BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.57.102, 37.57.105, 37.57.106, 37.57.109, 37.57.110, 37.57.111, 37.57.117, and 37.57.118 pertaining to children's special health services

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT

 

TO:  All Concerned Persons

 

            1.  On June 27, 2012, at 2:00 p.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 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 June 20, 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:

 

            37.57.102  DEFINITIONS  Unless otherwise indicated, the following definitions apply throughout this subchapter:

            (1)  "Advisory committee" means a committee that is composed of health care service providers, public health providers, consumers, and children's special health service (CSHS) program staff and that advises the department about CSHS program operation.

            (2) (1) "Applicant" means a child or youth with special health care needs (CYSHCN) who has applied or whose parent or guardian has applied on the child's behalf to receive CSHS benefits children's special health service (CSHS) financial assistance from the department.

            (3)  "Benefits" means payment by the department for CSHS-authorized medical care for a child or youth eligible for the CSHS program.

            (4)  "Child or youth" means an individual under 22 years of age.

            (5)  "CHIP" means the Montana children's health insurance plan administered by the department.

            (2) "Child or Youth with Special Health Care Needs" (CYSHCN) means a child or youth, under the age of 22, who has or is at increased risk for chronic physical, development, behavioral, or emotional condition and who also requires health and related services of a type or amount beyond that required by children generally.

            (6) (3)  "Client" means a child or youth CYSHCN who is eligible to receive CSHS benefits financial assistance as determined by the department under this subchapter.

            (7)  "Clinic" means a place where a team of health care providers with specialties appropriate to treating children come together to evaluate and develop a comprehensive plan of care for children with specific disabilities.

            (8) remains the same, but is renumbered (4).

      (9)  "CSHCN" means children with special health care needs, the population served by CSHS.

      (10) through (12) remain the same, but are renumbered (5) through (7).

            (13) (8)  "Eligibility year" means the federal fiscal year in which a child or youth CYSHCN receives CSHS benefits, beginning with the date the application for those benefits is received by the department and ending 12 months later direct payment financial assistance.

            (14)  "Evaluation" means the medical examination and testing needed to determine the cause and possible treatment for a suspected or known disability.

            (15) and (16) remain the same, but are renumbered (9) and (10).

            (11)  "Financial Assistance" means payment by the department for CSHS-authorized medical care for a CYSHCN eligible for the CSHS program.

            (12)  "HMK" means Healthy Montana Kids insurance plan administered by the department.

            (13)  "HMK Plus" means Healthy Montana Kids Plus plan administered by the department.

            (17)  "ICD-9-CM" means the World Health Organization's International Classification of Diseases, Clinical Modification, 9th Revision.

            (18) (14)  "Initial diagnosis and evaluation" means taking a medical history and performing a physical examination, medical procedures, laboratory tests, hearing and other diagnostic tests, or other procedures necessary for the diagnosis of a condition for the purpose of establishing CSHS eligibility and possible treatment for a suspected or known disability.

            (15)  "Interdisciplinary Team" means a group of allied health professionals and a patient, family, or both a patient and family who work together to address the shared health goals.

            (19) (16)  "Medical advisor" means a Montana licensed physician, who serves as an advisor to the department, with expertise in treating children and youth with special health care needs and licensed by the state of Montana who serves as an advisor to the department.

            (20) (17)  "Poverty income guidelines" means the poverty income guidelines published in 2003 2012 in the Federal Register by the U.S. Department of Health and Human Services.  The department hereby adopts and incorporates by reference the federal poverty guidelines that establish income thresholds according to family unit size for purposes of determining eligibility for government assistance or services and that are published in the February 7, 2003 2012, Federal Register.  A copy of the 2003 2012 poverty guidelines may be obtained from the Department of Public Health and Human Services, Child and Adult Health Resources Public Health and Safety Division, Children's Special Health Services Program, 1218 East Sixth 1400 Broadway Rm A-116, Helena, MT 59620, telephone (406) 444-3617.

            (21) (18)  "Program" means the department's children's special health services program for children a CYSHCN with special health care needs, authorized by 50-1-202, MCA.

