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Montana Administrative Register Notice 37-638 No. 12   06/20/2013    
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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 37.86.5101, 37.86.5102, 37.86.5103, 37.86.5104, 37.86.5110, 37.86.5111, and 37.86.5112 pertaining to passport to health

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT

 

 

TO: All Concerned Persons

 

            1. On July 12, 2013, at 9:00 a.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, at 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 July 3, 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:

 

            37.86.5101 PASSPORT TO HEALTH PROGRAM: AUTHORITY (1) The department has been granted by the United States Department of Health and Human Services (HHS), as provided in 42 U.S.C. 1396n(b), the authority to establish a primary care case management program for Medicaid recipients members.

 

AUTH:     53-2-201, 53-6-113, MCA

IMP:        53-6-116, MCA

 

            37.86.5102 PASSPORT TO HEALTH PROGRAM: DEFINITIONS

            (1) "Authorization" means the approval by a primary care provider for the delivery to an enrollee by another provider of a service defined in ARM 37.86.5110. Authorization includes the provision of the primary care provider's Medicaid number, unique physician identifying number (UPIN), or the provider's Passport number to the other treating provider. The primary care provider shall establish parameters of the authorization.

            (2) through (6) remain the same, but are renumbered (1) through (5).

            (7) (6)  "Enrollee" means a Medicaid recipient member participating in the program and who is enrolled with a primary care provider under the program.

            (8) (7)  "Exempt" means a Medicaid recipients member who are is: eligible for       (a) eligible for managed care but are able to establish it that participating would be a hardship to participate in a managed care program.; The department has the discretion to determine hardship and to place time limits on all exemptions on a case by case basis.

            (b) enrolled in a health maintenance organization that provides case management services;

            (c) unable to find a primary care provider willing to provide case management; or

            (d) residing in a county in which there are not enough primary care providers to serve the Medicaid population required to participate in the program. The department has the discretion to determine hardship and to place time limits on all exemptions described in (a) through (d) on a case-by-case basis.

            (9) (8)  "Ineligible" means a Medicaid recipient member who is not allowed eligible to participate in a managed care program, such as the Passport Program, but is eligible for regular Medicaid. The following categories of recipients members are ineligible for the Passport Program:

            (a) recipients eligible for Medicaid with a spend down (medically needy) requirement;

            (b) recipients living in a nursing home or institutional setting;

            (c) recipients receiving Medicaid for less than three months;

            (d) recipients who have eligible for Medicare;

            (e) recipients who live in an area without Medicaid managed care;

            (f) (e)  recipients in the Medicaid eligibility subgroup of eligible for Medicaid subsidized adoption assistance or guardianship;

            (f) eligible for Medicaid foster care;

            (g) recipients whose eligibility period is only retroactive Medicaid eligibility;

            (h) recipients who cannot find a primary care provider who is willing to provide case management;

            (i) (h)  recipients who are receiving Medicaid home and community-based services for persons who are aged or disabled; and

            (i) eligible for Plan First; and

            (j) recipients who reside in a county in which there are not enough primary care providers to serve the Medicaid population required to participate in the program receiving Medicaid under a presumptive eligibility program.

            (10) and (11) remain the same, but are renumbered (9) and (10).

            (12) (11)  "Passport to Health Program" or "the program" means the primary care case management (PCCM) program for Medicaid recipients members.

            (13) and (14) remain the same, but are renumbered (12) and (13).

            (14) "Primary care provider" means a physician, clinic, or midlevel practitioner other than a certified registered nurse anesthetist that is responsible by agreement with the department for providing primary care case management to enrollees in the Passport to Health Program.

            (15) "Referral" means the approval by the Passport enrollee's primary care provider for the delivery by another provider of a service(s) that requires Passport referral. Referral is the provision of the primary care provider's Passport referral number to the other provider. The primary care provider shall establish the parameters of the referral.

            (15) (16)  "Team cCare" means a program for recipients members identified as excessive or inappropriate utilizers of the Medicaid program as set forth in ARM 37.86.5303A Medicaid recipient living in a nursing home or institutional setting and a recipient whose eligibility period is limited to a retroactive period only are ineligible for the team care program.

            (16) "Primary care provider" means a physician, clinic, or mid-level practitioner other than a certified registered nurse anesthetist that is responsible by agreement with the department for providing primary care case management to enrollees in the passport to health program.

