BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.57.101, 37.57.102, 37.57.105, 37.57.106, 37.57.109, 37.57.111, 37.57.112, and 37.57.117, and the repeal of ARM 37.57.110 pertaining to financial assistance for children and youth with special health care needs

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT AND REPEAL

 

TO: All Concerned Persons

 

            1. On July 26, 2018, at 11:00 a.m., the Department of Public Health and Human Services will hold a public hearing in Room 207 of the Department of Public Health and Human Services Building, 111 North Sanders, at Helena, Montana, to consider the proposed amendment and repeal of the above-stated rules.

 

2. The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require an accommodation, contact the Department of Public Health and Human Services no later than 5:00 p.m. on July 16, 2018, to advise us of the nature of the accommodation that you need. Please contact Gwen Knight, 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:

 

37.57.101 PURPOSE OF RULES (1) The purpose of the children's special health services program rules is to provide health care treatment and enabling services for children and youth with special health care needs.

 

AUTH: 50-1-202, MCA

IMP: 50-1-202, MCA

 

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

            (1) remains the same.

            (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, developmental, behavioral, or emotional condition and who also requires health and related services of a type or amount beyond that required by children generally.

            (3) remains the same.

            (4) "CSHS" means the children's special health services program of the department, authorized by 50-1-202, MCA, that serves children and youth with special health care needs.

            (5) through (8) remain the same.

            (9)  "Enabling services" means nonclinical services that enable individuals to access health care and improve health outcomes.  Enabling services include, but are not limited to:  case management, care coordination, referrals, home visiting, respite care, specialized daycare or preschool, translation/interpretation, transportation, eligibility assistance, health education for individuals or families, and outreach.

            (9) and (10) remain the same but are renumbered (10) and (11).

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

            (12) (13)  "HMK" means Healthy Montana Kids (Children’s Health Insurance Program or CHIP) insurance plan administered by the department.

            (13) (14)  "HMK Plus" means Healthy Montana Kids Plus (children's Medicaid) plan administered by the department.

            (14) (15)  "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.

            (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.

            (17) (16)  "Poverty income guidelines" means the poverty income guidelines published in 2015 2018 in the Federal Register by the U.S. Department of Health and Human Services. The department 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 2015 January 2018, Federal Register. A copy of the 2015 2018 poverty guidelines may be obtained from the Department of Public Health and Human Services, Public Health and Safety Division, Children's Special Health Services Program, 1400 Broadway, Rm A-116, Helena, MT 59620, telephone (406) 444-3617.

            (18) remains the same but is renumbered (17).

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

            (19) "Risk category" means any condition of a child or youth's life which qualifies them as being at an increased risk for chronic physical, development, behavioral, or emotional condition, further qualifying them as a CYSHCN.  This may include but is not limited to:  living in poverty, in the foster care or Child Protective Services system, having a parent with a disabling condition, multiple adverse childhood experiences, or homelessness.

            (20)  "Services" means assistance other than financial assistance provided to a CYSHCN, such as resource and referral information, transition information, specialty clinic services, and care coordination enabling or treatment services covered by the rule.

            (21) and (22) remain the same.

            (23) "Treatment" means medical, corrective, and/or surgical intervention to alleviate a disabling condition or as recommended by a provider based on a CYSHCN's risk category, including for initial testing and diagnosis.  This includes medications and medical equipment.

 

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) 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.

            (2) The 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 CSHS FINANCIAL ASSISTANCE (1) Eligibility criteria for CSHS financial assistance are:

            (a)  an individual under the age of 22 who meets the definition of a child or youth with special health care needs (CYSHCN); a 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 is suspected of having a disabling physical condition or a medical condition or disease;

            (b) a CYSHCN is under 19 years of age or up to 22 years of age and has a qualifying condition for which long-term care is needed and approved by the interdisciplinary team or the program's medical advisor;

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

            (c)  in need of a treatment or enabling services related to their disabling condition or risk category, which is recommended by a medical professional, where an out-of-pocket expense would be the responsibility of the family and no other means of payment is available to cover the out-of-pocket expenses.

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

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

            (i) and (ii) remain the same.

            (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's income with whom the child resides the majority of the year; and

            (iv) through (c) remain the same.

 (d) A family whose income, less any out-of-pocket expenses for health insurance premiums, care expenses for children, disabled or elderly adults while adults are working, and earned income disregards is at or less than 300% of the federal poverty income guidelines and one of the following:

            (i) remains the same.