            (22) (19)  "Provider" means a supplier of medical care or services, interventions, medical appliances, prescribed medications, or formula or foods, and consultations.

            (23) (20)  "Services" means assistance other than benefits financial assistance provided to CSHCN a CYSHCN, such as resource and referral information, transition information, specialty clinic services, and care coordination.

            (21)  "Special Health Care Need" means a chronic condition that requires

health and related services of a type or amount beyond that generally required by children.

            (24) (22)  "Third-party payer" means a public or private agency entity that is or may be liable to pay all or part of the medical costs for a client, including, but not limited to, private insurance, tri-care, Medicaid, Medicare, CHIP, the caring program for children, and the early intervention program, part C, of the department's disabilities services division.

            (25) remains the same, but is renumbered (23).

 

AUTH:  50-1-202, MCA

IMP:     50-1-202, MCA

 

            37.57.105  GENERAL REQUIREMENTS FOR CSHS FINANCIAL ASSISTANCE  (1)  In order to receive CSHS financial assistance for a particular benefit:

            (a)  child or youth a CYSHCN must meet the eligibility requirements of ARM 37.57.106; and

            (b)  a CYSHCN must have an eligible condition that is listed in ARM 37.57.110;.

            (c) (2)  tThe benefit in question must be one of the covered benefits cited in ARM 37.57.110, and the provider must meet the standards of ARM 37.57.117.

 

AUTH:  50-1-202, MCA

IMP:     50-1-202, MCA

 

            37.57.106  ELIGIBILITY FOR BENEFITS CSHS FINANCIAL ASSISTANCE 

            (1)  With the exception noted in (6), a child or youth, to be eligible for CSHS benefits, must be: Eligibility criteria for CSHS financial assistance are:

            (a)  a child or youth CYSHCN with either a disabling physical condition that can be substantially improved or corrected with surgery, or a condition or disease that can be cured, improved, or stabilized with medical treatment, or a child or youth is suspected of having a disabling physical condition or a medical condition or disease;

            (b)  a CYSHCN is under 19 years of age or under up to 22 years of age if the child or youth and has a disability qualifying condition for which a final cleft surgery or dental work is necessary long-term care is needed and approved by the interdisciplinary team or the program's medical advisor;

            (c)  a resident of the state of Montana and either a U.S. citizen or a qualified alien as defined under federal statute;.

            (2)  Family income must be verified to determine eligibility.  The department will request documentation of income from the applicant.

            (a)  Family income may include one or more of the following:

            (i)  the income of both parents if the child resides with both parents;

            (ii)  the income of the parent with whom the child resides the majority of the year, including any child support received for the child, if the child resides with one parent in a single parent household;

            (iii)  if the parent with whom the child resides the majority of the year has remarried, the stepparent's income is imputed to the parent with whom the child resides the majority of the year;

            (iv)  the income of individuals under the age of 19 who live in the home but do not attend school is imputed to the parent with whom the child resides the majority of the year.

            (b)  Family income does not include:

            (i)  money received from assets drawn down such as withdrawals from a savings account, an annuity, or for the sale of a house or car;

            (ii)  gifts, loans, one-time insurance payments, or lump sum compensation for an injury;

            (iii)  the first $2,000 of an enrolled tribal member's per capita payment;

            (iv)  the first $2,000 of an enrolled tribal member's tribal land income;

            (v)  the interest earned on (4)(a), (4)(b), or (4)(c);

            (vi)  dependent care expenses which are deducted from income under the HMK Plus coverage group;

            (vii)  foster care income for any children unless the only children in the family are foster care; or

            (viii)  income of any individual with whom a child resides who has no legal obligation to support the child.

            (c)  Income information will be used by the department to project the family's income.

            (d)  A member of a family whose income, less any out-of-pocket expenses for health insurance premium, care expenses for children, disabled or elderly adults while adults are working, and earned income disregards is at or less than 200% 250% of the federal poverty income guidelines; and

            (e) one of the following:

            (i)  ineligible for Medicaid HMK Plus or HMK;

            (ii)  eligible for Medicaid HMK Plus or HMK, but in need of services or benefits financial assistance that are not covered by medicaid HMK Plus or HMK, or determined nonaccessible but are covered by CSHS; or

            (iii)  potentially eligible for medicaid HMK Plus or HMK from information provided on the application, the family will be referred to the county office of public assistance for medicaid HMK Plus or HMK eligibility determination.

