HOME    SEARCH    ABOUT US    CONTACT US    HELP   
           
Montana Administrative Register Notice 37-679 No. 18   09/18/2014    
Prev Next

 

BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.86.3006, 37.87.102, 37.87.903, 37.87.1013, and 37.87.1223, and the repeal of ARM 37.87.303 pertaining to the revision of the rules for serious emotional disturbance for youth, mental health outpatient partial hospital services, and Medicaid mental health authorization requirements

)

)

)

)

)

)

)

)

)

NOTICE OF AMENDMENT AND REPEAL

 

TO: All Concerned Persons

 

1. On July 10, 2014, the Department of Public Health and Human Services published MAR Notice No. 37-679 pertaining to the public hearing on the proposed amendment and repeal of the above-stated rules at page 1491 of the 2014 Montana Administrative Register, Issue Number 13.

 

2. The department has amended ARM 37.86.3006, 37.87.102, and 37.87.1223 as proposed. The department has repealed ARM 37.87.303 as proposed.

 

3. The department has amended the following rules as proposed, but with the following changes from the original proposal, new matter underlined, deleted matter interlined:

 

            37.87.903 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, SERIOUS EMOTIONAL DISTURBANCE AND AUTHORIZATION REQUIREMENTS  (1) through (7) remain as proposed.

            (8) In addition to the requirements contained in rule, the department has developed and published a provider manual entitled Children's Mental Health Bureau, Medicaid Services Provider Manual, dated September 5, 2014 September 19, 2014, for the purpose of utilization management. The department adopts and incorporates by reference the Children's Mental Health Bureau, Medicaid Services Provider Manual, dated September 5, 2014 September 19, 2014. A copy of the manual may be obtained from the department by a request in writing to the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210 or at www.dphhs.mt.gov/publications/index.shtml#cmh.

            (9) and (10) remain as proposed.

 

AUTH: 53-2-201, 53-6-113, MCA

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

 

            37.87.1013 THERAPEUTIC GROUP HOME (TGH), REIMBURSEMENT

            (1) through (6) remain as proposed.

            (7) Reimbursement will be made to a provider for reserving a TGH bed while the youth is temporarily absent for a THV for a maximum of 14 patient days per state fiscal year; requests for additional days must be prior authorized by the department.

           

AUTH: 53-2-201, 53-6-113, MCA

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

 

4. The department has thoroughly considered the comments and testimony received. A summary of the comments received and the department's responses are as follows:

 

COMMENT #1: A few commenters noted a discrepancy between the new manual and ARM 37.87.1013 pertaining to Therapeutic Home Visits (THV). The commenters state that the discrepancies are in requirement for prior authorization for THVs over 3 days in duration and in the availability to receive over 14 days of THV with prior approval from the department.

 

RESPONSE #1: The department thanks the commenters for their comments and has corrected the discrepancies.

 

COMMENT #2: One provider requested a section-by-section economic impact statement to allow the provider to respond to what the department perceives as the financial impact of the rule. The provider stated that they believe this is consistent with the Montana Administrative Procedure Act (MAPA).

 

RESPONSE #2: An economic impact statement may only be requested by an administrative review committee as provided for in 2-4-405, MCA.

 

COMMENT #3: One commenter stated that incorporating this many rules by reference in a single action without citing or referencing the underlying rules that are impacted is extremely difficult to respond to and asked that the rulemaking process include clear reference to what rules are being changed.

 

RESPONSE #3:   In order to make review of the proposed changes easier for the public, the department included a synopsis at the beginning of the new proposed Children's Mental Health Bureau (CMHB) Medicaid Services Provider Manual that outlines the major changes from the current CMHB "Provider Manual and Clinical Guidelines for Utilization Management." As noted in the first notice for this rulemaking, the department has amended six rules that are directly impacted by the adoption of the proposed CMHB Medicaid Services Provider Manual. An additional impacted rule has since been identified and will be repealed through a rulemaking notice, MAR No. 37-689, filed with the Secretary of State on August 11, 2014. The rule affected is ARM 37.87.701, pertaining to Community Based Psychiatric Rehabilitation and Support Services (CBPRS).

 

COMMENT #4: One commenter noted that the date of the manual differs from the title page to the reference to the manual as stated on page 5. The commenter also stated that the comment period for this rule is extremely limited.

 

RESPONSE #4: The department apologizes for this discrepancy and has corrected the date at page 5 of the proposed manual. The comment period of this rule amendment conforms with MAPA requirements, which requires a minimum of 28 days from the day of publication for public comment.

 

COMMENT #5: One commenter asked that when referring to the Montana CANS functional assessment that the same language be used to describe it in all references.

 

RESPONSE #5: The department agrees with this comment and has made the appropriate changes to the final CMHB Medicaid Services Provider Manual.

