| HOME | SEARCH | ABOUT US | CONTACT US | HELP | ||
 |
 |
|
|
| Montana Administrative Register Notice 37-947 | No. 15 08/05/2022 | |
|
||
| Prev | Next | ||
|
BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Concerned Persons
1. On August 26, 2022, at 9:00 a.m., the Department of Public Health and Human Services will hold a public hearing via remote conferencing to consider the proposed adoption and repeal of the above-stated rules. Interested parties may access the remote conferencing platform in the following ways: (a) Join Zoom Meeting at: https://mt-gov.zoom.us/j/86785903743?pwd=aDF3TnlCbmFHdXhXdC9ic05leVZWUT09, Meeting ID: 867 8590 3743, Password: 475171; or (b) Dial by telephone: +1 646 558 8656, Meeting ID: 867 8590 3743, Password: 475171. Find your local number: https://mt-gov.zoom.us/u/kfQuprzhf.
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 12, 2022, to advise us of the nature of the accommodation that you need. Please contact Kassie Thompson, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail dphhslegal@mt.gov.
3. The rules as proposed to be adopted provide as follows:
NEW RULE I DEFINITIONS The definitions applicable to Applied Behavior Analysis (ABA) therapy services are as follows: (1) "Applied Behavior Analysis" (ABA) means a type of therapy that applies human behavior principles to improve a member's adaptive functioning and reduce problem behaviors due to a psychiatric and/or behavioral condition. (2) "Autism spectrum disorder" (ASD) means a condition as defined in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) of the American Psychiatric Association. The DSM-5 ASD definition is adopted and incorporated by reference. The DSM-5 defines and classifies mental disorders. A copy is available for public inspection at: Department of Public Health and Human Services, Behavioral Health and Developmental Disabilities Division, Developmental Disabilities Program, 111 N. Sanders, Helena, MT 59604-4210. A copy may be purchased online at https://dsm.psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787. (3) "Behavior identification assessment" (BIA) means a developmentally appropriate assessment that identifies strengths and weaknesses across domains and potential barriers to progress. Areas of assessment may include challenging behaviors and skill deficits, co-occurring medical and psychiatric conditions, cognitive, adaptive, and developmental functioning, and family dynamics. (4) "Board Certified Behavior Analyst®" (BCBA) means an individual with a graduate-level certification in behavior analysis who has been certified by the Behavior Analyst Certification Board (BACB). Professionals certified at the BCBA level are independent practitioners who provide ABA services. (5) "Board Certified Behavior Analyst-Doctoral®" (BCBA-D) means a Board Certified Behavior Analyst who has earned their PhD, in addition to their Master's and/or Bachelor's degrees, and had been certified by the BACB. Any reference to a BCBA in these rules includes BCBA-Ds, unless indicated otherwise. (6) "Board Certified Assistant Behavior Analyst®" (BCaBA) means an individual with an undergraduate level certification in behavior analysis who has been certified by the BACB. Professionals certified at the BCaBA level provide behavior analysis services under the supervision of a BCBA. (7) "DD eligible" means a member found eligible for the receipt of state-sponsored developmental disabilities services pursuant to ARM 37.34.201. (8) "Department" means the Montana Department of Public Health and Human Services. (9) "Developmental disability" (DD) means a condition or disability that meets the definition of "developmental disability" set forth in 53-20-202(3), MCA. (10) "Diagnostic evaluation" means an evaluation performed by a qualified health care professional with expertise in the diagnostic area, that establishes the qualifying diagnosis. (11) "Eligibility criteria" means those criteria established for the purposes of the program of ABA services authorized by the department, as specified in the Montana Medicaid Applied Behavior Analysis Services Manual (ABA Services manual), dated July 26, 2022. The department adopts and incorporates by reference the ABA Services manual which provides the public with greater detail about ABA services. Any conflict between these rules and what is outlined in the ABA Services