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Montana Administrative Register Notice 37-859 No. 15   08/10/2018    
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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 37.34.3005, 37.85.104, 37.85.105, 37.85.106, 37.86.705, 37.86.805, 37.86.1006, 37.86.1101, 37.86.1105, 37.86.1406, 37.86.1807, 37.86.2005, 37.86.2605, 37.86.2803, 37.86.2806, 37.86.2905, 37.86.2912, 37.86.3007, 37.86.3109, 37.86.3205, and 37.86.3607 pertaining to updating the effective dates of non-Medicaid and Medicaid fee schedules

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT

 

TO: All Concerned Persons

 

            1. On August 30, 2018, 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 the Department of Public Health and Human Services no later than 5:00 p.m. on August 17, 2018, to advise us of the nature of the accommodation that you need. Please contact Todd Olson, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-9503; 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:

 

37.34.3005 REIMBURSEMENT FOR SERVICES OF MEDICAID FUNDED DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES (HCBS) WAIVER PROGRAMS (1) remains the same.

            (2)  The department adopts and incorporates by this reference the rates of reimbursement for the delivery of services and items available through each Home and Community-Based Services Waiver Program as specified in the Montana Developmental Disabilities Program Manual of Service Rates and Procedures of Reimbursement for Home and Community-Based Services (HCBS) 1915c, 0208, 1037 and 0667 Waiver Programs, effective July 1, 2018 September 1, 2018. A copy 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 http://dphhs.mt.gov/dsd/developmentaldisabililities/DDPratesinf

 

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

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

 

37.85.104 EFFECTIVE DATES OF PROVIDER FEE SCHEDULES FOR MONTANA NON-MEDICAID SERVICES (1) The department adopts and incorporates by reference the fee schedule for the following programs within the Addictive and Mental Disorders Division and Developmental Services Division on the dates stated:

            (a) Mental health services plan provider reimbursement, as provided in ARM 37.89.125, is effective July 1, 2018 September 1, 2018.

            (b) 72-hour presumptive eligibility for adult-crisis stabilization services reimbursement for services, as provided in ARM 37.89.523, is effective July 1, 2018 September 1, 2018.

            (c) Youth respite care services, as provided in ARM 37.87.2203, is effective July 1, 2018 September 1, 2018.

            (d) Substance use disorder services provider reimbursement, as provided in ARM 37.27.905, is effective July 1, 2018 September 1, 2018.

            (2) remains the same.

 

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

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

 

37.85.105 Effective dates, CONVERSION FACTORS, POLICY ADJUSTERS, AND COST-TO-CHARGE RATIOS of Montana Medicaid Provider Fee Schedules (1) remains the same.

            (2) The department adopts and incorporates by reference, the resource-based relative value scale (RBRVS) reimbursement methodology for specific providers as described in ARM 37.85.212 on the date stated.

            (a) remains the same.

            (b) Fee schedules are effective July 1, 2018 September 1, 2018. The conversion factor for physician services is $36.68 $37.99. The conversion factor for allied services is $22.96 $23.78. The conversion factor for mental health services is $23.20 $24.03. The conversion factor for anesthesia services is $28.87 $29.90.

            (c) remains the same.

            (d) The payment-to-charge ratio is effective January 1, 2018 September 1, 2018 and is 45.59% 47% of the provider's usual and customary charges.

            (e) through (h) remain the same.

            (i) Reimbursement for physician-administered drugs described in ARM 37.86.105 is determined in 42 CFR 414.904 (2016). The department adopts 102.83% 106% of the Average Sale Price (ASP), effective January 1, 2018 September 1, 2018.

            (j) Reimbursement for vaccines described at ARM 37.86.105 is effective July 1, 2018 September 1, 2018.

            (3) The department adopts and incorporates by reference, the fee schedule for the following programs within the Health Resources Division, on the date stated.

            (a) The inpatient hospital services fee schedule and inpatient hospital base fee schedule rates including:

            (i) the APR-DRG fee schedule for inpatient hospitals as provided in ARM 37.86.2907, effective March 1, 2018 September 1, 2018; and

            (ii) the Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), outlier thresholds, and APR grouper version 34 35 are contained in the APR-DRG Table of Weights and Thresholds effective March 1, 2018 September 1, 2018. The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds effective March 1, 2018 September 1, 2018.

            (b) The outpatient hospital services fee schedules including:

            (i) remains the same.

            (ii) the conversion factor for outpatient services on or after March 1, 2018 September 1, 2018 is $49.46 $51.22;

            (iii) remains the same.

            (iv) the bundled composite rate of $244.47 $252.00 for services provided in an outpatient maintenance dialysis clinic effective on or after January 1, 2018 September 1, 2018.

            (c) The hearing aid services fee schedule, as provided in ARM 37.86.805, is effective March 1, 2018 September 1, 2018.

            (d) The Relative Values for Dentists, as provided in ARM 37.86.1004, reference published in 2017 2018 resulting in a dental conversion factor of $32.77 $33.94 and fee schedule is effective March 1, 2018 September 1, 2018.

            (e) The dental services covered procedures, the Dental and Denturist Program Provider Manual, as provided in ARM 37.86.1006, is effective March 1, 2018 September 1, 2018.

            (f) The outpatient drugs reimbursement, dispensing fees range as provided in ARM 37.86.1105(3)(b) is effective July 1, 2018 September 1, 2018:

            (i) for pharmacies with prescription volume between 0 and 39,999, the minimum is $2.75 and the maximum is $14.55 $15.07;

            (ii) for pharmacies with prescription volume between 40,000 and 69,999, the minimum is $2.75 and the maximum is $12.61 $13.06; or

            (iii) for pharmacies with prescription volume greater than 70,000, the minimum is $2.75 and the maximum is $10.67 $11.05.

            (g) remains the same.

            (h) The outpatient drugs reimbursement, vaccine administration fee as provided in ARM 37.86.1105(6), will be $20.68 $21.32 for the first vaccine and $13.42 $13.90 for each additional administered vaccine, effective July 1, 2018 September 1, 2018.