 

COMMENT #6: One commenter proposes adding to the list of purposes for the Montana CANS functional assessment: "e) sharing and reporting to Montana legislature, federal granting agencies, families, providers, internal reporting and program monitoring" or in the alternative, eliminate the language from part (2) which describes these purposes and uses of Montana CANS all together.

 

RESPONSE #6: The department has added language in 9(d) to ensure that it is clear that CANS data in the aggregate may be used for sharing and reporting.

 

COMMENT #7: One commenter asked if the department expects Montana CANS to be implemented for preschool children enrolled in Comprehensive School and Community Treatment (CSCT).

 

RESPONSE #7: The Montana CANS must be implemented for all youth receiving CSCT services.

 

COMMENT #8: One commenter asked for clarification of the availability of Targeted Case Management (TCM) Services to youth who have a serious emotional disturbance (SED) who may also be eligible and receiving services from the Developmental Disabilities Program's (DDP) children's waiver and if a family has a choice in electing who provides the case management service and whether a family has the right to deny a service.   The commenter also asked if the current requirement that a family must receive case management through the DDP if they receive DDP services is an exception in Montana rule to the federal requirement that one Medicaid service cannot be predicated on receipt of another Medicaid service.

 

RESPONSE #8: This comment is outside of the scope of this rulemaking. The commenter is welcome to directly contact the program with these questions.

 

COMMENT #9: One commenter asked about the list of community-based services and if targeted case management (TCM) is still a service available through the Children's Mental Health Bureau (CMHB) and should be added to this list.

 

RESPONSE #9: TCM is still a service available through the CMHB and has been added to the list of community-based services.

 

COMMENT #10: One commenter stated that the section in the proposed manual that provides a table of services which may not be provided concurrently lends to confusion and is more confusing than it is helpful. Other commenters asked that the department review all services on the proposed table to ensure accuracy and provide clarifications; these commenters supplied the department with specific examples of services they were concerned about.

 

RESPONSE #10: The department's intent with the new table is to replace the current matrix adopted in the current CMHB "Provider Manual and Clinical Guidelines for Utilization Management" with a more comprehensive and readable guide. The department receives many calls from providers who express confusion over the current matrix format. Also, many of the services offered through the CMHB are not on the current matrix. The department has reviewed the examples the commenters provided as well as the rest of the table to ensure the accuracy of the new table.

 

COMMENT #11: One commenter made a comment listing both definitions for youth Community-Based Psychiatric Rehabilitation and Support (CBPRS) and the adult CBPRS definition as provided in ARM 37.88.901.

 

RESPONSE #11: Because there seemed to be no question asked, the department is unsure as to the intention of the commenter's statement and is therefore unable to respond.

 

COMMENT #12: One commenter would like to know if one-on-one CBPRS may still be provided and what if the needs of a youth exceed the two-hour group therapy limit identified for CBPRS.

 

RESPONSE #12: CBPRS may still be provided one-on-one to any youth who meets the SED criteria. At this time the department limits group CBPRS to two hours. The department may consider whether, in a future rulemaking, to increase the amount of CBPRS that is available for youth when it is medically necessary.

 

COMMENT #13: One commenter asked how to document that Part C services cannot meet the identified need prior to service provision of Home Support Services (HSS). The commenter stated that Part C does not have staff trained in mental illness and has a completely different focus in Montana. By virtue of requiring documentation that Part C services cannot meet the identified need, the commenter would like to know if the department's intent is to eliminate the availability of HSS services for these children.

 

RESPONSE #13The department's intent with this requirement is to ensure that youth whose needs can be fully met by Part C services are appropriately receiving those services. Part C can provide for social and emotional needs for youth three and under. In the event that the Part C provider cannot provide enough services, the person seeking HSS services should document why that is. As the new manual states, the youth can be referred as needing services to HSS by Head Start, child care, or a physician.

 

COMMENT #14: One commenter stated that limiting HSS to 365 days is arbitrary, not based upon individual need, and flies in the face of the Adverse Childhood Experience Study (ACES). The commenter states that it will negatively impact young children. Moreover, the commenter indicated that the rule takes the choice out of the hands of clinicians and puts it in the hands of the state.

 

RESPONSE #14: This is not a new requirement for HSS; therefore, this comment is outside of the scope of this rulemaking.

 

COMMENT #15: A few commenters asked if the documentation of HSS required at 180 days requires a full clinical reassessment or a reassessment/review of goals and if it is a clinical assessment to allow a provider to bill for the assessment? One of the commenters pointed out that SED assessments are only required annually.

 

RESPONSE #15: The department thanks the commenters for identifying this discrepancy and need for clarification. The department has amended the language in the new manual to state the 180-day reassessment must demonstrate the youth continues to meet the continued stay functional impairment criteria listed in (a) and (b) excluding the SED criteria for the 180-day reassessment.

 

COMMENT #16: One commenter asked if the department is responsible for collecting and forwarding discharge forms from Psychiatric Residential Treatment Facilities (PRTF) as they are not interested in policing this requirement for the department.

