BEFORE THE Department of Public

health and human services of the

STATE OF MONTANA

 

In the matter of the adoption of New Rule I and the amendment of ARM 37.86.2207, 37.87.733, 37.87.809, 37.87.903, and 37.87.2233 pertaining to Medicaid reimbursement of children's mental health services

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NOTICE OF ADOPTION AND AMENDMENT

 

TO:  All Concerned Persons

 

1.  On April 15, 2010, the Department of Public Health and Human Services published MAR Notice No. 37-503 pertaining to the public hearing on the proposed adoption and amendment of the above-stated rules at page 866 of the 2010 Montana Administrative Register, Issue Number 7.

 

2.  The department has adopted New Rule I (37.87.901) as proposed.  The department has amended the above-stated rules as proposed.

 

            3.  After MAR Notice 37-503 was filed with the Secretary of State on April 15, 2010, the department made some changes to the Children's Mental Health Bureau's Provider Manual and Clinical Guidelines for Utilization Management (provider manual) for clarification.  The psychiatric residential treatment facility (PRTF) waiver admission criteria was changed to align with the approved Centers for Medicare and Medicaid Services (CMS) waiver amendment and the enrollment criteria was changed because it was inaccurate.  Enrollment does not start with a referral to the plan manager or provider.

 

On the list of required forms in the provider manual, some forms have been renamed or consolidated and two new forms have been added.  The forms themselves are not part of the manual or administrative rules, but the names are.  One new form is the Discharge Plan Review form, required with continued stay request at PRTF level of care; the second new form is an Administrative Review Request form.  The form is consistent with administrative rules and we encourage, but do not require its use.  In the administrative review section of the manual, the department clarified that both the provider and the legal custodian have a right to request an administrative review.  Coordination and collaboration between them for a review is encouraged.

 

The other form changes were:  (1) Separating prior authorization of community-based psychiatric rehabilitation and support (CBPRS) concurrent with comprehensive school and community treatment (CSCT) from partial hospital (PHP), day treatment (Day Tx), and therapeutic group home (TGH).  The form is not new, however it has a new name and is described in the provider manual.  (2)  The department combined the PRTF and PRTF-AS (Assessment) forms.  (3)  The department renamed the therapeutic home visit (THV) form.  The number of forms was reduced from 31 to 28.  The department corrected the required forms list at the end of the services sections to align with the names on the list in section 6 and with the instructions in the manual. 

 

In a couple of cases, the department aligned more closely the clinical guidelines in the manual with the forms.  The department clarified the lead clinical staff in a TGH or the program therapist in a Day Tx, CSCT, or PHP with direct knowledge of the youth needs to complete the CBPRS prior authorization request, while youth are in these programs.  The department clarified that the prior authorization request for outpatient therapy concurrent with CSCT is a separate authorization process from the request for more than 24 outpatient sessions in a state fiscal year (SFY).  The department clarified therapeutic home visits beyond three days must be prior authorized.  The department also clarified that continued stay reviews may be requested "no more than ten business days prior to the end of the current authorization span", and no less than five business days.

 

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 indicated that the changes to New Rule I (37.87.901) regarding the concurrent approval of outpatient therapy for youth enrolled in CSCT will be efficient, provide better integration of services, assure both services are warranted, and require the CSCT providers to work closely with community therapists.

 

RESPONSE #1:  The department assumes the commenter is referring to the Medicaid Mental Health and Mental Health Services Plan for Youth Services Excluded from Simultaneous Reimbursement (service matrix) moved to New Rule I (37.87.901) and agrees.  However, requiring prior authorization of outpatient therapy on the same day as CSCT is not a new requirement.

 

COMMENT #2:  Healthy Montana Kids (HMK) extended coverage allows for community-based psychiatric rehabilitation and support services CBPRS to be billed for CSCT services provided during the day.  This is supportive to children and families and helps improve outcomes.  The commenter would like to see this practice continued and allow CSCT providers to bill CBPRS during school hours.

 

RESPONSE #2:  The department assumes the commenter is referring to the service matrix and the new language "When CBPRS is authorized to be reimbursed on the same day as CSCT, CBPRS may not be provided during school hours."  The department will not make this proposed change to the service matrix and will remove the proposed language, as CBPRS is allowed in CSCT when prior authorized per ARM 37.87.703.  CSCT is not a covered benefit under Healthy Montana Kids (CHIP) program.  CSCT is a covered benefit under Healthy Montana Kids Plus (Medicaid program). 

