BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
In the matter of the adoption of New Rule I, amendment of 37.87.903, 37.87.1201, 37.87.1202, 37.87.1206, 37.87.1217, 37.87.1222, and 37.87.1223, and repeal of 37.88.910 pertaining to psychiatric residential treatment facility reimbursement
NOTICE OF PUBLIC HEARING ON PROPOSED ADOPTION, AMENDMENT, AND REPEAL
TO: All Concerned Persons
1. On March 30, 2011, at 10:30 a.m., the Department of Public Health and Human Services will hold a public hearing in the Auditorium, 111 North Sanders, Helena, Montana, to consider the proposed adoption, amendment, and repeal 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 March 23, 2011, to advise us of the nature of the accommodation that you need. Please contact Gwen Knight, 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 email@example.com.
3. The rule as proposed to be adopted provides as follows:
NEW RULE I OUT-OF-STATE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICE REQUIREMENTS (1) Payment for Psychiatric Residential Treatment Facility (PRTF) services provided outside the state of Montana will be made only under the conditions specified in this rule and subchapter. The Montana Medicaid program will not make payment for PRTF services provided by out-of-state facilities unless the department or its designee determines that PRTF, and applicable PRTF waiver services in the state of Montana are unavailable. PRTF waiver sites are identified in ARM 37.87.1303.
(2) PRTF and PRTF waiver services in the state of Montana will be determined unavailable when:
(a) the youth has been officially screened for admission by all enrolled in-state PRTFs, and an applicable PRTF waiver site, and denied admission because the PRTFs or PRTF waiver site cannot meet the youth's treatment needs; or
(b) the youth has been officially screened for admission by all enrolled in-state PRTFs, and an applicable PRTF waiver site, and denied admission for one of the following reasons:
(i) a bed or opening is not available in a PRTF or PRTF waiver site; or
(ii) the youth's parent or legal guardian refuses PRTF waiver services; or
(iii) the youth's psychiatric condition prevents the youth from being temporarily and safely placed in another setting while awaiting admission to an in-state PRTF or PRTF waiver site.
(3) The department or its designee will not commence a preadmission review for or certify an admission to an out-of-state PRTF until receiving from the prospective PRTF written verification that the youth cannot be served within the state of Montana.
(a) Written verification must be provided on a form approved by the department or its designee, and must be completed and signed on behalf of the in-state PRTFs and an applicable PRTF waiver site indicating that the requirements of (2)(a) or (2)(b) are met.
(b) In-state PRTFs and a PRTF waiver site that do not complete, sign, and return the form by fax to the prospective out-of-state PRTF within three days after receipt will be deemed to be unable to serve the youth.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
4. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
37.87.903 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, AUTHORIZATION REQUIREMENTS (1) Mental health services for a Medicaid youth under the Montana Medicaid program will be reimbursed only if the following requirements are met:
(a) the youth, defined in ARM 37.87.102, has been determined to have a serious emotional disturbance as defined in ARM 37.87.303;
(b) the department or its designee has determined on a case by case basis, that treatment is medically necessary for early intervention and prevention of a more serious emotional disturbance:
(i) prior to treatment, (prior authorization); and
(ii) when required, (continued authorization).
(c) for prior authorized services, the serious emotional disturbance has been verified by the department or its designee.
(2) If a youth has a mental health diagnosis designated by the department, the youth is not required to have a serious emotional disturbance to receive the following services:
(a) group outpatient therapy; and
(b) the first 24 sessions per state fiscal year of individual and family outpatient therapy.
(3) Prior authorization and when required continued authorization by the department or its designee is required for the following services:
(a) individual or family outpatient therapy services in excess of 24 sessions per state fiscal year, subject to such additional limitations for outpatient therapy services as may be set forth in the Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted at ARM 37.87.901. This rule does not apply to a session with a physician or midlevel practitioner for the purpose of medication management;
(b) targeted case management in excess of 120 units of service per state fiscal year and in accordance with ARM 37.87.808;
(c) all outpatient therapy services provided on the same day as comprehensive school and community treatment (CSCT) described at ARM 37.86.2224, 37.86.2225, 37.106.1955, 37.106.1956, 37.106.1960, 37.106.1961, and 37.106.1965;
(d) therapeutic group home services and extraordinary needs aide services in accordance with ARM 37.87.1011, 37.87.1013, 37.87.1015, and 37.87.1017;
(e) therapeutic family care (TFC) and therapeutic foster care (TFOC) services in accordance with ARM 37.87.1021, 37.87.1023, and 37.87.1025 and ARM Title 37, chapter 51;
(f) psychiatric residential treatment facility services defined in ARM 37.87.1202;
(g) psychiatric hospital and partial psychiatric hospital services defined in ARM 37.86.2901 and 37.86.3001; and
(h) as provided for in other rules.
