BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
TO: All Concerned Persons
1. On September 24, 2015, the Department of Public Health and Human Services published MAR Notice No. 37-724 pertaining to the public hearing on the proposed amendment of the above-stated rules at page 1415 of the 2015 Montana Administrative Register, Issue Number 18.
2. The department has amended the following rules as proposed: ARM 37.89.103, 37.89.114, and 37.89.509.
3. The department has amended the following rules as proposed, but with the following changes from the original proposal, new matter underlined, deleted matter interlined:
37.86.3503 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, SEVERE DISABLING MENTAL ILLNESS
(1) "Severe disabling mental illness" means with respect to a person who is 18 or more years of age that the person meets the requirements of (1)(a)
, or (b), or and (c). The person must also meet the requirements of (1)(d). The person:
(a) has been involuntarily hospitalized for at least 30 consecutive days because of a mental disorder at Montana State Hospital
at least once within the past 12 months; or
recurrent thoughts of death, recurrent suicidal ideation within the past 12 months, a history of suicide attempts, or a specific plan for committing completing suicide; or and
(c) has a primary diagnosis of one of the following
except for (excluding "mild, not otherwise specified (NOS)," unspecified, or due to "physiological disturbances and physical factors ,") has a DSM diagnosis of:
schizophrenia spectrum, and other psychotic disorders delusional disorder, schizophreniform disorder, schizoaffective disorder;
spectrum I disorder and bipolar II disorder;
(iii) major depressive disorder;
anxiety disorders panic disorder with agoraphobia or panic disorder without agoraphobia;
(v) obsessive-compulsive disorder;
(v) (vi) posttraumatic stress disorder s;
(vi) remains as proposed, but is renumberd (vii).
(vii) (viii) autism spectrum disorder s; and
(d) has ongoing functioning difficulties because of the mental illness for a period of at least six months or
for a predictable period over six months, as indicated by the presence of at least three of the following indicators:
(i) and (ii) remain as proposed.
(iii) an inability to maintain housing due to mental illness;
(iv) through (vi) remain as proposed, but are renumbered (iii) through (v).
(vii) (vi) the person maintains a living arrangement housing only with ongoing supervision, is homeless, or is at imminent risk of homelessness due to mental illness; or
(viii) remains as proposed, but is renumbered (vii).
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, MCA
37.88.101 MEDICAID MENTAL HEALTH SERVICES FOR ADULTS, AUTHORIZATION REQUIREMENTS (1) remains as proposed.
(2) For mental health services provided to an adult Medicaid client under the Montana Medicaid program, a maximum of 24 sessions may be reimbursed per state fiscal year for individual and family outpatient therapy billed under 2015 Current Procedure Terminology codes 90832, 90833, 90834, 90836, 90837, 90838, 90846, and 90847 only. Prior authorization must be obtained for additional sessions.
(3) (2) Adult intensive outpatient therapy services may be medically necessary for a person with safety and security needs who has demonstrated the ability and likelihood of benefit from continued outpatient therapy. The person must meet the requirements of (3)(2)(a) or (b). The person must also meet the requirements of (3)(2)(c). The person has:
(a) a DSM diagnosis with a severity specifier of moderate or severe bipolar I disorder, bipolar II disorder,
spectrum or major depressive disorder; or
(b) through (c)(iv) remain as proposed.
(4) The department may waive a requirement for prior authorization when the provider can document that:
(a) there was a clinical reason why the request for prior authorization could not be made at the required time; or
(b) a timely request for prior authorization was not possible because of a failure or malfunction of equipment that prevented the transmittal of the request at the required time.
(5) The prior authorization requirement will not be waived except as provided in this rule.
(6) Under no circumstances may a waiver under (4) be granted more than 30 days after the initial date of service.
(7) Review of authorization requests by the department or its designee will be made with consideration of the adult intensive outpatient therapy services Clinical Management Guidelines (2015). A copy of the Adult Intensive Outpatient Therapy Services Clinical Management Guidelines (2015) can be obtained from the following web site: https://montana.fhsc.com/ or by a request in writing to the Department of Public Health and Human Services, Addictive and Mental Disorders Division, Mental Health Services Bureau, P.O. Box 202905, Helena, MT 59620-2905.
