BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.34.3001, 37.34.3002, and 37.34.3005 and the repeal of ARM 37.34.3006, 37.34.3007, 37.34.3012, 37.34.3013, and 37.34.3015 pertaining to reimbursement for services

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT AND REPEAL

 

TO:  All Concerned Persons

 

            1.  On May 15, 2013, 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 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 May 9, 2013, 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:

 

            37.34.3001  REIMBURSEMENT FOR SERVICES:  GENERALLY  (1) remains the same.

            (2)  Reimbursement for services and items is only available:

            (a)  through payments made to providers that have a current contract with the department authorizing the provider to deliver developmental disabilities services.;  In addition a provider must be:

            (i)  currently enrolled in conformance with ARM 37.85.402 as a Montana Medicaid provider as evidenced by a signed current provider enrollment agreement, unless the type of provider is expressly exempted from the requirement by the department; and

            (ii)  designated by Developmental Disabilities Program (DDP) to be a qualified developmental disabilities provider, unless the program does not require the provision of the particular type of service or item by or through a qualified provider.

            (b)  for services and items that are authorized in rule or federal agreements for delivery through the particular developmental disabilities services program that the consumer person is authorized by the DDP to participate in;

            (c)  when the particular services and items delivered are authorized for delivery to the consumer person through the consumer's person's individual cost plan (ICP) as provided for in ARM 37.34.3002, or if the ICP is not applicable, the planning and authorization procedures applicable to the particular program;

            (d)  if the consumer person has received the services and items authorized; and

            (e) remains the same.

            (3)  The contracted provider must be:

            (a)  currently enrolled in conformance with ARM 37.85.402 as a Montana Medicaid provider as evidenced by a signed current provider enrollment agreement, unless the type of provider is expressly exempted from the requirement by the department; and

            (b)  designated by the Developmental Disabilities Program (DDP) to be a qualified developmental disabilities provider, unless the program does not require the provision of the particular type of service or item by or through a qualified provider process.

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

            (4) (5)  Reimbursement for the delivery of a service or item delivered to a consumer person through the department's DDP is payment in full and the provider may not receive further reimbursement for the service or item from the program, other departmental programs, the consumer or the person, or other parties.

            (5) (6)  A provider in order to receive reimbursement for a service or item must properly invoice for the service or item through the DDP's electronic billing system, Agency Wide Accounting Client System (AWACS), unless the service or item is not reimbursed through that payment system.

            (6) (7)  A provider may receive reimbursement from a consumer  for a service or item that is not reimbursable through the DDP if, prior to delivery of the service or item, the provider and the consumer or the consumer's legitimate representative have entered into a written agreement that allows for the delivery of and payment for the service or item in an accountable manner.  A provider may seek reimbursement from a person receiving services for a service or an item only if the service or item is not covered for Medicaid purposes and the billing is allowed for and conducted in accordance with ARM 37.85.406(11)(a).

            (7) (8)  A provider may not seek or obtain reimbursement from a consumer the person for a service or item that, though reimbursable by the DDP as a service or item, has not been reimbursed by the program due to the failure of the provider to properly seek reimbursement for the service or item or due to the failure of the provider to properly deliver the service or item to the consumer person.

            (8) remains the same, but is renumbered (9).

            (9) remains the same, but is renumbered (10).

            (a) remains the same, but is renumbered (11).

            (i) through (v) remain the same, but are renumbered (a) through (e).

            (b) remains the same, but is renumbered (12).

 

            (10) (13)  Reimbursement for services and items is not made directly to consumers persons receiving DDP funded services or their representatives. 

 

AUTH:          53-2-201, 53-6-113, 53-6-402, 53-20-204, MCA

IMP:             53-6-101, 53-6-111, 53-6-402, 53-20-203, 53-20-205, MCA

 

            37.34.3002  REIMBURSEMENT FOR SERVICES:  INDIVIDUAL COST PLANS  (1)  Authorization for the reimbursement of to a provider for the delivery of particular services and items to an individual consumer a person receiving Developmental Disabilities Program (DDP) funded services is based on the implementation of an individual cost plan (ICP) for the consumer person prior to the delivery of those services and items.  Absent an approved ICP for a consumer, reimbursement is not available for services and items delivered to the consumer.

            (2)  Services and items delivered to a consumer may not be reimbursed unless authorized in the consumer's ICP prior to the delivery of those services and items.

            (3) (2)  Total Rreimbursement for the delivered services and items delivered to a person may not exceed the sum designated for the person's fiscal year maximum in the person's ICP.

            (3)  For each service specified in a person's ICP, the total sum expended for the service may not exceed the sums designated as available for those services that service in the consumer's person's ICP.  Nor may total reimbursement for the delivered services and items exceed the total of the sums designated as available for those services in the consumer's ICP.