manual should be resolved in favor of what is written in these rules. A copy may be accessed on the DPHHS website at the following link: https://medicaidprovider.mt.gov/manuals/appliedbehavioranalysisservicesmanual or a paper copy may be obtained from the department by a request in writing to the Department of Public Health and Human Services, Behavioral Health and Developmental Disabilities Division, Developmental Disabilities Program, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210 or at https://medicaidprovider.mt.gov/76. (12) "Functional impairment criteria" are defined in the ABA Services manual. (13) "Member" means a person enrolled in Montana Medicaid who is eligible to receive ABA services. (14) "Provisional qualifying diagnosis" means a member's diagnosis that qualifies the member for initiation of ABA services but that has not yet been confirmed by a qualified health care professional with expertise in the diagnostic area. The diagnosis must meet functional impairment criteria and be: (a) SED; (b) ASD; or (c) DD eligible. (15) "Qualified health care professional with expertise in the diagnostic area," for the purpose of Montana Medicaid ABA therapy services, refers to one of the following: (a) child and adolescent psychiatrist; (b) general psychiatrist with child and adolescent experience; (c) psychiatric mental health nurse practitioner with child and adolescent experience; (d) developmental pediatrician; or (e) neuropsychologist or psychologist. (16) "Qualifying diagnosis" means a member's diagnosis that is established by a qualified health care professional with expertise in the diagnostic area through a diagnostic evaluation. The diagnosis must meet functional impairment criteria and the diagnosis must be: (a) SED; (b) ASD; or (c) DD eligible. (17) "Registered behavior technician" (RBT) means an individual with a paraprofessional certification by the BACB in behavior analysis. The RBT assists in delivering behavior analysis services and practices under the direction and close supervision of a BCBA. The supervising BCBA is responsible for all work the RBT performs. (18) "Serious emotional disturbance" (SED), for the purposes of the program of ABA services authorized by the department, is a mental disorder as defined in the Clinical Guidelines chapter of the ABA Services manual. (19) "Treatment plan" means an individualized written document that has been developed from the BIA and contains all the critical features listed in the Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers Second Edition (ABA Treatment of ASD: Practice Guidelines) issued by the Behavior Analyst Certification Board, Inc.® (BACB) and/or Council of Autism Service Providers. The department adopts and incorporates by reference the ABA Treatment of ASD: Practice Guidelines, which provides guidelines and other information about ABA treatment for ASD. A copy is available for public inspection at the Department of Public Health and Human Services, Behavioral Health and Developmental Disabilities Division, Developmental Disabilities Program, located at 111 N. Sanders, Helena, MT 59604-4210 and is available online at https://casproviders.org/wp-content/uploads/2020/03/ABA-ASD-Practice-Guidelines.pdf. (20) "Unit of service" means 15 minutes of treatment service.
AUTH: 53-2-201, 53-6-113, 53-21-703, MCA IMP: 53-1-601, 53-1-602, 53-2-201, 53-6-101, MCA
NEW RULE II INITIAL ELIGIBILITY (1) For a member to qualify for initial ABA services, the member must meet the functional impairment criteria and must: (a) have a provisional qualifying diagnosis of ASD and be under 21 years of age; (b) be DD eligible and under 21 years of age; or (c) have a provisional qualifying diagnosis of SED and be either: (i) 17 years of age or younger; or (ii) up to 20 years of age and enrolled in an accredited secondary school. (2) A physician, licensed mental health professional, nurse practitioner, or psychologist must deem ABA services medically necessary to alleviate the symptoms of the stated provisional qualifying diagnosis and must document the medical necessity of the service in the form of a prescription. The prescription must state the diagnosis for which the member is being referred and that the referral is for ABA services. (3) The BCBA must complete, and submit to the department, the ABA Services Intent to Initiate Treatment form.