 

COMMENT #3:  We believe the language on the service matrix about CBPRS services "during school hours" is not needed.  Clarification that this restriction applies only to youth receiving CSCT services should be included.  Currently there are schools without CSCT services where CBPRS is authorized during school hours.  The state recently allowed CBPRS during school hours for children covered through HMK.  This is the right thing to do for kids.  It allows for continuation of services from what is happening in the school to follow through in the home, and has high quality outcomes.

 

We have attached the March 5, 2010 HMK memo describing this policy change.  We would like to have clarification of the definitions for HMK and HMK Plus in relationship to the Basic and Extended Mental Health Plan of services.  

 

RESPONSE #3:  See response #2.  The service matrix does not address CBPRS and whether it can be provided in school.  The service matrix identifies mental health services that may duplicate one another if provided on the same day without prior authorization.

 

A clarification of the definitions for HMK, HMK Plus in relationship to the basic and extended mental health plan of services will not be done as a part of this rule notice because it is outside the scope of the proposed rule changes.  Questions outside the scope of the proposed rule changes should be directed to the Children's Mental Health Bureau.

 

COMMENT #4:  Several commenters recommend that targeted case management (TCM) services be allowed for youth in a PRTF in the matrix for Services Excluded from Simultaneous Reimbursement.  Not allowing TCM services complicates discharge planning for the youth.  Youth are often placed in a PRTF many miles from their home and it is difficult to engage community agencies in developing a plan for the return of the youth without TCM to the home or community placement.  This is particularly frustrating since the Centers for Medicare and Medicaid Services (CMS) has reversed their position on this issue and allow Medicaid funding for TCM services for youth in a PRTF.

 

RESPONSE #4:  Adding TCM and PRTF services to the service matrix were for clarification purposes only.  TCM services for youth in a PRTF is not allowed per ARM 37.87.1222.

 

COMMENT #5:  A commenter indicated there may be unintended consequences in the service matrix by not allowing outpatient therapy with CSCT.  This could disallow evaluations conducted by mental health centers if CSCT is being provided.  Please look at codes 90801 and 90802 to assure if this is the intent of the department.

 

RESPONSE #5:  The department assumes commenter is referring to the service matrix in New Rule I (37.87.901).  Codes 90801 and 90802 are psychiatric diagnostic or evaluative interview procedures and not considered psychotherapy or outpatient therapy services, per our definition of outpatient therapy in ARM 37.87.102(10).  The outpatient therapy or psychotherapy codes listed on the department's service matrix require prior authorization when provided on the same day as CSCT.

 

COMMENT #6:  Many commenters object to the language which references the attributes of a private corporation on page 8 as inappropriate for a technical state government document.

 

RESPONSE #6:  The department assumes commenter is referring to the provider manual in ARM 37.87.903 and the paragraph that starts out "As a pioneer in the management of Medicaid mental health and substance abuse treatment, . . . ."  The department agrees, the paragraph will be taken out of the provider manual.

 

COMMENT #7:  Prior authorization for CBPRS reimbursement requires two different types of authorization, one for group and one for individual.  It would be helpful if this could be integrated into one step.  The prior authorization process is difficult and takes almost an hour of staff time per request. 

 

The time it takes to request authorization is not reimbursable and takes staff away from providing services.  This defeats the purpose of being able to provide efficient services to clients.

 

RESPONSE #7:  The department assumes the commenter is referring to the authorization requirements in the CBPRS section of the provider manual in ARM 37.87.903. The department will clarify the CBPRS authorization requirements in the CBPRS section.  The department is not proposing a separate authorization processes for individual and group CBPRS.  Prior authorization for CBPRS is required when provided on the same day as other children's mental health services identified on the service matrix in New Rule I (37.87.901). 

 

COMMENT #8:  A commenter has heard that CBPRS authorization will be capped at 210 units per month.  This equates to 4.4 units per week.  If this is the case, this is a disservice to some clients.  There are children who will require more units than this arbitrary cap will allow.  There are programs that offer afterschool and summer programs that are critical to the support of families and children.  These programs provide solid outcomes in creating self-sufficiency of families and permanency for children.  Having an arbitrary cap on units for CBPRS would devastate these programs and potentially close several of them.  Parents could not function without afterschool and summer programs for children with this level of need. You would see placements break down and permanency lost.  Is there a way to clarify the rules to allow enough hours for afterschool and summer programs?  Could the number of units allowed for afterschool and nonschool days be treated differently?