            (i) remains the same.

            (j) The home infusion therapy services fee schedule, as provided in ARM 37.86.1506, is effective January 1, 2018 September 1, 2018.

            (k) Montana Medicaid adopts and incorporates by reference the Region D Supplier Manual, effective January 1, 2018 September 1, 2018, which outlines the Medicare coverage criteria for Medicare covered durable medical equipment, local coverage determinations (LCDs), and national coverage determinations (NCDs) as provided in ARM 37.86.1802, effective January 1, 2018 September 1, 2018. The prosthetic devices, durable medical equipment, and medical supplies fee schedule, as provided in ARM 37.86.1807, is effective March 1, 2018 September 1, 2018.

            (l) Fee schedules for nutrition, children's special health services, and orientation and mobility specialists as provided in ARM 37.86.2207(2), are effective July 1, 2018 September 1, 2018.

            (m) and (n) remain the same.

            (o) The ambulance services fee schedule, as provided in ARM 37.86.2605, is effective July 1, 2018 September 1, 2018.

            (p) The audiology fee schedule, as provided in ARM 37.86.705, is effective July 1, 2018 September 1, 2018.

            (q) The therapy fee schedules for occupational therapists, physical therapists, and speech therapists, as provided in ARM 37.86.610, are effective July 1, 2018 September 1, 2018.

            (r) The optometric fee schedule provided in ARM 37.86.2005, is effective July 1, 2018 September 1, 2018.

            (s) The chiropractic fee schedule, as provided in ARM 37.85.212(2), is effective July 1, 2018 September 1, 2018.

            (t) The lab and imaging fee schedule, as provided in ARM 37.85.212(2) and 37.86.3007, is effective July 1, 2018 September 1, 2018.

            (u) remains the same.

            (v) The Targeted Case Management for Children and Youth with Special Health Care Needs fee schedule, as provided in ARM 37.86.3910, is effective March 1, 2018 September 1, 2018.

            (w) The Targeted Case Management for High Risk Pregnant Women fee schedule, as provided in ARM 37.86.3415, is effective January 1, 2018 September 1, 2018.

            (x) The mobile imaging fee schedule, as provided in ARM 37.85.212, is effective July 1, 2018 September 1, 2018.

            (y) The licensed direct entry midwife fee schedule, as provided in ARM 37.85.212, is effective July 1, 2018 September 1, 2018.

            (z) remains the same.

            (4) The department adopts and incorporates by reference, the fee schedule for the following programs within the Senior and Long Term Care Division on the date stated:

            (a) Home and community-based services for elderly and physically disabled persons fee schedule, as provided in ARM 37.40.1421, is effective July 15, 2018 September 1, 2018.

            (b) Home health services fee schedule, as provided in ARM 37.40.705, is effective January 1, 2018 September 1, 2018.

            (c) Personal assistance services fee schedule, as provided in ARM 37.40.1135, is effective January 1, 2018 September 1, 2018.

            (d) Self-directed personal assistance services fee schedule, as provided in ARM 37.40.1135, is effective January 1, 2018 September 1, 2018.

            (e) Community first choice services fee schedule, as provided in ARM 37.40.1026, is effective January 1, 2018 September 1, 2018.

            (5) The department adopts and incorporates by reference, the fee schedule for the following programs within the Addictive and Mental Disorders Division on the date stated:

            (a) Mental health center services for adults reimbursement, as provided in ARM 37.88.907, is effective July 1, 2018 September 1, 2018.

            (b) Home and community-based services for adults with severe disabling mental illness, reimbursement, as provided in ARM 37.90.408, is effective July 15, 2018 September 1, 2018.

            (c) Substance use disorder services reimbursement, as provided in ARM 37.27.905, is effective July 1, 2018 September 1, 2018.

            (6) The department adopts and incorporates by reference, the fee schedule for the following program within the Developmental Services Division, on the date stated: Mental health services for youth, as provided in ARM 37.87.901 in the Medicaid Youth Mental Health Services Fee Schedule, is effective July 1, 2018 September 1, 2018

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-125, 53-6-402, MCA

 

37.85.106 MEDICAID BEHAVIORAL HEALTH TARGETED CASE MANAGEMENT FEE SCHEDULE (1) remains the same.

(2) The Department of Public Health and Human Services (department) adopts and incorporates by reference the Medicaid Behavioral Health Targeted Case Management Fee Schedule effective January 1, 2018 September 1, 2018 for the following programs within the Developmental Services Division (DSD) and the Addictive and Mental Disorders Division (AMDD):

(a) through (3) remain the same.

 

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

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

 

37.86.705 AUDIOLOGY SERVICES, REIMBURSEMENT (1) remains the same.

            (2) Subject to the requirements of this rule, the Montana Medicaid program pays the following for audiology services:

            (a) For patients who are eligible for Medicaid, the lowest of:

            (i) and (ii) remain the same.

            (iii) 97.01% 100% of the Medicare Region D allowable fee; or

            (iv) remains the same.

 

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

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

 

37.86.805 HEARING AID SERVICES, REIMBURSEMENT (1) The department will pay the lowest of the following for covered hearing aid services and items:

            (a) and (b) remain the same.

            (c) 97.01% 100% of the Medicare Region D allowable fee.

            (2) For items or services where no Medicare allowable fee is available, the fee schedule amount in (1)(b) will be calculated using the following methodology: 

            (a) remains the same.

 (b) For supplies or equipment, reimbursement will be set at 72.8% 75% of the manufacturer's suggested retail price. For items without a manufacturer's suggested retail price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount. For items that are custom-fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Medicaid providers by more than 20%.

            (c) and (3) remain the same.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA

 

            37.86.1006 DENTAL SERVICES, COVERED PROCEDURES (1) through (4) remain the same.

            (5) Covered services for adults age 21 and over include:

            (a) and (b) remain the same.