(8) and (9) remain as proposed, but are renumbered (3) and (4).
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
4. The department has thoroughly considered the comments and testimony received. A summary of the comments received and the department's responses are as follows:
Comment #1: A commenter stated that for services described in ARM 37.86.3503(1)(a) and (b) the mental health provider does not have a mechanism to bill for the services if these are the only criteria met. The commenter requested a billing code be attached to each of these requirements.
Response #1: The mental health provider is providing assessment services and can bill for those services even if the individual does not have a severe disabling mental illness (SDMI).
Comment #2: A commenter requested a clarification in ARM 37.86.3503(1)(a) on the qualifications that an individual who as a minor was committed to the Montana State Hospital (MSH); and the minor, now an adult, has not had any mental health symptoms since discharge from the MSH. A commenter stated that according to ARM 37.86.3503(1)(a) this minor would meet the definition of SDMI.
Response #2: It was not the intent of the department that individuals admitted to MSH years ago should be the only criteria to qualify for having a SDMI. The department added the qualifying statement "within the last 12 months." The department changed ARM 37.86.3503(1) to meet the requirement of ARM 37.86.3503(1)(a) or (1)(b) and (1)(c). The individuals must also meet the requirements of ARM 37.86.3503(1)(d).
Comment #3: A commenter expressed concern that those individuals admitted to MSH due to illicit-drug use or criminal activity would meet the criteria for SDMI.
Response #3: It was not the intent of the department that individuals admitted to MSH years ago should be the only criteria to qualify for having a SDMI. The department added the qualifying statement "within the last 12 months." The department changed ARM 37.86.3503(1) to meet the requirement of ARM 37.86.3503(1)(a) or (1)(b) and (1)(c). The individuals must also meet the requirements of ARM 37.86.3503(d).
Comment #4: A commenter stated that in ARM 37.86.3503(1)(b) "recurrent thoughts of death" is a subjective assessment and persons categorized as anti-social personality disorder or malingering may meet the criteria for severe disabling mental illness which has not been the case in the past.
Response #4: The department removed "recurrent thoughts of death." "Recurrent suicidal ideation within the last three months" was added. The department added history of suicide attempt(s). In addition, a specific plan for "committing" was changed to "completing."
Comment #5: A commenter stated that for persons who use the threat of suicide to access mental health services and do not meet SDMI criteria, a mental health provider does not have a billable code for payment of services rendered.
Response #5: The mental health provider is providing assessment services to determine if the individual has a SDMI. Please see Response #1.
Comment #6: Two comments related to the exclusion of physiological disturbances and physical factors in the SDMI criteria. The mental health providers do have individuals that exhibit psychotic symptoms only due to medical conditions. The commenters request that the text "due to physical disturbances and physical factors" be removed from the exclusionary statement.
Response #6: The department believes that a medical professional and not the mental health provider more appropriately serves individuals exhibiting psychotic behaviors due to a medical condition. This will remain an exclusion.
Comment #7: A commenter asked for clarification in ARM 37.86.3503(1)(c), if the definition still allows for "unspecified" disorder?
Response #7: No, "unspecified" disorder is not allowed. Unspecified is excluded and was added for clarification.
Comment #8: A commenter expressed concerned that in ARM 37.86.3503(1)(c)(iii) depressive disorder diagnosis would now include persistent depressive disorder (formerly dysthymia) and premenstrual dysphoric disorder. In the past, these disorders did not meet the SDMI criteria.
Response #8: It was not the department's intent to include persistent depressive disorder or premenstrual dysphoric disorder. The department clarified what diagnoses are acceptable. Bipolar spectrum was changed to "bipolar I disorder" and "bipolar II disorder." Depressive disorder was changed to "major depressive disorder."
Comment #9: A commenter was concerned that in ARM 37.86.3503(1)(c)(iv) "anxiety disorder" would now include generalized anxiety disorder, selective mutism, and specific phobias which have not previously met the SDMI criteria.
