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| Montana Administrative Register Notice 37-863 | No. 17 09/07/2018 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Concerned Persons
1. On September 27, 2018, at 10:00 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 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 September 14, 2018, to advise us of the nature of the accommodation that you need. Please contact Todd Olson, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-9503; 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:
37.34.3005 REIMBURSEMENT FOR SERVICES OF MEDICAID FUNDED DEVELOPMENTAL DISABILITIES HOME AND COMMUNITY-BASED SERVICES (HCBS) WAIVER PROGRAMS (1) remains the same. (2) The department adopts and incorporates by this reference the rates of reimbursement for the delivery of services and items available through each Home and Community-Based Services Waiver Program as specified in the Montana Developmental Disabilities Program Manual of Service Rates and Procedures of Reimbursement for Home and Community-Based Services (HCBS) 1915c, 0208, and 0667 Waiver Programs, effective July 1, 2018, as revised and labeled "version 2." A copy of the manual may be obtained through the Department of Public Health and Human Services, Developmental Services Division, Developmental Disabilities Program, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210 and at http://dphhs.mt.gov/dsd/developmentaldisabililities/DDPratesinf.
37.40.830 HOSPICE, REIMBURSEMENT (1) through (11) remain the same. (12) The hospice fee schedules are effective
AUTH: 53-6-113, MCA IMP: 53-6-101, MCA
37.85.104 EFFECTIVE DATES OF PROVIDER FEE SCHEDULES FOR MONTANA NON-MEDICAID SERVICES (1) The department adopts and incorporates by reference the fee schedule for the following programs within the Addictive and Mental Disorders Division and Developmental Services Division on the dates stated: (a) Mental health services plan provider reimbursement, as provided in ARM 37.89.125, is effective July 1, 2018, as revised and labeled "version 2." (b) 72-hour presumptive eligibility for adult-crisis stabilization services reimbursement for services, as provided in ARM 37.89.523, is effective July 1, 2018, as revised and labeled "version 2." (c) Youth respite care services, as provided in ARM 37.87.2203, is effective July 1, 2018, as revised and labeled "version 2." (d) Substance use disorder services provider reimbursement, as provided in ARM 37.27.905, is effective July 1, 2018, as revised and labeled "version 2." (2) remains the same.
AUTH: 53-2-201, 53-6-101, 53-6-113, MCA IMP: 53-2-201, 53-6-101, 53-6-111, MCA
37.85.105 Effective dates, CONVERSION FACTORS, POLICY ADJUSTERS, AND COST-TO-CHARGE RATIOS of Montana Medicaid Provider Fee Schedules (1) The Montana Medicaid Program establishes provider reimbursement rates for medically necessary, covered services based on the estimated demand for services and the legislative appropriation and federal matching funds. Provider reimbursement rates are stated in fee schedules for covered services applicable to the identified Medicaid program. New rates are established by revising the identified program's fee schedule and adopting the new fees as of the stated effective date of the schedule. Copies of the department's current fee schedules are posted at http://medicaidprovider.mt.gov and may be obtained from the Department of Public Health and Human Services, Health Resources Division, 1401 East Lockey, P.O. Box 202951, Helena, MT 59620-2951. A description of the method for setting the reimbursement rate and the administrative rules applicable to the covered service are published in the chapter or subchapter of this title regarding that service. The department will make (2) The department adopts and incorporates by reference, the resource-based relative value scale (RBRVS) reimbursement methodology for specific providers as described in ARM 37.85.212 on the date stated. (a) remains the same. (b) Fee schedules are effective July 1, 2018, as revised and labeled "version 2." The conversion factor for physician services is (c) remains the same. (d) The payment-to-charge ratio is effective (e) through (h) remain the same. (i) Reimbursement for physician-administered drugs described in ARM 37.86.105 is determined in 42 CFR 414.904 (2016). The department adopts (j) Reimbursement for vaccines described at ARM 37.86.105 is effective July 1, 2018, as revised and labeled "version 2." (3) The department adopts and incorporates by reference, the fee schedules for the following programs within the Health Resources Division, on the date stated. (a) The inpatient hospital services fee schedule and inpatient hospital base fee schedule rates including: (i) the APR-DRG fee schedule for inpatient hospitals as provided in ARM 37.86.2907, effective (ii) the Montana Medicaid APR-DRG relative weight values, average national length of stay (ALOS), outlier thresholds, and APR grouper version (b) The outpatient hospital services fee schedules including: (i) remains the same. (ii) the conversion factor for outpatient services on or after (iii) remains the same. (iv) the bundled composite rate of (c) The hearing aid services fee schedule, as provided in ARM 37.86.805, is effective (d) The Relative Values for Dentists, as provided in ARM 37.86.1004, reference published in $33.78 and fee schedule is effective (e) The dental services covered procedures, the Dental and Denturist Program Provider Manual, as provided in ARM 37.86.1006, is effective (f) The outpatient drugs reimbursement, dispensing fees range as provided in ARM 37.86.1105(3)(b) is effective July 1, 2018, as revised and labeled "version 2": (i) for pharmacies with prescription volume between 0 and 39,999, the minimum is $2.75 and the maximum is (ii) for pharmacies with prescription volume between 40,000 and 69,999, the minimum is $2.75 and the maximum is (iii) for pharmacies with prescription volume greater than 70,000, the minimum is $2.75 and the maximum is (g) remains the same. (h) The outpatient drugs reimbursement, vaccine administration fee as provided in ARM 37.86.1105(6), will be (i) remains the same. (j) The home infusion therapy services fee schedule, as provided in ARM 37.86.1506, is effective (k) Montana Medicaid adopts and incorporates by reference the Region D Supplier Manual, effective (l) Fee schedules for nutrition, children's special health services, and orientation and mobility specialists as provided in ARM 37.86.2207(2), are effective July 1, 2018, as revised and labeled "version 2." (m) and (n) remain