 

RESPONSE #16: The requirement to submit a discharge form is not new. It has historically been handled through the department's utilization review contractor and will continue to be handled in that manner.

 

COMMENT #17: One commenter asked when will the HSS Continued Stay form and the Discharge Notification form be sent out and if the public will have an opportunity to provide feedback on the forms.

 

RESPONSE #17: The forms are available now on the CMHB web site. The public may provide their input on the forms at any time as they are not attached to the new manual or adopted into rule.

 

COMMENT #18: One commenter stated that ARM 37.87.807 provides a different definition of Targeted Case Management (TCM) and would like to know if they will be required to provide a broader range of service coordination activities. The commenter would also like to know if the responsibilities for "referral activities" change.

 

RESPONSE #18: The definition of targeted case management (TCM) is located in ARM 37.87.802 which refers to ARM 37.86.3301, Medicaid's general definition of TCM. The definition in the new manual is the same as in ARM 37.86.3301, with the exception of replacing "client" with "youth." The commenter's reference to ARM 37.87.807 is to covered services. Covered services and "referral activities" have not been amended as part of this rulemaking and therefore are outside the scope of this rulemaking.

 

COMMENT #19: One commenter asked for clarification for the authorization requirements for Therapeutic Group Homes (TGH). The commenter asked how long the continued stay is for and if another one must be submitted.

 

RESPONSE #19: The department has added this information to the new manual.

 

COMMENT #20: One commenter asked if Magellan will continue to contract with the state of Montana and in what role. The commenter also asked that their physicians be compensated at the same rate as those working for Magellan.

 

RESPONSE #20: This comment is outside of the scope of this rulemaking.

 

COMMENT #21: One commenter stated that there needs to be financial compensation and economic impact analysis for providers to comply with the state's quality initiatives, outcome measures, and cost containment measures.

 

RESPONSE #21: An economic impact statement may only be requested by an administrative review committee as provided for in 2-4-405, MCA. This rulemaking does not change the rate of compensation for services; therefore this is outside of the scope of this rulemaking.

 

COMMENT #22: One commenter stated that current Center for Medicare and Medicaid (CMS) guidance that state plan services for Autism Spectrum Disorders must include applied behavior analysis type services.

 

RESPONSE #22: The comment is outside the scope of this rulemaking.

 

COMMENT #23: One commenter stated that they wish that the department would show some restraint in continual rewriting and implementation of the Montana Administrative Rule (ARM). The commenter believes that a more thorough understanding, strategy, and communicated planning would provide reasonable alternative to substantial rewrites of the entire system.

 

RESPONSE #23: The purpose of the department's revision of the current CMHB "Provider Manual and Clinical Guidelines for Utilization Management" (UR manual) dated November 15, 2013 is to respond to public feedback that the UR manual is difficult to navigate and not comprehensive enough. In the past 14 months, the CMBH has promulgated the following rulemaking:

1. three fee schedule changes to increase rates for providers;

2. a change to psychiatric residential treatment facility billing that was mandated by CMS;

3. a small program change made necessary by legislative changes to the Magellan contract;

4. a change to HSS in the UR manual requested by and crafted with providers and a small change to CSCT requested by providers; and

5. the current manual rewrite.

           

Secondly, the department agrees that a thorough understanding, strategy, and communicated planning is reasonable and necessary and the reformatting of the new manual will assist in this process by providing a good foundation.

           

COMMENT #24: One commenter asked if children aged four to six are eligible for CMHB services.

 

RESPONSE #24: In the new manual under the section titled "Serious Emotional Disturbance (SED)," number (3) provides the SED requirements for youth under six years of age. If the youth meets the SED criteria and any service specific criteria, then the youth would be eligible for the appropriate CMHB services.

 

COMMENT #25: One commenter stated that prior interventions as identified as part of the medical necessity criteria for HSS are irrelevant for preschoolers. The commenter states that there needs to be an option to list what has been tried in Head Start or child care agencies. The commenter would like clarification on what qualifies as a crisis intervention for a preschooler. Also the commenter would like to know what the department is looking for in regards to physician care or consultation specific to mental health.

 

RESPONSE #25: The department agrees that there is more work to do in defining service-specific requirements for youth under eight. However, the intent is to pursue this work as part of a future collaborative process. The intent of this rulemaking was not to promulgate new requirements for HSS. The comment regarding physician care or consultation is outside the scope of this rulemaking because this was not amended in the new manual.

 

COMMENT #26: One commenter asked the state to reconsider the 14-day limit on therapeutic home visits (THV) because the needs of the children and families vary.

 

RESPONSE #26: The department recognizes that the needs of youth and their families vary. However, the department will not raise the limit for 14 THVs per state fiscal year at this time.

