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Montana Administrative Register Notice 37-585 No. 9   05/10/2012    
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BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.86.3001, 37.86.3002, 37.86.3003, 37.86.3005, 37.86.3006, 37.86.3016, 37.86.3018, 37.86.3020, 37.86.3025, 37.86.3031, 37.86.3033, 37.86.3037, 37.86.3109 and repeal of 37.86.3014 pertaining to Medicaid outpatient hospital services

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT AND REPEAL

 

TO:  All Concerned Persons

 

            1.  On May 30, 2012, at 10:00 a.m., the Department of Public Health and Human Services will hold a public hearing in Room 207 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 May 23, 2012, 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:

 

            37.86.3001  OUTPATIENT HOSPITAL SERVICES, DEFINITIONS

            (1) through (6) remain the same.

            (7)  "Disproportionate share hospital-specific uncompensated care" means the costs of inpatient and outpatient hospital services provided to clients who have no health insurance or source of third-party coverage.

            (7) through (14) remain the same, but are renumbered (8) through (15).

            (15) (16) "Partial hospitalization services" means an active treatment program that offers therapeutically intensive, coordinated, structured clinical services provided only to individuals who are determined to have a serious emotional disturbance or severe disabling mental illness.  Partial hospitalization services are time-limited and provided within either an acute level program or a sub-acute level program.  Partial hospitalization services include day, evening, night, and weekend treatment programs that employ an integrated, comprehensive, and complementary schedule of recognized treatment or therapeutic activities.

            (a)  Acute level partial hospitalization is provided by programs which:

            (i)  are operated by a hospital as described in 50-5-101, MCA and are colocated with that hospital such that in an emergency a patient of the acute partial hospitalization program can be transported to the hospital's inpatient psychiatric unit within 15 minutes;

            (ii)  serve primarily individuals being discharged from inpatient psychiatric treatment or inpatient psychiatric residential treatment; and

            (iii)  provide psychotherapy services consisting of at least individual, family, and group sessions at a frequency designed to stabilize patients sufficiently to allow discharge to a less intensive level of care at the earliest appropriate opportunity, on average, after 15 or fewer treatment days.

            (b)  Acute level partial hospitalization is reimbursed according to ARM 37.86.3022.

            (c)  Sub-acute level partial (SAP) hospitalization is provided by programs which:

            (i)  operate under the license of a general hospital with a distinct psychiatric unit or an inpatient psychiatric hospital for individuals under 21;

            (ii)  operate in a self-contained facility and offer integrated mental health services appropriate to the individual's needs as identified in an individualized treatment plan;

            (iii)  provide psychotherapy services consisting of at least three group sessions per week and five individual and/or family sessions per month;

            (iv)  encourage and support parent and family involvement;

            (v)  provide services in a supervised environment by a well-integrated, multi-disciplinary team of professionals which includes but is not limited to program therapists, behavioral specialists, teachers, and ancillary staff;

            (A)  a program therapist must be a licensed mental health professional who is site based;

            (B)  a program therapist must have an active caseload that does not exceed ten program clients;

            (C)  a behavioral specialist must be site based and have a bachelor's degree in a behavioral science field or commensurate experience working with children with serious emotional disturbance.  There must be one behavioral specialist for each five youth in the SAP program; and

            (D)  all staff responsible for implementing the treatment plan must have a minimum of 24 hours orientation training and 12 additional hours of continuing education each year relating to serious emotional disturbance in children and its treatment.  Training must include specific instruction on recognizing the effects of medication.

            (vi)  provide education services through one of the following:

            (A)  full collaboration with a school district;

            (B)  certified education staff within the program; or

            (C)  interagency agreements with education agencies.

            (vii)  provide crisis intervention and management, including response outside of the program setting;

            (viii)  provide psychiatric evaluation, consultation, and medication management on a regular basis.  Psychiatric consultation to the program treatment staff is provided at least twice each month and includes at least one face-to-face evaluation with each youth each month;

            (ix)  serve children or youth with a serious emotional disturbance being discharged from inpatient psychiatric treatment or residential treatment or who would be admitted to such treatment in the absence of partial hospitalization; and

            (x)  are designed to stabilize patients sufficiently to allow discharge to a less intensive level of care, on average, after 60 or fewer treatment days.