 

RESPONSE #8:  The department is not proposing a cap on the number of CBPRS units per month in administrative rule or the CBPRS section of the provider manual in ARM 37.87.903.

 

COMMENT #9:  A commenter asks if the required behavioral assessment for CBPRS authorization could be completed by an in-training practitioner.  Completing this will require extra time for which providers are not reimbursed.  This defeats the purpose of being able to provide efficient services to clients.  Will rates be adjusted to take this into account?

 

RESPONSE #9:  The department assumes the commenter is referring to the CBPRS section of the provider manual in ARM 37.87.903.  The department believes the behavior assessment must be completed by the lead clinical staff of a TGH or by the program therapist in a Day Tx or PHP program to get good clinical information on why a CBPRS aide is needed in addition to the program staff already required.  Yes, an in-training practitioner may be used to complete the behavior assessment.

 

The commenter is correct, the time it takes to complete prior authorization requests is not a reimbursable activity.  The CBPRS rate will not be adjusted.  Administrative expenses are included in the reimbursement rate.

 

COMMENT #10:  The conditions under which prior or continued authorization requirements may be waived by the department is too limited, only allowing for clinical or equipment failure reasons.  Several commenters requested the department reconsider this narrow limitation, especially in the case of a continued authorization request that is missed by the provider because of human error.  It is clear that the department's statutory responsibility is to determine medical necessity but it is not clear how taking this position is consistent with this role.  This requirement seems like a management versus a medical necessity issue.  If the youth meets medical necessity criteria the day the authorization runs out and meets medical necessity the day the authorization is renewed, the youth most likely met medical necessity criteria during the time span that was missed due to provider error.  This requirement seems unreasonably punitive and unfair to the provider who has to absorb the cost of providing the treatment, when a continued authorization request is late.  This seems more applicable to private insurance plans instead of an entitlement program like Medicaid.  The commenter requests a limited time period be allowed for requests to be submitted and reviewed to accommodate these errors.

 

RESPONSE #10:  The department assumes the commenter is referring to ARM 37.87.903.  The department did not propose changes to the conditions under which prior authorization may be waived.  Requiring continued authorizations intermittently is a management tool for checking whether or not a service continues to be medically necessary.  Forgetting to request a continued authorization does occur on occasion, however the requirement is not new.

 

The word "continued" was added to ARM 37.87.903 to clarify that both initial and continued authorization requests must be submitted prior to the service being delivered for Medicaid reimbursement.  The department believes the conditions in ARM 37.87.903 to waive authorization requirements remain appropriate.

 

COMMENT #11:  In the provider manual, the statement "All required CON's must actually and personally be signed by each team member" seems contradictory or ambiguous to the statement that a minimum of two signatures are required.  Does this means a CON can be signed by a physician and licensed mental health provider and meet the standard,  or do all team members have to sign the CON?  This statement needs clarification.  Requiring every team member to sign the CON would create logistical challenges.  The commenter requests the department permit the practitioner in training to sign the CON.

 

RESPONSE #11:  The department assumes the commenter is referring to page 13, in section 2.2.1 of the provider manual, regarding the CON procedure.  Yes, a CON can be signed by a physician and licensed mental health professional and meet the standard.  Not all team members need to sign the CON.  The department's CON requirements are based on the federal CON requirement for inpatient hospitalization.

 

Regarding the commenter's second recommendation, the department assumes the commenter is referring to an in-training mental health professional defined in ARM 37.87.702(3).  The department does not believe in-training mental health professionals have enough experience to sign a CON.  The CON is based on the professional's competence in diagnosis and treatment of mental illness, the youth's psychiatric condition and certifies other community services do not meet the youth's needs and the service is expected to improve the youth's condition.