(4) The department may waive a requirement for prior authorization or continued authorization when the provider submits documentation that:
(a) there was a clinical reason why the request for prior authorization or continued authorization could not be made at the required time, and the provider submitted a subsequent authorization request within ten business days; or
(b) a timely request for prior authorization or continued authorization was not possible because of a failure or malfunction of the department's or its designee's equipment that prevented the transmittal of the request at the required time and
the provider submitted a subsequent authorization request within ten business days.
(5) The prior authorization or continued authorization requirement shall not be waived except as provided in this rule.
(6) Review of authorization requests by the department or its designee will be made with consideration of the department's clinical management guidelines. The department adopts and incorporates by reference the Children's Mental Health Bureau's Provider Manual and Clinical Guidelines for Utilization Management dated
January 15, 2011 May 13, 2011. A copy of the manual can be obtained from the department by a request in writing to the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210 or at www.dphhs.mt.gov/mentalhealth/children/index.shtml.
(7) 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 in compliance with applicable requirements, the department may deny payment or may recover any overpayment in accordance with applicable requirements.
(8) The department or its designee may require providers to report outcome data or measures regarding mental health services, as determined in consultation with providers and consumers.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
37.87.1201 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, PURPOSE (1) The purpose of ARM 37.87.1201, 37.87.1202, 37.87.1203, 37.87.1206, 37.87.1207, 37.87.1214, 37.87.1215, 37.87.1216, 37.87.1217, 37.87.1222, 37.87.1223, 37.87.1224,
and 37.87.1225, and [New Rule I] is to specify provider participation and program requirements and to define the basis and procedure the department will use to pay for psychiatric residential treatment facility (PRTF) services.
(2) Facilities in which these services are available are referred to as providers.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
37.87.1202 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, DEFINITIONS As used in this subchapter, the following definitions apply:
(1) "Care coordination" means monitoring and referral services provided to youth in a PRTF by an outside provider to assist in discharging the youth from the PRTF to create a smooth transition in which to transfer the clinical gains the youth has made in the PRTF to the community. Care coordination may be provided by a licensed or in-training mental health professional, or targeted case manager who has extensive knowledge of community services. In-training mental health professional services are only reimbursed when provided by a licensed mental health center. Care coordination includes the following:
(a) monitoring, which means attending telephonically the youth's monthly PRTF treatment team meetings and consultation with the team about:
(i) the youth's treatment goals and progress in treatment;
(ii) the youth's readiness for discharge and promoting discharge at the earliest opportunity;
(iii) the youth's discharge plan and specific service needs; and
(iv) advocating for the parent or legal guardian's recommendations about treatment and discharge.
(b) referral services, which means:
(i) making appointments for needed psychiatric, medical, educational, psychological, social, behavioral, developmental, and chemical dependency treatment services, as appropriate upon discharge from the PRTF; and
(ii) ensuring communication exists and pertinent clinical information is shared between the youth's PRTF treatment team and community providers prior to discharge.
(1) (2) "Continuity of care payment" means an annual payment made to qualifying hospital-based psychiatric residential treatment facilities (PRTF) according to the eligibility criteria and payment calculation methodology in ARM 37.87.1224.
(2) (3) "Devoted to the provision of inpatient psychiatric care for persons under the age of 21" means an inpatient psychiatric hospital facility or residential treatment facility whose goals, purpose, and care are designed for and devoted exclusively to persons under the age of 21.
(3) (4) "Hospital-based psychiatric residential treatment facility" means a residential treatment facility that meets the requirements of ARM 37.87.1207.
(4) (5) "Inpatient psychiatric services" means psychiatric residential treatment facility, or hospital-based psychiatric residential treatment facility services.
(5) (6) "Patient day" means a whole 24-hour period in which a person is present and receiving inpatient psychiatric services. Even though a person may not be present for a whole 24-hour period, the day of admission and, subject to the limitations and requirements of ARM 37.87.1223, therapeutic home leave days are patient days. The day of discharge is not a patient day for purposes of reimbursement.
(6) (7) "Psychiatric residential treatment facility (PRTF)" means a facility other than a hospital that provides psychiatric services only to individuals under age 21. The PRTF must be certified for Medicaid participation by:
(a) the department as a PRTF; or
(b) the appropriate agency in the state where the facility is located as a PRTF.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
37.87.1206 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, PARTICIPATION REQUIREMENTS (1) These requirements are in addition to those contained in rule generally applicable to Medicaid providers.