            (c) basic restorative services including prefabricated crown; and

            (d) extractions.; and

            (e) porcelain fused to base metal crowns with prior authorization, limited to two per person per year, total.  For second molars, base metal crowns only.

            (6) remains the same.

            (7) Full maxillary and full mandibular dentures are a Medicaid-covered service.  Coverage is limited to one set of dentures every ten years.  Only one lifetime exception to the ten-year time period is allowed per person if one of the following exceptions is authorized by the department:

            (a)  The dentures are no longer serviceable and cannot be relined or rebased; or

            (b)  The dentures are lost, stolen, or damaged beyond repair.

            (8)  Maxillary partial dentures and mandibular partial dentures are a Medicaid-covered service.  Coverage is limited to one set of partial dentures every five years. Only one lifetime exception to the five-year limit is allowed per person if one of the following exceptions is authorized by the department:

            (a)  The partial dentures are no longer serviceable and can no longer be relined or rebased; or

            (b)  The partial dentures are lost, stolen, or damaged beyond repair.

            (9)  The limits on coverage of denture replacement may be exceeded when the department determines that the existing dentures are causing the person serious physical health problems.  The dentist or denturist should indicate "replacement dentures" on the request for prior authorization of replacement dentures and document the medical necessity for the replacement.

            (10)  Coverage of all denture services is subject to the following requirements and limitations:

            (a)  A denturist may provide initial immediate full prosthesis and initial immediate partial prothesis only when prescribed in writing by a dentist.  The prescription must be signed and dated within 90 days of the order and must be maintained in the patient file.

            (b)  Requests for full prothesis must show the approximate date of the most recent extractions, and/or the age and type of the present prosthesis.

            (7) through (13) remain the same, but are renumbered (11) through (17).

            (14) (18)  All crowns Porcelain/ceramic crowns, noble metal crowns, and bridges are not covered benefits of the Medicaid program for individuals age 21 and over.

 

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

IMP: 53-6-101, 53-6-113, MCA

 

            37.86.1101 OUTPATIENT DRUGS, DEFINITIONS (1) and (2) remain the same.

            (3) "Allowed ingredient cost" means the "Average Acquisition Cost (AAC)" or "submitted ingredient cost," whichever is lower. If AAC is not available, drug reimbursement is determined at the lesser of "Wholesale Acquisition Cost (WAC)" minus 2.99%, "Federal Maximum Allowable Cost (FMAC)," or the "submitted ingredient cost."

            (4) through (15) remain the same.

 

AUTH: 53-2-201, 53-6-113, MCA

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

 

            37.86.1105 OUTPATIENT DRUGS, REIMBURSEMENT (1) through (12) remain the same.

            (13) Specialty pharmacies, hemophilia treatment centers, or centers of excellence that dispense clotting factors:

            (a) not purchased through the 340B program will be reimbursed at the lesser of the usual and customary charge, submitted ingredient cost, or wholesale acquisition cost minus 2.99%, plus the professional dispensing fee; or

            (b) when purchased through the 340B program, will be reimbursed the lesser of the usual and customary charge or wholesale acquisition cost minus 2.99%, plus the professional dispensing fee.

 

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

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

 

37.86.1406 CLINIC SERVICES, REIMBURSEMENT (1) Ambulatory surgical center (ASC) services as defined in ARM 37.86.1401(2) provided by an ASC will be reimbursed on a fee basis as follows:

            (a) 97.01% 100% of the Medicare allowable amount. For purposes of determining the Medicare allowable amount for ASC services to Medicaid members under this rule, the department adopts and incorporates by reference the methodology at 42 CFR part 416, subpart F, and the schedule listing the allowable amounts for ASC services in the Medicare Claims Processing Manual. The cited authorities are federal regulations and manuals specifying the methods and rules used to determine reasonable cost for purposes of the Medicare program. The Medicare Claims Processing Manual can be found on the Centers for Medicare and Medicaid website at www.cms.gov. The Code of Federal Regulations can be found at www.gpo.gov.

            (i) through (2) remain the same.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-6-101, 53-6-141, MCA

 

37.86.1807 PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, FEE SCHEDULE (1) and (2) remain the same.

            (3) The department's DMEPOS Fee Schedule for items other than those billed under generic or miscellaneous codes as described in (1) will include fees set and maintained according to the following methodology:

            (a) 97.01% 100% of the Medicare region D allowable fee;

            (b) remains the same.

            (c) Except as provided in (4), for all items for which no Medicare or Medicaid allowable fee is available, the department's fee schedule amount will be 72.8% 75% of the provider's usual and customary charge.

            (i) remains the same.

            (ii) Items having no product retail list price, such as items customized by the provider, will be reimbursed at 72.8% 75% of the provider's usual and customary charge as defined in (3)(b)(i).

            (4) The department's DMEPOS Fee Schedule, referred to in ARM 37.86.1807(2), for items billed under generic or miscellaneous codes as described in (1) will be 72.8% 75% of the provider's usual and customary charge as defined in (3)(b)(i). 

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA

 

            37.86.2005 OPTOMETRIC SERVICES, REIMBURSEMENT (1) remains the same.

            (2) For items or services where no RBRVS or Medicare is available, the fee schedule amount in (1)(c) will be calculated using the following methodology:

            (a) remains the same.

            (b) For supplies or equipment, reimbursement will be set at 72.8% 75% of the manufacturer's suggested retail price. For items without a manufacturer's suggested retail price, the charge will be considered reasonable if the provider's acquisition charge from the manufacturer is at least 50% of the charge amount. For items that are custom-fabricated at the place of service, the amount charged will be considered reasonable if it does not exceed the average charge of all Medicaid providers by more than 20%.

            (c) and (3) remain the same.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, 53-6-113, 53-6-141, MCA

 

            37.86.2605 AMBULANCE SERVICES, REIMBURSEMENT (1) through (3) remain the same.

            (4) For supplies or equipment, where there is no Medicare or Medicaid set fee, the provider's usual and customary charge in (1)(a) will be considered reasonable if set at 72.8% 75% of the manufacturer's suggested retail price. For items without a manufacturer's suggested retail price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount.