AUTH: 53-2-201, 53-6-113, 53-21-703, MCA IMP: 53-1-601, 53-1-602, 53-2-201, 53-6-101, 53-6-111, MCA
NEW RULE III CONTINUED ELIGIBILITY FOR ADDITIONAL UNITS OF SERVICE (1) For a member to continue receiving ABA services after the initial 180 calendar days or the initial authorized units of service are exhausted, they must meet all criteria for continued eligibility and for additional units of service, and the department must authorize such additional units of service. The criteria for continued eligibility and additional units of service, as well as the process and rules governing authorization of additional units of service are set forth below and in the ABA Services manual. (2) For a member to meet all criteria for continued eligibility: (a) The member must continue to meet the age criteria for initial eligibility in [NEW RULE II]; (b) The member's original provisional diagnosis must then be confirmed as a qualifying diagnosis through a diagnostic evaluation, performed by one of the qualified healthcare professionals with expertise in the diagnostic area; (c) The member must continue to meet functional impairment criteria that is supported in documentation the BCBA submits to the department; (d) The department must deem the member eligible through its authorization process; and (e) Both the BCBA and the referring physician, nurse practitioner, licensed mental health professional, or psychologist must deem the services medically necessary. (3) For a member to meet the criteria for additional units of service: (a) The member must continue to meet the eligibility criteria outlined above, the service requirements in [NEW RULE IV], and: (i) the BCBA providing services must have a reasonable expectation that the member will continue to benefit from the services and that the skill deficits and behaviors identified in the treatment plan will improve to a clinically meaningful extent; (ii) the treatment plan must demonstrate progress in each of the identified goals or provide a clinical explanation and modification to address a lack of progress; and (iii) the treatment plan demonstrates that the member is not experiencing a worsening of skill deficits or behaviors due to the treatment services. (b) The member must be excluded from eligibility for service if any of the following criteria occur: (i) The member demonstrates consistent worsening of skill deficits and/or behaviors with the service being delivered; (ii) The member's parent/guardian is not engaged in treatment and/or does not agree to continued service delivery; (iii) The member has medical conditions or impairments that would prevent beneficial utilization of services; (iv) The member has demonstrated no significant progress in treatment goals for two consecutive additional units of service request reviews, and the BCBA provider cannot sufficiently explain the lack of progress to justify continuing to authorize the service; or (v) The member can be safely and effectively treated at a less intensive level of service or care. (4) The BCBA must receive authorization from the department for additional units of services before such units of service can be provided. (5) For the department to authorize additional units of service: (a) The BCBA must complete and submit the ABA Services Additional Units of Service Request form and additional required documentation at least 14 calendar days prior to the intended onset of continued service delivery. Additional required documentation is specified in the ABA Services manual; and (b) The member must continue to have a qualifying diagnosis that meets the criteria of (2)(b). (6) The processes for a service provider to request additional units of service and for the department's review and authorization are outlined in the ABA Services manual's Authorization of Additional Units of Service section. (7) If a previous request is denied, a service provider may submit a request for additional units of service if they have additional information to satisfy any deficiencies noted with respect to such denied request. This is considered a new submission and all required documents will need to be submitted again for a new department review and determination.
AUTH: 53-2-201, 53-6-113, 53-21-703, MCA IMP: 53-1-601, 53-1-602, 53-2-201, 53-6-101, 53-6-111, 53-21-701, 53-21-702, MCA
NEW RULE IV SERVICE REQUIREMENTS (1) Services are covered only when within the scope of the provider's license. All providers must comply with all applicable state and federal statutes, rules, and regulations. (2) Individuals receiving ABA services must meet the department's applicable initial and/or continuing eligibility criteria. The services delivered must meet all the following service requirements: (a) The services must be approved by utilizing the processes, including the authorization process, outlined in the ABA Services manual. The ABA provider must satisfy the service requirements listed here and in the ABA Services manual. (b) The services must be directed by a BCBA or BCBA-D. Some services may be provided by a BCaBA or an RBT if the BCaBA or RBT meets the qualifications of [NEW RULE VI] and is supervised by the BCBA in accordance with ARM 24.189.910. (c) The services delivered must be consistent with the following elements as outlined in the ABA Treatment of ASD Practice Guidelines: (i) ABA core characteristics; (ii) Essential practice elements; and (iii) Assessment, formulation of treatment goals, and measurement of client progress. (d) Services are delivered in compliance with the member's individualized treatment plan, developed within 30 calendar days of onset of services, and containing all the critical features listed in the ABA Treatment of ASD Practice Guidelines. (e) Services must be provided or supervised by the BCBA, BCBA-D, or BCaBA who wrote the treatment plan. (f) Services must be provided to the member in person, with the provider and the member in the same physical location, unless specifically authorized in writing by the department. (3) ABA services may continue so long as the member does not meet any of the service exclusion criteria set forth in [NEW RULE III(3)(b)]. (4) In addition to the requirements outlined in this rule, the ABA Services manual sets forth requirements, request and review processes, and procedures for ABA services with which an ABA provider must comply.