            (2) (3)  Eligibility for program benefits financial assistance will be determined within 30 days of receipt of the application by the department.

            (3) (4)  Eligibility continues for 12 months from begins on the date an application is received by CSHS and continues for the duration of the federal fiscal year in which the application is received unless the child's or youth's age of the CYSHCN precludes them from participation or the child or youth moves from CYSHCN no longer resides in Montana.

            (4) (5)  A new or renewal application for a subsequent year must be submitted to the department in order for the department to determine if eligibility is to continue and must be completed and approved before any CSHS benefits financial assistance in a subsequent year may be provided.

            (5) (6)  CSHS financial eligibility will be determined in accordance with the financial eligibility guidelines contained in CHIP's HMK's ARM 37.79.201, with the following exceptions:

            (a)  children who are eligible to receive state employee health coverage may be eligible for CSHS benefits;

            (b) (a)  children may have health insurance coverage and the out-of-pocket expenses for health insurance premiums are deducted from household income; and

            (c) (b)  CSHS financial eligibility is at or below 200% 250% of the federal poverty income guidelines.

            (6) (7)  The above financial eligibility limits do not apply to a child or youth who has or is suspected of having a condition covered by CSHS and wishes to attend a clinic specifically for that condition A CYSHCN attending an interdisciplinary team pediatric specialty clinic does not need to apply for financial assistance.

 

AUTH:  50-1-202, MCA

IMP:     50-1-202, MCA

 

            37.57.109  APPLICATION PROCEDURE FOR CSHS FINANCIAL ASSISTANCE  (1)  A person who desires CSHS benefits financial assistance for a child or youth CYSHCN must submit a completed application, along with supporting documents required by the department, to the department on a form it prescribes.

            (2)  If the department notifies the applicant that the application is incomplete and is not provided with the requested information within six weeks after the date the applicant was notified of the deficiency, the requested missing information must be received by CSHS within six weeks from the date of notification; otherwise the application will be considered inactive.  If the requested information is subsequently received and the child or youth CYSHCN is found to be eligible, the eligibility year will begin on the date the additional requested information is received.

            (3)  If the child or youth CYSHCN is found determined not ineligible, the department will send the applicant a written notice stating the reasons for ineligibility and explaining how an informal reconsideration of its determination may be obtained pursuant to ARM 37.57.112.

            (4)  If When the applicant CYSHCN is determined eligible, the department will send the applicant a written notice of that fact specifying which conditions services are eligible for CSHS financial assistance and the term of eligibility.

 

AUTH:  50-1-202, MCA

IMP:     50-1-202, MCA

 

            37.57.110  CONDITIONS, BENEFITS AND SERVICES FOR CSHS FINANCIAL ASSISTANCE  (1)  To the extent department funding allows, and up to a maximum of $12,000 $2,000 per eligibility federal fiscal year, the department will provide benefits financial assistance as cited in (3) for the eligible conditions listed in (2), subject to the exceptions to benefits financial assistance and conditions in (4) and (5).

            (2)  Eligible conditions are:

            (a)  genitourinary disorders endocrine, nutritional and metabolic diseases, and immunity disorders;

            (b)  gastrointestinal disorders diseases of the blood and blood-forming organs;

            (c)  metabolic disorders diagnosis only for mental disorders;

            (d)  neurological disorders diseases of the nervous system and sense organs;

            (e)  orthopedic disorders diseases of the circulatory system;

            (f)  craniofacial anomalies, including cleft lip and cleft palate diseases of the respiratory system;

            (g)  ophthalmic conditions diseases of the digestive system;

            (h)  pulmonary disorders diseases of the genitourinary system;

            (i)  endocrine disorders diseases of the skin and subcutaneous tissue;

            (j)  juvenile rheumatoid arthritis, or similar arthritic disorders diseases of the musculoskeletal system and connective tissue;

            (k)  cardiovascular disorders congenital anomalies;

            (l)  chronic infectious disease; certain conditions originating in the perinatal period; and

            (m)  hematologic disorders; and initial diagnosis evaluation for certain symptoms, signs, and ill-defined conditions.