            (5) remains the same.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-6-101, 53-6-113, 53-6-141, MCA

 

            37.86.2803 ALL HOSPITAL REIMBURSEMENT, COST REPORTING

            (1) Allowable costs will be determined in accordance with generally accepted accounting principles as defined by the American Institute of Certified Public Accountants.

            (a) through (d) remain the same.

            (e) For cost report periods ending on or after January 1, 2018 through August 31, 2018, for each hospital which is a critical access hospital, as defined in ARM 37.86.2901, reimbursement for reasonable costs of inpatient and outpatient hospital services will be limited to 97.98% of allowable costs, as determined in accordance with (1).

            (f) For cost report periods ending on or after September 1, 2018, for each hospital which is a critical access hospital, as defined in ARM 37.86.2901, reimbursement for reasonable costs of inpatient and outpatient hospital services will be limited to 101% of allowable costs, as determined in accordance with (1).

            (2) and (3) remain the same.

 

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

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-149, MCA

 

37.86.2806 COST-BASED HOSPITAL, GENERAL REIMBURSEMENT 

(1) Cost-based reimbursement shall be applied as follows:

           (a) Critical access hospital (CAH) interim reimbursement is based on a hospital specific Medicaid inpatient cost-to-charge ratio (CCR), not to exceed 100%. For dates of service on or after January 1, 2018 through August 31, 2018, critical access hospital (CAH) interim reimbursement is based on a hospital-specific Medicaid inpatient cost-to-charge ratio (CCR), less 2.99%, not to exceed 100%.

           (b) For cost report periods ending on or prior to December 31, 2017, CAH final reimbursement is for reasonable costs of hospital services limited to 101% of allowable costs, as determined in accordance with ARM 37.86.2803(1). For cost report periods ending on or after January 1, 2018 through August 31, 2018, CAH final reimbursement is for reasonable costs of hospital services limited to 97.98% of allowable costs as determined in accordance with ARM 37.86.2803(1). For cost report periods ending on or after September 1, 2018, CAH final reimbursement is for reasonable costs of hospital services limited to 101% of allowable costs as determined in accordance with ARM 37.86.2803(1).

            (2) through (8) remain the same.

 

AUTH: 53-2-201, 53-6-113, MCA

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

 

            37.86.2905 INPATIENT HOSPITAL SERVICES, GENERAL REIMBURSEMENT (1) remains the same.

            (2) Interim reimbursement for cost-based facilities is based on a hospital-specific Medicaid inpatient cost-to-charge ratio, not to exceed 100%. For dates of service on or after January 1, 2018 through August 31, 2018, the interim reimbursement is based on a hospital-specific Medicaid inpatient cost-to-charge ratio, less 2.99%, not to exceed 100%. Cost-based facilities will be reimbursed their allowable costs as determined according to ARM 37.86.2803For cost report periods ending on or prior to December 31, 2017 final cost settlements for CAH facilities will be reimbursed at 101% of allowable costs. For cost report periods ending on or after January 1, 2018 through August 31, 2018, final cost settlements for CAH facilities will be reimbursed at 97.98% of allowable costs. For cost report periods ending on or after September 1, 2018, final cost settlements for CAH facilities will be reimbursed at 101% of allowable costs.

            (3) through (5) remain the same.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA

 

37.86.2912 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, CAPITAL-RELATED COSTS (1) remains the same.

            (2) The interim payment made to CAHs is based on the hospital-specific cost-to-charge ratio and includes capital costs. For dates of service on or after January 1, 2018 through August 31, 2018, the interim payment made is based on the hospital-specific cost-to-charge ratio, less 2.99%, and includes capital costs. For dates of service on or after September 1, 2018, the interim payment made is based on the hospital-specific cost-to-charge ratio, and includes capital costs.

            (3) remains the same.

 

AUTH: 2-4-201, 53-2-201, 53-6-113, MCA

IMP: 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.86.3007 OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, CLINICAL DIAGNOSTIC LABORATORY SERVICES

            (1) Clinical diagnostic laboratory services, including automated multichannel test panels (commonly referred to as "ATPs") and lab panels, will be reimbursed on a fee basis as follows with the exception of hospitals reimbursed under ARM 37.86.3005 and specific lab codes which are paid under ARM 37.86.3020:

            (a) The fee for a clinical diagnostic laboratory service is the applicable percentage of the Medicare fee schedule as follows:

            (i) 58.206% 60% of the prevailing Medicare fee schedule for a birthing center or where a hospital laboratory acts as an independent laboratory, i.e., performs tests for persons who are nonhospital patients;

            (ii) 60.1462% 62% of the prevailing Medicare fee schedule for a hospital designated as a sole community hospital as defined in ARM 37.86.2901; or

            (iii)  58.206% 60% of the prevailing Medicare fee schedule for a hospital that is not designated as a sole community hospital as defined in ARM 37.86.2901.

            (b) and (c) remain the same.

            (2) For purposes of this rule, clinical diagnostic laboratory services include the laboratory tests listed in codes defined in the HCPCS and listed in the Clinical Diagnostic Fee Schedule (CLAB) published January 1, 2017 January 1, 2018.

            (3) remains the same.

 

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

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

 

37.86.3109 OUTPATIENT CARDIAC AND PULMONARY REHABILITATION REIMBURSEMENT (1) Critical access hospital (CAH) interim reimbursement is based on a hospital-specific Medicaid outpatient cost-to-charge ratio, not to exceed 100%. For dates of service on or after January 1, 2018 through August 31, 2018, the interim reimbursement is based on the hospital specific Medicaid outpatient cost-to-charge ratio (CCR), less 2.99% not to exceed 100%. For dates of service on or after September 1, 2018, the interim reimbursement is based on the hospital-specific Medicaid outpatient cost-to-charge ratio. CAHs will be reimbursed their actual allowable costs determined according to ARM 37.86.2803.