(2) PRTF providers, as a condition of participation in the Montana Medicaid program, must comply with the following requirements:
(a) maintain a current license as a residential treatment facility under the rules of the department's Quality Assurance Division to provide PRTF services, or, if the provider's facility is not located within the state of Montana, maintain a current license in an equivalent category under the laws of the state in which the facility is located;
(b) maintain a current PRTF certification for Medicaid participation by the state in which the facility is located as required by the Centers for Medicare and Medicaid;
(c) for all providers, enter into and maintain a current provider enrollment form with the department's fiscal agent to provide psychiatric PRTF services;
(d) license and/or register facility personnel in accordance with applicable state and federal laws;
(e) accept, as payment in full for all operating and property costs, the amounts paid in accordance with the reimbursement method set forth in this rule and ARM 37.87.1201, 37.87.1202, 37.87.1203, 37.87.1207, 37.87.1214, 37.87.1215, 37.87.1216, 37.87.1217, 37.87.1222, 37.87.1223, 37.87.1224, and 37.87.1225;
(f) for providers maintaining patient trust accounts, ensure that any funds maintained in those accounts are used only for those purposes for which the youth, legal guardian, or personal representative of the patient has given written authorization. A provider may not borrow funds from these accounts for any purpose;
(g) maintain accreditation as a PRTF by the Joint Commission on Accreditation of Health Care Organizations (JCAHO), Council on Accreditation (COA), or the Commission on Accreditation of Rehabilitation Facilities (CARF) or any other organization designated by the Secretary of the United States Department of Health and Human Services as authorized to accredit PRTF for Medicaid participation;
(h) submit to the department prior to receiving initial reimbursement payments and thereafter within 30 days after receipt, all accreditation determinations, findings, reports, and related documents issued by the accrediting organization to the provider;
(i) provide PRTF services according to the service requirements for individuals under age 21 specified in Title 42 CFR, part 441, subpart D (2008). The department adopts and incorporates by reference Title 42 CFR, part 441, subpart D. A copy of these regulations may be obtained through the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951;
(j) agree to indemnify the department in the full amount of the state and federal shares of all Medicaid inpatient psychiatric services reimbursement paid to the facility during any period when federal financial participation is unavailable due to facility failure to meet the conditions of participation specified in these rules or due to other facility deficiencies or errors
(k) complete periodic surveys requested by the department. At a minimum, a PRTF must provide the following information:
(i) average length of stay;
(ii) special treatment programs offered or facility's ability to treat co-occurring issues such as developmental disabilities, chemical dependency; medically fragile and sexual reactivity or offending issues;
(iii) specialized staff or evidence-based practices used;
(iv) special assessments used, such as psychosexual or forensic; and
(v) frequency of seclusion and restraint.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
37.87.1217 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES, TREATMENT REQUIREMENTS (1) PRTF services must include active treatment designed to achieve the youth's discharge to a less restrictive level of care at the earliest possible time. Active treatment includes, but is not limited to, the following services provided regularly and as clinically indicated:
(a) individual psychotherapy;
(b) group psychotherapy; and
(c) family therapy.
(2) PRTF services must be provided under the direction of a licensed physician.
(3) The PRTF plan of care must be comprehensive and address all psychiatric, medical, educational, psychological, social, behavioral, developmental, and chemical dependency treatment needs.
(4) The youth's plan of care and discharge plan must be reviewed at least every 30 days at the multidisciplinary treatment team meeting, and more frequently if there is a significant change in the youth's condition. The youth's parent or legal guardian must be invited to participate in these meetings, and given adequate notice to participate. Adequate notice means generally a week unless the youth's condition dictates otherwise. At a minimum the following must be discussed:
(a) diagnosis or changes to diagnosis;
(b) mental status or changes to mental status;
(c) medication use, purpose, and any changes;
(d) youth's treatment goals, progress or lack of progress, and revisions to the treatment plan;
(e) risk behaviors and the use of special treatment procedures;
(f) co-occurring issues that impact youth's treatment, such as developmental or cognitive delays, chemical dependency, and sexual reactivity or offending;
(g) individual, group, and family therapy outcomes; and
(h) youth's readiness for discharge, specific services needed on discharge, and who will be making the appointments for discharge services.
(4) (5) PRTF services include only treatment or services provided in accordance with all applicable licensure, certification, and accreditation requirements, and these rules.
(5) (6) In addition to the requirements in (4) that pertain to discharge planning the following activities are required. The PRTF must:
(a) identify the community to which the youth will discharge;
(b) decide whether or not to contract with a care coordinator to assist in discharge planning;
(a) (c) develop a discharge plan with the care coordinator, if assistance is needed, within 30 days of admission that identifies the youth and family's needed services and supports upon discharge:
(i) the discharge plan must address psychiatric, medical, educational, psychological, social, behavioral, developmental, and chemical dependency treatment needs, as appropriate.
(b) identify the community to which the youth will discharge;
(c) (d) make referrals appointments for needed services and supports upon discharge, no less than 30 seven days before discharge; and
(d) (e) work with the youth's parent or legal guardian, independently or with a care coordinator in making agreed upon discharge plans and referrals for needed services.
