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Montana Administrative Register Notice 37-763 No. 19   10/14/2016    
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BEFORE THE Department of Public

health and human services of the

STATE OF MONTANA

 

In the matter of the adoption of New Rules I through IV and the repeal of ARM 37.87.1303, 37.87.1333, and 37.87.1335 pertaining to integrated co-occurring treatment provider requirements

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NOTICE OF ADOPTION AND REPEAL

 

TO: All Concerned Persons

 

1. On August 19, 2016, the Department of Public Health and Human Services published MAR Notice No. 37-763 pertaining to the public hearing on the proposed adoption and repeal of the above-stated rules at page 1408 of the 2016 Montana Administrative Register, Issue Number 16.

 

2. The department has adopted New Rules I (37.87.1350), II (37.87.1351), III (37.87.1352), and IV (37.87.1353) as proposed. 

 

3. The department has repealed the above-stated rules as proposed.

 

4. 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: One commenter proposed a retrospective review rather than prior authorization for the Integrated Co-Occurring Treatment (ICT) service. The commenter suggested using the Integrated Bio-Psycho-Social Assessment, which outlines the serious emotional disturbance (SED) and substance use disorder (SUD), to support the referral to the ICT program as a means to ensure that the program is being utilized appropriately.

 

RESPONSE #1: The prior authorization requirement is being proposed not as a means to ensure appropriate use of the ICT program, but as a means to track youth who are in the program for purposes of acquiring data about this population. In addition, it allows the department to manage payment through the claims system. Retrospective review will still be utilized as a means to ensure appropriate use of the service.

 

COMMENT #2: Two commenters asked the department to reconsider the rates for ICT. One commenter asked how the department calculated the rates for ICT. Both commenters stated that the ICT model would not be sustainable using the proposed rates.

 

RESPONSE #2: Medicaid rates are modeled using defined methods and parameters developed using federal regulation, national guidelines, and contracted consultant guidance. Rates are based on estimated reasonable costs as applicable to each service and caseload assumptions. Model inputs are developed for average benefit amounts, program supports, auxiliary operational costs, and administrative and indirect costs. Standards for variable inputs have been established using audit information, provider surveys, national publications and resources, and contracted national expertise. In addition, the department collected data specifically from ICT providers regarding all rate components, including a time study of both the licensed clinician and supervisors.

 

Montana Medicaid can only reimburse providers for allowable costs under federal rule. Nonreimbursable expenditures reported by providers are excluded from the rate methodology. In addition, cost information is tested for reasonableness. If reported costs deviate significantly outside state and national standards, and, do or do not, reconcile with financial audit information, expenditure assumptions are normalized or averaged.

 

The new ICT program was developed to be budget neutral to the department as there was not additional budget authority approved for a new program or new set of services.

 

The department submitted a state plan amendment in the Other Practitioners' Services page proposing the following calculation for ICT services.

 

Montana has a prospective Medicaid rate-setting method that was developed to reflect service definitions, provider requirements, operational service delivery, and administrative considerations. ICT service rates are calculated on a unit basis and set at an amount which will reasonably estimate the cost of providing covered services to Medicaid members.

 

Rate Components

 

The calculation separates out direct service components from indirect program components and overhead expenses essential to administer the service and program. The following elements are used to determine the rate, based on estimated reasonable costs, as applicable to each service.

 

1. Direct service expenditures including: direct staff wages, employee benefit costs, direct supervision, on-call differential for services that require 24-hour per day, 7-day a week on call for crisis intervention and response, program support costs, and mileage allowance.

 

2. Administrative overhead and indirect costs.

 

3. Auxiliary operational expenditures.

 

4. Productivity or billable time.  The productivity adjustment factor accounts for the amount of nonbillable time spent by staff.

 

5. Calculation Adjustors including Medicaid Offsets.

 

          a. Offsets are accounted for when providers receive other revenues in relation to the service, e.g., direct care wage.

 

          b. Other inflationary adjustments. Inflationary adjustments are allowed for legislative provider rate changes, other legislative adjustments, or changes in service scope from year to year.

 

          c. Policy adjustor. A policy adjustor may be applied to increase or decrease rates when the department determines that relative adjustments to specific rates are appropriate to meet Medicaid policy goals and appropriated budgets.

 

ICT Services includes ICT therapeutic interventions and Community Psychiatric Supportive Treatment (CPST) services. The two charts below outline the rate components for both services.

 

 Name of Service

Service Bundle Includes:

Rate Components Include:

Unit

  ICT  

  therapeutic   

  interventions

Crisis response and management, individual and family counseling and behavioral management and skill training

·     Direct staff wages

·     Employee benefit costs

·     Direct supervision

·     On-call differential (crisis services)

·     Program support costs

·     Mileage allowance

·     Administrative overhead/Indirect costs

·     Auxiliary Operational Expenditures

·     Productivity adjustment factor

·     Medicaid offsets

·     Other inflationary adjustments

·     Policy adjustor

Per 15-minutes

 

 

 

  Name of 

  Service

 

Service Bundle Includes:

Rate Components Include:

Unit

  Community

  Psychiatric 

  Supportive      Treatment  (CPST)

Assist the youth and family members or other collaterals to identify strategies or treatment options associated with the youth's mental illness, with the goal of minimizing the negative effects of mental illness symptoms or emotional disturbances or associated environmental stressors which interfere with the youth's daily living, financial management, housing, academic and/or employment progress, personal recovery or resilience, family or interpersonal relationships and community integration.