(2) and (3) remain the same.

 

AUTH: 53-2-201, 53-6-111, MCA

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

 

            37.86.3205 NONHOSPITAL LABORATORY AND RADIOLOGY (X-RAY) SERVICES, REIMBURSEMENT (1) through (3) remain the same.

            (4) For clinical laboratory services, the department pays the lower of:

            (a) remains the same.

            (b) 58.206% 60% of the Medicare fee schedule for physician offices and independent labs and hospitals functioning as independent labs; or

            (c) remains the same.

 

AUTH: 53-6-113, MCA

IMP: 53-6-113, 53-6-141, MCA

 

37.86.3607 CASE MANAGEMENT SERVICES FOR PERSONS WITH DEVELOPMENTAL DISABILITIES, REIMBURSEMENT (1) Reimbursement for the delivery by provider entities of Medicaid funded targeted case management services to persons with developmental disabilities is provided as specified in the Montana Developmental Disabilities Program Manual of Service Reimbursement Rates and Procedures for Developmental Disabilities Case Management Services for Persons with Developmental Disabilities Who Are 16 Years of Age or Older or Who Reside in a Children's Community Home, dated January 1, 2018 September 1, 2018.

            (2) The department adopts and incorporates by this reference the Montana Developmental Disabilities Program Manual of Service Reimbursement Rates and Procedures for Developmental Disabilities Case Management Services for Persons with Developmental Disabilities Who Are 16 Years of Age or Older or Who Reside in a Children's Community Home, dated January 1, 2018 September 1, 2018. A copy 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 http://dphhs.mt.gov/dsd/developmentaldisabililities/DDPratesinf.

 

AUTH: 53-6-113, MCA

IMP: 53-6-101, MCA

 

            4. STATEMENT OF REASONABLE NECESSITY

 

The Department of Public Health and Human Services (department) administers the Montana Medicaid and non-Medicaid programs to provide health care to Montana's qualified low income, elderly, and disabled residents. Medicaid is a public assistance program paid for with state and federal funds appropriated to pay health care providers for the covered medical services they deliver to Medicaid members. Pursuant to 53-6-113(3), MCA, the legislature has delegated authority to the department to set by rule, the reimbursement rates that Medicaid pays to providers for covered services.

 

The purpose of the proposed rule amendment is to:  1) increase provider rates effective September 1, 2018; 2) reflect the rebasing of the All Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement methodology for inpatient services used by several divisions in the department which is necessary to stay within legislative appropriation; 3) increase the fee schedule rates for certain durable medical equipment in accordance with CMS final published rule – CMS 1687-IFC, effective September 1, 2018; and 4) modify the adult benefit package for restoring certain high cost, extensive dental procedures and dentures.

 

These rules apply to services for all people and eligibility categories for Montana Medicaid, including the Montana Medicaid Health and Economic Livelihood Partnership (HELP) Program that serves the Medicaid expansion population.

 

Proposed Provider Rate Increases

 

The department is proposing a number of provider rate increases effective September 1, 2018. The rate increases reverse across-the-board Medicaid provider rate reductions implemented in state fiscal year 2018. The provider rate increases are expected to distribute $5,085,784 of the Senate Bill (SB) 9 general fund budget restoration in 10 months of state fiscal year 2019.

 

The department has determined the new proposed provider rates are consistent with the efficiency, economy, and quality of care. The department believes these rates are sufficient to enlist enough providers so that care and services are available to the general population in the geographic area.

 

The department has posted proposed fee schedules to http://medicaidprovider.mt.gov/proposedfs.

 

The department has posted the Montana Developmental Disabilities Program Manual of Service Rates and Procedures of Reimbursement for Home and Community-Based Services (HCBS) 1915c, 0208, and 0667 Waiver Programs manual at http://dphhs.mt.gov/dsd/developmentaldisabililities/DDPratesinf.

 

Hospital Rates

 

The department proposes to adopt a new version of the APR-DRG grouper effective September 1, 2018. Version 35 of the APR-DRG grouper contains changes to DRG weights, average length of stays, and adds new DRGs. Hospital base rates are proposed to increase to meet the appropriated budget for inpatient hospitals. In addition, an increase in the conversion factor for outpatient hospitals is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.  This increase applies to free-standing birthing centers as they are paid under the outpatient hospital reimbursement methodology.

 

Fee Schedules

 

The department is proposing the adoption of September 1, 2018 fee schedules. The rates contained within these proposed fee schedules were modified to implement the provider rate increases discussed in the preceding section titled Proposed Provider Rate Increases.

 

Conversion Factor

 

The department is proposing an increase of 3.56% to the conversion factors utilized within the Resource Based Relative Value Scale (RBRVS) reimbursement methodology, to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

Medicare Rates

 

Many Montana Medicaid programs utilize Medicare rates for fee schedules, cost settlements, and reimbursements. The proposed rule change will increase reimbursement at posted Medicare rates for applicable codes. The September 1, 2018 proposed fee schedules reflect the rate increase, Medicare updates, and procedure code changes.  The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

Durable Medical Equipment

 

CMS published a final rule (CMS 1687-IFC) on May 11, 2018, that increases the Medicare fee schedule rates for certain durable medical equipment to safeguard beneficiary access for necessary items and services furnished in rural areas. 

 

The CMS rule increases the fee schedule amounts for certain DME items in rural areas effective June 1, 2018. In order to align the fee schedule effective date with the State Plan Amendment – Introduction Page, Attachment 4, 19B, the department is proposing an effective date of September 1, 2018.