            (d)  Sub-acute level partial hospitalization is reimbursed at the rate specified in the department's Medicaid Mental Health Fee Schedule.

            (16) remains the same, but is renumbered (17).

            (17)  "Qualified rate adjustment (QRA)" payment means an additional payment to a county owned, operated or partially county funded rural hospital in Montana as provided in ARM 37.86.3005, when the hospital's most recently reported costs are greater than the reimbursement received from Montana Medicaid for outpatient care.

            (18) and (19) remain the same.

            (20)  "340B drug pricing program" means a drug pricing program established under section 340B of the Veterans Health Care Act which offers outpatient pharmaceuticals at substantially reduced prices to qualified entities.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:    53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA

 

            37.86.3002  OUTPATIENT HOSPITAL SERVICES, SCOPE AND REQUIREMENTS  (1) through (2)(d) remain the same.

            (e)  diabetic education services provided by a hospital whose diabetic education protocol has been approved by the Medicare Part A Program, P.O. Box 5017, Great Falls, MT  59403 6732, Fargo, ND 58108-6732.  Coverage of diabetic education services is limited to those services meeting the requirements of  42 CFR, part 410, subpart H as revised through October 1, 2005 2010.  A copy of this section is adopted and incorporated by reference and is available through the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT  59620-2951.

 

AUTH:   53-2-201, 53-6-113, MCA

IMP:      53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA

 

            37.86.3003  OUTPATIENT HOSPITAL SERVICES, EXCLUSIONS

(1) through (1)(c) remain the same.

            (d)  experimental or investigational services, clinical trials, such as the use of off-label drugs where this usage is not a national standard of practice, or non-FDA-approved use of drugs, biologicals, and devices;

            (e) and (f) remain the same.

 

AUTH:   53-2-201, 53-6-113, MCA

IMP:      53-2-201, 53-6-101, MCA

            37.86.3005  OUTPATIENT HOSPITAL SERVICES, REIMBURSEMENT AND QUALIFIED RATE ADJUSTMENT PAYMENT  (1) remains the same.

            (2)   Outpatient hospital services that are not provided by exempt hospitals or critical access hospitals as defined in ARM 37.86.2901 will be reimbursed under ARM 37.86.3007, 37.86.3009, 37.86.3016, 37.86.3018, 37.86.3020, 37.86.3025, 37.86.3109, and 37.86.3037 for medically necessary services.

            (3) remains the same.

            (4)  For critical access hospitals and exempt hospitals, interim reimbursement for outpatient hospital services is based on hospital-specific Medicaid outpatient cost-to-charge ratio, not to exceed 100%.  Critical access hospitals and exempt hospitals will be reimbursed their actual allowable costs determined according to ARM 37.86.2803.

            (5)  Subject to the availability of sufficient county and federal funding, the department will pay in addition to the established Medicaid rates provided in this rule a qualified rate adjustment payment to an eligible rural hospital in Montana as provided in ARM 37.86.2810.

 

AUTH:   53-2-201, 53-6-113, MCA

IMP:      53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-141, MCA

 

            37.86.3006  MENTAL HEALTH OUTPATIENT PARTIAL HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY REQUIREMENTS  (1) remains the same.

            (2)  Partial hospitalization services include day, evening, night, and weekend treatment programs that employ an integrated, comprehensive, and complementary schedule of recognized treatment or therapeutic activities.

            (a)  Acute level partial hospitalization is provided by programs which:

            (i)  are operated by a hospital as described in 50-5-101, MCA, and are collocated with that hospital such that in an emergency a patient of the acute partial hospitalization program can be transported to the hospital′s inpatient psychiatric unit within 15 minutes;

            (ii)  serve primarily individuals being discharged from inpatient psychiatric treatment or inpatient psychiatric residential treatment; and

            (iii)  provide psychotherapy services consisting of at least individual, family, and group sessions at a frequency designed to stabilize patients sufficiently to allow discharge to a less intensive level of care at the earliest appropriate opportunity, on average, after 15 or fewer treatment days.

            (b)  Acute level partial hospitalization is reimbursed according to ARM 37.86.3022.

