BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
In the matter of the amendment of ARM 37.86.1001, 37.86.1004, 37.86.1005, and 37.86.1006 pertaining to Medicaid dental service providers' reimbursement rates
NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT
TO: All Concerned Persons
1. On May 20, 2009, at 3:00 p.m., the Department of Public Health and Human Services will hold a public hearing in the auditorium of the Department of Public Health and Human Services Building, 111 North Sanders, Helena, Montana, to consider the proposed amendment of the above-stated rules.
2. The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require an accommodation, contact Department of Public Health and Human Services no later than 5:00 p.m. on May 11, 2009, to advise us of the nature of the accommodation that you need. Please contact Rhonda Lesofski, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail firstname.lastname@example.org.
3. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
37.86.1001 DENTAL SERVICES, DEFINITIONS For purposes of this subchapter, the following definitions apply:
(1) remains the same.
(2) "Conversion factor" means the multiplier used to convert the relative value unit or units of a procedure to a reimbursement rate a provider may receive in payment from Montana Medicaid. The dental conversion factor approximates the amount the Legislature has appropriated for one unit of value of dental services.
(2) through (4) remain the same but are renumbered (3) through (5).
(6) "Policy adjustor" means a factor by which the product of the relative value units of a procedure or the conversion factor is multiplied to increase or decrease the fees paid by Montana Medicaid for certain categories of services.
(7) "Procedure code" means the number identifying a particular procedure. Montana Medicaid has adopted national uniform procedure codes.
(5) through (7) remain the same but are renumbered (8) through (10).
AUTH: 53-6-113, MCA
37.86.1004 REIMBURSEMENT METHODOLOGY FOR SOURCE BASED RELATIVE VALUE FOR DENTISTS (RVD) (1) For procedures listed in the relative values for dentists scale, reimbursement rates shall be determined using the following methodology:
(a) The fee for a covered service shall be the amount determined by multiplying the relative value unit specified in the relative values for dentists scale by the conversion factor specified in
(1)(b) (1)(c). The department adopts and incorporates by reference the rRelative vValues for dDentists scale (RVDs) published in 2007 2009. Copies of the relative values for dentists scale are The RVDs scale is available upon request from for inspection at the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.
(b) The conversion factor and provider fees for dentists, dental hygienists, and denturists procedures are calculated as follows:
(i) The total units of each procedure code paid in a prior period is multiplied by the RVU as published in (1)(a) to equal the RVD for each procedure code. Typically, the prior period used is the prior state fiscal year.
(ii) The sum of all RVDs calculated in (1)(b)(i) equals the total units of dental service.
(iii) The Montana Legislature's appropriation for dental service during the appropriation period is divided by the total units of dental service calculated in (1)(b)(ii). The resulting dollar value is equal to one unit of dental value and is the dental conversion factor.
(iv) The RVU as published in (1)(a) for each dental procedure is multiplied by the dental conversion factor calculated in (1)(b)(iii) to calculate the Medicaid reimbursement for the procedure. When this calculation is made for all covered procedures the Montana Medicaid Dental, Dental Hygienist, and Denturist Fee Schedules are generated.
(v) A policy adjuster may be applied to some fees calculated in (1)(b)(iv) for certain categories of services or to the conversion factor to increase or decrease the fees paid by Medicaid.
(b) (c) The conversion factor used to determine the Medicaid payment amount for services provided to eligible individuals is $31.27 $31.77.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-6-101, MCA
37.86.1005 DENTAL SERVICES, REIMBURSEMENT (1) through (6) remain the same.
(7) Payment for orthodontia will be as follows:
(a) Full band orthodontia for Medicaid recipients who have cleft lip/palate, craniofacial anomalies or malocclusions caused by traumatic injury and interceptive orthodontia for Medicaid recipients who have posterior crossbite with shift, anterior crossbite and/or anterior deep bite at 80% or greater vertical incisor overbite, will be reimbursed at 85% of the provider's usual and customary charge, subject to the maximum allowable charge as published in the department's Dental and Denturist Program Provider Manual effective
October 2007 July 2009.
(b) and (c) remain the same.
(d) Maximum allowable charges for each phase of orthodontic treatment, time lines for orthodontic phases of care, and the services included in each phase of orthodontic care are listed in the department's Dental and Denturist Program Provider Manual. The department adopts and incorporates by reference the department's Dental and Denturist Program Provider Manual effective
October 2007 July 2009. The guidelines, issued by the department to all providers of orthodontic services, inform providers of the requirements applicable to the delivery of services. A copy of the department's Dental and Denturist Program Provider Manual is available from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-6-101, 53-6-113,
37.86.1006 DENTAL SERVICES, COVERED PROCEDURES (1) For purposes of specifying coverage of dental services through the Medicaid program, the department adopts and incorporates by reference the Dental and Denturist Program Provider Manual effective
October 2007 July 2009. The Dental and Denturist Program Provider Manual informs the 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.hhs.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.
(2) through (8)(a) remain the same.
(9) Coverage of denture services
are is subject to the following requirements and limitations:
(a) through (17) remain the same.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-6-101, 53-6-113, MCA
4. The Department of Public Health and Human Services (department) is proposing the amendment of ARM 37.86.1001, 37.86.1004, 37.86.1005, and 37.86.1006 pertaining to Medicaid dental services. Montana Medicaid is a program administered by the department that pays for medical assistance to qualified low income and disabled Montana residents. Montana and the federal government jointly fund the program.