 

ARM 37.34.3005

 

The department proposes to amend this rule to incorporate a new edition of the Montana Developmental Disabilities Program Manual of Service Rates and Procedures of Reimbursement for Home and Community-Based Services (HCBS) 1915c, 0208, and 0667 Waiver Programs, effective September 1, 2018, which includes increases in the rates of reimbursement for Medicaid-funded home and community services. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.104(1)(a), (b), and (d)

 

The department is updating the effective date of the mental health services plan, the 72-hour presumptive eligibility for adult crisis stabilization services, and substance use disorder services fee schedules to September 1, 2018. This includes updating codes. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.104(1)(c)

 

The department proposes to amend the Medicaid Youth Mental Health Fee Schedule to update the effective date to September 1, 2018.

 

ARM 37.85.105(2)(b)

 

The department proposes to update the following conversion factors in the following amounts to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases: physician services conversion factor from $36.68 to $37.99; allied services conversion factor from $22.96 to $23.78; mental health services conversion factor from $23.20 to $24.03; and anesthesia services conversion factor from $28.87 to $29.90. These changes will be effective on September 1, 2018, and therefore the RBRVS fee schedules will be made effective on that date.

 

ARM 37.85.105(2)(d)

 

The department is proposing to reinstate the provider payment to charge percentage to 47%. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(2)(i)

 

The department proposes to update reimbursement for physician-administered drugs as determined at 42 CFR 414.904 (2016). The department is proposing an increase in the percentage of average sales price (ASP) paid for physician-administered drugs. This increase is to reinstate the Medicare reimbursement of 106% of ASP. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(2)(j)

 

The department proposes to increase the fee schedule for vaccines effective September 1, 2018 by 3.56%, to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(a)(i)

 

The department proposes to update and revise the APR-DRG fee schedule for inpatient hospitals as provided in ARM 37.86.2907 effective September 1, 2018. The base rates will be increased to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(a)(ii)

 

The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds effective September 1, 2018, and updates the APR-DRG grouper version 34 to version 35. The department proposes these changes to include the revisions to the weights, thresholds, and DRGs proposed in version 35 of the APR-DRG grouper. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(b)(ii)

 

The department proposes to revise the conversion factor for outpatient services on or after September 1, 2018 from $49.46 to $51.22. The conversion factor for outpatient services is being increased to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(b)(iv)

 

The department proposes to revise the composite Rate for Dialysis from $244.47 to $252.00 effective September 1, 2018. The change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(c)

 

The department proposes to increase the hearing aid services fee schedule by 3.56% effective September 1, 2018, to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(d)

 

The department proposes to revise the relative value for dentists publish date to 2018 and revise the fee schedule effective date to September 1, 2018. This change is required to incorporate the most recently published relative value units for dentists. In addition, the department proposes to increase the dental conversion factor from $32.77 to $33.94. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(e)

 

The department proposes to update the fee schedules for dental services to reinstate coverage of certain high cost, extensive dental procedures, and dentures for adults. These changes result in a required update to the effective date of the fee schedule to September 1, 2018. The department proposes to update the Dental and Denturist Program Provider Manual effective September 1, 2018, to reflect changes outlined in ARM 37.86.1006.

 

ARM 37.85.105(3)(f)

 

The department proposes to revise the effective date regarding the outpatient drugs reimbursement dispensing fee ranges to September 1, 2018. The department is increasing the maximum dispensing fees by 3.56%. The change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(f)(i)

 

The department proposes to revise the maximum dispensing fees for pharmacies with prescription volumes between 0 and 39,999 from $14.55 to $15.07. The change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(f)(ii)

 

The department proposes to revise the maximum dispensing fee for pharmacies with prescription volumes between 40,000 and 69,999 from $12.61 to $13.06. The change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(f)(iii)

 

The department proposes to revise the maximum dispensing fee for pharmacies with prescription volumes greater than 70,000 from $10.67 to $11.05. The change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(h)

 

The department proposes to revise the outpatient drugs reimbursement vaccine administration fee, as provided in ARM 37.86.1105(6), from $20.68 to $21.32 for the first vaccine, and from $13.42 to $13.90, for each additional administered vaccine effective September 1, 2018. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(j)

 

The department proposes to revise the effective date of the home infusion therapy services fee schedule to September 1, 2018 increasing rates by 3.56%. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(k)

 

The department proposes to revise the effective date of the reference to the Region D Supplier Manual to September 1, 2018. The department will remove the 2.99% reductions to the 2018 Medicare rates, department set fees, and MSRP rates. Effective date of the revised fee schedule is September 1, 2018. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(l)

 

The department proposes to revise the effective date regarding the Early Periodic Screening, Diagnostic, and Treatment (EPSDT) fee schedule for nutrition, and orientation and mobility specialists to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(o)

 

The department proposes to revise the effective date regarding the ambulance services fee schedule to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(p)

 

The department proposes to revise the effective date for the audiology services fee schedule to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(q)

 

The department proposes to revise the effective date of the fee schedule for occupational therapists, physical therapists, and speech therapists to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(r)

 

The department proposes to revise the effective date of the optometric fee schedule to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(s)

 

The department proposes to revise the effective date of the chiropractic fee schedule to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(t)

 

The department proposes to revise the effective date of the lab and imaging fee schedule to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(v)

 

The department proposes to revise the effective date of the Targeted Case Management for Children and Youth with Special Health Care Needs fee schedule to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(w)

 

The department proposes to revise the effective date of the Targeted Case Management for High Risk Pregnant Women fee schedule to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(x)

 

The department proposes to revise the effective date of the mobile imaging fee schedule to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(3)(y)

 

The department proposes to revise the effective date of the licensed direct entry midwife fee schedule to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(4)(a)

 

The department proposes to increase the fee schedule date for Home and Community Based Services (HCBS) Waiver program to September 1, 2018. A rate increase (excluding member mileage) of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(4)(b)

 

The department proposes to update the fee schedule date for Home Health Services to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(4)(c) and (d)

 

The department proposes to update the fee schedule date for Personal Assistance Services to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(4)(e)

                                                                                           

The department proposes to update the fee schedule date for Community First Choice program services to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(5)(a)

 

The department proposes to update the fee schedule date for mental health center services to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(5)(b)

 

The department proposes to update the fee schedule date for home and community based services to September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(5)(c)

 

The department proposes to update the fee schedule for a reference for substance use disorder services reimbursement with an effective date of September 1, 2018. A rate increase of 3.56% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.105(6)

 

The department proposes to incorporate by reference the new fee schedules to implement the rates set by Montana Medicaid's resource based relative value scale (RBRVS) reimbursement for psychologists, social workers, and professional counselors. The department proposes to update the fee schedule date to September 1, 2018. A rate increase of 3.56% is proposed.