            (c)  Subacute level partial (SAP) hospitalization is provided by programs which: 

            (i)  operate under the license of a general hospital with a distinct psychiatric unit or an inpatient psychiatric hospital for individuals under 21;

            (ii)  operate a self-contained facility and offer integrated mental health services appropriate to the individual′s needs as identified in an individualized treatment plan;

            (iii)  provide psychotherapy services consisting of at least three group sessions per week and five individual and/or family sessions per month;

            (iv)  encourage and support parent and family involvement;

            (v)  provide services in a supervised environment by a well-integrated, multidisciplinary team of professionals which includes program therapists, behavioral specialists, teachers, and ancillary staff;

            (A)  a program therapist must be a licensed mental health professional who is site-based;

            (B)  a program therapist must have an active caseload that does not exceed ten program clients;

            (C)  a behavioral specialist must be site-based and have a bachelor′s degree in a behavioral science field or commensurate experience working with children with serious emotional disturbance.  There must be one behavioral specialist for each five youth in the SAP program; and

            (D)  all staff responsible for implementing the treatment plan must have a minimum of 24 hours orientation training and 12 additional hours of continuing education each year relating to serious emotional disturbance in children and its treatment.  Training must include specific instruction on recognizing the effects of medication.

            (vi)  provide education services through one of the following:

            (A)  full collaboration with a school district;

            (B)  certified education staff within the program; or

            (C)  interagency agreements with education agencies.

            (vii)  provide crisis intervention and management, including response outside of the program setting;

            (viii)  provide psychiatric evaluation, consultation, and medication management on a regular basis.  Psychiatric consultation to the program treatment staff is provided at least twice each month and includes at least one face-to-face evaluation with each youth each month;

            (ix)  serve children or youth with a serious emotional disturbance being discharged from inpatient psychiatric treatment or residential treatment or who would be admitted to such treatment in the absence of partial hospitalization; and

            (x)  are designed to stabilize patients sufficiently to allow discharge to a less intensive level of care, on average, after 60 or fewer treatment days.

            (d)  Subacute level partial hospitalization is reimbursed at the rate specified in the department′s Medicaid Mental Health Fee Schedule.

            (2) through (6) remain the same, but are renumbered (3) through (7).

 

AUTH:  53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

IMP:     53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.86.3016  OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, IMAGING SERVICES  (1) and (a) remain the same.

            (b)  For imaging services where no APC rate or Medicare fee has been assigned, a Medicaid fee will be set in accordance with the resource based relative value scale (RBRVS) methodology found at ARM 37.86.212 37.85.212.

            (c)  For imaging services where no APC rate, Medicare fee, or Medicaid fee has been assigned, outpatient hospital-specific percent of charges will be paid.  Birthing centers and out-of-state hospitals will be reimbursed the statewide outpatient cost-to-charge ratio.

 

AUTH:    53-2-201, 53-6-113, MCA

IMP:       53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

            37.86.3018  OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, OTHER DIAGNOSTIC SERVICES  (1)  Other diagnostic services will be reimbursed as follows with the exception of hospitals reimbursed under ARM 37.86.3005(3) (4):

            (a) and (b) remain the same.

            (c)  for other diagnostic services where no APC rate, Medicare fee, or Medicaid fee has been assigned, outpatient hospital-specific percent of charges will be paid.  Birthing centers and out-of-state hospitals will be reimbursed the statewide outpatient cost-to-charge ratio.

 

AUTH:   53-2-201, 53-6-113, MCA

IMP:      53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.86.3020  OUTPATIENT HOSPITAL SERVICES, OUTPATIENT PROSPECTIVE PAYMENT SYSTEM (OPPS) METHODOLOGY, AMBULATORY PAYMENT CLASSIFICATION  (1)  Outpatient hospital or birthing center services that are not provided by exempt hospitals or critical access hospitals as defined in ARM 37.86.2901(4) and (8) will be reimbursed on a rate-per-service basis using the Outpatient Prospective Payment System (OPPS) schedules.  Under this system, Medicaid payment for outpatient services included in the OPPS is made at a predetermined, specific rate.  These outpatient services are classified according to a list of APCs published annually in the Code of Federal Regulations (CFR).  The rates for OPPS are determined as follows:

