Montana Administrative Register Notice 37-773 No. 24   12/23/2016    
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BEFORE THE Department of Public

health and human services of the



In the matter of the amendment of ARM 37.85.104 and 37.85.105 pertaining to updating Medicaid fee schedules with Medicare rates and updating effective dates to July 1, 2016 and January 1, 2017








TO: All Concerned Persons


1. On October 28, 2016, the Department of Public Health and Human Services published MAR Notice No. 37-773 pertaining to the public hearing on the proposed amendment of the above-stated rules at page 1924 of the 2016 Montana Administrative Register, Issue Number 20.


2. The department has amended the above-stated rules as proposed.


3. 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:  Commenters requested the department reimburse optometrists the same as ophthalmologists for identical codes and service and reasoned that federal Medicare regulation defined physicians to include optometrist, and expressed concern that Montana Medicaid does not define physician to include optometry. They wanted to know why there was a disparity and what the rationale behind it was.


Response #1Prior to 2008, optometrists were reimbursed using the same conversion factor as physicians. In 2007, the Montana 60th Legislature passed Senate Bill (SB) 354, which defined and clarified the Medicaid reimbursement conversion factor for physicians. SB 354, which was codified in 53-6-124 and 53-6-125, MCA defined "Physician" as having the same meaning provided in 37-3-102, MCA, which states: (11) "Physician" means a person who holds a degree as a doctor of medicine or doctor of osteopathy and who has a valid license to practice medicine or osteopathic medicine in this state.


Therefore, beginning in 2008, the department established separate conversion factors to comply with this statutory requirement.


Comment #2: A commenter requested clarification, or explanation, with regard to the table included on page 1928, of the proposed MAR notice, regarding fiscal impact, asked why are optometric and optician provider types included on the same line, wanted to know how much of the physician estimate was for ophthalmologists, was concerned the numbers seemed high, and wanted to know the total match dollars amount per provider type and per state fiscal year. 


Response #2: The department has historically combined the fiscal impact of optometrist and optician services together. In regards to the ophthalmologist's portion of physician services the department does not break this information out when projecting the program's fiscal impact. Because the Medicare rates were not published at the time MAR Notice Number 37-773 was published, the fiscal impact was estimated based on the 12-month Consumer Price Index for all urban consumers (CPI-U) ending in June 2016 adjusted by the change in the economy-wide productivity equal to the 10-year moving average of changes in annual economy-wide private nonfarm business multi-factor productivity (MFP). The federal match rates used to calculate the fiscal impacts were estimated at 65.56 percent for SFY 2017, 65.95 percent for SFY 2018, and 66.20 percent for SFY 2019.


Comment #3: A commenter made an observation regarding the telephone calls for eligibility stating it is often three, four, or five phone calls to get in. The department limits how many eligibility calls we can make, five calls to eligibility and we are bumped off and the staff has to call back in.


Response #3: Due to increased call volume, limitations are currently in place to service as many providers as possible. Once the limitation is reached, the caller is offered to be placed back into the queue of incoming calls or a caller can make a phone call at a later time. Hold times are steadily decreasing as more Xerox staff have been added. Average wait time was 30 minutes at highest, 20 minutes for most of the year, and is currently around five minutes; more agents are being trained and the department anticipates the time decreasing again before year's end. Providers can avoid the longer hold times by avoiding peak call times, 9:30 to 11:30 a.m. and 1:30 to 2:30 p.m. Alternatively, the department recommends that Medicaid eligibility can be best established through the Montana Access to Health Web Portal or by utilizing the faxback tool offered by the department to all providers. Detailed information on verifying member eligibility can be found in the General Information for Providers Manual found under Resources by Provider Type at http://medicaidprovider.mt.gov/.


Comment #4A commenter made note of claims being rejected because member eligibility changing within Medicaid, HELP, and Healthy Montana Kids (HMK), and then needing to start the whole billing process over again.


Response #4It is important to check member eligibility via the Web Portal prior to the member's appointment. The department acknowledges there are occasions where eligibility of Medicaid, HMK, or HELP members has changed after the member has been seen by a provider. When a billing of a service is denied for incorrect eligibility, the department should be contacted and correct eligibility will be investigated and the service will be reimbursed.


A large number of comments received were not applicable to the rules being adopted, amended, or repealed in this notice; therefore, they are not being responded to in this notice.


          4. The following rule amendments are effective January 1, 2017: ARM 37.85.104(1)(c), 37.85.105(2)(a), 37.85.105(2)(b), 37.85.105(3)(c), 37.85.105(3)(l), 37.85.105(3)(r), 37.85.105(3)(s), 37.85.105(3)(u), 37.85.105(3)(v), 37.85.105(4)(a), and 37.85.105(6)(a).


          5. The department intends to apply these rules retroactively to July 1, 2016: ARM 37.85.105(3)(w) and 37.85.105(3)(x). A retroactive application of the proposed rules does not result in a negative impact to any affected party.




/s/ Brenda K. Elias                                 /s/ Richard H. Opper                            

Brenda K. Elias                                     Richard H. Opper, Director

Rule Reviewer                                       Public Health and Human Services



Certified to the Secretary of State December 12, 2016.


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