 

COMMENT #12:  Several commenters noted in the provider manual that most of the admission requirements for the clinical programs require that lower level interventions  be tried and found insufficient to meet the youth's needs before the next level of treatment may be tried.  Youth should not be placed in a level of care that is too restrictive.  This approach requires youth to fail before they can access an appropriate service.  The commenters request the department reword the clinical guidelines to allow for some flexibility, so youth can access appropriate treatment without having to start and fail at the lowest level.  Sometimes it is obvious that they are not likely to succeed and requiring failure just prolongs the time it will take for them to get into the appropriate treatment.  The commenters request the guidelines recognize the lack of available lower-level alternatives in some areas of the state.  Since the clinical guidelines are being followed quite strictly, please reword them and allow more flexibility.

 

RESPONSE #12:  The department, for the most part, did not propose changes to the admission criteria in the clinical guidelines in the provider manual.  The department assumes the commenters' questions and recommendations pertain to all service admission criteria versus a specific service.  The commenter is correct.  The admission criteria for most services require outpatient interventions or less restrictive services to have been attempted and documented to be insufficient to meet the youth's needs and safety concerns or have failed to meet the youth's needs in the community setting.  The admission criteria for each service was developed with an understanding of the specific service requirements and reimbursement in mind, as well as the clinical needs of youth with a serious emotional disturbance.

 

As indicated in section 5.0 of the provider manual, the utilization management contractor (UMC) uses the clinical guidelines strictly as guidelines along with their professional judgment about whether the medical necessity criteria is met.  The guidelines do not prohibit a reviewer, under certain circumstances, from authorizing a higher level of care when less restrictive services have not been attempted.

 

COMMENT #13:  Several commenters noted in the provider manual under Outpatient Therapy that practitioners in training (PITs) are not referenced as eligible providers.  Other Medicaid rules (Licensed Mental Health Center) allow for this.  It would be helpful and consistent with other rules to reference PITs in this section.

 

RESPONSE #13:  The department assumes the commenter is referring to the outpatient therapy definition section in 5.8 and in-training mental health professionals as defined in Medicaid ARM 37.87.702(3).  As commenter points out, Medicaid reimburses mental health centers for in-training mental health professional services.  The department agrees with the recommendation and will add the following underlined language to this section.

 

"Outpatient therapy services include individual, family, and group therapy in which psychotherapy and related services by a licensed mental health professional acting within the scope of the professional's license or a mental health center in-training mental health professional defined in ARM 37.87.702(3).  Outpatient therapy services represent community-based treatment that incorporates Current Procedural Terminology (CPT) codes.  Outpatient therapy services may only be provided by individuals licensed by the state of Montana or a mental health center in-training mental health professional.  To be reimbursed for outpatient therapy services, the provider must be enrolled in Montana Medicaid."

 

COMMENT #14:  A commenter recognizes the need to restrict eligibility for permanency level therapeutic family care to youth in foster care.  This was the original intent of this level of care.  The commenter has been successful in using this level of care for youth in birth, kinship, and post-adoptive families from needing higher levels of care and would like an option developed to provide this level of service to these families.  Could this service be covered in the PRTF Waiver programs?  Consider providing this level of service to these families.  It has been proven in the past that if we do not intervene at this level when the child is still in the family, the child and family will continue to "fail up" for higher level of services and end up costing more in the long run.

 

RESPONSE #14:  The department assumes commenter is referring to the Therapeutic Family Care section of the provider manual in ARM 37.87.903.  The department wanted to clarify its policy that permanency level therapeutic family care may only be authorized in a foster home intended to support the placement in becoming an adoptive placement and not in a youth's biological or adoptive home.  In the near future the department will work with stakeholders and propose changes to the therapeutic family care administrative rules.  In the mean time, moderate level therapeutic family care and CBPRS services are available.  During these tight budgetary times, the department is not expanding services.

 

The PRTF Waiver program provides intensive in-home services similar to permanency level therapeutic family care.  If permanency level therapeutic family care services were provided in the Waiver program, the program would follow the same rules governing the service as Medicaid.

 

COMMENT #15:  Can a mental health center bill for respite services even if the child is not in the PRTF Waiver program?

 

RESPONSE #15:  Yes, per the respite definition in ARM 37.87.2202.

 

            5.  The department intends for the adoption and amendment of these rules to be effective July 1, 2010.

 

 

 

/s/  John Koch                                                /s/  Anna Whiting Sorrell                              

Rule Reviewer                                               Anna Whiting Sorrell, Director

                                                                        Public Health and Human Services

 

Certified to the Secretary of State June 14, 2010.