BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
In the matter of the amendment of ARM 37.87.903 pertaining to Children's Mental Health Bureau Medicaid Services Policy Manual Revisions
NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT
TO: All Concerned Persons
1. On May 26, 2016, at 9:00 a.m., the Department of Public Health and Human Services will hold a public hearing in the auditorium of the Department of Public Health and Human Services Building, 111 North Sanders, Helena, Montana to consider the proposed amendment of the above-stated rule.
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 the Department of Public Health and Human Services no later than 5:00 p.m. on May 18, 2016, 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 email@example.com.
3. The rule as proposed to be amended provides as follows, new matter underlined, deleted matter interlined:
37.87.903 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, AUTHORIZATION REQUIREMENTS (1) remains the same.
(2) Medicaid mental health services for youth requiring approval prior to treatment, prior authorization, or continued stay authorization
will be is reimbursed only if the following requirements are met:
(a) the youth has been determined to have a serious emotional disturbance defined in the Manual adopted and incorporated by reference in (8), which has been verified by the department or designee its utilization review contractor ; or
(b) the department or designee has determined on a case-by-case basis, that treatment is medically necessary for early intervention and prevention of a more serious emotional disturbance.
(3) through (6) remain the same.
(7) The prior authorization or continued authorization requirement shall not be waived except as provided in this rule.
(8) (7) 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 (Manual), dated October 1, 2015 July 15, 2016, for the purpose of implementing requirements for utilization management. The department adopts and incorporates by reference the Children's Mental Health Bureau, Medicaid Services Provider Manual, dated October 1, 2015 July 15, 2016. 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 http://dphhs.mt.gov/dsd/CMB/Manuals.aspx.
(9) and (10) remain the same, but are renumbered (8) and (9).
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
4. STATEMENT OF REASONABLE NECESSITY
The department proposes to amend ARM 37.87.903 and to modify the Children's Mental Health Bureau Medicaid Services Provider Manual (Manual), adopted and incorporated by reference in ARM 37.87.903. The proposed rule and Manual changes are a result of provider feedback and the department's periodic review of its rules, policies, and services.
Specifically, the department proposes the following amendments:
The department proposes to remove ARM 37.87.903(2)(b) and (7), and renumber current (8), (9), and (10) as (7), (8), and (9), respectively.
The removal of ARM 37.87.903(2)(b) is necessary for clarification because current rule language could be interpreted to mean that a youth does not need a Serious Emotional Disturbance (SED) diagnosis for a provider to be reimbursed for the mental health services provided to the youth. Such an interpretation would not be consistent with current department policy.
The removal of ARM 37.87.903(7) is necessary because the rule language is redundant to other rule and Manual provisions. The department articulates its utilization review requirements in the Manual adopted and incorporated by reference in current (8) of this rule.
The department proposes amendment in the rule of the reference date of the Manual described in (8) – proposed to be renumbered to (7) – to reflect Manual revisions with a desired effective date of July 15, 2016. It is necessary to amend the version date of the referenced material to inform providers and other interested parties that the new manual version has the force and effect of law upon adoption of the rule.
Children's Mental Health Bureau Medicaid Services Provider Manual (Manual)
Global changes affecting all Chapters
All instances of the word "designee," whether used in the context of "the Department or its designee" or the "department's designee," are proposed to be replaced with "utilization review contractor" because the term "designee" has become too vague and it is necessary for the department to clarify the roles of different entities for providers.
The department proposes adding definitions to the Definitions section to identify "Authorized Representative," "Claimant," "Medical Assistance Provider," "Utilization Review Contractor," and "Youth" because it is necessary to define commonly used terms associated with the administrative review process. Other definitions applicable to the Montana Child and Adolescent Needs and Strengths (CANS) system are proposed for removal for the purposes described in the succeeding paragraph.
Montana Child and Adolescent Needs and Strengths (CANS) Functional Assessment Subchapter
All references to the Montana CANS Functional Assessment are proposed for removal as the department has discontinued the requirement of the CANS assessment and the Montana CANS system (MCS). The changes are necessary because the MCS was not functioning as anticipated, consequently the department cannot require utilization of the MCS by providers. Providers may choose to use the paper CANS functional assessment.
Discharge from Services Subchapter
The department proposes the following amendments concerning prior authorization requirements to the Discharge from Services Subchapter:
(a) remove Acute Inpatient Hospitalization and Partial Hospitalization, which is necessary because MAR Notice No. 37-719 (adopted September 14, 2015 – effective October 1, 2015) removed the prior authorization requirement for these services, therefore the form is no longer required;
(b) add Home Support Services discharge notification form requirement, which is necessary because these services require prior authorization and there is a continued stay review requirement.
NEW Subchapter - Youth Leaving a Correctional Facility
A new subchapter of Chapter 2, titled "Youth Leaving a Correctional Facility," is proposed to outline the process and requirements for providers for youth who are leaving a correctional facility and entering services provided by Montana Medicaid. This content is currently located under the Psychiatric Residential Treatment Facility (PRTF) Service section of the Services subchapter of Chapter 3, but the department has identified a need for it to be applicable for all Montana Medicaid funded services when a youth is leaving a correctional facility and proposes to relocate the text.