 

It is necessary for the department to incorporate new assigned relative values to implement rates set by Montana Medicaid's RBRVS reimbursement for psychologists, social workers, and professional counselors. The RBRVS is located in ARM 37.85.212.

 

These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.85.106(2)

 

The department proposes to amend this rule and update the fee schedule for targeted case management for adult and children's mental health services. The updated provider rates reflect a 3.56% increase to implement the provider rate increases outlined in the section titled Proposed Provider Rate Increases.

 

ARM 37.86.705 and 37.86.805

 

The department is proposing that the Montana Medicaid program pays the following for audiology and hearing aid services: the lowest of:  the provider's usual and customary charge for the service; the department fee schedule for each respective service; or 100% of the Medicare Region D allowable fee.

 

This change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.86.1006

 

The department proposes to reinstate dental coverage of certain high cost, extensive dental procedures and dentures for the adult Medicaid population. The Dental and Denturist Program Provider Manual informs providers of the requirements applicable to the delivery of services. Copies of the manual are available on the Montana Medicaid provider web site at http://medicaidprovider.mt.gov and from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

 

ARM 37.86.1101

 

The department proposes to eliminate the 2.99% reduction to WAC reimbursements made when Average Acquisition Cost (AAC) is not available. This change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.86.1105

 

The department proposes to eliminate the 2.99% reduction to WAC, within the clotting factor reimbursement calculation when dispensed by specialty pharmacies, hemophilia treatment centers, or centers of excellence. This increase is to both 340B and non-340B dispensed drugs. This change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.86.1406

 

The department proposes to reinstate reimbursement for ambulatory surgical centers services at 100% of the Medicare allowable amount. This change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.86.1807

 

The department proposes to modify the department's DMEPOS Fee Schedule for items other than those billed under generic or miscellaneous to 100% of the Medicare region D allowable fee. The department proposes to multiplicatively modify the Medicaid fee for all items for which there is no Medicare allowable fee available. The department is modifying the reimbursement percentage of the provider's usual and customary charge to 75%, effective September 1, 2018. In addition, for items that have no product retail list price, the department is proposing a reimbursement of 75% of the provider's usual and customary charge, effective September 1, 2018. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.86.805, 37.86.2005, and 37.86.2605

 

The department proposes to change the percentage of the manufacturer's suggested retail price that is considered reasonable when there is no established Medicare or Medicaid fee to 75%. For items without a manufacturer's suggested retail price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount effective September 1, 2018. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.86.2803, 37.86.2806, 37.86.2905, 37.86.2912, and 37.86.3109

 

The department proposes to increase the final cost settlement for critical access hospitals amount to 101%. In addition, the department proposes to increase the interim payment for all Critical Access Hospitals (CAHs) to their individual cost to charge ratios. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.86.3007

 

The department proposes to increase the percentage of the prevailing Medicare fee schedule for clinical diagnostic laboratory services. The revised percentages are as follows:  60% for a birthing center or where a hospital laboratory acts as an independent laboratory; 62% for a hospital designated as a sole community hospital; and 60% for a hospital that is not designated as a sole community hospital. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.86.3205

 

The department proposes to increase the percentage of the Medicare fee schedule for nonhospital laboratory services to 60%. This change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

ARM 37.86.3607

 

The purpose of this proposed amendment is to incorporate into the rule a new edition of the Montana Developmental Disabilities Program Manual of Service Reimbursement Rates and Procedures for Developmental Disabilities Case Management Services for Persons with Developmental Disabilities Who Are 16 Years of Age or Older or Who Reside in a Children's Community Home, to be dated September 1, 2018. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.

 

FISCAL IMPACT

 

The following table displays the fiscal impact as well as number of providers affected by the proposed changes.

 

Provider Type

SFY 2019 State Funds Impact

SFY 2019

Fed. Funds Impact

SFY 2019 Total Funds Impact

Enrolled Provider Count

Health Resources Division

 

 

 

 

Hospital - Inpatient

$1,927,995

$3,666,883

$5,594,878

376

Hospital - Outpatient

$1,072,455

$2,039,719

$3,112,174

315

Critical Access Hospital

$1,062,972

$2,021,684

$3,084,656

50

Physician

$1,269,757

$2,414,971

$3,684,728

8,830

Pharmacy Dispensing Fee

$257,272

$489,310

$746,582

425

Pharmacy WAC

$456,332

$867,904

$1,324,236

425

Dental

$824,814

$1,568,726

$2,393,540

584

Audiologist

$1,687

$3,209

$4,896

59

Licensed Professional Counselor

$31

$59

$90

657

Physical Therapist

$58,631

$111,511

$170,142

634

Podiatrist

$15,174

$28,860

$44,034

67

Private Duty Nursing Agency

$53,185

$101,153

$154,338

4

Psychiatrist

$2,931

$5,575

$8,506

260

Psychologist

$15

$29

$44

192

Occupational Therapist

$39,796

$75,690

$115,486

155

Social Worker

$578

$1,100

$1,678

454

Speech Pathologist

$42,378

$80,600

$122,978

171

Ambulance

$75,997

$144,539

$220,536

160

Ambulatory Surgical Center

$94,231

$179,219

$273,450

23

Case Mngmnt - Targeted HRPW/CSHCN

$8,388

$15,954

$24,342

15

Children's Special Health Svcs

$3,906

$7,430

$11,336

3

Chiropractor

$17,145

$32,607

$49,752

208

Denturist

$34,835

$66,253

$101,088

19

Dentists/Denturists (High Cost Dental Services)

