BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
In the matter of the amendment of ARM 37.86.2402, 37.86.2602, and 37.86.2606 pertaining to Medicaid transportation, personal per diem, and ambulance services
NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT
TO: All Concerned Persons
1. On May 20, 2015, 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, 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 the Department of Public Health and Human Services no later than 5:00 p.m. on May 13, 2015, 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 email@example.com.
3. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
37.86.2402 TRANSPORTATION AND PER DIEM, REQUIREMENTS
(1) and (2) remain the same.
(3) Coverage for transportation and per diem is only available for transportation and per diem to the site of medical services at the provider closest to the locality of the recipient
or to a Center of Excellence, as defined in ARM 37.86.2901, if prior authorization requirements have been met. unless:
(a) through (b)(iii) remain the same.
(c) Transportation and per diem to a site, other than the one nearest to the locality of the recipient, is available if the combined total cost to the Medicaid program of medical services and transportation and per diem at the more distant site is less than the total cost to the Medicaid program for the provision of the services in the closest location
., or to a Center of Excellence, as defined in ARM 37.86.2901, if prior authorization requirements have been met.
(4) and (5) remain the same.
(6) Coverage of nonemergent transportation and per diem must be prior authorized by the department or its designee.
(a) If a medical appointment has been rescheduled, any prior authorization of the original appointment does not apply to the rescheduled appointment. Prior authorization must be obtained for the rescheduled appointment
if the appointment is scheduled for a date other than the original appointment date.
(7) remains the same.
(8) Reimbursement for transportation
and per diem is made to the common carrier or lodging facility unless otherwise authorized by the department or its designee.
(9) Coverage of transportation is limited to the least expensive available
means mode of transportation suitable to the recipient's medical needs plus any applicable per diem.
(10) through (11)(c) remain the same.
(d) Coverage of per diem and transportation is available for a responsible adult to accompany a minor
for whom the responsible adult is necessary to provide legal consent for medical procedures.
(12) through (15) remain the same.
AUTH: 53-6-113, MCA
37.86.2602 AMBULANCE SERVICES, REQUIREMENTS
(1) through (8) remain the same.
(9) Emergency ambulance services must be reported to the department's designee within 180 days of the emergency transport or within 180 days of the retroactive eligibility determination date, by submitting an ambulance trip report and the associated professional claim form.
Ambulance claims for emergency services are screened for medical necessity and appropriateness by the designated review organization prior to payment. Prior to processing payment, the department's designated review organization will evaluate ambulance claims for emergency services for medical necessity and appropriateness by reviewing the ambulance trip report and the associated professional claim form.
(11) and (12) remain the same.
AUTH: 53-6-113, MCA
IMP: 53-6-101, 53-6-113,
37.86.2606 AMBULANCE SERVICES, QUALIFIED RATE ADJUSTMENT, PAYMENT ELIGIBILITY AND COMPUTATION
(1) through (3) remain the same.
(4) The QRA payment will be computed separately for all eligible ambulance providers on or before December 31, annually, using the following formula:
QRA payment = C x D x FMAP
(a) For the purposes of calculating the QRA payment amount, the following definitions apply:
(i) "C" represents the number of the provider's complete set of Medicaid paid claims for dates of service
during the prior for the most recent state fiscal year filed in accordance with ARM 37.85.406;
(ii) "D" represents the difference between the Medicare and Medicaid allowed amount per the Healthcare Common Procedure Coding System (HCPCS); and
(iii) "FMAP" represents the Federal Medical Assistance Percentage (FMAP) in effect
during the prior state fiscal year at the time of department payment. This percentage is the amount of federal participating matching funds for payment of Montana Medicaid program services. The methodology for determining this percentage is set forth in 42 USC 1396b(a) (2004). The department adopts and incorporates by reference the methodology set out in 42 USC 1396b(a) (2004). A copy of that statute may be obtained from the Department of Public Health and Human Services, Health Resources Division, P.O. Box 202951, Helena, MT 59620-2951.
(5) The QRA is subject to the following conditions:
(a) remains the same.
(b) information submitted from the eligible ambulance provider, the local Medicare fiscal intermediary, and the Montana Medicaid Paid Claims Database will be used for calculations, utilizing data from the most recent state fiscal year with completed Medicaid paid claims data filed in accordance with ARM 37.85.406;
(c) through (6) remain the same.
AUTH: 53-6-113, MCA
IMP: 53-6-113, MCA
4. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (the department) proposes the above-described amendments to ARM 37.86.2402, 37.86.2602, and 37.86.2606 pertaining to Medicaid Transportation Services and Ambulance IGT provider reimbursement to improve the accuracy and clarity of Medicaid program benefits requirements to providers and members and to strengthen departmental compliance with federal Medicaid laws. The proposed changes are the result of feedback received by the department from providers, members, and contractors and the department's required periodic review of its administrative rules.