the same. (o) The ambulance services fee schedule, as provided in ARM 37.86.2605, is effective July 1, 2018, as revised and labeled "version 2." (p) The audiology fee schedule, as provided in ARM 37.86.705, is effective July 1, 2018, as revised and labeled "version 2." (q) The therapy fee schedules for occupational therapists, physical therapists, and speech therapists, as provided in ARM 37.86.610, are effective July 1, 2018, as revised and labeled "version 2." (r) The optometric fee schedule provided in ARM 37.86.2005, is effective July 1, 2018, as revised and labeled "version 2." (s) The chiropractic fee schedule, as provided in ARM 37.85.212(2), is effective July 1, 2018, as revised and labeled "version 2." (t) The lab and imaging fee schedule, as provided in ARM 37.85.212(2) and 37.86.3007, is effective July 1, 2018, as revised and labeled "version 2." (u) remains the same. (v) The Targeted Case Management for Children and Youth with Special Health Care Needs fee schedule, as provided in ARM 37.86.3910, is effective (w) The Targeted Case Management for High Risk Pregnant Women fee schedule, as provided in ARM 37.86.3415, is effective (x) The mobile imaging fee schedule, as provided in ARM 37.85.212, is effective July 1, 2018, as revised and labeled "version 2." (y) The licensed direct entry midwife fee schedule, as provided in ARM 37.85.212, is effective July 1, 2018, as revised and labeled "version 2." (z) remains the same. (4) The department adopts and incorporates by reference, the fee schedule for the following programs within the Senior and Long Term Care Division on the date stated: (a) Home and community-based services for elderly and physically disabled persons fee schedule, as provided in ARM 37.40.1421, is effective (b) Home health services fee schedule, as provided in ARM 37.40.705, is effective (c) Personal assistance services fee schedule, as provided in ARM 37.40.1135, is effective (d) Self-directed personal assistance services fee schedule, as provided in ARM 37.40.1135, is effective (e) Community first choice services fee schedule, as provided in ARM 37.40.1026, is effective (5) The department adopts and incorporates by reference, the fee schedule for the following programs within the Addictive and Mental Disorders Division on the date stated: (a) Mental health center services for adults reimbursement, as provided in ARM 37.88.907, is effective July 1, 2018, as revised and labeled "version 2." (b) Home and community-based services for adults with severe disabling mental illness, reimbursement, as provided in ARM 37.90.408, is effective J (c) Substance use disorder services reimbursement, as provided in ARM 37.27.905, is effective July 1, 2018, as revised and labeled "version 2." (6) The department adopts and incorporates by reference, the fee schedule for the following program within the Developmental Services Division, on the date stated: Mental health services for youth, as provided in ARM 37.87.901 in the Medicaid Youth Mental Health Services Fee Schedule, is effective July 1, 2018, as revised and labeled "version 2."
IMP: 53-2-201, 53-6-101, 53-6-125, 53-6-402, MCA
37.85.106 MEDICAID BEHAVIORAL HEALTH TARGETED CASE MANAGEMENT FEE SCHEDULE (1) remains the same. (2) The Department of Public Health and Human Services (department) adopts and incorporates by reference the Medicaid Behavioral Health Targeted Case Management Fee Schedule effective (a) through (3) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-113, MCA
37.86.705 AUDIOLOGY SERVICES, REIMBURSEMENT (1) remains the same. (2) Subject to the requirements of this rule, the Montana Medicaid program pays the following for audiology services: (a) For patients who are eligible for Medicaid, the lowest of: (i) and (ii) remain the same. (iii) (iv) remains the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
37.86.805 HEARING AID SERVICES, REIMBURSEMENT (1) The department will pay the lowest of the following for covered hearing aid services and items: (a) and (b) remain the same. (c) (2) For items or services where no Medicare allowable fee is available, the fee schedule amount in (1)(b) will be calculated using the following methodology: (a) remains the same. (b) For supplies or equipment, reimbursement will be set at (c) and (3) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113,
37.86.1006 DENTAL SERVICES, COVERED PROCEDURES (1) through (4) remain the same. (5) Covered services for adults age 21 and over include: (a) and (b) remain the same. (c) basic restorative services including prefabricated crown; (d) extractions (e) porcelain fused to base metal crowns with prior authorization, limited to two per person per year, total. For second molars, base metal crowns only. (6) remains the same. (7) Full maxillary and full mandibular dentures are a Medicaid-covered service. Coverage is limited to one set of dentures every ten years. Only one lifetime exception to the ten-year time period is allowed per person if one of the following exceptions is authorized by the department: (a) The dentures are no longer serviceable and cannot be relined or rebased; or (b) The dentures are lost, stolen, or damaged beyond repair. (8) Maxillary partial dentures and mandibular partial dentures are a Medicaid-covered service. Coverage is limited to one set of partial dentures every five years. Only one lifetime exception to the five-year limit is allowed per person if one of the following exceptions is authorized by the department: (a) The partial dentures are no longer serviceable and can no longer be relined or rebased; or (b) The partial dentures are lost, stolen, or damaged beyond repair. (9) The limits on coverage of denture replacement may be exceeded when the department determines that the existing dentures are causing the person serious physical health problems. The dentist or denturist should indicate "replacement dentures" on the request for prior authorization of replacement dentures and document the medical necessity for the replacement. (10) Coverage of all denture services is subject to the following requirements and limitations: (a) A denturist may provide initial immediate full prosthesis and initial immediate partial prothesis only when prescribed in writing by a dentist. The prescription must be signed and dated within 90 days of the order and must be maintained in the patient file. (b) Requests for full prothesis must show the approximate date of the most recent extractions, and/or the age and type of the present prosthesis. (7) through (13) remain the same, but are renumbered (11) through (17).