 

COMMENT #27: A few commenters would like to know an anticipated implementation date for the DSM-V and ICD-10 code. The commenters also would like to have direction on how a provider should rectify the fact that many youth come into services with DSM-V diagnosis and the provider must "rediagnose" under DSM-IV code in order to bill.

 

RESPONSE #27: The DSM-V and ICD-10 implementation is currently scheduled for October 2015. The DSM-V has a reference guide in the back that provides a DSM-IV to DSM-V crosswalk a provider may find helpful during the conversion time frame. The department is not allowed to transition to ICD-10 before the date mandated by CMS.

 

COMMENT #28: One commenter wants instruction on where they should record Montana CANS data for non-Medicaid youth in CSCT since the Montana CANS System will only accept data of youth funded through Medicaid.

 

RESPONSE #28: The electronic CANS system will accept non-Medicaid youth data and it should be recorded in the electronic system. The requirement for completing Montana CANS for CSCT is a licensing requirement; therefore, the department suggests the commenter contact licensing to find out where and how to record the Montana CANS.

 

COMMENT #29: One commenter thanked the department for allowing CSCT and TGH concurrently with Outpatient Therapy (OP) in the proposed manual but wanted clarification if the allowance also pertains to youth that do not have a SED diagnosis that may be referred for up to 20 units of CSCT.

 

RESPONSE #29: Youth referred to CSCT for the brief intervention, assessment, and referral for up to the 20 unit allowance may also receive OP. The department has amended this section of the new manual to state that the youth must meet the SED criteria specific to the service that is provided concurrently with OP.

 

COMMENT #30: A few commenters asked for clarification on which services require the discharge notification to be completed.

 

RESPONSE #30: The services which require a discharge notification form are Acute Inpatient, PRTF, PRTF-AS, HSS, TGH, and partial hospital program, which are submitted to the department or the department's designee. The department has added all services that require discharge notification to the list of services which require submission of a discharge notification form.

 

COMMENT #31: A few commenters stated concern regarding the requirement in the proposed manual for a Licensed Mental Health Practitioner (Professional) to complete the clinical assessment required for the SED determination. They also would like to know if a Mental Health Center in-training professional as defined in ARM 37.87.702(3) also qualifies to make a SED determination and asked that all sections of the manual be amended to be consistent with this language where appropriate.

 

RESPONSE #31: Chapter 3 in the revised manual has language that was brought directly over from ARM 37.87.303, which is being repealed with the material relocated to the new manual as part of this rulemaking. The only thing that was amended upon transfer of the language was the numbering convention; therefore, this is not a new regulation. Mental Health Center providers must follow licensure rules pertaining to the Mental Health Center in-training professionals. Per ARM 37.87.702(3) in-training mental health professionals must be under the supervision of a Licensed Mental Health Professional (LMHP). It is this mental health professional that must certify the SED criteria. The department has amended the language to state that the SED diagnosis must be "certified" by the LMHP. The department has also clarified that an in-training mental health professional may complete the clinical assessment along with the signatory approval by the supervising LMHP.

 

COMMENT #32: One commenter thanked the department for discontinuing the certificate of need (CON) requirement for TGH services and moving the utilization process to CMHB. The commenter stated that it will be a more effective process and makes more sense clinically. A few commenters would like to know if the continued stay form will be online and if so, where, and if it can be submitted via online or fax.

 

RESPONSE #32: The department thanks this commenter for their support in the changes to the utilization review processes. The continued stay form is available online under the forms and applications page. There are directions on the form as to how and where to submit it.

 

COMMENT #33: One commenter asked for clarification regarding if social and legal problems in the benefit exclusions section on page 26 section (c) of the proposed manual includes lack of discharge placement. The commenter would also like to know how CMHB will determine the level of care for the youth if the provider has documented attempts to engage the family or legal representative of the youth in discharge planning. The commenter would like the department to add the language, "(c) The primary problem is not psychiatric. It is a social, legal, or medical problem without a major concurrent psychiatric episode meeting criteria for this level of care and/or does not otherwise meet SED and Continued Stay Criteria." Another commenter requested this language be removed all together.

 

RESPONSE #33: The department understands the commenters' concerns related to lack of discharge placement and shares those concerns. However, Medicaid funds may not be used to pay for services for a youth that are not medically necessary and lack of discharge placement is not covered under medical necessity. The department will not remove the language in (c) but has added the suggested language to (c) of the benefit exclusion section for all applicable services.  The department reviewed the section regarding documenting attempts to engage the family or legal representative of the youth and discharge planning and agrees that this is not appropriate for continued stay criteria. Therefore, the department will relocate that language into the service requirement area.

 

COMMENT #34: One commenter asked the department to reword the definition for CSCT to acknowledge that the services are also focused on support within the family through family therapy and functioning within the family. The commenter recommends "improving the youth's functional level by facilitating the development of skills related to exhibiting appropriate behaviors in the school, family, and the community setting."

 

RESPONSE #34: The proposed definition is consistent with state plan language; therefore, it cannot be changed at this time. The department will consider this comment during the next state plan amendment.

