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Montana Administrative Register Notice 37-510 No. 8   04/29/2010    
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BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment ARM 37.86.5201, 37.86.5202, 37.86.5204, 37.86.5205, and 37.86.5206 pertaining to Medicaid Health Improvement Program

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT

 

TO:  All Concerned Persons

 

            1.  On May 27, 2010, 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 Department of Public Health and Human Services no later than 5:00 p.m. on May 18, 2010, 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 dphhslegal@mt.gov.

 

            3.  The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:

 

            37.86.5201  DISEASE MANAGEMENT PROGRAM HEALTH IMPROVEMENT PROGRAM:  DEFINITIONS  The following terms and definitions apply to the disease management Health Improvement pProgram:

            (1)  "Disease management organization (DMO)" means a clinically qualified organization that has a disease management program which uses evidence based health care practices. 

            (2)  "Disease management program services" means specialized services provided to Medicaid clients meeting the eligibility criteria listed in ARM 37.86.5205. Disease management program services are aimed at care coordination, client education, improved client self-care, and efficiency, and cost effectiveness of services.

            (3) (1)  "Eligible client" means a Montana Medicaid or Healthy Montana Kids Plus (HMK Plus) client who has the disease management Health Improvement pProgram's specified combination of eligibility and disease risk factors.

            (4) (2)  "Enrolled client" means an eligible client who has been notified in writing of enrollment in the disease management Health Improvement pProgram and eligibility to receive disease management program services and who has not declined to participate.

            (5) (3)  "Evidence based healthcare health care practice" means a clinical approach to practicing medicine based on the clinician's awareness of medical evidence and the strength of that evidence to support the management of a disease treatment process.

            (4)  "Health center" means a tribal health center or a community-based health clinic or center that serves populations with limited access to care, has a patient majority governing board and a sliding payment scale.

            (5)  "Health improvement program services" means specialized services provided to Medicaid and HMK Plus clients meeting the eligibility criteria listed in ARM 37.86.5205.  Health improvement program services are care coordination and client education for improved client self-care, efficiency, and cost effectiveness of services.

            (6)  "Medical home" means one primary care provider or clinic who provides that delivers the majority of all ambulatory health care services to each client.  This provider The medical home is the client's source for routine or preventive healthcare health care.

 

AUTH:  53-6-101, 53-6-113, MCA

IMP:  53-6-101, 53-6-113, MCA

 

            37.86.5202  DISEASE MANAGEMENT HEALTH IMPROVEMENT PROGRAM:  GENERAL  (1)  The disease management Health Improvement pProgram provides coordinated health care interventions and education for Medicaid and HMK Plus clients meeting the eligibility criteria listed in ARM 37.86.5205.  The purpose of the program is to provide and/or coordinate services that decrease utilization and cost while optimizing treatment and improving health outcomes for clients.

            (2)  A disease management program must include the following procedures:

            (a)  evaluate each enrolled client;

            (b)  prioritize disease management program services provided to an enrolled client based on the client's need or other criteria, as appropriate; and

            (c)  contact and coordinate with a department or department authorized case manager as appropriate for planned service delivery to an enrolled client.

            (3) (2)  Disease management Health improvement program services must provide include one or more of the following to each enrolled identified high risk client:

            (a) and (b) remain the same.

            (c)  instruction regarding self-managing the targeted conditions;

            (d) remains the same.

            (e)  coordination with a department or department other authorized case managers.

            (4)(3)  Disease management Health improvement program services do not:

            (a) through (d) remain the same.

 

AUTH:  53-6-101, 53-6-113, MCA

IMP:  53-6-101, 53-6-113, MCA

 

            37.86.5204  CRITERIA FOR DETERMINING CHRONIC DISEASES MEDICAID AND HEALTHY MONTANA KIDS PLUS (HMK PLUS) ELIGIBLE INDIVIDUALS MANAGED UNDER THE DISEASE MANAGEMENT HEALTH IMPROVEMENT PROGRAM  (1)  The department uses the criteria listed in this rule to specify the chronic conditions included in the disease management program and the age groups eligible to participate.  Conditions and age groups employs high risk case identification to assign those individuals who are potentially high risk or high cost to the Health Improvement Program.  Selection criteria are subject to change as clinical practices and evidenced-based health care practice guidelines change.  The following criteria are used:

