Montana Administrative Register Notice 37-596 No. 20   10/25/2012    
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BEFORE THE Department of Public

health and human services of the



In the matter of the amendment of ARM 37.87.1303, 37.87.1333, and 37.87.1335 and the repeal of 37.87.1305, 37.87.1306, 37.87.1307, 37.87.1321, 37.87.1325, and 37.87.1331 pertaining to home and community-based services (HCBS) for youth with serious emotional disturbance











TO:  All Concerned Persons


1.  On July 26, 2012, the Department of Public Health and Human Services published MAR Notice No. 37-596 pertaining to the public hearing on the proposed amendment and repeal of the above-stated rules at page 1514 of the 2012 Montana Administrative Register, Issue Number 14.  On September 6, 2012, the Department of Public Health and Human Services published an Amended Notice of Public Hearing on Proposed Amendment and Repeal at page 1735 of the 2012 Montana Administrative Register, Issue No 17.  The purpose of the amended notice was to clarify some questions regarding high fidelity wraparound facilitation services and reimbursement rates.  The rules remained as proposed.


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  The department has amended and repealed the above-stated rules as proposed.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:  Several commenters expressed concern about the proposed unit and rate for wraparound facilitation (proposed "encounter" unit of 50 minutes minimum with only one unit allowable per day and proposed encounter rate that allows billing only for face-to-face time working with the youth and family).  The commenters noted this unit does not allow for the time flexibility facilitators need to do their work and does not allow billing for non-face-to-face care coordination and paperwork which are required when providing wraparound facilitation.


RESPONSE #1:  The department has changed the unit of service for wraparound facilitation back to a 15-minute unit and will allow some specific non-face-to-face care coordination activities to be billable.  The policy manual has been updated to reflect these changes and to include a table of billable activities.  Paperwork activities will still not be billable as paperwork time was included in calculation of the unit rate.


COMMENT #2:  Several comments noted concern about the setting of an encounter rate for in-home therapy with the encounter unit being a minimum of 50 minutes face-to-face care, given that youth and families referred for these services may not be able to sit through a session of that length.  Commenters requested a return to a 15-minute unit and rate to allow needed flexibility for providers of this service for this population and suggested that some non-face-to-face time be billable as well, such as telephone support in crises.


RESPONSE #2:  The department considered work-related components (including non-face-to-face components) in the rate as part of the rate-setting process.  The unit will remain an encounter with a minimum of 50 minutes with the assumption that in-home therapy is a scheduled service (for the therapy itself), which the practice model for licensed mental health professionals is providing mental health therapy.  The in-home therapist may bill one encounter per day unless they attend a wraparound team meeting for the same youth on the same day, in which case they can bill for both.  The billing code will be the same for the encounter and the wraparound team meeting, but an informational modifier will be added to the code to denote the team meeting.  The department did not include a separate unit and rate of reimbursement for an in-home therapist who may respond to a crisis.  The department remains open to further evaluation and consideration of the type of unit for the in-home therapy service.


COMMENT #3:  Several comments noted concern about the requirement that in-home therapists provide crisis response during and after work hours and suggested that a way be provided to bill for that requirement.


RESPONSE #3:  If a provider responds to a crisis in person and spends 50 or more minutes working with the youth or family, the provider may bill for an encounter if they have not provided therapy for the youth/family on the same day.  Non-face-to-face crisis responses are not billable.  As noted above, non-face-to-face activities were considered in the setting of the rate for this service.  Family teams generally have crisis plans that include the therapist as one of a number of potential responders, not the only one.  The department remains open to discussion and consideration about more clearly defining this expectation.


COMMENT #4:  One commenter noted that requiring therapy be provided in the home is not always clinically appropriate and the family may not want it to occur in their home.


RESPONSE #4:  The department agrees and notes that the language in the policy manual does indicate the therapy will be provided "in the youth's residence at times convenient for the youth and family."  The department's intent was to convey that the therapy would be provided at places and times convenient for the youth and family, including in the home.  The department will consider amending this language at the next opportunity to address this concern.


COMMENT #5:  A commenter asked whether the requirement that the in-home therapist develop and write an individual treatment plan meant that it should be a separate plan from the wraparound plan and if so stated that it defeats the purpose of having one plan for the family based on need.  The commenter suggested that perhaps instead the therapist could stipulate specific interventions in the wraparound plan relating to the therapy.


RESPONSE #5:  The individual treatment plan for therapy is developed by the therapist with the youth and family based on their needs and is directly integrated with the wraparound plan.  Specific interventions relating to therapy can be included in the wraparound plan.


COMMENT #6:  A comment was received asking for the rationale behind the new peer-to-peer rate and requesting consideration of increasing the peer-to-peer rate to be closer to the family support specialist rate.


RESPONSE #6:  The department's rate setting process and analysis does not support a rate higher than the proposed rate.  The department is willing to ask providers to participate in time studies for further analysis of rates for services when there are provider concerns about adequacy of the rates.


COMMENT #7:  A comment was received requesting that the requirement for peer-to-peer specialist services remove the criterion that the peer-to-peer specialist be an adult who also received mental health services as a youth.


RESPONSE #7:  The policy manuals have been amended to reflect that a person providing peer-to-peer services to a parent/legal guardian does not have to have received mental health services as a youth.


COMMENT #8:  A comment was received requesting clarification of the requirement that the family support specialist (FSS) works under the guidance of the in-home therapist, given that there is no guidance about who supervises the FSS.  The commenter also requests consideration of allowing the provider agency that employs the FSS to provide a licensed therapist to provide the guidance, rather than obligating the in-home therapist to do it.