 

COMMENT #35: One commenter asked what level of documentation or type of verification meets the standard to verify that a youth meets the clinical guidelines for meeting SED criteria for OP and if it is full clinical assessment, to allow providers to bill the clinical assessment code for the reverification of the SED criteria after the first 24 sessions. Another commenter stated that requiring prior authorization for OP sessions in excess of 24 sessions for this service seems unduly prohibitive.

 

RESPONSE #35: A youth may receive up to 24 sessions of OP without the SED diagnosis. If the youth requires more than 24 sessions then a youth would at that time need to be determined to meet the SED criteria. If the youth has met the SED criteria within the last 12 months, then the youth meets the eligibility requirements for that year regardless of how many sessions of OP they have received. If the youth has had a clinical assessment within the preceding 12 months and has been determined to meet the SED criteria, that documentation is sufficient to meet the documentation requirements for over 24 sessions. If the youth has not received a clinical assessment and a SED determination within the past 12 months, then the therapist could complete one and it would be reimbursable. The department is not requiring prior authorization for OP in excess of 24 sessions as indicated in the section of the table that addresses prior authorization requirements, "A prior authorization is not required." For OP sessions in excess of 24, a provider must document in the file of the youth that the youth meets the SED criteria in the clinical guidelines for the service as described above.

 

COMMENT #36: One commenter asked for clarification as to what level of documentation is required to meet the requirements to verify that the youth meets the clinical guidelines for meeting the SED criteria for TCM. The commenter also wanted clarification for the continued stay review time line for TCM.

 

RESPONSE #36: In order to document the youth meets the clinical guidelines for meeting the SED criteria, the provider must have a clinical assessment, completed within the last 12 months. The assessment must reflect that the youth has at least one of the covered diagnoses with a severity specifier of moderate or severe. The documentation must also speak to the medical necessity criteria required to receive TCM. Because coordination of services is a required function for TCM, the continued stay requirement is met by documenting the coordination of treatment plans, progress notes, and recommendations of the treatment teams. The department will reword this section to clarify this.

 

COMMENT #37: Many commenters asked what kind of documentation is required for the continued stay reviews that require the provider to verify SED criteria and that if a clinical assessment is required, that the department allow them to bill for more than one clinical assessment annually.

 

RESPONSE #37: A full clinical assessment is required annually to confirm the SED criteria are met. For services requiring a reassessment for continued stay, a full clinical assessment is not required; a provider must document in the file of the youth that the youth continues to meet functional impairment criteria as stated for the service the youth is receiving. In addition the annual clinical assessment must be in the file of the youth.

 

COMMENT #38: One commenter asked if the department will pay the provider when a denial with additional days for discharge is issued. The commenter would like clarification regarding the note that states: "Providers and parents/legal representatives must make plans for discharge when a denial is issued, whether or not additional days for discharge planning are authorized. Additional days for discharge planning may not be authorized or reimbursed by Medicaid. This may result in nonpayment to providers."

 

RESPONSE #38: If a denial with approval for additional days is issued, the additional days will be reimbursed. The intent of the note is to notify providers that there is not a guarantee that additional days for discharge will be approved; therefore, it is imperative that thorough discharge planning takes place. The department amended the language in the new manual to state the intent of the note more clearly.

 

COMMENT #39: Some commenters stated that the coordination of services requirements on page 8 of the proposed manual imposes additional work without any additional pay. Of those, a few of the commenters proposed that the department remove this language and one of the commenters suggested the department simply state that the provider will coordinate with any and all services as possible and to be aware of other providers involved with the youth. Another commenter requested the department clarify that "all" providers are responsible for the coordination of services. One of the commenters suggested that TCMs be responsible to perform the coordination efforts. A few commenters also asked why TCM was left off the list of home and community-based services.

 

RESPONSE #39: Federal regulation prohibits the delivery of services at the same time which are duplicative in nature. Coordination of services helps to prevent unintended duplication which could potentially result in provider payback and is also imperative in providing the most effective and efficient care possible to the youth and their families. It provides a synergy of care that is proven to achieve optimal patient outcomes. The department will specify that "all" providers are responsible for coordination of services but will also add language that if a youth has TCM, then the TCM must be responsible for the coordination effort. The department omitted TCM from the list of services because it is not a direct care service; however, the department will add this service to the list to help alleviate the confusion.

 

COMMENT #40: One commenter stated that under the services section for TGH it states that a complete clinical assessment must be completed within 10 business days of admission and a clinical assessment from a previous provider does not substitute for this requirement. The commenter pointed out that licensure rules allow for the application of a clinical assessment completed within the last 12 months. The commenter is also concerned that this requirement will cause unnecessary continued investigation and disclosure by the youth and families causing them much bother. The commenter asks the department to allow them to respect the experience and qualifications of the providers who previously worked with the youth.