Serious Emotional Disturbance (SED) Subchapter
The department proposes to generally revise this subchapter to identify and clarify SED diagnosis requirements for youth under six and youth 18 to 20 who are in an accredited secondary school. The department proposes new (2), to clarify diagnosis requirements for youth under the age of six, and new (3) to better articulate the requirement that a youth must have an annual reassessment by a mental health professional to determine if the youth still meets the SED requirements.
Acute Inpatient Hospitalization Section
The department proposes to remove the discharge notification form requirement for in-state acute hospital. In MAR Notice No. 37-719, the department removed the prior authorization (PA) requirement for this service, which renders this form unnecessary.
Further, the department proposes to adopt into the Manual a PA requirement for out-of-state Acute Inpatient Hospitals. This amendment is necessary because in ARM 37.86.2801 out-of-state acute inpatient hospital providers are required to obtain a PA to receive the full reimbursement rate for services provided, without which hospitals are reimbursed at 50% of the submitted claim.
Psychiatric Residential Treatment Facility (PRTF) Subchapter
The department proposes to amend the following items in this subchapter:
(a) change medical necessity and continued stay criteria, which are necessary to clarify the level of care and purpose of PRTF services. Current language reflects the minimum requirements, as stated in the Code of Federal Regulations, and is outdated and lacks substance;
(b) add exclusion criteria, which is necessary to further clarify the level of care and purpose of PRTF services;
(c) add a requirement that providers must keep documentation of in-state denials in the file of a youth before the youth may be admitted into an out-of-state PRTF. Previously all in-state PRTFs were required to submit a letter of denial but the department removed the requirement for a hard copy letter in MAR Notice No. 37-719. Verbal denials are still compulsory and this amendment requires documentation that the denials were received;
(d) add the language "short (less than 30 days) continued stays for lack of step down placement" to continued stay criteria in order to improve the discharge process. The amendment is necessary to make the Manual consistent with department practice and clarify the limit of 30 days for providers who are responsible for discharge planning;
(e) provide that the discharge plan review form be optional rather than required because the form is not one that is used for utilization review and is intended to provide guidance to providers if they choose to incorporate this tool; and
(f) relocate the text regarding youth in correctional facilities to the new subchapter in Chapter 2 titled "Youth Leaving a Correctional Facility" as described above.
Therapeutic Group Home Subchapter
The department proposes to change prior authorization and continued stay request language to remove the requirement that a prior authorization request must be submitted two days prior to admission and a continued stay request must be submitted five days prior to the last covered day of service. These changes are necessary to align the Manual with the current department policy which is to issue prior authorization and continued stay approvals effective the date the department receives the requests or at the end of the current service span. The department does not issue retrospective approvals. Further, if the provider submits the request after the current approval span has expired, the department will approve or deny the request based upon the date the request was received rather than issuing a technical denial for the entire span.
Home Support Services Subchapter
The department proposes to amend continued stay criteria by removing the requirement that continued stay requests must be submitted five days prior to the 365th billable day of service. This amendment is necessary to align Manual language with department policy for approving continued stay requests which is to issue continued stay approvals effective the date the department receives the request or at the end of the current service span. The department does not issue retrospective approvals. Further, if the provider submits the request after the current approval span has expired, the department will approve or deny the request based upon the date the request was received rather than issuing a technical denial for the entire span.
Technical Denial Subchapter
The department proposes relocating language describing the process for administrative review and submitting new prior authorization requests after a technical denial of an initial request into the section "Reconsideration review process for PRTF services" because these processes are only applicable to PRTF services and this amendment clarifies the technical-denial procedures for providers as they pertain to PRTF services.
The department determined that there is no fiscal impact from the proposed amendments to ARM 37.87.903 and the Children's Mental Health Bureau Medicaid Services Provider Manual.
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 firstname.lastname@example.org, and must be received no later than 5:00 p.m., June 3, 2016.
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.
10. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment of the above-referenced rule will not significantly and directly impact small businesses.
11. Section 53-6-196, MCA, requires that the department, when adopting by rule proposed changes in the delivery of services funded with Medicaid monies, make a determination of whether the principal reasons and rationale for the rule can be assessed by performance-based measures and, if the requirement is applicable, the method of such measurement. The statute provides that the requirement is not applicable if the rule is for the implementation of rate increases or of federal law.
The department has determined that the proposed program changes presented in this notice are appropriate for performance-based measurement and therefore are subject to the performance-based measures requirement of 53-6-196, MCA.
|Principal reason for the rule ||Measurement (what is being measured overall)||Data Collection Method/Metrics||Period of Measurement|
|Ensure most effective level of care to avoid unnecessary and potentially harmful higher levels of PRTF care for Medicaid youth that can be served in a lower level care.||PRTF admission and readmission ||Track PRTF enrollment via MMIS Claims data system|| Annually|
/s/ Cary B. Lund /s/ Richard H. Opper
Cary B. Lund, Attorney Richard H. Opper, Director
Rule Reviewer Public Health and Human Services
Certified to the Secretary of State April 25, 2016.