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Montana Administrative Register Notice 37-543 No. 10   05/26/2011    
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BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.86.2224, 37.87.808, 37.87.901, and 37.87.903 pertaining to Children's Mental Health Bureau rate reduction

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT

 

TO:  All Concerned Persons

 

            1.  On June 15, 2011, at 2:00 p.m., the Department of Public Health and Human Services will hold a public hearing in Room 207 of the Department of Public Health and Human Services Building, 111 North Sanders, Helena, Montana, to consider the proposed amendment of the above-stated rules.

 

2.  The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice.  If you require an accommodation, contact Department of Public Health and Human Services, no later than 5:00 p.m. on June 6, 2011, to advise us of the nature of the accommodation that you need.  Please contact Kenneth Mordan, 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 amended provide as follows, new matter underlined, deleted matter interlined:

 

            37.86.2224  EARLY AND PERIODIC SCREENING, DIAGNOSTIC, AND TREATMENT SERVICE (EPSDT), COMPREHENSIVE SCHOOL AND COMMUNITY TREATMENT  (1)  Comprehensive school and community treatment (CSCT) means a comprehensive, planned course of outpatient treatment provided in the school and community to a child or adolescent with a serious emotional disturbance (SED), as defined in ARM 37.87.303.  A CSCT program may must be operated by a licensed mental health center with a CSCT endorsement.  The criteria for a mental health center's CSCT endorsement are found in ARM 37.106.1955.

            (2) remains the same.

            (3)  Prior authorization pursuant to ARM 37.88.101 is required for outpatient therapy services that are provided to a child or adolescent concurrently with CSCT services. 

 

AUTH:  53-2-201, 53-6-113, MCA

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

 

            37.87.808  TARGETED CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, AUTHORIZATION REQUIREMENTS  (1)  To be reimbursed, targeted case management services for youth with SED must be authorized by the department or its designee via an authorization process as outlined below.

            (2)  A case manager may request up to 120 units in an initial request for authorization.

            (a)  A unit of targeted case management services is equal to 15 minutes.

            (3)  An initial request for authorization must also include:

            (a)  demographic information about the youth;

            (b)  the name and mailing address of a responsible party, if any;

            (c)  the name of the provider and other provider information; and

            (d)  the youth's DSM-IV diagnosis code.

            (4)  A case manager may submit an unscheduled revision (continued stay) requesting authorization for continued services of up to 120 units more than the initial number of authorized units.  The department or its designee will determine if further targeted case management services are medically necessary.  The unscheduled revision request must include:

            (a)  documentation of an SED diagnosis and functional impairment;

            (b)  documentation of the need for continued targeted case management services;

            (c)  a case formulation that includes measurable case management goals and objectives;

            (d)  a complete list of other services currently in place; and

            (e)  a discharge plan.

            (5)  Targeted case management services requested in excess of 240 units in a single state fiscal year (July 1 – June 30) must be reviewed by the department or its designee to determine medical necessity.  All the requirements of (4) also apply. 

            (1)  Targeted case management services for youth with SED do not require prior authorization to be reimbursed.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:     53-1-601, 53-1-602, 53-1-603, 53-2-201, 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 January 15, 2011 August 1, 2011.  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)  The department will not reimburse providers for Medicaid services unless the prior authorization and continued authorization requirements in ARM 37.87.903 are met.

            (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 January 15, 2011.  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)  Mental health services for a Medicaid youth under the Montana Medicaid program will be reimbursed only if the following requirements are met:

            (a)  the youth, defined in ARM 37.87.102, has been determined to have a serious emotional disturbance as defined in ARM 37.87.303;

            (b)  the department or its designee has determined on a case by case basis, that treatment is medically necessary for early intervention and prevention of a more serious emotional disturbance:

            (i)  prior to treatment, (prior authorization); and

            (ii)  when required, (continued authorization).

            (c)  for prior authorized services, the serious emotional disturbance has been verified by the department or its designee.

            (2)  If a youth has a mental health diagnosis designated by the department, the youth is not required to have a serious emotional disturbance to receive the following services:

            (a)  group outpatient therapy; and

            (b)  the first 24 sessions per state fiscal year of individual and family outpatient therapy.

            (1)  The department will not reimburse providers for some Medicaid services unless the prior authorization and continued authorization requirements are met.

            (2)  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 August 1, 2011.  A copy of the service matrix may be obtained from the department or at www.mt.medicaid.org.

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

            (a) remains the same.

            (b)  targeted case management in excess of 120 units of service per state fiscal year and in accordance with ARM 37.87.808;

            (c)  all outpatient therapy services provided on the same day as comprehensive school and community treatment (CSCT) described at ARM 37.86.2224, 37.86.2225, 37.106.1955, 37.106.1956, 37.106.1960, 37.106.1961, and 37.106.1965;

            (d) through (h) remain the same but are renumbered (b) through (f).