 

RESPONSE #40: The department agrees with this commenter that the requirement conflicts with licensing requirements as written and has amended the new manual to state that the clinical assessment must be completed as stated in ARM 37.97.905.

 

COMMENT #41: One commenter would like to know how a provider tracks the 365- day limit for HSS if the family has received services through another provider.

 

RESPONSE #41: The department issued a provider notice dated May 1, 2014, which provides instructions related to tracking HSS in excess of 365 days. This notice can be found at: http://medicaidprovider.hhs.mt.gov/pdf/provider_notices/2014/homesupportservicesnotification05022014.pdf.

 

COMMENT #42: One commenter stated that there is no reason to have training from a licensed person in Therapeutic Foster Care - Permanency (TFOC-P) when it has been adequately performed for years by a less credentialed but more engaged professional worker. The commenter asked the department to allow the home support specialist to provide this service.

 

RESPONSE #42: TFOC-P is an intensive level of treatment reimbursed at a much greater rate than therapeutic foster care or home support services (HSS); currently the rate is $83.42 more. Home support specialists are not appropriately trained and qualified to deliver this level of services. Service requirements in ARM 37.87.1413 state that individual, family, and group therapies must be provided as part of the service.

 

COMMENT #43: A few commenters requested the department reconsider the 90- day reauthorization for continued stays in TGHs and return it to the previous 120-day reauthorization time frames. The commenters state it is unnecessary, causes extra paperwork, and that 120 days allows for adequate discharge.

 

RESPONSE #43: The department has not amended the 90-day reauthorization requirement because the 90-day time frame corresponds with the treatment plan cycle.

 

COMMENT #44: One commenter asked that the initial service authorization for home support service remain at 180 days and stated they believe the department is reducing the reauthorization to 90 days.  Another commenter stated that the continued stay criteria for HSS is confusing because it follows the service requirement section regarding documentation after the initial 180 days; therefore, it seems to indicate that the parent or provider may petition the department for additional 90-day increments at that point. It should be clarified that, in fact, it is a request for continued stay beyond the allowable 365 days and is requested in 90- day increments.

 

RESPONSE #44: These service requirements and utilization have not been amended from the current practice. As stated under the prior authorization section for HSS, prior authorization is not required for up to 365 days of HSS. Under the service requirement section, at 180 days, a provider must document in the file of the youth the continued need for the service. In the continued stay section, after 365 days, a provider may still request additional days in 90-day increments. The department has changed this section to clarify it is if the youth receives services for over 365 days that the additional increments will be 90 days if approved.

 

COMMENT #45: One commenter stated they noticed the information regarding retroactive eligibility that was in the CMHB "Provider Manual for Utilization Management" has been omitted in the proposed manual.

 

RESPONSE #45:   The department thanks the commenter for informing the department that this information is missing and has added the information regarding retroactive eligibility into the new manual.

 

COMMENT #46: One commenter asked what the protocol is for a youth residing at the Montana Department of Corrections (DOC) who needs to obtain mental health services in a PRTF.

 

RESPONSE #46: The department has added information to the new manual to clarify what the process is for youth entering a PRTF from DOC.

 

COMMENT #47One commenter requested the department retain the coordination of service language to allow multiple treatment plans to be maintained in the file for the youth. The commenter stated that even though more than one service may be interrelated, the services may have sufficient enough differences to create an unmanageable document if combined into one treatment plan.

 

RESPONSE #47: The department appreciates the commenter's suggestion and has retained the option for having multiple treatment plans in the file for the youth as part of the coordination efforts.

 

COMMENT #48: One commenter asked that the certificate of need (CON) requirement for TGHs be kept to allow objective assessments by an independent mental health professional.

 

RESPONSE #48: While the department does understand the commenter's concerns, the department will no longer retain this requirement. Many providers requested this requirement be removed during a meeting held by the department to receive provider input. Providers still have the option to seek a certificate of need from a third party to provide them with an objective assessment, but it will no longer be a requirement the department will be enforcing.

 

COMMENT #49: A few commenters asked the department to allow the prior authorization for TGHs to be amended to 180 days. The commenter states that due to the severity of the youth accessing the service, 180 days is a reasonable amount of time to develop and implement a viable treatment plan to address the SED of the youth.

 

RESPONSE #49: The department has not adjusted the prior authorization requirement to 180 days. The department will be completing the prior authorization reviews for TGHs in house upon adoption of this rule and does not feel it would be prudent to make such a substantial change until the new process has been monitored and tested.

 

COMMENT #50: One commenter asked the department to remove the requirement to have THVs in excess of three days per visit prior authorized. The commenter stated that the three day requirement is arbitrary and seems capricious.

 

RESPONSE #50: The department disagrees with the commenter. The department holds the authority to ensure Medicaid services are delivered in a manner that is appropriate for the use of Medicaid funding. It is the department's responsibility to ensure that THV services are used appropriately for times when a youth will be absent from the facility for reasons other than the prescribed use.