            (n)  dermatologic disorders.

            (3)  The following are covered benefits services that may be provided, per eligibility year, to a CSHS-eligible child or youth CYSHCN:

            (a) through (c) remain the same.

            (d)  medical foods for the treatment of a metabolic disorder, including prescriptive supplements for a child CYSHCN with inborn errors of metabolism;

            (e)  prosthetic devices, such as orthotics for a covered orthopedic condition;

            (f) and (g) remain the same, but are renumbered (e) and (f).

            (h) (g)  hearing aids, up to a maximum of $1,500 per ear per year;

            (i) through (k) remain the same, but are renumbered (h) through (j).

            (l) (k)  eyeglasses corrective lenses for a child CYSHCN with a medical disorder-related condition, limited to a single pair of frames per eligibility year up to a maximum of $175 for frames, lenses and evaluation, plus an additional prescription lens change in six months as needed;

            (m) (l)  disposable and durable medical equipment for covered conditions;

            (n) (m)  apnea monitor purchase or rental for a covered condition (up to one year);

            (o) through (q) remain the same, but are renumbered (n) through (p).

            (4)  No benefits are financial assistance is available for the following:

            (a) remains the same.

            (b)  insulin pumps;

            (c) through (g) remain the same, but are renumbered (b) through (f).

            (h)  wheelchairs;

            (i) (g)  transplants, including follow up care;

            (j) remains the same, but is renumbered (h).

            (k)  growth hormone therapy, except for medically established hypothalamic/pituitary insufficiency;

            (l) (i)  services provided outside of Montana, unless the required service is not available in-state or, due to the vast distances within Montana, the requirement to obtain in-state services places an undue hardship on a family or has been approved by the program's medical advisor;

            (m)  appliances, with the exception of orthopedic braces, prosthetic devices and appliances required for the correction of an orthodontic condition that affects an otherwise CSHS covered condition, such as that caused by the presence of a cleft palate or another syndrome-caused craniofacial anomaly;

            (n) remains the same, but is renumbered (j).

            (o) (k)  treatment for cleft/craniofacial conditions that are not planned and recommended by a multi-disciplinary cleft/ craniofacial team that meets American cleft palate-craniofacial association parameters. cleft palate team recognized by the American Cleft Palate Association (ACPA) Commission on Approval of Cleft Palate and Craniofacial Teams (CAT); and

            (l)  clinical trial services and medications.

            (5) remains the same.

            (6)  Standards for services that may be provided by CSHS are the following:

            (a)  to the extent CSHS funding allows and up to a maximum of $5,000 per person per federal fiscal year, the following services may be provided by the department to persons diagnosed with a CSHS-covered condition:

            (i)  resource and referral information;

            (ii)  transition information; and

            (iii)  nutritional counseling and management, medical formula or foods, and/or prescriptive medications not funded by other sources for a person identified with an inborn error of metabolism.

            (b)  services provided may not be covered by another payment source; and

            (c)  a person receiving services must:

            (i)  be a Montana resident; and

            (ii)  live in a household that meets CSHS income standards for benefit eligibility.

 

AUTH:  50-1-202, MCA

IMP:     50-1-202, MCA

 

            37.57.111  PAYMENT LIMITS AND REQUIREMENTS  (1)  The department will provide benefits financial assistance for a CSHS-eligible child or youth CYSHCN with a covered condition:

            (a) and (b) remain the same.

            (c)  up to a maximum of $12,000 $2,000 per eligibility year;

            (d)  up to a the maximum of $1,500 each $2,000 for speech, physical, nutritional, occupational, or respiratory therapy related to a covered condition.  For children a CYSHCN under age three, CSHS will pay after the early intervention program, part C, of the disabilities services division; and

            (e)  after all third parties, if any, have paid the provider, in which case the department pays any balance remaining for services not covered by another payment source, within CSHS limits to the lower of the insurance allowed amount or the CSHS allowed amount for the services in question.

            (2)  The department will pay providers directly for CSHS-eligible care services and will not reimburse clients.