            (a)  disease management program services improve client self-management, decrease medical service utilization and costs, or improve clinical measures and health outcomes;

            (b)  the existing clinical practice for the condition varies from evidence-based health care best practice guidelines;

            (c)  the prevalence of the condition in the Medicaid population is sufficient to warrant management;

            (a)  individuals who have high medical costs;

            (b)  individuals who are at risk for above-average future medical service utilization; and

            (d) (c)  a client with the condition is individuals who are able to understand and apply condition specific recommended health management techniques.; and

            (e)  management of the condition does not clinically conflict with other co-morbidities.

 

AUTH:  53-6-101, 53-6-113, MCA

IMP:  53-6-101, 53-6-113, MCA

 

            37.86.5205  DISEASE MANAGEMENT HEALTH IMPROVEMENT PROGRAM:  CLIENT ELIGIBILITY AND ASSIGNMENT  (1)  To receive disease management health improvement services an eligible client must be:

            (a)  a recipient of Montana Medicaid or HMK Plus; and

            (b)  eligible for the Passport to Health Program. diagnosed with at least one of the chronic conditions selected for program management as determined by Montana Medicaid under ARM 37.86.5204; and

            (c)  within the specified age criteria as determined under ARM 37.86.5204 for the chronic condition selected for program management.

            (2)  A To receive Health Improvement Program services an eligible client must not be:

            (a)  receiving mental health service plan (MHSP) benefits, specified low income Medicare beneficiary (SLMB) benefits, qualified Medicare beneficiary (QMB) benefits, qualified individual program (QI) benefits, or both Medicare and Medicaid (dual eligibility) benefits;

            (b)  residing in a nursing home or institutional setting;

            (c)  receiving Medicaid benefits through presumptive eligibility;

            (d) (a)  eligible for receiving third party coverage that provides disease management program services or requires administrative controls that would duplicate or interfere with Montana Medicaid's disease management Health Improvement pProgram; or

            (e) (b) receiving case management services that disease management health improvement program services would duplicate.; or

            (c)  receiving Medicaid or HMK Plus for less than three months.

            (3)  A client meeting the eligibility requirements in this rule:

            (a)  is automatically enrolled in the disease management Health Improvement pProgram;

            (b) through (d) remain the same.

 

AUTH:  53-6-101, 53-6-113, MCA

IMP:  53-6-101, 53-6-113, MCA

 

            37.86.5206  DISEASE MANAGEMENT HEALTH IMPROVEMENT PROGRAM:  SCOPE OF SERVICES AND REIMBURSEMENT (1)  If a disease management A Health Improvement pProgram is provided by a DMO, the program must meet the following criteria:

            (a)  if the department chooses to contract for services, the contractor must have the ability to provide the program described in ARM 37.86.5202 and the program requirements stated in the contract between the department and the DMO must be fulfilled;

            (b)  if the department chooses to contract for service, the scope of practice must be appropriate for the contractor provider of the health care service; and

            (c)  the DMO contractor must comply with all other applicable state and federal requirements.

            (2)  Only a DMO contracted with the department may bill and be reimbursed for providing disease management services.  Billing requirements and payment methodology will be described in a contract between the DMO and the department.   A health center contracted with the department will be paid a per member per month case management fee for every eligible client in their service area for providing health improvement services.  A health center as defined in ARM 37.86.5201 is qualified to contract with the department to provide a health improvement program.  The health center must offer supportive services including but not limited to health coaching, care management, coordination with primary care providers, and referrals.  The health center must be a Passport to Health provider.

 

AUTH:  53-6-101, 53-6-113, MCA

IMP:  53-6-101, 53-6-113, MCA

 

            4.  The Department of Public Health and Human Services (the department) is proposing the amendment of ARM 37.86.5201, 37.86.5202, 37.86.5204, 37.86.5205, and 37.86.5206.  The department administers the Montana Medicaid program, a public assistance program jointly funded by the state and federal government.  Montana Medicaid pays providers for covered health care services delivered to eligible low income and disabled Montana residents enrolled in Medicaid.