            (a)  The department uses a conversion factor for each APC group as defined at in ARM 37.86.3001(5).  The conversion factor for August 1, 2003 through September 30, 2007 is $47.75.  The conversion factor for October 1, 2007 through June 30, 2008 is $49.71.  The conversion factor for services on or after July 1, 2008 is $50.61.  The APC-based fee equals the Medicare specific relative weight for the APC times the conversion factor that is the same for all APCs with the exceptions of services in ARM 37.86.3025.  APCs are based on classification assignment of CPT/HCPCS codes.

            (b)  At the claim level, payment will be the lower of the provider's charge and or the payment as calculated using OPPS.  There will be no charge cap at the line level.

            (c) and (d) remain the same.

            (e)  If the OPPS does not assign a Medicare fee or APC for a particular procedure code, a Medicaid fee will be assigned in accordance with the resource based relative value scale (RBRVS) methodology found at ARM 37.85.212.  If there is not a Medicaid fee, the service will be reimbursed at hospital-specific outpatient cost-to-charge ratio as in ARM 37.86.2803.  Birthing centers and out-of-state hospitals will be reimbursed the statewide outpatient cost-to-charge ratio.:

            (i)  Medicaid statewide average outpatient cost-to-charge ratio is 44.5%.

            (f)  The department will make separate payment for observation care procedure codes if the following criteria are met: only if the patient has a primary diagnosis code of asthma, chest pain, congestive heart failure, or obstetric complications.  If an observation service does not meet Medicare's criteria for these services, payment for observation care will be considered bundled into the APC for other services.

            (i)  The diagnosis used to define a potential obstetric qualification will be taken from diagnosis related groups 382 (false labor) and 383 (other antepartum diagnosis with medical complications). hours or units of service must be equal to or greater than eight;

            (ii)  must be a direct admit or have a high level clinic visit, high level critical care, or high level emergency room visit; and

            (iii)  must have a qualifying diagnosis as per the CMS Claims Processing Manual.

            (g) and (h) remain the same.

            (2)  The department adopts and incorporates by reference the OPPS Schedules published by the Centers for Medicare and Medicaid Services (CMS) in 71 Federal Register 226, November 24, 2006, effective January 1, 2007 and reviewed annually by CMS as required in 42 CFR 419.5.  A copy 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.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:     53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.86.3025  OUTPATIENT HOSPITAL SERVICES, REIMBURSEMENT FOR SERVICES NOT PAID UNDER THE AMBULATORY PAYMENT CLASSIFICATION SYSTEM  (1)  Therapy services will be paid 90% of the reimbursement provided the facility fee in accordance with the RBRVS methodologies in ARM 37.85.212 using the allied services conversion factor.  Therapy services include physical therapy, occupational therapy, and speech-language pathology and are subject to requirements and restrictions as in ARM 37.86.606.

            (2)  Screening mammography will be paid the same reimbursement provided in accordance with the RBRVS methodologies in ARM 37.85.212 for HCPCS 76092-TC.

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

            (7) (6)  The department adopts and incorporates by reference the Outpatient Hospital Fee Schedule dated January 1, 2007 which is updated each quarter and is posted on the Medicaid web site.  A written copy 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.

 

AUTH:    53-2-201, 53-6-113, MCA

IMP:       53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.86.3031  PROVIDER-BASED ENTITY SERVICES, GENERAL  (1)  For services provided on or after August 1, 2003, hospitals receiving provider-based status from the Centers for Medicare and Medicaid Services (CMS) must send a copy of the CMS letter granting provider-based status to the department's hospital program officer at Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951 and must receive department approval prior to billing as a provider based clinic.

            (2)  Before a provider may bill as a provider-based entity, a copy of the CMS letter verifying provider-based status must be received by the department.  In addition, the provider must be in receipt of written approval from the department allowing provider-based billing status.

            (2) through (4) remain the same, but are renumbered (3) through (5).

            (6)  Medicaid does not recognize provider-based status for out-of-state providers.

