BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.87.1202, 37.87.1210, 37.87.1214, 37.87.1217, and 37.87.1223 and the repeal of ARM 37.87.1222, pertaining to psychiatric residential treatment facility (PRTF) services

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT AND REPEAL

 

TO: All Concerned Persons

 

            1. On November 20, 2013, at 11:00 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 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 November 13, 2013, to advise us of the nature of the accommodation that you need. Please contact Kenneth Mordan, 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:

 

            37.87.1202 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.

            (2) through (6) remain the same but are renumbered (1) through (5).

            (7) (6) "Psychiatric residential treatment facility (PRTF)" means a facility other than a hospital that provides psychiatric services only to individuals persons under age 21. The PRTF must be certified for Medicaid participation by:

            (a) and (b) remain the same.

 

AUTH: 53-2-201, 53-6-113, MCA

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

 

            37.87.1210 OUT-OF-STATE PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICE REQUIREMENTS (1) Payment for psychiatric residential treatment facility (PRTF) services provided to a youth outside the state of Montana will be made only under the conditions specified in this rule and subchapter. The Montana Medicaid pProgram will not make payment for PRTF services provided by out-of-state facilities to a youth unless the department or its designee determines that PRTF, and applicable PRTF waiver services in the state of Montana are unavailable for the youth. 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 of the youth; 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)(ii) the youth's psychiatric condition of the youth 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

 

            37.87.1214 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY SERVICES, CHEMICAL DEPENDENCY SUBSTANCE USE DISORDER ASSESSMENT AND TREATMENT (1) PRTF services may include chemical dependency (CD) substance use disorder assessment and treatment. Substance use disorder assessment and treatment must be completed in accordance with according to the American Society of Addictions Medicine PPC-2R Manual (Second Edition, revised April 2001) for youth with a primary SED diagnosis who have a co-occurring CD substance use disorder diagnosis.

            (2) remains the same.

            (3) CD Substance use disorder treatment includes the following services based on the individual plan of care developed with the youth:

            (a) through (4) remain the same.

 

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 of the youth 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) through (3) remain the same.

            (4) The PRTF must use a the Montana children and adolescent needs and strengths (MT-CANS) functional assessment approved by the department's children's mental health bureau for youth on admission and prior to discharge to assist in the development of the plan of care and the discharge plan.

            (5) The PRTF plan of care must be comprehensive and address all psychiatric, medical, educational, psychological, social, behavioral, and developmental, and chemical dependency treatment needs.

            (6) The youth's plan of care and discharge plan for the youth 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 of the youth. The youth's parent or legal guardian representative of the youth 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 of the youth dictates otherwise. At a minimum the following must be discussed:

            (a) through (c) remain the same.

            (d) youth's treatment goals of the youth, progress or lack of progress, and revisions to the treatment plan;

            (e) remains the same.

            (f) co-occurring issues that impact youth's treatment of the youth, such as developmental or cognitive delays, chemical dependency substance use disorder, and sexual reactivity or offending;

            (g) remains the same.

            (h) youth's readiness for discharge of the youth, specific services needed on discharge, and who will be making the appointments for discharge services.

            (7) remains the same.

            (8) In addition to the other requirements in (4) this rule that pertain to discharge planning the following activities are required. The PRTF must:

            (a) remains the same.

            (b) decide whether or not to contract with a care coordinator to assist in discharge planning;

            (c) (b) 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) remains the same.

            (d) remains the same, but is renumbered (c).

            (e) (d) work with the youth's parent or legal guardian representative of the youth, independently, or for out-of-state PRTFs, with a care coordinator targeted case manager, in making agreed upon discharge plans and referrals for needed services.

            (e) provide targeted case management services according to the limitations in ARM 37.87.1223, as needed.

            (9) remains the same.

            (10) As part of the discharge planning requirements, PRTFs shall must 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 for the youth. If medication has been used during the youth's PRTF treatment of the youth, but is not needed upon discharge, the reason the medication is being discontinued must be documented in the youth's medical record for the youth.

 

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 September 1, 2010 inpatient psychiatric services provided in a PRTF on or after December 31, 2013, for youth as defined in ARM 37.87.102, the Montana Medicaid pProgram will pay a provider PRTF for each patient day as provided in these rules.

            (a) remains the same.

            (2) For inpatient psychiatric services provided by a PRTF in the state of Montana in-state PRTFs, the Montana Medicaid pProgram 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. Services included in Tthe interim bundled per diem rate is are defined in ARM 37.87.1222 (5).

            (3) The statewide bundled per diem interim rate for in-state PRTF services is the lesser of:

            (a) the amount specified in the department's Medicaid Youth Mental Health fee schedule, as adopted in ARM 37.87.901 37.85.105; or

            (b) remains the same.

