BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
In the matter of the amendment of ARM 37.79.304 and 37.79.501 pertaining to healthy Montana kids
NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT
TO: All Concerned Persons
1. On July 10, 2013, at 10:00 a.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 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 firstname.lastname@example.org.
3. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
37.79.304 SERVICES COVERED (1) The department adopts and incorporates by reference the HMK Evidence of Coverage dated
July 1, 2013 October 1, 2013, which is available on the department's web site at www.hmk.mt.gov.
(2) The HMK Evidence of Coverage describes the health care benefits available to an HMK coverage group enrollee if the service is medically necessary. Prior authorization may be required and copayments may apply.
AUTH: 53-4-1009, 53-4-1105, MCA
IMP: 53-4-1005, 53-4-1109, MCA
37.79.501 COST SHARING PROVISIONS (1) Except as provided in (2) and (3), the parent or guardian of each HMK coverage group enrollee whose family income is greater than 100% of the federal poverty level must pay to the provider of service the following copayments not to exceed the cost of service:
(a) $25 per admission for inpatient hospital services including hospitalization for physical, mental, and substance abuse reasons;
(b) $5 per visit for emergency room services;
(c) $5 per visit for outpatient hospital visits including outpatient treatment for physical, mental, and substance abuse reasons; and
(d) $3 per visit for physician, APRN, PA, optometrist, audiologist, mental health professional, substance abuse counselor, or other covered health care provider services
(e) $3 per prescription or refill of an outpatient generic drug;
(f) $5 per prescription or refill for an outpatient brand-name drug;
(g) $6 per mail order prescription or refill of an outpatient generic drug (90 day supply); and
(h) $10 per mail order prescription or refill of an outpatient brand name drug (90 day supply).
(2) No copayment will apply to:
(a) well baby or well child care, including age-appropriate immunizations;
(b) outpatient hospital visits for x-ray and laboratory services;
(c) dental, pathology, radiology, or anesthesiology services;
(d) families with at least one enrollee who is a Native American Indian or Native Alaskan;
(e) extended mental health services for children with a serious emotional disturbance;
(f) pharmacy services.
(3) The total copayment for each family shall not exceed $215 per family per benefit year.
AUTH: 53-4-1004, 53-4-1009, 53-4-1105, MCA
IMP: 53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA
4. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (the department) is proposing to amend ARM 37.79.304 and 37.76.501. These proposed amendments will align the Health Montana Kids (MHK) pharmacy benefits with the Montana Medicaid pharmacy benefits. The rule amendments are required when the pharmacy benefit for HMK is managed by the department instead of a third party administrator.
The effective date of the HMK Evidence of Coverage document is being updated to October 1, 2013 to reflect the revisions that will be made to the HMK Evidence of Coverage.
The department is proposing to delete language from the cost sharing provisions of this rule. The proposed deleted language effectively eliminates cost sharing for prescription drugs.
The department is also proposing to add language in order to more clearly describe cost sharing for prescriptions.
There is no anticipated fiscal impact to the HMK program. These changes are expected to be budget neutral.
The proposed rules are estimated to effect 273 in-state pharmacies, 122 out-of-state pharmacies and 23,149 HMK persons.
5. The department intends to adopt these rule amendments effective October 1, 2013.
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 email@example.com, and must be received no later than 5:00 p.m., July 18, 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/ 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.