(6) (7) If appropriate arrangements for services upon discharge are not made as required in (5) (6) the PRTF may be at risk of losing its enrollment in the Montana Medicaid program.
(7) (8) As part of the discharge planning requirements, PRTFs shall ensure the youth has a seven-day supply of needed medication and a written prescription for medication to last through the first outpatient visit in the community with a prescribing provider. Prior to discharge, the PRTF must identify a prescribing provider in the community and schedule an outpatient visit. Documentation of the medication plan and arrangements for the outpatient visit must be included in the youth's medical record. If medication has been used during the youth's PRTF treatment but is not needed upon discharge, the reason the medication is being discontinued must be documented in the youth's medical record.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
37.87.1222 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES, IN-STATE INTERIM RATE AND COST SETTLEMENT PROCESS
(1) The interim rate for services provided to "youth
s" as the term "youth" is defined at ARM 37.87.102 for PRTF providers located in the state of Montana is composed of:
(a) the psychiatric service rate provided in the department's Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Years of Age Fee Schedule adopted in ARM
(b) a direct care wage add-on through a contract with the department or in the psychiatric service rate in (1)(a), as applicable; and
(c) a facility-specific ancillary add-on rate for
Medicaid services provided in and by the PRTF ancillary costs, not already included in the base psychiatric service rate in (1)(a).
(2) Medicaid services included in the ancillary add-on rate in (1)(c)
must may be provided in and by the PRTF by individuals employed by or under contract with the PRTF who have appropriate credentials or by outside providers. and who will be subject to the Montana Medicaid program's prevailing payment methodology and/or fee schedule for reimbursement. Services provided outside the PRTF are not separately reimbursable and must be reimbursed by the PRTF. At a minimum, covered ancillary services include the following services:
(a) the professional component of physician, psychiatrist, and mid-level practitioner services;
(b) licensed addiction counselor services;
(c) lab and pharmacy services not related to the youth's psychiatric condition; and
(d) other Medicaid services approved by the department to address the youth's treatment needs in the facility.
(a) ambulatory surgical center;
(c) care coordination per the limits in (3);
(e) dentist, denturist, and orthodontist;
(f) durable medical equipment;
(g) emergency room services not related to the youth's psychiatric condition;
(i) federally qualified health center;
(j) hearing provider and hearing aides;
(k) Indian health services for enrolled tribal members;
(l) lab and pharmacy services not related to the youth's psychiatric condition;
(m) licensed addiction counselor;
(n) medical transportation and ambulance services;
(o) MRI, or other diagnostic services;
(q) optometrist and ophthalmologist;
(r) outpatient hospital services not related to the youth's psychiatric condition;
(s) pharmacy for post-discharge medication;
(t) physical and speech therapist;
(u) physician, psychiatrist, and mid-level practitioner;
(w) public health clinic;
(x) respiratory therapist;
(y) rural health clinic;
(z) any other Medicaid service approved by the department to address the youth's plan of care needs in the facility.
(3) If a PRTF contracts for care coordination the following limits apply:
(a) up to 16 units per month to attend multidisciplinary treatment team meetings to monitor the youth's progress; and
(b) up to 32 units within 30 days of the youth's discharge. Of these 32 units, up to 16 units may be used for attending treatment team and discharge planning meetings and up to 16 units may be used for making referrals and related activities for needed services upon discharge; and
(c) only one care coordinator will be reimbursed per youth.
(4) Reimbursement for in-house practitioner services in (2) only includes the professional component of the service.
(3) (5) The ancillary add-on rate in (1)(c) will be adjusted retrospectively when:
(a) allowable ancillary costs are reported using auditable data, standardized forms, instructions, definitions, and timelines supplied by the department; and
(b) ancillary costs in the facility-specific aggregate for all discharges, for Montana Medicaid paid youth, in a state fiscal year exceed or are less than the reimbursement that the facility received as an interim rate:
(i) the department will reimburse the facility for costs exceeding 100% of the aggregate; and
(ii) the facility will reimburse the department for costs less than 100% of the aggregate.
(4) (6) The psychiatric service rate in (1)(a) is a bundled per diem rate, and includes:
(a) services, therapies, and items related to the youth's psychiatric condition;
(b) services provided by licensed psychologists, licensed clinical social workers, and licensed professional counselors; and
(c) lab and pharmacy services related to the youth's psychiatric condition, with the exception noted in (2)(s) pharmacy for post discharge medication.
(7) Covered ancillary services provided by the PRTF will be cost-settled using the existing Medicaid reimbursement rate according to the applicable Medicaid fee schedule. Covered ancillary services provided by outside providers will be cost-settled using the amount the PRTF reimbursed the outside providers. This amount may not exceed the outside provider's usual and customary charge. Whenever possible, outside ancillary service providers will be reimbursed the Medicaid rate.