            (4)  An ICP is developed by the consumer's person's case manager for submission to the DDP regional office for review and approval.  For services reimbursed on time units the case manager estimates the levels of service delivery based on a reasonable assessment of the direct care staff time necessary to meet the health and safety needs of the consumer person.  The case manager uses the standardized reimbursement rates and any specified rates of reimbursement for particular services and items to calculate the amount of monies necessary to fund the services and items to be provided to the consumer person.

            (5)  All new proposed ICPs or proposed amendments to ICPs must be reviewed and authorized by the DDP's regional manager.

            (6) remains the same, but is renumbered (5).

 

AUTH:         53-2-201, 53-6-402, MCA

IMP:             53-2-201, 53-6-402, MCA

 

            37.34.3005  REIMBURSEMENT FOR SERVICES:  THE 0208 COMPREHENSIVE PROGRAM OF MEDICAID FUNDED HOME AND COMMUNITY-BASED SERVICES WAIVER PROGRAMS  (1)  Reimbursement through the Developmental Disabilities Program's (DDP) Medicaid Home and Community-Based Services 0208 Comprehensive Services Program wWaiver Programs is only available to a provider for services or items:

            (a) remains the same.

            (b)  delivered in accordance with the terms and conditions of the formal approval by the Centers for Medicare and Medicaid (CMS) governing this waiver each waiver program; and

            (c)  specified as 0208 comprehensive program services in ARM 37.34.911; and

            (d) (c)  authorized in accordance with ARM 37.34.3002 for reimbursement through the consumer's person's individual cost plan (ICP).

            (2)  The department adopts and incorporates by this reference the rates of reimbursement for the delivery of services and items available through the 0208 Comprehensive Program of each Home and Community-Based Services Waiver Program as specified in Section Two:  Rates of Reimbursement for the HCBS 1915(c) 0208, 0371 1037, 0667 Waiver Programs, of the Developmental Disabilities Program Manual of Service Reimbursement Rates and Procedures, published September 1, 2011 effective July 1, 2013.  A copy of Section Two of the manual may be obtained through the Department of Public Health and Human Services, Developmental Services Division, Developmental Disabilities Program, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210 and at www.dphhs.mt.gov/dsd/ddp/forms.shtml http://www.dphhs.mt.gov/dsd/ddp/ddprateinformation.shtml.

 

AUTH:            53-2-201, 53-6-402, MCA

IMP:                53-2-201, 53-6-402, MCA

 

4.  The department proposes to repeal the following rules:

 

            37.34.3006  REIMBURSEMENT FOR SERVICES:  THE 0371 COMMUNITY SUPPORTS PROGRAM OF MEDICAID FUNDED HOME AND COMMUNITY SERVICES, is found on page 37-7706 of the Administrative Rules of Montana. 

 

AUTH:            53-2-201, 53-6-402, MCA

IMP:                53-2-201, 53-6-402, MCA

 

            37.34.3007  REIMBURSEMENT FOR SERVICES:  THE 0667 AUTISM PROGRAM OF MEDICAID FUNDED HOME AND COMMUNITY SERVICES, is found on page 37-7707 of the Administrative Rules of Montana. 

 

AUTH:            53-2-201, 53-6-402, MCA

IMP:                53-2-201, 53-6-402, MCA

 

            37.34.3012  REIMBURSEMENT FOR SERVICES:  HOME AND COMMUNITY SERVICES FUNDED WITH NON-MEDICAID MONIES, is found on page 37-7709 of the Administrative Rules of Montana.

 

AUTH:            53-2-201, 53-20-204, MCA

IMP:                53-2-201, 53-20-203, 53-20-205, MCA

 

            37.34.3013  REIMBURSEMENT FOR SERVICES:  PART C EARLY INTERVENTION SERVICES PROGRAM, is found on page 37-7710 of the Administrative Rules of Montana. 

 

AUTH:            53-2-201, 53-20-204, MCA

IMP:                53-2-201, 53-20-203, 53-20-205, MCA

 

            37.34.3015  REIMBURSEMENT FOR SERVICES:  TARGETED CASE MANAGEMENT SERVICES, is found on page 37-7710 of the Administrative Rules of Montana. 

 

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

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

 

            5.  STATEMENT OF REASONABLE NECESSITY

 

The Department of Public Health and Human Services (the department) is proposing amendments to Title 37, chapter 34, subchapter 30, Reimbursement for Services.  This is necessary to reflect changes to the Section Two:  Rates of Reimbursement for the HCBS 1915(c) 0208, 0371, 0667 Waiver Programs, of the Developmental Disabilities Program, Manual of Service Reimbursement Rates and Procedures, which is adopted and incorporated into rule.  The department is applying for the renewal of the Home and Community-Based 1915(c) for Individuals with Developmental Disabilities waiver, as well as a new waiver, Supports for Community Working and Living.  These proposed changes are shown in the manual.

 

ARM 37.34.3001 and 37.34.3002

 

The department proposes to amend ARM 37.34.3001 and 37.34.3002 in order to update rule language to provide clarity, achieve consistency with the other rules in Title 37, chapter 34, and to improve readability. 