Response #9: It was not the department's intent to include the additional disorders. The department changed the anxiety disorders to "panic disorder with agoraphobia" and "panic disorder without agoraphobia" to clarify what is included in SDMI.
Comment #10: A commenter stated that the exclusion of personality disorders from the SDMI criteria will create significant barriers to serve individuals who have been formerly eligible and need of service. The diagnoses specifically referenced are paranoid personality disorder, schizoid personality disorder, schizotypal personality disorder, histrionic and narcissistic personality disorder, obsessive compulsive disorder, and dependent personality disorder. The commenter recommended that personality disorders, which have historically been included in the SDMI criteria, be included.
Response #10: It was not the intent of the department to exclude "obsessive compulsive disorder." The department has added this disorder to the SDMI criteria. The department will include only "borderline personality disorder." It is not the intent to grandfather anyone that does not meet the definition of "borderline personality disorder" effective October 1, 2015. A reasonable transition plan written by the mental health provider would be expected to move these individuals from SDMI-covered services to more appropriate services.
Comment #11: A commenter stated the additional requirement of three functionality indicators was concerning. The commenter recommends the department continue to require only two indicators of functionality needed for SDMI criteria in ARM 37.86.3503(1)(d).
Response #11: The department added an additional two indicators to the functioning difficulties. The department will request in ARM 37.86.3503(1)(d) three indicators be identified in the area of functioning difficulties. The department believes this will not put any undue hardship on the mental health provider to assess an appropriate SDMI.
Comment #12: A commenter stated that ARM 37.86.3503(1)(d)(iii) appears to be redundant to ARM 37.86.3503(1)(d)(iv).
Response #12: The department agrees with this comment. The department has combined ARM 37.86.3503(1)(d)(iii) and (vi). ARM 37.86.3503(1)(d)(vi) now states "inability to maintain housing without ongoing supervision; is homeless; or is at imminent risk of homelessness due to mental illness."
Comment #13: A commenter would like the catch line for ARM 37.86.3503(1)(c)(v) updated to "trauma and stressor related disorders" to be consistent with the DSM 5.
Response #13: The department appreciates the comment; however, it is the department's intent to cover posttraumatic stress disorder only.
Comment #14: A commenter requested further consideration and review of diagnoses currently qualified within the Children Mental Health Bureau. There is concern that when these youth transition to adult services they will no longer be covered by the SDMI criteria.
Response #14: The department agrees that youth transitioning to adult services is difficult. The department has a transition team with primary focus of youth transitioning to adult services. The transition team is making every effort to ensure a smooth transition for the youth to adult services.
Comment #15: A commenter would like the department to delete the phrase "complications due to premature discharge" in ARM 37.89.509(8)(a). This phrase is used often in the 72-hour crisis stabilization program.
Response #15: The department has a mechanism under ARM 37.89.509(8)(a) that the mental health provider can request an informal review if a person was discharged prematurely due to complications. The department is unclear how this is detrimental to the mental health provider of a 72-hour crisis stabilization program.
Comment #16: A commenter would like the department to consider the inclusion of substance use-related disorders. This is an ongoing contributing factor in a 72-hour crisis program.
Response #16: The program is designed for individuals in a mental health crisis. It is understood, by the department, that many times an individual may be under the influence of substances. The department will not include substance use disorder.
Comment #17: A commenter stated in ARM 37.88.101 a maximum of 24 sessions may be reimbursed per state fiscal year. The Centers for Medicare and Medicaid (CMS) essential benefit plan cannot have limits placed on outpatient services. This section should be deleted to be compliant with CMS.
Response #17: The department deleted the limits on 24 outpatient sessions from the rule and any reference to prior authorization.
5. The department intends to apply these rule amendments retroactively to October 1, 2015. A retroactive application of the proposed rule amendments does not result in a negative impact to any affected party.
/s/ Susan Callaghan Robert Runkel for Richard H. Opper
Susan Callaghan, Attorney Richard H. Opper, Director
Rule Reviewer Public Health and Human Services
Certified to the Secretary of State December 14, 2015