 

AUTH:     53-2-201, 53-6-113, MCA

IMP:        53-6-113, 53-6-116, MCA

 

            37.86.5103 PASSPORT TO HEALTH PROGRAM: ELIGIBILITY (1) The department may require a Medicaid recipient member in any of the following Medicaid eligibility groups to enroll and participate in the Passport to Health Program, unless exempted from or ineligible for participation as defined by ARM 37.86.5102(8)(7) or (9)(8):.

            (a) families achieving independence in Montana (FAIM);

            (b) supplemental security income (SSI); or

            (c) SSI-related.

            (2) A Medicaid recipient is exempt from or is not allowed to participate in pPassport to health if the recipient:

            (a) is exempted by the department from participation because of hardship; or

            (b) is enrolled in a health maintenance organization (HMO).

            (3) A nonpregnant, Medicaid recipient 21 years of age or older and eligible for Medicaid as a participant in the TANF welfare demonstration project as required at ARM 37.78.101, et seq., must enroll in an HMO unless an HMO is not available or the available HMOs are at capacity.

            (4) (2)  At the department's discretion, Medicaid recipients members who are exempted from participation, as defined in ARM 37.86.5102(8)(7), may elect to enroll in a the Passport to Health Program by choosing a primary care provider from a county that the program serves, unless the recipient member is ineligible.

 

AUTH:     53-2-201, 53-6-113, MCA

IMP:        53-6-113, 53-6-116, 53-6-117, MCA

 

            37.86.5104 PASSPORT TO HEALTH PROGRAM: ENROLLMENT IN THE PROGRAM (1) The department will notify a Medicaid recipient member required by ARM 37.86.5103 to enroll in the program that the recipient member must enroll in the program.

            (2) The recipient member required to enroll in the program must select a primary care provider within 45 days of being notified of the enrollment requirement. For tTeam cCare pProgram recipients members, enrollment with a provider will be as required at ARM 37.86.5303.

            (3) If the recipient member does not choose a provider within 45 days of the notification, the department may will designate a primary care provider for the recipient member.  For tTeam cCare pProgram recipients members, enrollment with a provider will be as required in ARM 37.86.5303.

            (4) An enrolling recipient must choose a primary care provider from the list of primary care providers.

            (5) (4)  An enrollee may choose a new primary care provider up to once per month. For tTeam cCare pProgram recipients members, a change of provider may be made in accordance with ARM 37.86.5303. The frequency of a recipient's member's request to change providers will be monitored by the department.

            (6) (5)  Each enrollee in a household may choose a different primary care provider.

 

AUTH:    53-2-201, 53-6-113, MCA

IMP:      53-6-113, 53-6-116, MCA

 

            37.86.5110 PASSPORT TO HEALTH PROGRAM: SERVICES (1) An enrollee must obtain the services in (1)(a), except as provided in (1)(b), directly from or through authorization by the enrollee's primary care provider: An enrollee must obtain services directly from, or through a Passport referral by the enrollee's primary care provider except for:

            (a) Medicaid services requiring authorization:

            (i) inpatient hospital services as defined in ARM 37.86.2901;

            (ii) surgery, physical therapy, occupational therapy, speech therapy, and home health services delivered as outpatient hospital services as defined in ARM 37.86.3001;

            (iii) ambulatory surgical center services as defined in ARM 37.86.1401;

            (iv) physician services as defined in ARM 37.86.101;

            (v) federally qualified health center services as defined in ARM 37.86.4401;

            (vi) rural health clinic services as defined in ARM 37.86.4401;

            (vii) mid-level practitioner services as defined in ARM 37.86.202;

            (viii) the following EPSDT services for enrollees under 21 years of age:

            (A) screening services for children as defined in ARM 37.86.2005;

            (B) chiropractic services as defined in ARM 37.86.2206;

            (C) respiratory therapy as defined in ARM 37.86.2206;

            (D) private duty nursing as defined in ARM 37.86.2206; and

            (E) nutrition services as defined in ARM 37.86.2206.

            (ix) physician services provided through a developmental diagnostic center as defined in ARM 37.86.1401;

            (x) public health departments as defined in ARM 37.86.1401;

            (xi) organ transplantation services as defined in ARM 37.86.4701;

            (xii) physical therapy services as defined in ARM 37.86.601;

            (xiii) occupational therapy services as defined in ARM 37.86.601;

            (xiv) speech therapy services as defined in ARM 37.86.601;

            (xv) home health services as defined in ARM 37.40.701;

            (xvi) podiatry services as defined in ARM 37.86.501; and

            (xvii) emergency room services for emergent conditions as defined in ARM 37.82.102(5).