 

ARM 37.34.3005

 

This rule adopts and incorporates Section Two:  Rates of Reimbursement for the HCBS 1915(c) 0208, 0371, 0667 Waiver Programs, of the Developmental Disabilities Program Manual of Service Reimbursement Rates and Procedures.  The department proposes to amend the title of the manual.  This change is necessary due to the proposed termination of the 0371 Waiver Program and the proposed establishment of the 1037 Waiver Program.  The effective date of the rates manual will be updated from September 1, 2011 to July 1, 2013.  The proposed language also updates the current and correct web site location for reviewing this manual.

 

ARM 37.34.3006 and 37.34.3007

 

The department proposes to repeal ARM 37.34.3006 and 37.34.3007.  The current format of these rules separates each of the individual waiver programs into three separate rules.  The proposed new language in ARM 37.34.3005 combines each waiver into this rule.  This is necessary because the manual adopted and incorporated into ARM 37.34.3005 encompasses each of the waiver programs and it is redundant to adopt the same manual into three separate rules.

 

ARM 37.34.3012, 37.34.3013, and 37.34.3015

 

The department proposes to repeal ARM 37.34.3012, 37.34.3013, and 37.34.3015.  In order to reorganize Title 37, chapter 34, the department proposes the information contained in these three rules be relocated into the applicable program's subchapters.  ARM 37.34.3012 applies to reimbursement for services, non-Medicaid funding, ARM 37.34.3013 applies to reimbursement for services, Part C Early Intervention Services, and ARM 37.34.3015 applies to Targeted Case Management Services.

 

Manual

 

The department is proposing adoption and incorporation into rule the Section Two: Rates of Reimbursement for the HCBS 1915(c) 0208, 1037, 0667 Waiver Programs, of the Developmental Disabilities Program Manual of Service Reimbursement Rates and Procedures.  This is necessary to update current language to reflect changes occurring in the HCBS 1915(c) 0208 waiver, the proposed merger of the 0371 waiver with the 0208 waiver, and the establishment of the proposed new waiver the department is applying for, 1037 waiver or the Supports for Community Working and Living Waiver Program. The proposed fee schedule will take into consideration the anticipated 2% provider rate increase funding, expected to be implemented for State Fiscal Year (SFY) 2014, mandated by HB2 of the 63rd Montana Legislature.

 

The HCBS provider reimbursement schedule defines the rates and units of service for each of the HCBS waiver categories.  As such, the HCBS waiver reimbursement services are intended to accomplish three purposes:

            (a)  that persons have fair and equitable access to services;

            (b)  that providers are fairly and equitably reimbursed for delivering those services; and 

            (c)  that services purchased by people are delivered in sufficient and at acceptable quality standards.

 

Standard rates are derived from four standardized cost centers.  Those include direct care staff compensation, employee-related expenses, program supervision and indirect expenses, and general and administrative expenses.  Geographical factors are also applied for residential habilitation and work and day services.  Economy-of-scale factors are applied to residential habilitation.

 

The proposed changes are necessary to add into Section Two of the manual the new day/work services rates for the HCBS 1915(c) 0208 Waiver.  The services include:   Supported Employment; Individual Employment Support; Follow Along Support; Small Group Employment Support; Co-Worker Support; and Job Discovery/Job Preparation.  The Day Services include:  Adult Day Health; and Day Supports and Activities.

 

In addition, the department proposes to add into Section Two of the manual, the HCBS 1915(c) 1037 Supports for Community Working and Living Waiver Service reimbursement rates and procedures.  The services are entirely employment related and self-directed, either through the agency with choice model or an employer authority using the financial management service (FMS) option.  The services include:

            Co-Worker Support

            Follow Along Support

            Individual Employment Support

            Job Discovery/Job Preparation

            Respite

            Small Group Employment Support

            Supports Brokerage

            Environmental Modifications/Adaptive Equipment

            Individual Goods and Services

            Meals

            Emergency Response System

            Personal Supports

            Transportation

 

The department removed the reference to the HCBS 1915(c) 0371 Waiver Program from the manual to reflect the proposed termination of the HCBS 1915(c) 0371 waiver with the HCBS 1915(c) 0208 Waiver.  Other changes include updating terminology to bring consistency within the manual itself as well as the terminology used within the department.

 

Fiscal Impact

 

The proposed amendments reflect the legislative appropriation of $1,828,934 in total funds for state fiscal year (SFY) 2014, effective July 1, 2013 for these rate increases regarding Medicaid services provided through the Developmental Disabilities Program. 

 

            6.  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., May 23, 2013.

 

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

 

8.  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 6 above or may be made by completing a request form at any rules hearing held by the department.

 

9.  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.

 

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

 

 

/s/ Cary B. Lund                                           /s/ Richard H. Opper                                   

Cary B. Lund                                                Richard H. Opper, Director

Rule Reviewer                                             Public Health and Human Services

           

Certified to the Secretary of State April 15, 2013.