RESPONSE #8:  The provider agency is required to provide clinical supervision for the FSS.  It is assumed that the provider agency supervises the FSS.  The department welcomes further discussion about this matter.  At this time, the requirement will remain the same given the need for close alignment of the work of the in-home therapist and the FSS.


COMMENT #9:  A comment was received recommending that the department strike the requirement that respite providers be employees of an agency given that it is cost prohibitive for agencies to employ respite providers.


RESPONSE #9:  The department will keep the requirement that respite providers be employed by an agency at this time.  Provider agencies may offset administrative costs by paying respite providers a portion of the billed amount for the service.  The department welcomes further discussion on this issue, as access to respite is a significant need of the youth and families, as noted by the commenter.


COMMENT #10:  A question was received requesting guidelines for agencies to follow to determine whether respite providers are physically and mentally qualified.


RESPONSE #10:  The department does not have guidelines for this determination.  The department welcomes provider input and discussion on this issue.


COMMENT #11:  A comment was received requesting the department consider allowing the in-home therapist and wraparound facilitator to work for the same agency, at family's request, to allow for family voice and choice.  The commenter noted this exclusion may restrict access of rural families to in-home therapy where there are few providers.


RESPONSE #11:  Centers for Medicare and Medicaid Services (CMS) requires strong safeguards against conflict of interest in service provision.  The safeguards must be written into the application for home and community-based services.  The department must keep the current language.


COMMENT #12:  Several commenters noted that the department has been advised the fees for services are inadequate, the fees structure will not attract new providers, and current providers will not be able to continue to afford to provide services.  The commenters request that the department consider seeking input from providers about the cost to provide the services and areas that the fee structure can be adjusted to support adequate rates for certain services.


RESPONSE #12:  The department will continue to seek and welcome input from providers about the cost to provide services and the costs that could be adjusted to support rate changes.  The department did seek provider input during the recent rate-setting process and will continue to welcome input from providers on the cost of providing these services.


COMMENT #13:  A comment was received asking why time wasn't considered in a rate for travel and asking the department to consider removing the restriction of "25 miles or greater" from the "geographical factor" and to consider increasing the rate for the factor to help defray cost of travel time away from the office or to consider adding a fee to cover travel time.


RESPONSE #13:  The department will keep the current rate and requirements for the geographical factor the same at this time.  Travel time was considered in the setting of the rates for each service.  The geographical factor is designed to assist providers willing to serve youth and families who live more than 25 miles from the provider's usual business location.  The department welcomes additional input and discussion on this matter.


COMMENT #14:  Several commenters stated that in appendix A of the policy manuals there is language indicating that the therapist and other providers can only bill for face-to-face time with the youth present.  The language is "Total time billed using one or multiple procedure codes may not exceed the total actual time spend with the Medicaid youth."


RESPONSE #14:  It is the department's intent that the services are to be provided related to the youth's needs and the family's needs in support of the youth.  The youth will not be present every time a service is provided.  Family therapy can occur with parents or legal representatives without the youth present.


COMMENT #15:  A commenter asked where the money comes from for the bridge waiver, why the billing process changed for the bridge waiver as well as for the 1915(i)(MAR 37-595), and asked why billing issues with regard to an atypical NPI number have not been resolved yet.


RESPONSE #15:  The funding for bridge waiver services comes from federal Medicaid dollars and state general fund match.  Funding for administration of the program comes from sustainability funding related to the PRTF waiver plus state general fund match. Sustainability funding also supports some of the capacity building for wraparound facilitation and peer-to-peer services.  The department continues to work with Xerox (formerly ACS) to address persistent billing difficulties for atypical providers.  Currently Xerox is working on plans for an updated system.


COMMENT #16:  A commenter expressed concern about the nonmedical transportation service because families are supposed to be focused on natural supports and an agency is required to provide the service but in some cases cannot afford to provide it.  The commenter requests an example when this service would apply.


RESPONSE #16:  Please refer to the description of the service in the policy manuals for examples of when the service may be used.


COMMENT #17:  A comment was received noting a few concerns about the service of respite care, including the suggestion that providers could bill for training and developing specialized skills respite providers develop and not be required to employ respite providers.


RESPONSE #17:  The department appreciates the suggestion but will continue to require that respite providers be employed by an agency.


COMMENT #18:  A commenter asked for information about outcomes from the PRTF waiver.  The commenter also inquired about the paradox of requiring families to participate in the PRTF waiver and now the 1915(i) in MAR 37-595, with respect to the issue of family choice.  The commenter wanted to know whether CMHB adequately researched statewide the service models already available before implementing the PRTF waiver and what CMHB's stance is in regard to models of service outside the current PRTF waiver being able to meet the needs of and appropriately serve youth currently enrolled in the PRTF waiver, if the proposed rule changes do not go through.


RESPONSE #18:  The department considers the above comments outside the scope of the proposed rules changes.


COMMENT #19:  A comment was received that there is no evidence to support the proposed rule change to implement the bridge waiver as the youth currently enrolled may continue services through qualified providers who provide community and home based services steeped within the wrap philosophy of care.


RESPONSE #19:  The proposed rule changes to implement the bridge waiver are necessary for youth currently enrolled in the PRTF waiver to have continuity of care in the services they have been receiving under the authority of the PRTF waiver despite the change in federal authority for the services.  Disruption of these services would not be in the best interest of the youth and their families.


            4.  The department intends to apply these rules retroactively to October 1, 2012.  A retroactive application of the proposed rules does not result in a negative impact to any affected party.




/s/ Cary B. Lund                                             /s/ Anna Whiting Sorrell                               

Rule Reviewer                                               Anna Whiting Sorrell, Director

                                                                        Public Health and Human Services



Certified to the Secretary of State October 15, 2012.



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