(8) Third party liability billing requirements apply for PRTF and ancillary services reimbursed by the Medicaid program. Medicaid prior authorization requirements for ancillary services in (2) do not apply when the youth is in a PRTF.
(9) Reimbursement for the following personal transportation may be included in the PRTF cost report, per the reimbursement rate on the current "Montana Medicaid Personal and Commercial Transportation Fee Schedule":
(a) When the personal transportation is provided by the PRTF for a youth to a medical appointment off site and the mileage exceeds 15 miles per month per specific youth. Documentation must be maintained regarding the youth's name, outside provider name, appointment date and time, and mileage; and
(b) When a youth's parent, guardian, or other family member is reimbursed mileage to drive to and from the PRTF to attend family therapy sessions. Reimbursement for transporting a youth to and from their home for a therapeutic home visit is not an allowable expense unless family therapy is provided prior to the youth's home visit and upon their return to the PRTF. Meals and/or lodging are not covered for a round trip that can reasonably be made in one day. If a round trip cannot be reasonably made in one day, meals and lodging may be reimbursed according to the fee schedule in (9), and the following documentation maintained:
(i) youth name;
(ii) date of family therapy session;
(iii) parent, guardian, or family member name;
(iv) community the parent, guardian, or family member is driving from;
(v) total mileage; and
(vi) total number of meals.
(5) (10) Emergency medical conditions treated by providers outside the PRTF will be reimbursed using state funds at the prevailing Montana Medicaid rate, and must be billed by an enrolled provider directly to the Montana Medicaid program. Emergency medical conditions treated outside the PRTF may be reimbursed when provided in a hospital emergency room. If the youth's condition requires admission to a hospital, the youth must be discharged from the PRTF for Medicaid or state funded reimbursement to be available for the hospitalization the hospital to be reimbursed.
(6) For purposes of this rule "emergency medical condition" means:
(a) a medical condition manifesting itself by acute symptoms of sufficient severity (including severe pain) such that the absence of immediate medical attention could reasonably be expected to result in:
(i) placing the health of the individual in serious jeopardy;
(ii) serious impairment to bodily functions; or
(iii) serious dysfunction of any bodily organ or part.
(7) Additional outside services that may be reimbursed using state funds to pay the prevailing Montana Medicaid rate for youth in a PRTF are:
(a) emergency dental services in accordance with the Montana Medicaid Dental Program as identified in ARM 37.86.1006 for adults ages 21 and over with basic Medicaid;
(b) eyeglasses and vision examinations;
(c) durable medical equipment; and
(d) hearing aids and hearing examinations.
(8) (11) If a youth receiving inpatient care in a PRTF has an unusually expensive medical condition that requires a higher ancillary rate, prior to the cost settlement process, the PRTF may request interim reimbursement for the ancillary care. The department at its discretion may grant the youth specific request if the PRTF:
(a) submits a request in writing to the department with documentation of the expenses; and
(b) interim payments must be requested within 90 days of the date of service and will be taken into consideration during the ancillary cost settlement process described in (3). Payment of these claims will be made by the department within 90 days from the date all requirements for payment are met.
(12) Care coordination services will be reimbursed to the PRTF at the prevailing Medicaid rate for Healthcare Common Procedure Coding System (HCPCS) code T1016 HA (Targeted Case Management) when:
(a) the parent or guardian is given the choice of eligible providers;
(b) services are not contingent on youth receiving other services from the agency providing care coordination;
(c ) services are adequately documented in a narrative form and maintained in the care coordinator's records to justify the number of units billed to the PRTF; and
(d) care coordination activities are included on the youth's PRTF's treatment plan. A separate care coordination assessment and care plan are not required.
(9) (13) Reimbursement will be made to an in-state PRTF provider for reserving a bed while the youth is temporarily absent for a therapeutic home visit if:
(a) the youth's plan of care documents the medical need for therapeutic home visits as part of a therapeutic plan to transition the youth to a less restrictive level of care;
(b) the youth is temporarily absent on a therapeutic home visit;
(c) the provider clearly documents staff contact and youth achievements or regressions during and following the therapeutic home visit; and
(d) the youth is absent from the provider's facility for no more than three patient days per therapeutic home visit, unless additional days are authorized by the department.
(10) (14) No more than 14 patient days per youth in each state fiscal year will be allowed for therapeutic home visits.
(11) (15) Providers must bill for PRTF services using the revenue codes designated by the department.
(12) (16) Notice of the youth's admission and discharge dates must be submitted to the department or its designee the day of admission or discharge. A $100 fine may be imposed against the facility for each instance where the department does not receive timely notification.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
37.87.1223 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES, REIMBURSEMENT (1) For PRTF services provided on or after
January September 1, 2010, the Montana Medicaid program will pay a provider for each patient day as provided in these rules.