 

AUTH:  53-2-201, 53-6-113, MCA

IMP:     53-6-101, MCA

 

            37.86.3033  PROVIDER-BASED ENTITY SERVICES, RECIPIENT ACCESS AND NOTIFICATION  (1) through (4) remain the same.

            (5)  Recipients must be notified that they will be assessed two cost shares for Medicaid and/or two copayment and deductible charges for cross-over claims per each visit.

            (a) remains the same.

 

AUTH:    53-2-201, 53-6-113, MCA

IMP:       53-6-101, MCA

 

            37.86.3037  PROVIDER-BASED ENTITY SERVICES, REIMBURSEMENT

            (1) and (a) remain the same.

            (b)  The facility component of provider-based entities provided by exempt hospitals or critical access hospitals as defined in ARM 37.86.2901(4) and (8) will be interim-reimbursed a hospital-specific outpatient cost-to-charge ratio.

            (2) through (6) remain the same.

 

AUTH:    53-6-101, 53-6-113, MCA

IMP:       53-6-101, MCA

 

37.86.3109  OUTPATIENT CARDIAC AND PULMONARY REHABILITATION REIMBURSEMENT  (1)  Exempt hospital and cCritical access hospital (CAH) interim reimbursement is based on a hospital-specific Medicaid outpatient cost-to-charge ratio, not to exceed 100%.  Exempt hospitals and CAHs will be reimbursed their actual allowable costs determined according to ARM 37.86.2803.

(2) and (3) remain the same.

 

AUTH:   53-2-201, 53-6-111, MCA

IMP:      53-2-201, 53-6-101, MCA

 

4.  The department proposes to repeal the following rule:

 

            37.86.3014  OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, DIALYSIS SERVICES, is found on page 37-20507 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

 

            5.  STATEMENT OF REASONABLE NECESSITY

 

The Department of Public Health and Human Services (the department) is proposing  amendments to ARM 37.86.3001, 37.86.3002, 37.86.3003, 37.86.3005, 37.86.3006,   37.86.3016, 37.86.3018, 37.86.3020, 37.86.3025, 37.86.3031, 37.86.3033, 37.86.3037, and 37.86.3109 and the repeal of 37.86.3014 regarding Medicaid Outpatient Hospital Services.

 

These changes are necessary to conform to changes in federal Medicaid regulations and to update reimbursement rules to reflect recent data.  The department is taking this opportunity to remove obsolete rules and terminology, reorganize rules to conform to current practices, and to edit rules to include more specific language.  This should make the rules easier for providers to use and interpret.

 

ARM 37.86.3001

 

The department is proposing changes to the list of definitions for outpatient hospital services.  These new entries are ″disproportionate share hospital-specific uncompensated care″ and ″340B drug pricing program.″  In addition, the definition of ″partial hospitalization services″ is being condensed with part of the wording being moved to ARM 37.86.3006.  One entry has been removed from the list of outpatient definitions, that being the definition of ″qualified rate adjustment."  It is necessary for the department to keep the list of definitions current in an effort to have the department and providers working with the most current and accurate information.

 

ARM 37.86.3002

 

The department is proposing changes to update the address for Medicare Part A, and the reference to the Code of Federal Regulations (CFR).  This proposed change is necessary to provide the most current and accurate information for both the department and providers.

 

ARM 37.86.3003

 

The department is proposing to add language to exclude experimental or investigational services as covered outpatient services.  It is necessary for the department to add this language in an effort to follow Medicare rules governing experimental or investigational services.

 

ARM 37.86.3005

 

The department is proposing to remove any reference to ″exempt hospitals″ and ″qualified rate adjustment″ from the rule.  It is necessary to remove this language from the rule as the department no longer recognizes ″exempt hospitals″ and no longer pays a ″qualified rate adjustment″ payment.  By removing this language from the rule, providers will receive clear and accurate information regarding the status of ″exempt hospitals″ and ″qualified rate adjustment″ payments.

 

ARM 37.86.3006

 

The department is proposing to add ″requirements″ to the title of ARM 37.86.3006 and to language regarding ″partial hospitalization services″ that was moved from ARM 37.86.3001.  This proposed change is necessary as it more completely describes the rule for both the department and for providers.