            (b) aspects of services listed in (1)(a) that do not require prior authorization by the enrollee's primary care provider:

            (i) (a)  obstetrical services, both inpatient and outpatient;

            (ii) inpatient and outpatient services for which the primary diagnosis is one of the following ICD-9 codes: 290 through 302, 306 through 314, or 316;

            (iii) (b)  family planning services as defined in Social Security Act 1905(a)(4)(c) and ARM 37.86.1701;

            (iv) (c)  anesthesiology services;

            (v) radiology services;

            (vi) (d)  pathology services;

            (vii) (e)  ophthalmology services for medical conditions of the eye;

            (viii) (f)  immunization;

            (ix) (g)  testing and treatment for sexually transmitted diseases as defined in ARM 37.114.101;

            (x) (h)  testing for lead blood levels;

            (xi) (i)  dental, vision, and hearing services portion of the screening services for children; and

            (xii) (j)  school-based health services.;

            (2) The primary care provider's authorization is not required for any of the following Medicaid services:

            (a) (k)  swing-bed hospital services as defined in ARM 37.40.401;

            (b) podiatry services as defined in ARM 37.86.501;

            (c) (l)  audiology services as defined in ARM 37.86.702;

            (d) (m)  hearing aid services as defined in ARM 37.86.801;

            (e) (n)  personal care services as defined in ARM 37.40.1101, except for personal care services as provided pursuant to ARM 37.86.2232;

            (f) (o)  home dialysis services for end-stage renal disease as defined in ARM 37.40.901;

            (p) home infusion therapy services as defined in ARM 37.86.1501;

            (g) (q)  mental health center services as provided in ARM 37.88.901 and 37.88.905 through 37.88.907;

            (h) family planning services provided by a local delegate agency of the Department of Public Health and Human Services as defined in ARM 37.86.1701;

            (i) (r)  licensed psychologists services provided in ARM 37.88.601, 37.88.605, and 37.88.606;

            (s) substance use disorder services as provided in ARM 37.27.102;

            (j) (t)  licensed clinical social work services provided in ARM 37.88.201, 37.88.205, and 37.88.206;

            (k) (u)  dental services as defined in ARM 37.86.1001;

            (l) (v)  licensed professional counselor services provided in ARM 37.88.301, 37.88.305, and 37.88.306;

            (m) (w)  outpatient drugs services as defined in ARM 37.86.1102 1101;

            (n) (x)  prosthetic devices, durable medical equipment, and medical supplies as defined in ARM 37.86.1801;

            (o) (y)  optometric services as defined in ARM 37.86.2001;

            (p) (z)  eyeglasses as defined in ARM 37.86.2101;

            (q) (aa)  transportation and per diem as defined in ARM 37.86.2401;

            (r) (ab)  specialized nonemergency medical transportation as defined in ARM 37.86.2501;

            (s) (ac)  ambulance services as defined in ARM 37.86.2601;

            (ad) emergency services as defined in ARM 37.82.102;

            (t) (ae)  skilled care facility services as defined in ARM 37.50.105;

            (u) (af)  intermediate care facility services as defined in ARM 37.40.106;

            (v) (ag)  institution for mental disease services as provided in ARM 37.88.1401, 37.88.1402, 37.88.1405, 37.88.1406, 37.88.1410, 37.88.1411, and 37.88.1420;

            (w) (ah)  home and community-based services as defined in ARM 37.40.1406;

            (x) (ai)  freestanding dialysis clinic for end-stage renal disease services as defined in ARM 37.86.4201;

            (y) (aj)  case management services as defined in ARM Title 37, chapter 86, subchapter 33 37.86.3301;

            (z) nonhospital laboratory and radiology (x-ray) as defined in ARM 37.86.3201;

            (ak) hospital inpatient laboratory and radiology (x-ray);

            (aa) (al)  admission for inpatient psychiatric services as provided in ARM 37.88.1101, 37.88.1105 through 37.88.1107, 37.88.1115 and 37.88.1116 37.86.2901, 37.86.2902, 37.87.1201, and 37.87.1203;

            (ab) (am)  therapeutic youth group home or therapeutic youth family care services under the EPSDT program; and

            (ac) (an)  hospice as defined in ARM 37.40.801 and 37.40.806.