$1,610,783

$3,063,574

$4,674,357

603

Dialysis Clinic

$50,860

$96,732

$147,592

21

Durable Medical Equipment

$297,390

$565,610

$863,000

443

Hearing Aid Dispenser

$2,998

$5,702

$8,700

35

Home Infusion Therapy

$17,711

$33,685

$51,396

15

Indep Diag Testing Facility

$6,474

$12,312

$18,786

19

Laboratory

$57,736

$109,808

$167,544

161

Mid-Level Practitioner

$280,069

$532,667

$812,736

3,127

Nutritionist/Dietician

$511

$971

$1,482

62

Optician

$1,795

$3,413

$5,208

34

Optometrist

$78,747

$149,769

$228,516

195

Free Standing Birthing Centers

$289

$551

$840

2

Orientation and Mobility

$467

$889

$1,356

3

Total

$8,115,553

$15,435,093

$23,550,646

 

Provider Type

SFY 2019 State Funds Impact

SFY 2019

Fed. Funds Impact

SFY 2019 Total Funds Impact

Enrolled Provider Count

Senior and Long Term Care Division

 

 

 

 

Home Health Agency

$10,645

$20,245

$30,890

26

Hospice

$62,774

$119,390

$182,164

30

Personal Care

$52,096

$99,082

$151,178

71

Community First Choice

$930,829

$1,770,357

$2,701,186

71

Home & Community Based Services

$765,082

$1,455,120

$2,220,202

583

Total

$1,821,425

$3,464,195

$5,285,620

 

Provider Type

SFY 2019 State Funds Impact

SFY 2019

Fed. Funds Impact

SFY 2019 Total Funds Impact

Enrolled Provider Count

Addictive and Mental Disorders Division

 

 

 

 

*Chemical Dependency Clinic (Sud) (Pt32)

$76,872

$146,204

$223,076

23

Targeted Case Management

$52,012

$98,923

$150,935

 

Critical Access Hospital
(Pt74)

$10,084

$19,180

$29,264

50

Home & Comm. Based Services (Pt28)

$80,685

$153,455

$234,140

583

Hospital - Inpatient (Pt01)

$53,183

$101,151

$154,334

141

Hospital - Outpatient (Pt02)

$14,912

$28,360

$43,272

315

Indep. Diag. Testing Facility (Pt72)

$3

$7

$10

19

Laboratory (Pt40)

$9,611

$18,279

$27,890

161

Licensed Professional Counselor (Pt58)

$82,422

$156,760

$239,182

657

Mental Health Center
(Pt59)

$331,687

$630,841

$962,528

19

Mid-Level Practitioner
(Pt44)

$30,534

$58,074

$88,608

3127

Physician(Pt27)

$24,886

$47,332

$72,218

8830

Psychiatrist (Pt65)

$21,387

$40,677

$62,064

260

Psychologist (Pt17)

$3,363

$6,395

$9,758

192

Social Worker(Pt42)

$41,424

$78,786

$120,210

454

1115 Waiver

$127,717

$242,907

$370,624

192

Total

$960,784

$1,827,329

$2,788,113

 

 

Provider Type

SFY 2019 State Funds Impact

SFY 2019

Fed. Funds Impact

SFY 2019 Total Funds Impact

Enrolled Provider Count

Disability Services Disorders Division

 

 

 

 

DD Waiver

$2,936,068

$5,343,876

$8,279,944

70

Case Management - DD

$115,915

$210,975

$326,890

1

Case Management – Children's Mental Health

$77,340

$147,095

$224,435

 19

Critical Access Hospital

$8,549

$16,259

$24,808

50

Home & Community Based Services 1915(i)

$730

$1,388

$2,118

583

Hospital - Inpatient

$119,504

$227,286

$346,790

141

Hospital - Outpatient

$44,103

$83,879

$127,982

315

Indep Diag Testing Facility

$14

$28

$42

19

Laboratory

$16,649

$31,665

$48,314

161

Licensed Professional Counselor

$153,478

$291,902

$445,380

657

Mental Health Center

$121,108

$230,336

$351,444

26

Mid-Level Practitioner

$26,154

$49,742

$75,896

3127

Physician

$34,850

$66,282

$101,132

8830

Psychiatric Res Treatment Facility

$334,252

$635,720

$969,972

15

Psychiatrist

$36,684

$69,770

$106,454

260

Psychologist

$11,474

$21,822

$33,296

192

Social Worker

$87,666

$166,732

$254,398

454

Home Support Services or Therapeutic Foster Care

$178,756

$339,978

$518,734

14

Therapeutic Group Home

$370,729

$705,095

$1,075,824

16

Comprehensive School & Community Treatment (Pt45)

$894,868

$1,701,962

$2,596,830

464

Total

$5,568,890

$10,341,793

$15,910,683

 

 

            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: Todd Olson, 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 the departmentlegal@mt.gov, and must be received no later than 5:00 p.m., September 7, 2018.

 

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

 

9. 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.

 

10. Section 53-6-196, MCA, requires that the department, when adopting by rule proposed changes in the delivery of services funded with Medicaid monies, make a determination of whether the principal reasons and rationale for the rule can be assessed by performance-based measures and, if the requirement is applicable, the method of such measurement.  The statute provides that the requirement is not applicable if the rule is for the implementation of rate increases or of federal law.

 

The department has determined that the proposed program changes presented in this notice are not appropriate for performance-based measurement and therefore are not subject to the performance-based measures requirement of 53-6-196, MCA.

 

            11. The department intends to apply these rule amendments retroactively to September 1, 2018. A retroactive application of the proposed rule amendments does not result in a negative impact to any affected party.

 

 

/s/ Brenda K. Elias                                       /s/ Sheila Hogan                                         

Brenda K. Elias                                            Sheila Hogan, Director

Rule Reviewer                                             Public Health and Human Services

 

Certified to the Secretary of State July 31, 2018.

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