Specifically, the department proposes the following amendments:
1. Relocate the Center of Excellence transportation and per diem exception from (3) to (3)(c) to the list of other transportation and per diem exceptions in (3)(a), (b), and (c). The amendment is necessary to group the exceptions into a list in a manner which will clarify that travel reimbursement to a Center of Excellence will be reimbursed as provided in ARM 37.86.2901, if out-of-state inpatient hospital prior authorization requirements have been met.
2. Remove duplicative language in (6)(a) to clarify that prior authorization must be obtained for any rescheduled medical appointment. This is a "housekeeping" amendment and is necessary to avoid confusion about preauthorization being required for cancelled and rescheduled medical appointments.
3. Remove direct payment language in (8) applicable to lodging facilities. The change is necessary because incorporation of the lodging facility reference into the original rule was made in error, as lodging facilities are not classified as providers and payment for lodging expenses is a Medicaid member's responsibility for which the department pays the member.
4. Revise language in (9) to refer to "mode of transportation" versus "means" plus any applicable per diem when determining the least expensive cost suitable to the member's medical needs. This amendment is necessary to clarify that the department views a member's transportation needs on more than just one criterion, and that the word "means" may infer a more restrictive analysis than what the department intends for what constitutes the "least expensive" cost.
5. Remove the current condition in (11)(d) that exists for coverage of transportation and per diem expenses for a minor's accompanying responsible adult. This amendment is necessary to simplify the rule through the removal of redundant and potentially confusing language regarding the role of an accompanying responsible adult for a minor enrolled in Medicaid.
6. Add specific language to (9) that an ambulance services provider must submit an ambulance trip report and the associated professional claim when seeking authorization for emergency transport service. This amendment is necessary to adopt into rule the department's current policy of utilizing ambulance trip reports and professional claim forms as being necessary corroborating documentation when reviewing and approving ambulance services claims.
7. Add language to (10) to provide that screening of an ambulance service provider's emergency services claims for medical necessity and appropriateness will be determined by the designated review organization's review of the provider's ambulance trip report and the associated professional claim form. Similar to the amendments in (9), this proposed amendment would adopt into rule current department practice of requiring ambulance trip reports and the associated professional claim form when reviewing and approving ambulance services claims.
8. Add language to (4) to clarify that the Qualified Rate Adjustment (QRA) payment will be computed separately for all eligible ambulance providers on or before December 31, annually. The proposed amendment is necessary for the department to remain in compliance with federal Medicaid laws which require, in part, a uniform schedule and procedure for processing QRA payments to providers.
9. Add clarifying language to (4)(a)(i) defining "C" to state that "C" represents the number of the provider's complete set of Medicaid paid claims for dates of service for the most recent state fiscal year filed in accordance with ARM 37.85.406. This rule amendment is necessary to clarify that in order for the QRA payment formula to function in accordance with federal Medicaid law, all provider Medicaid paid claims during the most recent state fiscal year, together with claims filed in accordance with ARM 37.85.406, must be included.
10. Add clarifying language to (4)(a)(iii), which defines the Federal Medical Assistance Percentage "FMAP," to state that FMAP represents the percentage used in the QRA payment in effect at the time of department payment. Because the federal government adjusts the FMAP each year, adoption of a uniform schedule aids the department in determining and scheduling QRA payments and providers in expecting QRA payments. The change also lends to greater departmental compliance with federal fiscal rules.
The department makes the proposed amendments only after having given careful consideration to: (a) its current internal policies in relationship to the affected administrative rules; (b) feedback received from providers and members regarding the need for greater clarity in rule language; and (c) the department's Medicaid compliance obligations. The department did explore alternatives to the proposed amendments, but as the intended amendments clarify operational procedures, improve current rules, or strengthen the department's compliance in the operation of its Medicaid program, the department contends the proposed amendments are the most efficient means of meeting these rulemaking goals.
The proposed amendments will have neutral fiscal impact to the program. This change will impact 109 ambulance providers and 20 IGT ambulance providers. This change will aide in providing clarifying information on Medicaid services for 113,047 members within Montana.
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 firstname.lastname@example.org, and must be received no later than 5:00 p.m., May 28, 2015.
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.
10. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment of the above-referenced rules will not significantly and directly impact small businesses.
/s/ Susan Callaghan /s/ Richard H. Opper
Susan Callaghan, Esq. Richard H. Opper, Director
Rule Reviewer Montana Department of Public Health and
Certified to the Secretary of State April 20, 2015.