            (4)  Medicaid mental health services for youth requiring prior authorization or continued authorization will be reimbursed only if the following requirements are met:

            (a)  the youth, defined in ARM 37.87.102, has been determined to have a serious emotional disturbance defined in ARM 37.87.303, which has been verified by the department or designee; or

            (b)  the department or designee has determined on a case-by-case basis, that treatment is medically necessary for early intervention and prevention of a more serious emotional disturbance:

            (i)  prior to treatment, (prior authorization); and

            (ii)  when required, (continued authorization).

            (5)  Prior authorization and continued authorization by the department or its designee is not required for targeted case management.

            (6)  Youth are not required to have a serious emotional disturbance to receive the following outpatient therapy services:

            (a)  the first 24 sessions of individual and/or family outpatient therapy per state fiscal year.  Group outpatient therapy is not included in the 24-session limit; and

            (b)  group outpatient therapy.

            (4) and (5) remain the same but are renumbered (7) and (8).

            (6) (9)  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 January 15, 2011 August 1, 2011.  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 but are renumbered (10) and (11).

 

AUTH:   53-2-201, 53-6-113, MCA

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

 

            4.  STATEMENT OF REASONABLE NECESSITY

 

The proposed amendments will be reducing the reimbursement rates to the identified Medicaid providers by up to 2% beginning on August 1, 2011.  These provider rate changes are based on a provider rate increase that went into effect in Fiscal Year (FY) 2010, and was held constant in FY 2011.  The 2010 provider rate increase was paid for with one-time-only funding appropriated by the 61st legislative session meeting in 2009. This one-time-only funding was not included in the budget base for FY 2012 and the funds were not appropriated by the 62nd legislative session.

 

The department considered whether a rate decrease could cause a cost shift to a more expensive service.  The department considered the impact of the rate changes on efficiency, economy, quality of care, and access to Medicaid services and concluded that the rates are still sufficient to meet the requirements of 42 USC 1396a (a) (30(A).

 

In evaluating the reductions needed to live within the legislative appropriation, the department considered the alternatives of eliminating covered services and/or decreasing Medicaid eligibility.  The department is unable to decrease eligibility for services after March 23, 2010 and be in compliance with the Medicaid maintenance-of-effort (MOE) requirements of the Patient Protection and Affordable Care Act, PL 111-148, Title II, Sections 2001, et seq.  Eliminating optional services was considered and rejected because of the impact on vulnerable Medicaid clients who would lose coverage for services.  For these reasons, the department is proposing the following proposed amendments:

 

ARM 37.86.2224

 

The department is proposing changes in this rule to eliminate the prior authorization requirement for outpatient therapy services provided to a child or adolescent concurrently with CSCT services.  The department reviewed the cost savings from prior authorizing outpatient therapy services and determined the cost savings was not significant enough to continue utilization review of outpatient therapy services.  It is the intent of the department to manage outpatient therapy services that appear to be duplicative with CSCT services.  All Medicaid services are subject to retrospective audit and recovery if applicable state and federal rules are not followed.

 

ARM 37.87.808

 

The department is proposing to amend Targeted Case Management (TCM) rules by eliminating the prior authorization and unscheduled revision requirements and unit limits on TCM in (1) through (5).  The department reviewed the cost savings of utilization review of TCM services and determined the cost savings is not significant enough to continue utilization review of TCM services.  It is the intent of the department to effectively manage TCM services within the projected budget and appropriation.

 

ARM 37.87.901

 

The department is proposing to move (2) and (3) of this rule to ARM 37.87.903 to clearly separate out reimbursement requirements from prior authorization requirements.  In (2) the date of the Medicaid Mental Health Plan and Mental Health Services Plan for Youth Services Excluded from Simultaneous Reimbursement (Service Matrix) will be changed to August 1, 2011, in the replacement language.

 

ARM 37.87.903

 

The department is proposing to clarify which services require prior authorization and the determination of a Severe Emotional Disturbance (SED) for reimbursement.  The proposed changes eliminate prior authorization of TCM and outpatient therapy services concurrent with CSCT.  The department reviewed the cost savings from prior authorizing TCM and outpatient therapy services.  The department determined the cost savings is not significant enough to continue utilization review of TCM and outpatient therapy services concurrent with CSCT.  It is the intent of the department to manage outpatient therapy and TCM services within the projected budget and appropriation. 

 

The Service Matrix will be updated to August 1, 2011 and the prior authorization for outpatient services concurrent with CSCT will be eliminated. 

 

The Children's Mental Health Bureau's Provider Manual and Clinical Guidelines for Utilization Management date will not change until all the language related to utilization review requirements is changed after August 1, 2011.

 

This section will be reorganized for better readability, but no other substantive changes are intended.  The department is clarifying that youth do not need an SED diagnosis for group outpatient therapy or the first 24 sessions of individual and family outpatient therapy services.

 

            5.  Concerned persons may submit their data, views, or arguments either orally or in writing at the hearing.  Written data, views, or arguments may also be submitted to: Kenneth Mordan, 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., June 23, 2011.

 

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

 

7.  The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency.  Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices.  Notices will be sent by e-mail unless a mailing preference is noted in the request.  Such written request may be mailed or delivered to the contact person in 5 above or may be made by completing a request form at any rules hearing held by the department.

 

8.  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.

 

9.  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 May 16, 2011.

 

 

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