(a) Medicaid payment is not allowable for treatment or services provided in a PRTF that are not consistent with the definition of PRTF in ARM 37.87.1202 and unless all other applicable requirements are met.
(2) For inpatient psychiatric services provided by a PRTF in the state of Montana, the Montana Medicaid program will pay a provider, for each Medicaid patient day, a bundled per diem interim rate as specified in (3), less any third party or other payments. The interim rate is defined in ARM 37.87.1222.
(3) The statewide bundled per diem interim rate for
inpatient psychiatric in-state PRTF services is the lesser of:
(a) the amount specified in the department's Medicaid Mental Health and Mental Health Services Plan Fee Schedule, Individuals Under 18 Years of Age; or
(b) the provider's usual and customary charges
(4) Out-of-state PRTF providers will be reimbursed 50% of their usual and customary charges. Reimbursement will include all Medicaid covered psychiatric, medical, and ancillary services provided
in and by the PRTF or by outside providers consistent with ARM 37.87.1222. Services provided by an outside provider while the youth is a patient in a PRTF are not separately reimbursable by the Montana Medicaid program. The usual and customary charge may not be more than twice the cost of providing the service.
(5) Emergency medical conditions treated by providers in a hospital emergency room outside the PRTF will not be included in the out-of-state PRTF's usual and customary rate, and must be billed by an enrolled provider directly to the Montana Medicaid program. Emergency medical services provided outside the PRTF will be reimbursed the prevailing Montana Medicaid rate using state funds. See ARM 37.87.1222 for the definition of emergency medical conditions, additional outside services that may be reimbursed using state funds at the prevailing Montana Medicaid rate and where services must be provided to be reimbursed.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
5. The department proposes to repeal the following rule:
37.88.910 RESIDENTIAL PSYCHIATRIC CARE OUTSIDE MONTANA, is found on page 37-21685 of the Administrative Rules of Montana.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
6. Statement of Reasonable Necessity
The Department of Public Health and Human Services (the department) is proposing to amend the above-stated Psychiatric Residential Treatment Facility (PRTF) administrative rules governing reimbursement for outside ancillary services. This is necessary to reflect recent federal policy direction the department received from the Centers for Medicare and Medicaid Services (CMS) pertaining to Federal Financial Participation (FFP) in the reimbursement of these services.
Approximately 417 mentally ill youth could be affected by the proposed changes. Approximately 14 in-state and out-of-state PRTFs could also be affected.
The department is proposing changes to the reimbursement rules for outside ancillary services retroactive to September 1, 2010. The department does not believe the changes will have a negative impact on Medicaid providers or clients. The changes are necessary to allow the department to use FFP for outside services youth receive while in a PRTF. The department currently reimburses the following outside services with 100% state general funds (some services require prior authorization): hospital emergency room services, eyeglasses and vision examination, durable medical equipment, hearing aids and hearing exams, and emergency dental procedures. If the proposed amendments are adopted, outside services received by youth in a PRTF could be reimbursed with a combination of Medicaid FFP and state general funds back to September 1, 2010.
Under the proposed rule changes almost all medically necessary state plan Medicaid services will be covered for youth in a PRTF. However, these outside services must be reimbursed by the PRTFs. In-state PRTFs receive a facility-specific ancillary rate. Expenses above or below the ancillary rate are cost-settled with the in-state PRTFs at the end of the state fiscal year (SFY). The estimated annual impact of the proposed amendments is approximately $881,189 federal funds which will offset current state general fund expenditures. The rule change opening up coverage of additional outside services will also be retroactive to September 1, 2010, with the exception of care coordination services, discussed below.
The department is proposing wording changes to the rule governing how out-of-state PRTFs are reimbursed. They will still be reimbursed 50% of their usual and customary rate. The proposed amendments are necessary to make the rule language clear that their usual and customary bundled facility rate charge must cover all psychiatric, medical, and ancillary services youth need while in their PRTF. To meet FFP requirements, no outside ancillary services will be reimbursed separately by the Montana Medicaid program.
The department is also proposing to allow limited care coordination services for youth in a PRTF for monitoring and referral for needed services to assist the PRTF in discharge planning. This is necessary to promote effective discharge planning. Care coordination is defined in the amended rule and would be performed by one of the following community providers: (1) a targeted case manager (TCM), (2) an in-training mental health professional, or (3) a licensed mental health professional. Please note that in-training mental health professional services are only separately reimbursable when provided by a licensed mental health center.
As part of the PRTF treatment requirements, the department is proposing to include individual, group, and family therapy sessions. This is necessary to further define active treatment. In some PRTFs these services are not being regularly provided. The department believes they are important interventions in treating youth with a serious emotional disturbance (SED) and are necessary to meet federal requirements for Medicaid services.