            (ad) dietician as provided in ARM 37.40.1475; and

            (ae) respiratory therapy as provided in ARM 37.40.1463.

            (3) (2)  The requirement that specific services not listed in (1)(a) be authorized referred by the primary care provider does not replace or eliminate other regulatory or statutory requirements for or limits on obtaining and being reimbursed for Medicaid services.

            (4) (3)  Nothing in this rule reduces or otherwise affects the requirements that must be met under ARM 37.88.101, to obtain or access adult mental health services as provided in this chapter.

 

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

IMP:     53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-116, MCA

 

            37.86.5111 PASSPORT TO HEALTH PROGRAM: PRIMARY CARE PROVIDERS REQUIREMENTS (1) A primary care provider must meet the following requirements:

            (a) enroll as a Medicaid provider;

            (b) provide primary care; and

            (c) sign a pPassport contract agreement for primary care case management.; and

            (d)  keep a paper or electronic log, spreadsheet, or other record of all Passport referrals given and received.

            (2) remains the same.

            (3) Passport providers who reach their specified caseloads of Passport patients, per their provider agreements with the department, will not be assigned additional members. Providers who have reached their capacity will be provided the opportunity to increase their caseloads.

 

AUTH:    53-2-201, 53-6-113, MCA

IMP:       53-6-116, MCA

 

            37.86.5112 PASSPORT TO HEALTH PROGRAM: REIMBURSEMENT

            (1) through (3) remain the same.

            (4) Services listed in ARM 37.86.5110(1) provided to enrollees are not reimbursable unless provided or authorized by an enrollee's primary care provider in accordance with these rules. Services requiring Passport referral are not reimbursable unless referral is provided by a Passport enrollee's primary care provider.

 

AUTH:    53-2-201, 53-6-113, MCA

IMP:       53-6-116, MCA

            4. STATEMENT OF REASONABLE NECESSITY

 

The Department of Public Health and Human Services (the department) is proposing amendments to the rules governing the Medicaid Passport to Health program. Rule changes are needed to make the rules consistent with the 1915(b) Waiver, state plan amendments, updates administrative rules and current practices. Substantive updates are needed to enumerate the services exempt from Passport referral necessity; groups of members ineligible for the Passport Program; and provider assignment requirements as well as updates to make the rules easier to use and to revise terminology throughout rules.

 

ARM 37.86.5101

 

The term "recipient" has been changed to "member" in this rule and throughout all Passport administrative rules. "Member" will be used in the new Medicaid Management Information System (MMIS) and in all associated references.

 

ARM 37.86.5102

 

The proposed change substitutes the term "authorization" with "referral". The term Passport "referral", rather than "authorization" is used to avoid confusion with the "prior authorization" requirement of medical necessity. The proposed amendment updates and more clearly defines exempt and ineligible groups.

 

ARM 37.86.5103

 

The proposed amendment eliminates TANF members from the list of members exempted from participation in the Passport Program. TANF members are no longer required to enroll in a Medicaid HMO since none currently exist in Montana.

The proposed change updates and more clearly defines who is not eligible for the Passport Program.

 

ARM 37.86.5104

 

The term "recipient" has been changed to "member" in this rule. The other proposed change more clearly specifies how a member may choose a primary care provider.

 

ARM 37.86.5110

 

The proposed amendment eliminates the list of services that require Passport referral. It is impossible to provide an exhaustive list of services that require referral under Passport. The focus of this rule change is to have a well-defined, specific list of services that do not require Passport referral.

 

ARM 37.86.5111

 

The department is proposing to add a requirement for providers to keep a record of all referrals given and received. The department is also proposing a change to prohibit providers from adding members if they have reached their caseload capacity. This provision eliminates pending lists of members from which providers may accept or reject members.

 

ARM 37.86.5112

 

The department is proposing changes to specify when a Passport referral is required.

 

Fiscal Impact

 

No fiscal impact is anticipated.

 

            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., July 18, 2013.

 

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/ Richard H. Opper                                   

John Koch                                                    Richard H. Opper, Director

Rule Reviewer                                             Public Health and Human Services

           

Certified to the Secretary of State June 10, 2013.

 

 

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