The Medicaid provider reimbursement rate is calculated using the Montana Legislature's bi-annual appropriations for Medicaid dental services. Fee schedules are generated by multiplying the relative value units for covered dental services by the dental conversion factor. Montana pays providers for service delivered to eligible individuals enrolled in the Medicaid program based on the fee schedules. These rule amendments are necessary to give notice of Montana Medicaid's dental reimbursement rate for state fiscal year 2010, which is based on the state fiscal year 2010 and 2011 appropriation for dental services by the 61st Legislative Session.
Rule amendments are also proposed to state Montana Medicaid's methodology for calculating the dental conversion factor. The department is not changing its method of calculating the dental conversion factor. The department is stating its methodology in rule to comply with requests for additional information by the Centers for Medicare and Medicaid Services, the federal agency that administers the Medicaid program.
The department is proposing to amend ARM 37.86.1001 to state in rule the definitions of the term "conversion factor", "policy adjuster", and "procedure code". ARM 37.86.1004 currently uses the term conversion factor and a definition is necessary for clarity. The term is commonly used to refer to the dollar factor by which the relative value of a medical procedure is multiplied to set a reimbursement rate. Montana Medicaid is adding the definition but it is not changing the method it uses to calculate the dental conversion factor.
Montana Medicaid is also adding the definition of policy adjuster. Policy adjusters are used to calculate some procedures' provider rates. Policy adjusters may be used to factor in forecasted utilization changes or errors in the reported RVUs.
A definition of "procedure code" is added because this term is used throughout the dental rules. "Procedure code" means the numerical code identifying a dental procedure. Montana Medicaid adopted the uniform coding system used nationwide.
The department is proposing an amendment to ARM 37.86.1004(1)(b) to state how it converts the relative value assigned to dental procedures into Montana Medicaid's dental fee schedules. The department has used fee schedules based on the relative value of dental services and an annual conversion factor for a number of years. This rule amendment is not a change in policy. The amendment is necessary to state in more detail the current rate setting process, which is similar to the method used by other health plans that reimburse on a fee for service basis.
Dental procedures are identified by uniform procedure codes. Montana does not create the coding system, it adopts the system used nationwide. The value of a particular procedure, identified by uniform code, is set relative to other dental procedures, based on factors such as work time, skill level, practice expense, and professional liability insurance. These values are expressed numerically as the relative value for dental services (RVD) referred to in rule. For example, if Procedure A has a RVU of 1 and procedure B has a RVU of 3, other factors being equal, procedure B will be reimbursed at three times the rate of procedure A. The department does not set RVDs, it adopts national RVDs.
Health plan fee schedules are calculated by multiplying RVDs by a conversion factor that represents the dollar value assigned by the payer, in this case Montana Medicaid, to one unit of dental service. Additionally, Montana Medicaid may use policy adjustors to calculate reimbursement rates for some procedures or the conversion factor to increase or decrease a fee for a particular service because of access or funding issues.
The conversion factor states the dollar value that Montana Medicaid assigns to one unit of dental care. Montana Medicaid calculates the conversion factor based on the Legislature's appropriation for the coming fiscal year divided by an estimate of total units of dental service that will be provided. Past year utilization and an estimate of increase in demand are used to estimate utilization. The department is proposing an amendment to ARM 37.86.1004(1)(c) to state the value it calculates for the dental conversion for state fiscal year (SFY) 2010.
These rules amendments are published prior to the end of the 61st Legislative Session in order to change rates by July 1, 2010. The final conversion factor may change based on the final appropriation of the Montana Legislature.
ARM 37.86.1005 and ARM 37.86.1006
These changes refer to a change in the Dental and Denturist Program Provider Manual. The change is intended to improve access to preventative dentistry services for babies and children through a new practice standard being developed by Montana dentists and the Montana Dental Association. The new practice standard is called Access to Baby and Child Dentistry (ABCD). This change allows dentists with the specialty training as an ABCD provider to utilize the new procedure codes D0145 and D0425 for children under age three and D1310 and D1330 for children under age six. Because the department is revising its Dental and Denturist Program Provider Manual effective July 1, 2009, it is amending the dates referenced in (7)(a) and (7)(d) of the rule from October 2007 to July 2009.
The estimated cumulative fiscal impact of these rules is based on the Legislative Appropriation for dental services in House Bill 2 as of April 15, 2009.
Total Cost State General Fund Federal Match
SFY 2010 $273,007 $64,348 $208,659
State General Fund and Federal Match based on the American Recovery and Reinvestment Act (ARRA) FMAP. At the time this proposed rule amendment was filed with the Secretary of State the 2009 Legislature had not finalized the biennial appropriation for dental services. When the appropriation is finalized, the amount of the conversion factor stated in this notice may change.
5. The department intends to apply these rules effective July 1, 2009. In the event the rules are amended retroactively no negative impact is anticipated.
6. Concerned persons may submit their data, views, or arguments either orally or in writing at the hearing. Written data, views, or arguments may also be submitted to: Rhonda Lesofski, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail email@example.com, and must be received no later than 5:00 p.m., May 28, 2009.
7. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing.
8. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 6 above or may be made by completing a request form at any rules hearing held by the department.
9. An electronic copy of this Proposal Notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. The Secretary of State strives to make the electronic copy of the Notice conform to the official version of the Notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the Notice and the electronic version of the Notice, only the official printed text will be considered. In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems.
10. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
/s/ Geralyn Driscoll /s/ Anna Whiting Sorrell
Rule Reviewer Anna Whiting Sorrell, Director
Public Health and Human Services
Certified to the Secretary of State April 20, 2009.