Montana Administrative Register Notice 37-683 No. 18   09/18/2014    
Prev Next


BEFORE THE Department of Public

health and human services of the



In the matter of the amendment of ARM 37.85.105 pertaining to fee schedule revisions for the durable medical equipment program, home and community based services, and personal assistance and self-directed personal assistance services










TO: All Concerned Persons


1. On July 24, 2014, the Department of Public Health and Human Services published MAR Notice No. 37-683 pertaining to the public hearing on the proposed amendment of the above-stated rule at page 1579 of the 2014 Montana Administrative Register, Issue Number 14.


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


            37.85.105 Effective dates, CONVERSION FACTORS, POLICY ADJUSTERS, AND COST-TO-CHARGE RATIOS of Montana Medicaid Provider Fee Schedules (1) and (2) remain as proposed.

            (3) The department adopts and incorporates by reference, the fee schedule for the following programs within the Health Resources Division, on the date stated.

            (a) remains as proposed.

            (b) The outpatient hospital services fee schedules including:

            (i) the Outpatient Prospective Payment System (OPPS) fee schedule as published by the Centers for Medicare and Medicaid Services (CMS) in 71 Federal Register 226, effective January 1, 2013 78 Federal Register 237, page 74826, effective January 1, 2014, and reviewed annually by CMS as required in 42 CFR 419.5 as updated by the department;

            (ii) through (6) remain as proposed.


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

IMP: 53-2-201, 53-6-101, 53-6-402, MCA


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


COMMENT #1: A commenter expressed concerns about the financial implications of the new rate structure for personal care providers, specifically, the additional administrative services that must be provided to consumers. The commenter said the additional administrative services will substantially increase the number of hours of oversight for staff who are involved in a consumer's case.


RESPONSE #1: The department agrees that additional administrative requirements are being requested from personal care providers. In order to meet the federal requirements for the Community First Choice state plan amendment, it was necessary to implement additional administrative requirements for person-centered planning and coordinated care. The department spent considerable time working with the Community First Choice Council, which was comprised of consumers, providers, advocates, case managers, and interested parties to design the state plan amendment. The additional requirements, including the policy and forms, were developed in collaborative work sessions and piloted by a provider agency to ensure that the federal requirements could be met in an efficient and effective manner by participating provider agencies.


The department made a strategic decision to apply the Community First Choice administrative standards to the standards of the personal care program as we estimate that 95% of consumers currently utilizing personal care will participate in Community First Choice. The department believes that utilizing the person-centered planning process for every consumer, regardless of program type, will improve the quality of services delivered.


The department conducted extensive rate analysis and evaluated the impact of the additional administrative requirements. This analysis included data from the pilot, claims, and provider comment and feedback. The reimbursement adjustment, outlined in this rule, was developed for the purpose of recognizing this increased level of effort. The department believes the adjustment is adequate to compensate for the additional administrative requirements.


COMMENT #2: A commenter expressed concern that the reimbursement structure, established for personal assistance, eliminates billing for oversight hours.


RESPONSE #2: The department evaluated the use of the oversight billing code in the Personal Care Program for the past few years. It was used minimally (less than .5% of total claims) by providers to compensate for administrative work at the agency level. Furthermore, the only time that it could be reimbursed as oversight was direct consumer work, not for general administrative oversight activity. The increase in administrative requirements that is covered, under this reimbursement fee increase, includes compensation for both direct client work and general oversight activity. To ensure adequate compensation, the department collapsed these two activities into one reimbursement rate that can be billed per direct service unit.


COMMENT #3: A commenter expressed concern about the disparity between the percentage increase that was proposed for case management services rate increase versus the personal care increase.


RESPONSE #3: The department reimbursement methodology included a cost per consumer per year for the increased administrative requirements for personal care providers and home and community service case managers. Due to the fact that the reimbursement structure is different for case management and personal care providers, the total percent increase reflects differently across the two programs. The case management rate is a daily rate specific to case management related activity. The personal care rate is a 15 minute unit rate for direct consumer service, with administrative and oversight costs included in that rate. The number of units billed per year for a consumer in personal care is far greater than the number of units billed per year for consumer case management. For these reasons the percent of change in the case management rate came out higher than the percent change in the personal care rate.


COMMENT #4: While reviewing the proposed rule, a commenter noticed that a citation to the federal register needed to be corrected.


RESPONSE #4: The department corrected this citation to the federal register in ARM 37.85.105(3).


            4. The department intends to apply the rule amendments found in ARM 37.85.105(3)(l), for the DME program, effective October 1, 2014.


            5. The department intends to apply the rule amendments found in ARM 37.85.105(4)(a), (c), and (d), for the Senior and Long Term Care (SLTC) program, retroactively to July 1, 2014. A retroactive application of the proposed rule amendments does not result in a negative impact to any affected party.



/s/ Valerie A. Bashor                                    /s/ Richard H. Opper                                   

Valerie A. Bashor                                         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