·     Direct staff wages

·     Employee benefit costs

·     Direct supervision

·     On-call differential (crisis services)

·     Program support costs

·     Administrative overhead/Indirect costs

·     Auxiliary Operational Expenditures

·     Productivity adjustment factor

·     Medicaid offsets

·     Other inflationary adjustments

Per 15-minutes

 

ICT Formula= (Hourly Provider Direct Costs + Hourly Provider Indirect Costs and Auxiliary Operational Expenditures) ÷ (Productivity Adjustment Factor or Billable Hours) x Calculation Adjustors)) ÷ 4 to convert to 15 minute unit)

 

Staffing ratios and caseload expectations are specific in rule. The commenter, in relation to costs, listed a staffing of two full-time clinicians and a half-time supervisor. The proposed model in NEW RULE III(3) states, an ICT team must have a minimum of one .125 full-time equivalent (FTE) ICT clinical supervisor and one FTE ICT clinician.  And (4) states, one FTE ICT clinical supervisor may supervise up to eight FTE ICT clinicians. This means that a half-time supervisor could have up to four ICT clinicians billing ICT services. The rate was calculated based on the proposed clinically based efficacy model.

 

Even though a half-time supervisor could have up to four ICT clinicians billing ICT services, an average of one-sixth of the salary and expenses of a supervisor is allotted in the rate calculation for one ICT therapist. Additionally, caseload expectations are listed in NEW RULE III(7):  one FTE ICT clinician may provide services for up to six families at a time. Although a therapist could have up to six clients, the rate methodology assumes a caseload of five.

 

Per the one-sixth supervisor assumption in the rate methodology, if a provider had a half-time supervisor with three clinicians billing for ICT services, the model assumes service to be billed for an average of five clients per clinician, or 15 clients per week in this scenario. Under these parameters, with an average of 15 clients at approximately $357 per week per client in ICT services, this would equate to approximately $280,000 per year in reimbursements to cover the cost of 3.5 FTE providing ICT service. With four clinicians billing under a half-time supervisor, the annual amount would climb to approximately $370,000 per year in reimbursements to cover the cost of 4.5 FTE serving an average of 20 Medicaid clients per week. If a clinician is able to serve more than an average of five clients in a week, or provide more hours of billable service, the amount of reimbursement would increase even more for providers.

 

The commenter states that they may not bill for ICT services for co-occurring Medicaid clients and instead use other Medicaid codes to bill for services. Based on the budget neutrality analysis, with correct billing there should not be a fiscal benefit for providers billing other outpatient services for co-occurring clients in lieu of ICT services. The department supports evidence-based services and encourages providers to aid youth with co-occurring practices when clinically necessary even when employing "usual" billing practices.

 

COMMENT #3: Two commenters asked if a Comprehensive School and Community Based Treatment (CSCT) could be allowed concurrently with ICT so long as CSCT service was limited to services provided in the school. Both commenters cited specific needs for this population that could not be addressed in full by either the ICT or CSCT clinicians. Additionally, one commenter stated that they were given permission by the ICT developer to have CSCT provided concurrently with ICT.

 

RESPONSE #3: The department is not allowing CSCT to be provided concurrently with ICT because of the potential for duplication of services. CSCT and ICT are both services which are considered to be community based and intensive level of services. It is required that CSCT be provided in the school, home, or community of the youth as determined by the needs of the youth, therefore, creating a duplication of services if provided concurrently with ICT. In addition, CSCT is reimbursed at a rate which is reflective of the services required for the youth.

 

In addition, the new ICT program was developed to be budget neutral to the department as there was not additional budget authority approved for a new program or new set of services. Providing CSCT concurrently with ICT compromises the budget neutrality of the ICT program.

 

COMMENT #4: One commenter expressed concerns about the statement of reasonable necessity stating that the youth must have a SED and a SUD, one of which must be severe.

 

RESPONSE #4: Although the severity specifier was included in the statement of reasonable necessity, it was not included in the official rule. There will not be a requirement that a youth must have a severe specifier, only that the youth must have an SED and SUD, which supports the necessity for being admitted into the ICT program. 

 

COMMENT #5: One commenter inquired if the department considered the requirement for an outside contractor to administer the ICT model fidelity tool when calculating the proposed rates.

 

RESPONSE #5: The department applied $4,815 under administrative indirects to reimburse a contractor to administer the ICT model fidelity tool. The figure was determined based upon the actual cost of administering the ICT model fidelity tool during the grant time frame.

 

COMMENT #6: One commenter asked if a provider must be licensed as a mental health center to provide ICT.

 

RESPONSE #6: A provider does not have to be licensed as a mental health center in order to provide this service.

 

 

/s/ Brenda K. Elias                                 /s/ Richard H. Opper                            

Brenda K. Elias, Attorney                       Richard H. Opper, Director

Rule Reviewer                                       Public Health and Human Services

 

         

Certified to the Secretary of State October 3, 2016.

 

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