department pays a claim but subsequently discovers that the provider was not entitled to payment for any reason, the department is entitled to recover the resulting overpayment, ARM 37.85.406(9). If prepayment was made in full and the patient never finished treatment, a recovery could also be made.

 

HMK Plus (Children's Medicaid) provides for 12 months of continuous coverage once eligibility is established. Further details can be found in ARM 37.79.120. The 12-month continuous coverage afforded to HMK Plus clients should alleviate the commenter's concern regarding the frequent migration into and out of Medicaid.

 

In regard to the cost of monthly billing, the department allows 365 days for a clean claim to be filed for payment. Multiple units of service could be billed at one time as opposed to monthly invoicing.

 

COMMENT #2: One practicing orthodontist commented that he is concerned about the long term commitment of the treatment plan and the potential loss of Medicaid. Another concern is that providers will have to keep track of a patient's eligibility. He is concerned that the proposed reimbursement method is a step backwards in reference to the amount of payment reimbursement.

 

RESPONSE #2: The department does not agree. As stated in the department's response to Comment #1, HMK Plus (Children's Medicaid) provides for 12 months of continuous coverage once eligibility is established. As a rule, providers are responsible to check eligibility monthly in the event a client's eligibility status has changed. The department has made available to providers several convenient methods for checking client eligibility. These methods can be found on the web at: www.medicaidprovider.hhs.mt.gov/pdf/clienteligibility.pdf.

 

The department's new payment methodology for orthodontia procedure codes is possible due to the publishing of an established unit value for such codes. In the past there were no published unit values for the orthodontic procedure codes, necessitating the payment "by report" methodology. The department, by removing reference to payment details for orthodontia makes it consistent with payment methodology of all other dental procedure codes: fee-for-service. Below are three comparative examples illustrating reimbursement before and after the rule change.

 

Current payment method

Lump sum payment upfront

New Payment Method 1/2011

Payment is per procedure when performed

#1

 

 

 

 

 

 

D8080

$4986.00

24 mos.

D8080

$2980.25

 

 

85%

$4161.60

 

D8670

$88.43/unit

24 units

$2122.32

 

 

 

D8680

$275.10

 

 

 

 

 

Total

$5377.67

 

 

 

#2

 

 

 

 

 

 

D8080

$3792.00

18 mos.

D8080

$2980.25

 

 

85%

$3223.20

 

D8670

$88.43/unit

18 units

$1591.74

 

 

 

D8680

$275.10

 

 

 

 

 

Total

$4846.84

 

 

 

#3

 

 

 

 

 

 

D8060

$2300.00

12 mos.

D8080

$1211.75

 

 

85%

$1955.00

 

D8670

$88.43/unit

12 units

$1061.16

 

 

 

D8680

$275.10

 

 

 

 

 

Total

$2548.01

 

 

 

COMMENT #3: The executive director of a dental professional association commented on the potential for ineligibility during the long treatment phase and the association's concern for denied claims. The commenter is concerned that providers will be providing care without payment.

 

RESPONSE #3: The department does not agree. As discussed in responses to comments #1 and #2, the 12-month continuous coverage afforded to HMK Plus clients should alleviate the commenter's concern regarding frequent migration into and out of Medicaid. In the event a client does become ineligible for Medicaid services, they are then responsible to pay their medical bills directly. It is essential that providers establish and frequently check a client's eligibility status.

 

DEPARTMENT COMMENT #1: The department intends to adjust the school-based services fee schedule on January 1, 2011 and again on April 1, 2011. This is necessary to keep pace with the American Recovery and Reinvestment Act (ARRA) adjustment to the Federal Medical Assistance Percentage (FMAP) for the state of Montana. The FMAP rate will be adjusted to 74.99% in January and again in April to 72.99%.

 

RESPONSE #1: The department's school-based fee schedule cited in ARM 37.86.2207(9) will be updated in January 2011 and again in April 2011.

 

            4. The department intends the rule amendments to be applied effective January 1, 2011.

 

 

/s/ John Koch                                               /s/ Anna Whiting Sorrell                

Rule Reviewer                                             Anna Whiting Sorrell, Director

                                                                        Public Health and Human Services

 

Certified to the Secretary of State December 13, 2010

Home  |   Search  |   About Us  |   Contact Us  |   Help  |   Disclaimer  |   Privacy & Security