            (4) Out-of-state PRTFs providers will be reimbursed 50% of their usual and customary charges. Services that must be included in the out-of-state PRTFs usual and customary rate are outlined in (7). Reimbursement will include all Medicaid covered psychiatric, medical, and ancillary services provided 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.

            (5) The bundled per diem rate for in-state PRTFs coverage includes the following services:

            (a) a direct-care wage add-on through a contract with the department or in the bundled per diem rate, as applicable; effective July 1, 2013;

            (b) services, therapies, and items related to treating the psychiatric condition of the youth;

            (c) services provided by licensed psychologists, licensed clinical social workers, and licensed professional counselors;

            (d) psychological testing;

            (e) lab and pharmacy services related to treating the psychiatric condition of the youth; and

            (f) supportive services necessary for daily living and safety.

            (6) The bundled per diem rate for in-state PRTFs does not include the following services, which are separately reimbursable by the Medicaid program for enrolled providers:

            (a) licensed physician, psychiatrist, and midlevel practitioner services;

            (b) non-psychotropic medication and related lab services;

            (c) adult mental health center evaluations for transition age youth 17 to 18, to determine whether or not they qualify for adult mental health services and have a severe and disabling mental illness; and

            (d) Medicaid state plan ancillary services, except targeted case management provided by the PRTF or by outside providers, if they are:

            (i) in the plan of care for the youth;

            (ii) provided under the direction of the PRTF physician; and

            (iii) provided under an arrangement with other qualified providers.

            (7) The bundled per diem rate for out-of-state PRTFs coverage includes the following services:

            (a) all services, therapies, and items related to treating the condition of the youth;

            (b) licensed physician, psychiatrist, and midlevel practitioner, psychologist, clinical social worker, and professional counselor services;

            (c) psychological testing;

            (d) lab and pharmacy services; and

            (e) supportive services necessary for daily living and safety.

            (8) The bundled per diem rate for out-of-state PRTFs does not include the following services, which are separately reimbursable by the Medicaid program for enrolled providers:

            (a) up to 80 units of targeted case management services as defined in ARM 37.87.802 per PRTF stay;

            (b) adult mental health center evaluations for transition age youth 17 to 18, to determine whether or not they qualify for adult mental health services and have a severe and disabling mental illness; and

            (c) Medicaid state plan ancillary services, provided by the PRTF or by outside providers, if they are:

            (i) in the plan of care for the youth;

            (ii) provided under the direction of the PRTF physician; and

            (iii) provided under an arrangement with other qualified providers.

            (9) The PRTF must maintain the medical records for Medicaid state plan ancillary services the youth receives.

            (10) Reimbursement will be made to in-state and out-of-state PRTF providers for reserving a bed while the youth is temporarily absent for a therapeutic home visit if:

            (a) the plan of care for the youth 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 provider clearly documents staff contact and youth achievements or regressions during and following the therapeutic home visit;

            (c) 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; and

            (d) the out-of-state PRTF pays for transportation for youth on a therapeutic home visit from an out-of-state PRTF.

            (11) No more than 14 patient days per youth in each state fiscal year will be reimbursed for therapeutic home visits.

            (12) Providers must bill for PRTF services using the revenue codes designated by the department.

            (13) Notice of the admission and discharge dates for the youth must be submitted to the department or its designee the day of admission or discharge. The department may impose a $200 charge 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

 

4. The department proposes to repeal the following rule:

 

37.87.1222 PSYCHIATRIC RESIDENTIAL TREATMENT FACILITY (PRTF) SERVICES, INTERIM RATE AND COST SETTLEMENT PROCESS is found on page 37-21379 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

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

 

            5. STATEMENT OF REASONABLE NECESSITY

 

On November 28, 2012, the Centers for Medicare and Medicaid (CMS) issued an informational bulletin announcing it would allow states the flexibility to ensure youth receiving inpatient psychiatric services would receive medically necessary Medicaid services to meet their medical, psychological, social, behavioral, and developmental needs as identified in their plan of care. Based upon this directive, the department is proposing changes to the psychiatric residential treatment facility (PRTF) administrative rules regarding how the ancillary services youth receive in a PRTF are reimbursed and regarding the services included in the bundled per diem rate. The proposed amendments and repeal are necessary to implement the changes in federal policy. The department believes the changes will benefit Montana providers and youth.

 

ARM 37.87.1202

 

The department is proposing to remove the definition of care coordination. Care coordination by a licensed or in-training mental health professional was an allowable ancillary service when PRTFs reimbursed ancillary services, and was not used. The department is proposing to allow reimbursement for ancillary services provided for youth in a PRTF by the Medicaid program and not the PRTF. A limited amount of targeted case management is being proposed for youth in out-of-state PRTFs.