The department is proposing another change to PRTF treatment requirements by specifying topics to be discussed at the youth's treatment team meetings. These topics are necessary to assure integrated treatment and discharge planning occurs. The department does not believe these topics are consistently discussed and believes they are an important component of active and integrated treatment.
The department has periodically experienced difficulty placing certain youths in psychiatric residential treatment facilities (PRTF). This is because of the limited number of PRTFs and limitations in the scope of services available. Consequently, certain Montana youth are treated in out-of-state PRTFs. The department's policy is to treat mentally ill persons in the least restrictive environment that meets the patient's needs and to do so as close to the patient's home, family, and community as possible.
The department applied for and received a Medicaid grant commonly referred to as the PRTF waiver to create regional programs for the treatment of mental illness. The department wishes to exhaust all in-state PRTF placements, including regional waiver projects before authorizing an out-of-state PRTF placement. The proposed new rule and amendments are necessary to implement this policy. Studies have shown faster recoveries and better outcomes when mentally ill youth are treated in or close to their homes and communities. Therefore, the department has rejected the alternative of authorizing out-of-state PRTF placement of mentally ill youth whenever in-state PRTF treatment that meets the youth's needs is available. The department finds the best and most economical way to accomplish this goal is to add the requirement that in-state treatment be exhausted prior to authorizing out-of-state PRTF placement. This would utilize the existing prior authorization resources and procedures.
The department is proposing an amendment to require four in-state PRTF denials before a youth may be served by an out-of-state PRTF starting July 1, 2011. The fourth PRTF denial would be from a PRTF Waiver site, for youth from their service area. A parent or legal guardian's lack of consent to participate in the PRTF Waiver would constitute a denial. The current in-state PRTF denial requirement is in ARM 37.88.910 and was inadvertently left out when the other PRTF rules were moved to the children's mental health section, ARM Title 37, chapter 87. The out-of-state PRTF rules in ARM 37.88.910 will be moved to New Rule I. This is necessary to correct an error in the children's mental health services rules. The reference to ARM 37.85.207, in 37.88.910, regarding services not provided by the Medicaid program will not be moved to New Rule I, however ARM 37.87.1206 already requires PRTFs to follow rules generally applicable to Medicaid providers in the Montana Medicaid program.
The in-state PRTF denial requirement is also stated in the Children's Mental Health Bureau's Provider Manual and Clinical Guidelines for Utilization Management (provider manual). If the proposed amendments are adopted, the PRTF Waiver denial requirement will also be added to the provider manual in the PRTF section. The provider manual will be updated and dated May 13, 2011 when the proposed rules are effective, even though the PRTF Waiver denial requirement will not be implemented until July 1, 2011. The TCM section of the provider manual will be updated in the following areas to make TCM requirements clearer; initial authorization and unscheduled revision requirements, nonbillable TCM activities and TCM discharge requirements. The Community-Based Psychiatric Rehabilitation and Support Services (CBPRS) section will be updated with regard to the length of the authorization spans for youth in the PRTF Waiver receiving day treatment. The outpatient therapy section will be updated and not require group therapy to be prior authorized on the same day as Comprehensive School and Community Treatment (CSCT) when provided after CSCT program hours and to clarify that when outpatient therapy is prior authorized on the same day as CSCT with an MSOTA therapist, the therapy must be for a qualifying SED diagnosis. The provider manual is posted on the CMHB web site for public review. The revisions are necessary so that the provider manual will be clear and accurate and easier to use.
An additional Montana Medicaid participation requirement is being proposed for all PRTFs. If adopted, the amendment would require each PRTF to complete periodic surveys about the treatment programs and special SED populations they serve. This is necessary to assure that youth are served by in-state PRTFs whenever possible. However, youth may need out-of-state PRTF services. The survey information is necessary in assisting decision-makers with determinations about where the youth's treatment needs can best be met when the youth cannot be served by an in-state PRTF.
Specific provisions of the new and amended rules are described below.
New Rule I
The requirements for receiving three in-state PRTF denials prior to reviewing an out-of-state PRTF certification for admission would be moved to New Rule I from ARM 37.88.910. The department is proposing to require a fourth in-state PRTF denial, from PRTF Waiver sites for youth from their service area starting July 1, 2011.
The department is proposing to update the provider manual effective date to May 13, 2011, and update the PRTF Prior Authorization for Out of State Facilities section of the provider manual to include a PRTF Waiver denial for youth in their service area, before they may be served by an out-of-state PRTF. Participation in the PRTF Waiver is based on parent or legal guardian approval. July 1, 2011 was selected as the effective date of the requirement to allow the new PRTF Waiver sites enough time to become established and develop service capacity. If these amendments are adopted, the TCM section will be updated to clarify the authorization and discharge requirements and nonbillable activities. The CBPRS section would be updated with regard to the length of authorization spans for youth in the PRTF Waiver receiving day treatment services. The Outpatient Therapy section would be updated to clarify that group therapy does not require prior authorization when provided on the same day as CSCT when provided after CSCT program hours and when outpatient therapy is prior authorized on the same day as CSCT and provided by an MSOTA therapist the focus of treatment must be a qualifying SED diagnosis. Other than requiring the PRTF waiver denial before a youth receives out-of-state PRTF services, the other changes in the provider manual are intended to be effective May 13, 2011.