AUTH: 53-2-201, 53-6-113, 53-21-703, MCA IMP: 37-17-403, 53-1-601, 53-1-602, 53-2-201, 53-6-101, 53-21-701, 53-21-702, MCA
NEW RULE V CONCURRENT SERVICES (1) The following Montana Medicaid Children's Mental Health Bureau (CMHB) services may be provided concurrently with ABA services if ABA services are provided and billed outside the authorized treatment hours of the other programs, and if providers demonstrate and document attempts made for coordination with community-based services: (a) partial hospital services (PHP); (b) day treatment (Day TX); (c) comprehensive school and community treatment (CSCT); (d) therapeutic group home (TGH); (e) home support services (HSS); (f) therapeutic foster care (TFC); (g) extraordinary needs aide (ENA); and/or (h) targeted case management (TCM) for youth with SED. (2) The following Montana Medicaid CMHB services may not be provided concurrently with ABA services, as they are considered duplicative: (a) community-based psychiatric rehabilitation and support services (CBPRS); (b) psychiatric residential treatment facility (PRTF); (c) acute inpatient hospital services; and/or (d) intensive outpatient services (IOP).
AUTH: 53-2-201, 53-6-113, 53-21-703, MCA IMP: 53-1-601, 53-1-602, 53-2-201, 53-6-101, 53-21-701, 53-21-702, MCA
NEW RULE VI PROVIDER REQUIREMENTS (1) A BCBA/BCBA-D must: (a) comply with, and agree to be bound by, all laws, rules, regulations, and policies generally applicable to Medicaid providers including the provisions of ARM 37.85.401, 37.85.402, 37.85.406, 37.85.407, 37.85.410, 37.85.414, and 37.85.415; (b) be licensed and have met the licensure requirements for the State of Montana located in ARM 24.189.901; (c) follow all supervision requirements of ARM 24.189.910; and (d) maintain responsibility for billing for BCaBA's and RBT's services and assuring that the services are delivered in accordance with the member's Treatment Plan. (2) A BCaBA must: (a) be licensed and have met the licensure requirements for the State of Montana found in ARM 24.189.907; and (b) work under the oversight of a BCBA who assumes full professional responsibility for the services delivered and billed. (3) An RBT must work under the oversight of a BCBA who bills and assumes full responsibility for services delivered.
AUTH: 53-2-201, 53-6-113, 53-21-703, MCA IMP: 53-1-601, 53-1-602, 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-21-701, 53-21-702, MCA
NEW RULE VII PROVIDER REIMBURSEMENT (1) The department will pay providers of ABA services the lesser of: (a) the provider's actual submitted charge for services; or (b) the rate established in the department's Medicaid fee schedule, as adopted in ARM 37.85.106. (2) Claims must be submitted by, or on behalf of, a BCBA licensed by the State of Montana and enrolled as a Montana Medicaid provider. (3) The provider may not: (a) utilize Current Procedural Terminology (CPT) codes not approved by the department; or (b) exceed the authorized units of service in an authorized 180 calendar day timespan. (4) The department may review the medical necessity of services or items at any time, either before or after payment, in accordance with the provisions of ARM 37.85.410. If the department determines that services or items were not medically necessary, or otherwise not in compliance with applicable requirements, the department may deny payment or may recover any overpayment in accordance with applicable requirements. (5) The department may not authorize provider's reimbursement retroactively for failure to submit timely, complete, and required documentation.
AUTH: 53-2-201, 53-6-113, 53-21-703, MCA IMP: 53-1-601, 53-1-602, 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-21-701, 53-21-702, MCA
NEW RULE VIII HEARING RIGHTS (1) Providers who are aggrieved by an adverse department action under these rules may request a hearing to the extent provided, and according to the procedures specified, in ARM 37.85.411.