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

            (iii) and (3) remain the same.

            (4) Eligibility 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 age of the CYSHCN precludes them from participation or the CYSHCN no longer resides in Montana.  Services provided up to six months prior to the date of eligibility are reimbursable by CSHS.

            (5) remains the same.

 (6) A CYSHCN attending an interdisciplinary team pediatric specialty clinic funded by CSHS does not need to apply for financial assistance to cover the cost of clinic visits. 

 

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 financial assistance for a CYSHCN must submit a completed CSHS financial assistance application, along with required supporting documents.  This application is available by contacting CSHS at 1-800-762-9891 or visiting www.cshs.mt.gov. required by the department, to the department on a form it prescribes.

            (2) and (3) remain the same.

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

 

AUTH: 50-1-202, MCA

IMP: 50-1-202, MCA

 

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

            (a) through (c) remain the same.

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

            (e) remains the same.

            (2) The department When possible, CSHS will pay providers directly for CSHS-eligible services and will not reimburse clients.  Clients may be reimbursed if the services were rendered prior to eligibility and proper documentation is provided as requested by CSHS.

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

            (4) and (5) remain the same.

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

            (a) Payment for o Orthodontia may only be covered for CYSHCN for CSHS clients who have a cleft or craniofacial conditions requiring orthodontia due to a medical condition with orthodontic implications.  This may include but is not limited to:  cleft/craniofacial anomalies, facial deformities, speech impediments, Treacher-Collins Syndrome, Marfan Syndrome, or Craniosynostosis will be subject to the maximum allowable 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 health care coverage a client may have.

            (7) remains the same.

            (8) Hospitals and surgicenters will be paid 85% of the actual submitted charge, 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 health care coverage allowed amount or the CSHS allowed amount for the services on the date of occurrence for inpatient and outpatient services.

            (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 health care coverage allowed amount or the CSHS allowed amount for an annual dental exam and dental extractions related to active or anticipated orthodontic treatment.

            (10) and (11) remain the same but are renumbered (8) and (9).

 

AUTH: 50-1-202, MCA

IMP: 50-1-202, MCA

 

            37.57.112 INFORMAL RECONSIDERATION PROCEDURE (1) A CYSHCN  child or youth who has been denied eligibility for CSHS, a provider who has been denied reimbursement for services or covered benefits, or anyone who is otherwise adversely affected by denial for CSHS financial assistance an action taken by the department may have an informal reconsideration. before the department by The party requesting such a reconsideration must do so within 60 days after notice of the adverse action in question has been placed in the mail or otherwise communicated to the aggrieved party.

            (2) through (6) remain the same.

 

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)  remains the same.

            (ii) be board-eligible or board-certified in the specialty for the condition being treated, or working in cooperation with a physician who is, unless the provider submits a curriculum vitae to the department and the CSHS medical advisor approves the provider as a specialty provider;

            (iii) remains the same but is renumbered (ii).

            (b) through (d) remain the same.

            (e) Any provider other than those listed in (1)(a) through (1)(d) must:

            (i) be certified and/or licensed by the appropriate Montana authority, or if Montana has no certification or licensure requirements for the provider, be certified by a nationally recognized professional organization in the provider's area of expertise; and

            (ii) shall provide services as ordered or prescribed by the attending physician.

            (2) A provider must immediately supply the department with requested reports in order to permit effective evaluation of claims.

            (3) remains the same.

 

AUTH: 50-1-202, MCA

IMP: 50-1-202, MCA

 

4. The department proposes to repeal the following rule:

 

37.57.110 CONDITIONS AND SERVICES FOR CSHS FINANCIAL ASSISTANCE found on page 37-12576 of the Administrative Rules of Montana.

 

AUTH:  50-1-202, MCA

IMP:  50-1-202, MCA

 

            5. STATEMENT OF REASONABLE NECESSITY

 

The Department of Public Health and Human Services (department) is proposing amendments to ARM 37.57.101, 37.57.102, 37.57.105, 37.57.106, 37.57.109, 37.57.111, 37.57.112, and 37.57.117, and is proposing to repeal ARM 37.57.110 pertaining to Children's Special Health Services (CSHS). CSHS is a public health program in the Family and Community Health Bureau. The program is required by the Federal Maternal Child Health Block Grant (MCHBG) to support development and implementation of comprehensive, culturally competent, coordinated systems of care for children and youth with special health care needs (CYSHCN). CYSHCN are 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 serve more families through the CSHS Financial Assistance Program. The changes will expand the program to a broader range of children and youth with CYSHCN by eliminating required diagnosis and instead, referencing the MCHBG definition of CYSHCN. Additionally, these proposed amendments will allow for reimbursement of "enabling services."