 

These proposed rule amendments pertain to the Health Improvement Program that is currently called "the Disease Management Program".  The Health Improvement Program is a Medicaid service for qualified Medicaid clients to coordinate health care and educate clients.  The purpose of the program is to improve clients' health and reduce Montana Medicaid's health care costs by reducing unnecessary health care utilization.

 

These proposed rule amendments are necessary to change the program name from "disease management" to "health improvement".  This is a shift in program philosophy from a disease-state focus to improving patients' overall health.  This involves managing a variety of diseases and co-morbidities as well as offering preventive services and assisting patients with psychosocial issues that may be hindering the ability to address medical issues.

 

These proposed rule amendments are also necessary to state the change of the delivery system from disease management organizations to health centers.  This change will bring the delivery of health improvement program services into the local community, rather than provision by an out-of-state vendor, which the department believes will be more effective.

 

Adding the term "Healthy Montana Kids Plus" (HMK Plus) is a necessary change because of the expansion and renaming of Montana Medicaid for children ages 0 through 19. 

 

The proposed amendments to this rule also change how Montana Medicaid will identify clients eligible for the Health Improvement Program.  Medicaid will now encourage primary care providers to refer clients at risk of high utilization of medical services and will identify clients through an analysis of claims history who are at risk of high utilization of medical services.  This change is necessary because the Centers for Medicare and Medicaid Services (CMS) requires it for Montana to operate this program as an enhanced primary care case management program under the department's Passport to Health waiver.  These proposed amendments will not result in additional costs or reduce the number of eligible clients. 

 

ARM 37.86.5201

 

The proposed amendment to ARM 37.86.5201 with the name change to the Health Improvement Program embodies a more accurate label of the philosophy of overall health improvement rather than focused disease management.  The definition of "health center" is added because the department intends to provide the service through health centers, including tribal health centers, rather than through the existing disease management organization model.  The program will deliver services in a local setting rather than limiting the provision of services to DMOs.  Approval for this approach as an enhancement to Montana Medicaid's primary care case management program, Passport to Health, was granted effective October 1, 2009 by CMS under a 1915(b) waiver amendment.  The rule change clarifies the definition of medical home and emphasizes the importance of coordinated care through the medical home.

 

ARM 37.86.5202

 

The term "disease management" is being proposed to be amended to "health improvement".  The HMK Plus eligibility group is added.  Procedures that must be included in a disease management program are deleted as these procedures no longer apply.

 

ARM 37.86.5204

 

The proposed amendment to ARM 37.86.5204 states that eligible clients will be identified through primary care provider referral and risk assessments.  This allows Montana Medicaid greater flexibility to provide preventive services for patients referred by primary care providers before they develop chronic health conditions.  Under the former Disease Management Program, clients were identified only through claims data, thus a current diagnosed illness was needed to benefit from the program.

 

ARM 37.86.5205

 

The proposed amendment to ARM 37.86.5205 clarifies the Medicaid and HMK Plus client groups eligible to receive services and those not eligible.  The program requires eligibility for Passport to Health.  ARM 37.86.5205 is amended to highlight the Passport eligibility requirement and to mirror the 1915(b) wavier approved by CMS for Passport to Health and enhanced primary care case management.

 

ARM 37.86.5206

 

The proposed amendments to ARM 37.86.5206 remove a specific reference to disease management organizations to clarify that the department may contract with a health center certified as a Passport to Health provider that is capable of meeting the program service and supportive services requirements.

 

There is no fiscal impact as the result of these rule changes.  The department estimates approximately 58,000 clients with Medicaid and 900 Passport providers will be affected by the Health Improvement Program.

 

            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: 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 dphhslegal@mt.gov, and must be received no later than 5:00 p.m., May 28, 2010.

 

6.  The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing.

 

7.  The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency.  Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices.  Notices will be sent by e-mail unless a mailing preference is noted in the request.  Such written request may be mailed or delivered to the contact person in 5 above or may be made by completing a request form at any rules hearing held by the department.

 

8.  An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register.  The Secretary of State strives to make the electronic copy of the notice conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered.  In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems.

 

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

 

 

 

 

/s/  John Koch                                                /s/  Anna Whiting Sorrell                              

Rule Reviewer                                               Anna Whiting Sorrell, Director

                                                                        Public Health and Human Services

           

Certified to the Secretary of State April 19, 2010.

 

 

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