 

COMMENT #51: One commenter asked if it is the state's intention to eliminate the reconsideration review process currently available through the state's utilization and review contractor for TGHs. The commenter is concerned that the appeal process would take too long and creates an unrealistic time frame for providers, youth, and their families.

 

RESPONSE #51: The desk review and peer-to-peer review is not available. However, if the clinical reviewer with the CMHB determines a youth does not meet criteria for a continued stay, the clinical reviewer automatically defers the case to a board-certified psychiatrist for a second review to make a final determination. If the board-certified psychiatrist also determines that the youth does not meet the medical necessity criteria, then the provider will still have the appeal process available.

 

COMMENT #52: One commenter asked for clarification regarding what "concurrently" means, for example, if it is at the same time or on the same day.

 

RESPONSE #52: The department cannot define concurrently because it is variable with the type of service being provided. The intent of the department is to prevent duplication of services provided. The department suggests the commenter refer to the table in the new manual for services that may not be provided concurrently.

 

COMMENT #53: One commenter requested the department amend language on page 12 of the proposed manual which states, "(4) Youth who are not court-ordered to participate in the service may voluntarily leave the service." The commenter believes this should state that the parent or legal representative of a youth who is not court-ordered to participate in the service can voluntarily withdraw the youth from the service.

 

RESPONSE #53: The department addresses the issue of the parent or legal representative removing a youth who is not court-ordered from services on page 12 in (3). CMHB services are considered voluntary if there isn't a commitment order. The department has added reference to the statutory requirements for a youth who may leave services voluntarily without the involvement of a parent or legal representative.

 

COMMENT #54: One commenter requested the requirement to complete a Montana CANS to be either in the service requirement section for all services requiring a Montana CANS or alternatively, to remove it from the service requirements section and have it all listed under the Montana CANS section.

 

RESPONSE #54: The department has removed the Montana CANS from the CSCT service requirement section and listed CSCT and all other services which require the Montana CANS in the Montana CANS section.

 

COMMENT #55: One commenter stated that they believe the discharge notification form for PRTFs has become very rote for providers and does not serve a purpose. The commenter suggested that the requirement be removed or the form reworked with provider input.

 

RESPONSE #55: The department appreciates the commenter's suggestions. The form serves the purpose to notify the department's vendors to remove the service span from the Medicaid Management Information System (MMIS), which, if left in place, prevents the youth from getting services when discharged from the PRTF. The department is considering the commenter's request to rework the form with provider input.

 

COMMENT #56: One commenter requested the information, that was in the CMHB "Provider Manual for Utilization Management," that stated a provider has three days to complete the in-state denial form or it is an automatic denial, be added to the new manual.

 

RESPONSE #56: The department has added the language back into the new manual which allows for the automatic denial if an in-state PRTF does not complete the denial form within three days.

 

COMMENT #57: One commenter stated they would like to know the time line that the board-certified doctor has in which to complete the continued-stay review referral.

 

RESPONSE #57: The board-certified psychiatrist has two business days to complete their review; the department has added the time frame to the new manual.

 

COMMENT #58: One commenter stated that it should be clarified that the time line for counting the 365-day limit for HSS was November 15, 2013.

 

RESPONSE #58: The department has added language to clarify the begin date for the 365 day limit.

 

COMMENT #59: One commenter asked if an in-training mental health professional can provide day treatment services.

 

RESPONSE #59: Only a licensed therapist may provide day treatment services.

 

COMMENT #60: One commenter requested the addition of time in and time out for Extraordinary Needs Aide (ENA) services.

 

RESPONSE #60: The department has added the requirement to document time in and time out for ENA services.

 

COMMENT #61: A few commenters thanked the department for the clarity about a case manager's role during a crisis.

 

REPONSES #61: The department thanks this commenter for providing not only their concerns but also positive feedback regarding the new manual.

 

COMMENT #62: One commenter asked that the department replace the term "mental disability" to "mental disorder" throughout the manual and the open rules to be consistent with DSM.

 

RESPONSE #62: The department has made the requested change to the final rule language and throughout the new manual.

 

COMMENT #63: One commenter stated that, in the past, a child receiving therapeutic foster care services was also eligible for THVs up to 14 days per year. The commenter noted that this was removed from the Medicaid Youth Mental Health Fee Schedule in July, 2013 as well as removed from ARM. The provider suggested that the youth's transition from Therapeutic Foster Care (TFC) back to their family or to a permanent family is as delicate and crucial as that from TGH or PRTF and THV should be similarly available to youth in that service.

 

RESPONSE #63The department removed THVs for TFC because the provider may already bill a patient day even if the youth is transitioning from a foster placement to a biological home; the service follows the youth. THV is appropriate for TGH and PRTFs because they would not get paid if the youth isn't in the TGH or PRTF.