AUTH: 2-4-201, 53-6-113, 53-21-703, MCA IMP: 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
4. The department proposes to repeal the following rules:
37.34.1901 MEDICAID HOME AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: AUTHORITY
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1903 MEDICAID HOME AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: GENERALLY
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1905 MEDICAID HOME AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: ELIGIBILITY
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1907 MEDICAID HOME AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: SCREENING AND ACCEPTANCE DETERMINATIONS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1909 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: TRANSITIONING FROM THE CHILDREN'S AUTISM WAIVER
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1911 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: REIMBURSEMENT
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1913 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: AVAILABLE SERVICES
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1915 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: GENERAL PROVIDER REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1917 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: INDIVIDUAL FAMILY SERVICE PLAN
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1919 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: NOTICES AND FAIR HEARINGS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1921 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: INFORMING BENEFICIARY OF CHOICE
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1923 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: CHILDREN'S AUTISM TRAINING, DEFINITION
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1925 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: CHILDREN'S AUTISM TRAINING, REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1927 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: WAIVER-FUNDED CHILDREN'S CASE MANAGEMENT
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1929 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: WAIVER-FUNDED CHILDREN'S CASE MANAGEMENT, REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1931 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: RESPITE, DEFINITION
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1933 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: RESPITE, REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1935 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: ENVIRONMENTAL MODIFICATION, DEFINITION
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1937 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: ENVIRONMENTAL MODIFICATION, REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1939 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: ADAPTIVE EQUIPMENT, DEFINITION
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1941 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: ADAPTIVE EQUIPMENT, REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1943 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: OCCUPATIONAL THERAPY, DEFINITION
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1945 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: OCCUPATIONAL THERAPY, REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1947 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: PHYSICAL THERAPY, DEFINITION
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1949 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: PHYSICAL THERAPY, REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1951 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: SPEECH THERAPY, DEFINITION
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1953 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: SPEECH THERAPY, REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1955 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: TRANSPORTATION, DEFINITION
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1957 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: TRANSPORTATION, REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1959 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: INDIVIDUAL GOODS AND SERVICES, DEFINITION
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1961 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: INDIVIDUAL GOODS AND SERVICES, REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1963 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: PROGRAM DESIGN AND MONITORING, DEFINITION
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
37.34.1965 MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: PROGRAM DESIGN AND MONITORING, REQUIREMENTS
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA
5. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (department) is proposing to adopt New Rules I through VIII to govern the Applied Behavior Analysis (ABA) Services Medicaid State Plan.
The purpose of the proposed new rules is to establish, in accordance with federal requirements and the intent of the 2017 Montana Legislature in Senate Bill 199, a Medicaid state program to provide appropriate services to youth who have not reached age 21 who have a diagnosis of autism, to individuals with other serious emotional disturbance (SED) diagnoses, and to DD eligible members that meet functional impairment criteria.
NEW RULE I DEFINITIONS New Rule I sets forth the definitions for the terms that are used in the context of the program. The proposed rule adopts, and incorporates by reference, a portion of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition, the Montana Medicaid Applied Behavior Analysis Services Manual (ABA Services manual), and the Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers Second Edition (ABA Treatment of ASD: Practice Guidelines). The proposed adoption of definitions in rule is necessary to ensure that the services to be provided and the forms and processes for service delivery are consistent and well-understood by providers, members, and state staff. The proposed adoption and incorporation by reference of these materials is necessary to provide the public with additional clarification about relevant mental disorders, program requirements, and guidelines and information about ABA treatment for individuals with autism.
NEW RULE II INITIAL ELIGIBILITY New Rule II establishes the criteria and process for the Medicaid provider to determine initial eligibility to receive services through the ABA services program for a youth receiving Medicaid. The proposed rule dictates that the initial services may be provided to members with a provisional qualifying diagnosis of autism spectrum disorder (ASD) or SED, or have been determined to be DD eligible. The member must also meet the specified functional impairment criteria. The criteria creates consistency for population types across various service programs, but ABA services may be available to individuals as an early and periodic screening, diagnostic, and treatment (EPSDT)-covered service if not covered directly under this rule. A physician, licensed mental health professional, or other qualified health care professional must deem ABA services medically necessary. The proposed rule would require that the medical necessity and the provisional qualifying diagnosis are documented in the form of a prescription. The BCBA will complete and submit the required documentation. No other advanced authorization is needed with respect to the authorized service units if the member meets the eligibility criteria as well as all criteria, processes, and procedures in the ABA Services manual. The proposed rule is necessary to identify who is eligible for initial service units.
NEW RULE III CONTINUED ELIGIBILITY FOR ADDITIONAL UNITS OF SERVICE New Rule III establishes the criteria and process for the Medicaid provider to determine a Medicaid member's continued eligibility to receive additional units of services available through the ABA services program. Continued service units are requested by a BCBA by submitting both a qualifying diagnosis established by a qualified health care professional with expertise in the diagnostic area, and functional impairment criteria must continue to be met and supported in documentation. The proposed rule states that a member must meet Medicaid initial eligibility criteria and all criteria for continued eligibility. The member must not be excluded from eligibility for service through any of the listed criteria in the proposed rule. The rule proposes that the required documentation must be completed and submitted within the defined timeframe. It is necessary to adopt this proposed rule to identify who has continued eligibility for additional service units, the process to request such additional service units, and to establish the medical necessity criteria required for the continuation of ABA services.