The department is proposing to add New Rule I to explain the purpose of the PRTF rules. This rule would be amended to add a cross reference to New Rule I.
A definition for "care coordination" services in a PRTF would be added to subsection (1) of this rule. Care coordination was developed to assist the PRTFs in making specific service appointments for youth on discharge, to ensure communication between the PRTF and the parent or legal guardian and community providers and to assist the youth in transferring the clinical gains they make in the PRTF to the community. Care coordination must be provided by a community provider and is limited to monitoring and referral services.
A new PRTF participation requirement would be added to (2) of this rule, completing periodic surveys. The survey results will be used to make decisions about where SED youth are placed for PRTF treatment.
Active treatment designed to discharge the youth to a less restrictive level of care at the earliest opportunity would be required for facilities providing PRTF services. Individual and family therapy are not consistently being provided under the existing rule. The department is proposing to add individual, group, and family therapy sessions to be provided regularly as clinically indicated.
Under the current rule, the youth's parent or legal guardian is not consistently being invited or given adequate notice to participate in the youth's treatment team meetings. The department believes parent or legal guardian participation is important in treatment and discharge planning and is proposing to add this requirement. The department is also proposing specific topics be reviewed at treatment team meetings to ensure treatment and discharge planning is active, integrated, and comprehensive.
The Medicaid Mental Health and Mental Health Services Plan, Individuals Under 18 Year of Age Fee Schedule (fee schedule) was recently moved to the children's mental health section, ARM 37.87.901. The old fee schedule rule is referenced in (1)(a) of this rule and would be updated to reflect the new fee schedule rule.
The facility-specific ancillary add-on rate described in this rule is being amended to include ancillary services from outside the PRTF. The proposed amendments would expand the list of services covered in the facility-specific ancillary rate. Outside services are not separately reimbursable by the Montana Medicaid program, with the exception of the day of admission to and discharge from the PRTF. Under federal regulations, PRTFs must reimburse outside providers for ancillary services a youth receives.
Care coordination services would be allowed on a limited basis to assist the PRTF in discharge planning. PRTF staff would not be reimbursed for care coordination services. Care coordination services would be allowed to provide a smooth transition for youth to community services and support the gains they made in the PRTF. If the PRTF works with a care coordinator to assist with discharge planning, additional requirements are proposed in (12). Care coordination may be provided by a TCM, in-training or licensed mental health professional. If the care coordination is provided by a TCM, the TCM agency may not, according to federal regulation, make other agency services contingent on receiving their TCM services.
PRTFs provide some practitioner services in-house. In such circumstances, only the professional component of these services will be reimbursed. Examples of practitioner services would include physician, psychiatrist, or licensed addiction counselor services.
Section (6) is modified for clarity. A supply of medication provided on discharge to treat the youth's psychiatric condition is included in the facility-specific ancillary rate. Section (7) would be added to identify how ancillary services provided in and by the PRTF will be reimbursed and the reimbursement rate and how ancillary services provided by outside providers will be reimbursed. Section (8) would be added to address third party liability and prior authorization requirements. Section (9) would be added to specify what transportation may be reimbursed by the PRTF and may be included in their cost report. Section (10) would be modified to reflect the department's practice of reimbursing only in-state PRTFs for therapeutic home visit days. Section (12) would be added to indicate that care coordination services may not be contingent on the youth receiving other services from the agency providing care coordination; and to identify the care coordinator's documentation and treatment plan requirements.
This rule would be amended to include reimbursement for additional outside services youth receive in a PRTF. The amendment in (1) would be applied retroactively to September 1, 2010.
The department is proposing changes to this rule to specify how out-of-state PRTFs are reimbursed. The out-of-state PRTF reimbursement rate would include all psychiatric, medical, and ancillary services needed by the youth according to their plan of care.
This rule would be repealed and most of its provisions moved to New Rule I. The reference to ARM 37.85.207(1) regarding services not provided by the Medicaid program would be repealed and not moved to New Rule I. ARM 37.87.1206 already requires PRTFs to follow rules generally applicable to Medicaid providers to participate in the Montana Medicaid program.
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: Gwen Knight, 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 firstname.lastname@example.org, and must be received no later than 5:00 p.m., April 18, 2011.
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. 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.
11. 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 February 28, 2011