 

COMMENT #64: One commenter stated they believe that the inability for a child in an in-state PRTF to access targeted youth case management in their home community leads to poor discharge plans, poor transition back to the community, and increased recidivism to PRTF level of care. The commenter recommends at a minimum 80 units of case management be available to children in the in-state PRTFs. The commenter also recommended that the department consider allowing additional TCM beyond the 80 units via a prior authorization method.

 

RESPONSE #64: The allowance for TCM in PRTFs was not amended as part of this rulemaking; therefore, this comment is outside of the scope of this rulemaking.

 

COMMENT #65: One commenter stated that there is an insufficient definition in the coordination of OP concurrent with CSCT and TGH section (1)(a), beyond trauma and grief, in the proposed manual as to what constitutes a qualified concurrent specific or specialized OP service.

 

RESPONSE #65: The department has changed this language to further define a qualified concurrent specific or specialized OP service.

 

COMMENT #66: One commenter stated that they believe it is excessive to allow OP services concurrent with TGHs within 60 days of the admission or discharge date, not to exceeding a total of 10 sessions. The commenter states that the time a youth has at a TGH is limited and continuing therapy with his or her previous therapist inhibits the ability of the youth to fully develop a new therapeutic relationship with the TGH therapist. The commenter also states that at the time of discharge, 30 days, or four sessions, would suffice for making an effective transfer to a community therapist. The commenter would like the funds saved by eliminating or limiting concurrent OP with TGH to be utilized to provide TCM to youth in in-state PRTFs.

 

RESPONSE #66: The department appreciates this comment and is considering the commenter's suggestions. However, OP concurrent with TGH services was not amended as part of this rulemaking; therefore, it is outside the scope of this rulemaking.

 

COMMENT #67: One commenter noted that CBPRS is listed in the table in the proposed manual as a service that may not be provided concurrently with the Partial Hospital Program (PHP) and asked the department to clarify that it is during program hours. The commenter also asked the department to modify the language to be consistent with ARM 37.88.901(3)(b)(i). The commenter also asked that it apply to CBPRS in respect to CSCT programs.

 

RESPONSE #67: The department has clarified the table in the new manual by adding language that states CBPRS cannot be provided during program hours. The department disagrees with the commenter's request to modify the language to be consistent with ARM 37.88.901(3)(b)(i). While the language in ARM 37.88.901(3)(b)(i) may be sufficient to disallow CBPRS concurrently with PHP and day treatment, it doesn't address the nuances of a program that is provided in a school setting in which the child is not at a "treatment location" during the entire treatment period. Youth in CSCT receive intervention services intermittently but by the nature of the CSCT program, the team is available to provide services throughout the entire school day, making CBPRS for these youth duplicative.

 

COMMENT #68: One commenter asked the department to amend the language in the definition of TGHs from "therapy and behavioral training" to "behavioral intervention and life skills development."

 

RESPONSE #68: The department has made the suggested changes to the language in the definition of TGHs.

 

COMMENT #69: One commenter stated that there appears to be a word missing from the first sentence of the CBPRS definition in the proposed manual.  Additionally, the commenter does not agree with the last sentence regarding the purpose of CBPRS. Additionally, the commenter suggests amending the description of the purpose of CBPRS from "reduce disability" and "restore function" to "reduce functional impairments and maintain the child's placement in a family setting."

 

RESPONSE #69: The department will consider these possible changes for future rulemaking opportunities; however, this language is present in the proposed EPSDT state plan so cannot be amended at this time without a state plan amendment. The department will add the missing word "means" to the definition.

 

COMMENT #70: One commenter disagrees with the new requirement for a behavioral assessment. The commenter wanted to know who would provide this behavioral assessment and how would it be reimbursed. The commenter does not believe that there is a clear method of behavioral assessment that could correlate to the number of CBPRS hours utilized. The commenter suggested, as an alternative, that the department limit the number of units of CBPRS that can be provided to any one client per month.

 

RESPONSE #70: The department appreciates the commenter's suggestion and has removed the requirement for a behavioral assessment until the department has had an opportunity to speak with providers of CBPRS regarding the commenter's suggestion.

 

COMMENT #71: One commenter suggested the removal of the term "group therapy services" in describing CBPRS because it is not a therapy service.

 

RESPONSE #71: The department agrees with the commenter and has changed the terminology to better reflect the services offered.

 

COMMENT #72: One commenter wanted to know if the proposed manual may be changed without a rule process.

 

RESPONSE #72: The new manual has been adopted and incorporated into rule; therefore, it can only be changed through the rule process.

 

 

 

/s/ Cary B. Lund                                           /s/ Mary E. Dalton acting for                      

Cary B. Lund                                               Richard H. Opper, Director

Rule Reviewer                                             Public Health and Human Services

           

Certified to the Secretary of State September 8, 2014

 

Home  |   Search  |   About Us  |   Contact Us  |   Help  |   Disclaimer  |   Privacy & Security