NEW RULE IV SERVICE REQUIREMENTS New Rule IV proposes the specific requirements that a Montana Medicaid provider must follow for appropriate billing of ABA services, the criteria for the receipt of authorization of continued authorized units of service, and requirements that ensure the program services a member receives are medically necessary. It is necessary to adopt this proposed rule to define the program parameters; doing so will effectively serve participants and aid the program's fiscal responsibility for Medicaid funds.
NEW RULE V CONCURRENT SERVICES New Rule V establishes the specific services that may not be provided concurrently with ABA services. This rule would also outline the services that may be provided concurrently with ABA services, provided that there is demonstrated and documented attempts to coordinate with the other community-based services. The proposed rule is necessary to add language which precludes the member from receiving certain other Medicaid-funded Children's Mental Health Bureau services that would be duplicative of the services being delivered through the Medicaid-funded ABA services program.
NEW RULE VI PROVIDER REQUIREMENTS New Rule VI establishes the various criteria that qualify a person to provide the Medicaid ABA services. Those who would qualify include a BCBA, a BCaBA, and a RBT. The proposed provider requirements are necessary to ensure that participating members receive services from qualified providers.
NEW RULE VII PROVIDER REIMBURSEMENT New Rule VII establishes both the various criteria by which a provider is reimbursed for services and how the department determines the provider's reimbursement rate pursuant to ARM 37.85.106. It also gives notice of the department's medical necessity review pursuant to ARM 37.85.410. This proposed rule is necessary to establish provider requirements and department responsibilities for reimbursement of services.
NEW RULE VIII HEARING RIGHTS New Rule VIII gives notice of the department's appeal process pursuant to ARM 37.85.411. This rule is necessary to inform the public of their hearing rights and the process to appeal a department decision.
The department is also proposing to repeal ARM 37.34.1901, 37.34.1903, 37.34.1905, 37.34.1907, 37.34.1909, 37.34.1911, 37.34.1913, 37.34.1915, 37.34.1917, 37.34.1919, 37.34.1921, 37.34.1923, 37.34.1925, 37.34.1927, 37.34.1929, 37.34.1931, 37.34.1933, 37.34.1935, 37.34.1937, 37.34.1939, 37.34.1941, 37.34.1943, 37.34.1945, 37.34.1947, 37.34.1949, 37.34.1951, 37.34.1953, 37.34.1955, 37.34.1957, 37.34.1959, 37.34.1961, 37.34.1963, and 37.34.1965, pertaining to children's autism waiver. These rules are for a waiver service that is no longer available and are unrelated to the new proposed rules pertaining to ABA services.
Fiscal Impact
The proposed new rules allow additional ABA services and expand program eligibility for the ABA program. The programmatic changes are projected to increase Medicaid provider enrollment while increasing the number of clients receiving ABA services by 130 clients over the biennium. With the ABA programmatic changes, an estimated total of 433 clients would receive ABA services over the biennium. The additional allowable ABA services will positively impact most clients receiving ABA services. Changes to the ABA program are anticipated to increase Medicaid expenditures by $585,000, or 67%, in state fiscal year 2022, and $1.1 million, or 113%, in state fiscal year 2023.
6. The department intends to apply these rule adoptions and repeals retroactively to August 1, 2021. A retroactive application of the proposed rule adoptions and repeals does not result in a negative impact to any affected party.
7. 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: Kassie Thompson, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail dphhslegal@mt.gov, and must be received no later than 5:00 p.m., September 2, 2022.
8. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing.
9. 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 7 above or may be made by completing a request form at any rules hearing held by the department.
10. The bill sponsor contact requirements of 2-4-302, MCA, do apply and the sponsor was contacted by phone and by email on July 15, 2022.
11. With regard to the requirements of 2-4-111, MCA, the department has determined that the adoption and repeal of the above-referenced rules will significantly and directly impact small businesses.
12. Section 53-6-196, MCA, requires that the department, when adopting by rule proposed changes in the delivery of services funded with Medicaid monies, to determine 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.
/s/ ALEEA SHARP /s/ CHARLES T. BRERETON Aleea Sharp Charles T. Brereton, Director Rule Reviewer Department of Public Health and Human Services
Certified to the Secretary of State July 26, 2022.
|
A directory of state agencies is available online at http://www.mt.gov/govt/agencylisting.asp.
For questions about the organization of the ARM or this web site, contact sosarm@mt.gov.