            (3)  The department will pay eligible providers after the department receives a signed authorization, claim form, and requested documentation that the care has been provided.

            (4)  A provider, family, or Any individual who erroneously or improperly is paid by receives payment from the department must promptly refund that payment to the department.

            (5)  A provider who accepts the CSHS level of payment for covered benefits services may not seek additional payment from a CSHS client or their family.

            (6)  The department will pay up to the following limits for orthodontia care:

            (a)  Payment for orthodontia for CSHS clients who have cleft or craniofacial conditions requiring orthodontia due to a medical condition with orthodontic implications will be subject to the maximum allowable charge published in the department's orthodontic coverage and reimbursement guidelines updated through July, 2001 payment as set forth in CSHS rule.

            (b)  Payment will be based on a treatment plan submitted by the provider that meets the requirements of the department's orthodontic coverage and reimbursement guidelines and that includes, at a minimum, a description of the plan of treatment, the provider's estimated usual and customary charge, and a time line for treatment.  The maximum payable amount for any one phase of treatment is 85%.  The department will reimburse 40% of the CSHS allowed amount upon initial billing for each phase of treatment, the remainder being paid in monthly installments as determined by the time line established in the provider's treatment plan for completing orthodontic care.  Payment is also subject to any insurance coverage a client may have.

            (c)  A client is limited to:

            (i)  an overall lifetime cap of $7,000 for all orthodontia phases; and

            (ii)  the maximum for each phase cited in the department's orthodontic coverage and reimbursement guidelines updated through December 1999.

            (d)  Maximum allowable charges for each phase of orthodontic treatment, time lines for orthodontic phases of care, and the services included in each phase of orthodontic care are listed in the department's orthodontic coverage and reimbursement guidelines.  The department hereby adopts and incorporates by reference the department's orthodontic coverage and reimbursement guidelines updated through July, 2001.  The guidelines, issued by the department to all providers of orthodontic services, inform providers of the requirements applicable to the delivery of services under the medicaid program.  A copy of the department's orthodontic coverage and reimbursement guidelines is available from the Department of Public Health and Human Services, Child and Adult Health Resources Division, Medicaid Services Bureau, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.

            (7)  For services to a CSHS client, with the exception of multiple surgeries, a provider will be paid 85% of the actual submitted charge. for If the CSHS client has third-party coverage, the department will pay the remaining balance for services to the lower of the insurance allowed amount or the CSHS allowed amount of the approved services.

            (8)  For multiple surgeries, the department will pay at the following rates:

            (a)  85% of the actual charge for multiple surgeries performed during the same admission, but on different days.

            (b)  for multiple surgeries performed on the same day, under the same anesthesia:

            (i)  involving a single surgical field or single surgical incision, regardless of how many organ systems are involved, performed by one or two surgeons:

            (A)  85% of the actual charge for the first procedure; and

            (B)  75% of the actual charge for the second procedure;

            (ii)  involving two surgical fields or two surgical incisions performed by one surgeon, whether the surgery involves separate organ systems, different anatomical locations, or bilateral surgical procedures:

            (A)  85% of the actual charge for the first procedure; and

            (B)  75% of the actual charge for the second and each subsequent procedure.

            (iii)  involving two surgical fields or two surgical incisions performed by two surgeons, whether the surgery involves separate organ systems, different anatomical locations, or bilateral surgical procedures, 85% of the actual charge for the first and second procedures.

            (iv)  involving bilateral surgical procedures (e.g. bilateral Colles' fracture):

            (A)  85% for the first procedure; and

            (B)  75% for the second procedure.

            (9) (8)  Hospitals and surgicenters will be paid 85% of the actual submitted charge, on or after all third-party payers, if any, have paid the provider, in which case the department pays any balance remaining for services to the lower of the insurance allowed amount or the CSHS allowed amount for the services in question for the date of occurrence for inpatient and outpatient services.

            (10) (9) Dentists will be paid 85% of billed charges, or after all third-party payers, if any, have paid the provider, in which case the department pays any balance remaining for services to the lower of the insurance allowed amount or the CSHS allowed amount for an annual dental exam and dental extractions related to active or anticipated orthodontia orthodontic treatment.