 

The alternative to the proposed rule amendments would be to make no changes to the existing rules. If this rule is not amended CSHS will not be able to expend these funds as budgeted.

 

ARM 37.57.101

 

The department is proposing amendments to ARM 37.57.101 to remove the term "health care" and replace it with "treatment and enabling services." These terms are defined in ARM 37.57.102. The proposed amendment also adds the word "youth" to "children and youth with special health care needs."  This is to match the Title V Maternal and Child Health definition.

 

ARM 37.57.102

 

The department is proposing to add definitions for "enabling services" and "risk category" to better define the population served and add clarifying language to several other definitions. It also removes definitions for "Interdisciplinary Team" and "Medical Advisor," which are no longer relevant to this rule. These definitions are no longer necessary because of the elimination of the requirement that the medical advisor or interdisciplinary team approve long term care for CYSHCN under this rule. Additionally, CSHS no longer has a medical advisor after the repeal of the advisory committee rule in 2003. The department is fixing the word "development" in (2), to read "developmental." 

 

ARM 37.57.105

 

The department is proposing to remove the eligible condition, covered benefits, and provider standards requirements in order to allow for all CYSHCN to receive both enabling and treatment services from medical and service providers. 

 

ARM 37.57.106

 

The department is proposing amendments to remove certain eligibility requirements for CYSHCN receiving financial assistance under this rule and add language clarifying coverage of treatment and enabling services for all CYSHCN. Language is being proposed to retroactively cover services up to 30 days prior to the application date. This is to cover families who seek services prior to knowing this service is available. With a new diagnosis or addition of a risk category (e.g., a child entering the foster care system) this is common.

 

ARM 37.57.109

 

The department is proposing amendments to ARM 37.57.109 to make it easier to find an application for CSHS financial assistance.

 

ARM 37.57.110

 

The department is proposing to repeal ARM 37.57.110 which describes services and conditions for which CSHS financial assistance is available. The services are being expanded and conditions eliminated as part of this rule change.

 

ARM 37.57.111

 

The department is proposing to amend ARM 37.57.111 to remove language about specific conditions and services. The proposed amendment will allow CSHS to reimburse families when necessary, if a service has already been paid for by the family. This proposed amendment clarifies medical necessity for orthodontia care and removes a section detailing requirements for orthodontic treatment phases to make the requirements more straightforward for families and providers. Details about payments to specific types of providers is removed so different types of medical and enabling service providers can be reimbursed.

 

ARM 37.57.112

 

The department is proposing amendments to this rule to clarify the reconsideration procedures because the language was confusing and redundant. 

 

ARM 37.57.117

 

The department is proposing to amend ARM 37.57.117 to remove some provider requirements and clarify that these requirements are for medical providers to be able to pay providers who are not board certified in a specialty. Montana has a medical provider shortage and access to board certified providers in specialty care is not always feasible. 

 

Fiscal Impact

 

The department expects the proposed amendments in this notice to have a fiscal impact of $100,000. This is the annual budget for the program which has not been expended in recent years because these rule amendments are restrictive. These rule amendments will allow CSHS to use these funds as they are intended and budgeted. 

 

            6. The department intends for these proposed rule amendments to be applied retroactive to August 1, 2018. There is no negative fiscal impact.

 

            7. Concerned persons may submit their data, views, or arguments either orally or in writing at the hearing. Written data, views, or arguments may also be submitted to: Gwen Knight, 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., August 3, 2018.

 

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

 

9. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency.  Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 7 above or may be made by completing a request form at any rules hearing held by the department.

 

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

 

11. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment and repeal of the above-referenced rules will not significantly and directly impact small businesses.

 

 

/s/ Shannon L. McDonald                          /s/ Sheila Hogan                                         

Shannon L. McDonald                               Sheila Hogan, Director

Rule Reviewer                                            Public Health and Human Services

 

 

Certified to the Secretary of State June 26, 2018.