 

ARM 37.86.3014

 

The department is proposing to repeal ARM 37.86.3014 in its entirety.  The department feels this rule is redundant and should be removed as the information contained in this rule is already written in ARM 37.86.4205.

 

ARM 37.86.3016

 

The department is proposing to correct the referenced ARM, for imaging services where no APC rate, Medicare fee, or Medicaid fee has been assigned, to 37.85.212.  Language was added to specify that out-of-state hospitals will be reimbursed the Montana statewide outpatient cost-to-charge ratio.  The department feels the proposed change is necessary to specify to providers the payment methodology for imaging services where no payment rate exists, as well as accurately referencing the correct rule regarding RBRVS payment methodology also for imaging services.

 

ARM 37.86.3018

 

The department is proposing to correct the referenced ARM, for other diagnostic services where no APC rate, Medicare fee, or Medicaid fee has been assigned, to 37.86.3005(4).  Language was added to specify that out-of-state hospitals will be reimbursed the Montana statewide outpatient cost-to-charge ratio.  The department feels the proposed change is necessary to inform providers of the payment methodology for diagnostic services where no payment rate exists, as well as accurately referencing the correct rule regarding payment methodology for diagnostic services performed in a nonhospital setting.

 

ARM 37.86.3020

 

The department is proposing to specify that out-of-state hospitals will be reimbursed the Montana statewide cost-to-charge ratio in instances where there is no Medicaid fee for the service; establish the Medicaid statewide cost-to-charge ratio at 44.5%; define the criteria for payment regarding observation care procedure codes; and update the CMS reference to the outpatient fee schedule.  The department feels the proposed change is necessary to inform providers of the payment methodology for any services where no payment rate exists; to specify the payment criteria for observation care; to accurately reference the correct Montana statewide cost-to-charge ratio, and to update the CMS reference to the outpatient fee schedule.

 

ARM 37.86.3025

 

The department is proposing to specify that therapy services will be paid the facility fee of the reimbursement provided in accordance with RBRVS payment methodologies described in ARM 37.85.212; establish that the department adopts and incorporates by reference the Outpatient Hospital Fee Schedule which is updated each quarter and is posted on the Medicaid web site; and remove the reference to screening mammography paid in accordance with RBRVS payment methodologies.  The department feels the proposed changes are necessary to inform providers of the payment methodology for therapy services, accurately describing when and where the outpatient fee schedule is updated, and condensing the rule by removing the reference to screening mammography as this information is already contained in ARM 37.85.212.

 

ARM 37.86.3031

 

The department is proposing to add language to exclude out-of-state providers from provider-based reimbursement status.  Language is also being added to specify that before an in-state provider can be paid, they must be approved by the department and that before a provider may bill as a provider-based entity, a copy of the CMS letter verifying provider-based status must be received by the department.  Also, additional language is proposed to specify that the provider must be in receipt of written approval from the department allowing provider-based billing status before the provider may bill Medicaid.  It is necessary for the department to add this language to the rule to notify providers of requirements of Montana Medicaid, and to inform providers of the criteria that must be met before an approved provider-based facility may bill claims to Montana Medicaid.

 

ARM 37.86.3033

 

The department is proposing to add language requiring applicable providers to notify recipients that they will be assessed two cost shares for Medicaid and/or two copayment and deductible charges for cross-over claims for each visit.  It is necessary for providers to inform Medicaid clients of the additional cost share requirements that clients will pay when deciding to seek services from a provider-based facility.

 

ARM 37.86.3037 and 37.86.3109

 

The department is proposing to remove the reference to ″exempt hospitals.″  The department no longer recognizes ″exempt hospitals" in its reimbursement methodology.

 

Fiscal Impact

 

The proposed rule changes regarding Medicaid Outpatient Hospital services will have a budget neutral effect on the Medicaid budget for State Fiscal Year (SFY) 2013.  Because of this, there will not be any fiscal impact to the Medicaid budget.  

The proposed changes will affect approximately 372 outpatient hospital providers both in and out of state.  Services provided to Medicaid clients will not be affected.

 

            6.  The department intends to apply these rules retroactively to July 1, 2012.  A retroactive application of the proposed rules 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., June 7, 2012.

 

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 April 30, 2012.

 

 

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