            (11) (10) In addition to the above, the department will pay:

            (a)  the lesser of either the actual charge for drugs and other prescribed supplies, or the wholesale price cited in the 2002 Drug Topics Redbook Pharmacy's Fundamental Reference, less 15%, plus a $4.70 dispensing fee and any minor adjustments deemed reasonable by the department to reflect market changes on the Medicaid point-of-sale system;

            (b)  85% of the cost of orthotics and prosthetic devices (orthopedic only) durable medical equipment to the appropriate amount when allowing financial assistance, or to the maximum amount set by the program for the federal fiscal year;

            (c)  100% 85% of the cost of specialized formula and foods and prescriptive or nonprescriptive medications prescribed by a physician for inborn errors of metabolism; and

            (d)  100% 85% of the cost of syringes and disposable medical equipment for the treatment of covered conditions; and.

            (e)  rental or purchase of durable medical equipment authorized by CSHS professional staff.

            (12) (11)  Clinic services provided at a clinic funded or supported by the department are provided free of charge, regardless of the client's household income.  A CYSHCN who attends interdisciplinary pediatric specialty clinics, supported by CSHS, is not responsible for copays, deductibles, or coinsurance, nor will they be balance-billed.

            (13)  The department hereby adopts and incorporates by reference the 2002 Drug Topics Redbook Pharmacy's Fundamental Reference, which suggests prices for drugs.  Anyone wishing to examine any of the above references may do so by contacting the department's CSHS program at Department of Public Health and Human Services, Child and Adult Health Resources Division, Children's Special Health Services Program, 1218 East Sixth Avenue, Helena, MT 59601, phone: 444-3617.

 

AUTH:  50-1-202, MCA

IMP:     50-1-202, MCA

 

            37.57.117  CSHS PROVIDERS RECEIVING CSHS FUNDS: REQUIREMENTS  (1)  In order to be a CSHS provider for a CSHS client, a provider must meet the following requirements:

            (a)  A physician or surgeon must:

            (i)  be currently licensed by the state of Montana pursuant to Title 37, chapter 3, MCA, to practice medicine as defined by state law if a Montana resident, or currently licensed to practice medicine in the state in which they reside;

            (ii) through (b) remain the same.

            (c)  A pediatric dentist may treat a child or youth CYSHCN under the age of 10 ten for orthodontia and must:

            (i) through (2) remain the same.

            (3)  A provider must accept CSHS level of payment for services and may not seek additional payment from a CSHS client or family.

 

AUTH:  50-1-202, MCA

IMP:     50-1-202, MCA

 

            37.57.118  PROGRAM RECORDS  (1)  The department shall will retain specialty clinic participants records of CSHS services provided for a client for a period of five years after the child reaches the age of 18 as set forth in the Montana Secretary of State records management form #1, record series profile, program code 6901073, records series title "Specialty Clinic Participant Case Files.".

            (2)  Prior to destroying specialty clinic participant records, the department shall will advertise that the records may be obtained by those to whom they pertain by publishing a notice in Montana's major newspapers once per week for three consecutive weeks.

            (3) remains the same.

            (4)  The department will retain financial assistance client records for five years from the last contact date, as set forth in the Montana Secretary of State records "Financial Assistance Case Files."

            (5)  The financial assistance records will be destroyed after the program receives approval from the state records committee required under 2-6-212, MCA.

            (6)  The department will retain all electronic data permanently as set forth in the Montana Secretary of State records management form #1, record series profile program code 6901073, records series title "CHRIS Files."

 

AUTH:  50-1-202, MCA

IMP:     50-1-202, MCA

 

            4.  STATEMENT OF REASONABLE NECESSITY

 

The department is proposing amendments to ARM 37.57.102, 37.57.105, 37.57.106, 37.57.109, 37.57.110, 37.57.111, 37.57.117, and 37.57.118 pertaining to Children's Special Health Services (CSHS).  CSHS is located in the Family and Community Health Bureau of the Montana Department of Public Health and Human Services.  The program is charged by the Federal Maternal Child Health Block Grant (MHBG) to:  "Support development and implementation of comprehensive, culturally competent, coordinated systems of care for children and youth who have or are at risk for chronic physical, developmental, behavioral, or emotional condition and who require health and related services of a type or amount beyond that required by children generally."