 

ARM 37.87.1210

 

The department is proposing to remove the "PRTF waiver" denial requirement in ARM 37.87.1210 before youth may be served in an out-of-state PRTF. This is necessary because the PRTF waiver is no longer available.

 

ARM 37.87.1214

 

The department is proposing to amend the term "chemical dependency" to "substance use disorder." This is necessary in order to align rule terminology with the DSM-V. Substance abuse (SA) assessment and treatment services provided by PRTFs were allowable when the PRTFs reimbursed ancillary services directly; however, SA assessment and treatment in a PRTF are now optional services because the Children's Mental Health Bureau does not reimburse for SA services.

 

ARM 37.87.1217

 

The department is proposing to require use of the Montana children and adolescent needs and strengths (MT CANS) tool as the functional assessment tool for PRTF services. This is necessary to clarify which functional assessment is approved by the department.

 

ARM 37.87.1222

 

The department is proposing to repeal ARM 37.87.1222 to remove a reference to the interim rate and payments and the cost settlement language. The language regarding how ancillary services are reimbursed would be located in ARM 37.87.1223. This is necessary because the department is also proposing in ARM 37.87.1223, that all state plan Medicaid ancillary services be reimbursed by the Montana Medicaid Program and not the PRTFs.

 

ARM 37.87.1223

 

The department is proposing new language in ARM 37.87.1223 regarding how ancillary services are to be reimbursed.  This is necessary to have the reimbursement requirements in the same rule as PRTF reimbursement. The department is proposing that all state plan Medicaid ancillary services be reimbursed by the Montana Medicaid Program and not the PRTF, as the rules currently provide. Targeted case management (TCM) will not be a covered ancillary service for youth in an in-state PRTF at this time.

 

The department is proposing language to clarify what services are included in the in-state and out-of-state PRTF bundled per diem rates. Limited TCM services are being added as a covered ancillary service for youth in an out-of-state PRTF. Out-of-state PRTFs have significant problems discharging some youth from their facility and the department determined that TCMs will assist out-of-state PRTFs with appropriate discharge plans. The department is piloting TCM concurrent with out-of-state PRTFs with the intention of reviewing the outcome of this allowance to ascertain if TCM would also be beneficial for youth discharging from in-state PRTFs.

 

The department is proposing clinical assessments completed by a mental health center serving adults as a covered ancillary service. This is necessary in order to determine whether a youth 17 to 18 years of age in a PRTF has a serious disabling mental illness (SDMI) and, if so, to help make transition to adult Medicaid services easier. The department finds that transitioning to adult mental health services is difficult; knowing what services the youth will qualify for will assist in the transition. Some serious emotional disturbance (SED) covered diagnoses are also SDMI covered diagnoses; however, many are not. The department is proposing to move the PRTF therapeutic home visit reimbursement requirements from ARM 37.87.1222. This is necessary because ARM 37.87.1222 would be repealed.

 

The department is proposing to move the charge from ARM 37.87.1222 because it would be repealed. The department is also proposing to increase the charge to $200.00 for PRTFs who do not correct admission dates that do not match the first day of the PRTF prior authorization. This charge also applies to providers who do not discharge the youth per the department's instruction in the utilization review (UR) contractor's system, on the day of discharge. This proposed amendment is necessary because the department is required by the CMS to track ancillary service expenses separately when they are provided to youth in a PRTF.  The department has been notified by other providers when a youth was not discharged in the UR contractor's system they could not get reimbursed for their services.  The current charge of $100 has not been a sufficient enough deterrent.

 

Fiscal impact

 

The unique caseload count for PRTF services as of March 1, 2013 for state fiscal year (SFY) 2013 is 255. For SFY 2011 it was 463. There are 3 in-state and 11 out-of-state PRTFs enrolled in the Montana Medicaid Program. All would be affected by the proposed amendments.

 

            6. The department intends to adopt these rule amendments and repeal effective December 31, 2013 except for ARM 37.87.1223(5)(a) which is retroactively effective to July 1, 2013. A retroactive application of (5)(a) 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: Kenneth Mordan, 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., November 29, 2013.

 

 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.

 

12. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment and repeal of the above-referenced rules will not significantly and directly impact small businesses.

 

 

/s/ Cary B. Lund                                           /s/ Richard H. Opper                                   

Cary B. Lund                                               Richard H. Opper, Director

Rule Reviewer                                              Public Health and Human Services

           

Certified to the Secretary of State October 21, 2013.