 

The purpose of the proposed rule amendments is to update the administrative rules governing the CSHS program.  These updates include the revision of the Federal Poverty Limit, clarifying the financial assistance application process, updating the conditions eligible for financial assistance, and reimbursement cap for financial assistance.  Some terms and definitions were changed to reflect current usage. Other changes have been proposed for ease of readability and clarification.

 

ARM 37.57.102

 

The proposed amendments provide definitions for the administration of the CSHS program.  Previously used terms have been updated to reflect the current management of the program.  Terms such as "HMK and HMK Plus" (updated state program names), "eligibility year" (reflects the span of time for coverage), and "interdisciplinary team" (to define a service).

 

ARM 37.57.105 and 37.57 109

 

These sections are proposed to be amended for clarification purposes to clarify the requirements for financial assistance and the application process.

 

ARM 37.57.106

 

The proposed amendments reflect program name changes within the department e.g., Healthy Montana Kids (formerly CHIP), specifies the duration of the eligibility year, and has increased the federal poverty level guideline used by CSHS from 200% to 250% to enable CSHS to complement the HMK program.  The potential impact of this amendment is not expected to exceed four children or youth with special health care needs.

 

ARM 37.57.109

 

The department is proposing to amend this section to clarify the functions and limitations of CSHS financial assistance.

 

ARM 37.57.110

 

The department is proposing to amend this section to correlate with how the program is currently operating.  The proposed amendment reflects the funding source guidance to limit assistance when applied as a direct service.  The funding source is federal funds allocated via the Maternal and Child Health Block Grant (MCHB).  Each federal fiscal year (FFY) the CSHS allocation from the MCHB is reviewed and a determination made as to the maximum funds available for each CSHS enrolled client.  CSHS has experienced a decline in number of financial assistance due to the Children Health Insurance Program (CHIP) expansion.  Recently CHIP became Healthy Montana Kids (HMK) and increased the federal poverty level (FPL) to 250%.  Medicaid was renamed, Healthy Montana Kids Plus (HMK+), and underwent expansion (FPL 133%).  Generally, CSHS finds the majority of financial assistance enrollees have health care coverage and requests do not exceed $2000.

 

ARM 37.57.111

 

The department is proposing to amend this section as it is necessary to provide a lower maximum amount of funding available to each client reflecting current practice.  The allocation from the block grant is reviewed each FFY and determination made as to the amount each client will receive for the current FFY.  The method of CSHS payment is calculated based on CSHS paying secondary to health care coverages.  Since block grant funding has decreased, the specified break down for reimbursement is no longer needed of multiple procedures e.g., surgeries.

 

ARM 37.57.117

 

The department is proposing to amend this section to ensure providers do not balance-bill the client families.

 

ARM 37.57.118

 

The department is proposing to amend this section to correlate with current record destruction retention schedules as recorded with the Montana Secretary of Records and Information Bureau for three types of records created in the CSHS program.  Records destruction are processed as required by 2-6-212, MCA.

 

Fiscal Impact

 

The department expects the proposed amendments in this notice to have a fiscal impact of less than $8000.

 

The proposed amendments will expand eligibility to include approximately four individuals in Montana per federal fiscal year.

 

Alternative Considered

 

The alternative to the proposed rule amendments would be to make no changes to the existing rules.  Leaving the existing rules unchanged would adversely affect CSHS clients that qualify on the income basis for Health Montana Kids and Healthy Montana Kids Plus, but not for CSHS financial assistance.

 

            5.  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., July 5, 2012.

 

6.  The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing.

 

7.  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 5 above or may be made by completing a request form at any rules hearing held by the department.

 

8.  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.

 

9.  The bill sponsor contact requirements of 2-4-302, MCA, do not apply.

 

 

 

 

/s/ Shannon L. McDonald                          /s/ Hank Hudson for                                               

Rule Reviewer                                             Anna Whiting Sorrell, Director

                                                                      Public Health and Human Services

           

Certified to the Secretary of State May 29, 2012.