37.86.1101 OUTPATIENT DRUGS, DEFINITIONS (1) and (2) remain the same. (3) "Allowed ingredient cost" means the "Average Acquisition Cost (AAC)" or "submitted ingredient cost," whichever is lower. If AAC is not available, drug reimbursement is determined at the lesser of "Wholesale Acquisition Cost (WAC)" (4) through (15) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
37.86.1105 OUTPATIENT DRUGS, REIMBURSEMENT (1) through (12) remain the same. (13) Specialty pharmacies, hemophilia treatment centers, or centers of excellence that dispense clotting factors: (a) not purchased through the 340B program will be reimbursed at the lesser of the usual and customary charge, submitted ingredient cost, or wholesale acquisition cost (b) when purchased through the 340B program, will be reimbursed the lesser of the usual and customary charge or wholesale acquisition cost
IMP: 53-2-201, 53-6-101, 53-6-113, MCA
37.86.1406 CLINIC SERVICES, REIMBURSEMENT (1) Ambulatory surgical center (ASC) services as defined in ARM 37.86.1401(2) provided by an ASC will be reimbursed on a fee basis as follows: (a) (i) through (2) remain the same.
37.86.1807 PROSTHETIC DEVICES, DURABLE MEDICAL EQUIPMENT, AND MEDICAL SUPPLIES, FEE SCHEDULE (1) and (2) remain the same. (3) The department's DMEPOS Fee Schedule for items other than those billed under generic or miscellaneous codes as described in (1) will include fees set and maintained according to the following methodology: (a) (b) remains the same. (c) Except as provided in (4), for all items for which no Medicare or Medicaid allowable fee is available, the department's fee schedule amount will be (i) remains the same. (ii) Items having no product retail list price, such as items customized by the provider, will be reimbursed at (4) The department's DMEPOS Fee Schedule, referred to in ARM 37.86.1807(2), for items billed under generic or miscellaneous codes as described in (1) will be
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113,
37.86.2005 OPTOMETRIC SERVICES, REIMBURSEMENT (1) remains the same. (2) For items or services where no RBRVS or Medicare is available, the fee schedule amount in (1)(c) will be calculated using the following methodology: (a) remains the same. (b) For supplies or equipment, reimbursement will be set at (c) and (3) remain the same.
AUTH: 53-6-113, MCA IMP: 53-6-101, 53-6-113,
37.86.2605 AMBULANCE SERVICES, REIMBURSEMENT (1) through (3) remain the same. (4) For supplies or equipment, where there is no Medicare or Medicaid set fee, the provider's usual and customary charge in (1)(a) will be considered reasonable if set at (5) remains the same.
IMP: 53-6-101, 53-6-113,
37.86.2803 ALL HOSPITAL REIMBURSEMENT, COST REPORTING (1) Allowable costs will be determined in accordance with generally accepted accounting principles as defined by the American Institute of Certified Public Accountants. (a) through (d) remain the same. (e) For cost report periods ending (f) For cost report periods ending on or after July 1, 2018, for each hospital which is a critical access hospital, as defined in ARM 37.86.2901, reimbursement for reasonable costs of inpatient and outpatient hospital services will be limited to 101% of allowable costs, as determined in accordance with (1). (2) and (3) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, 53-6-149, MCA
37.86.2806 COST-BASED HOSPITAL, GENERAL REIMBURSEMENT (1) Cost-based reimbursement shall be applied as follows: (a) Critical access hospital (CAH) interim reimbursement is based on a hospital specific Medicaid inpatient cost-to-charge ratio (CCR), not to exceed 100%. For dates of service (b) For cost report periods ending on or prior to December 31, 2017, CAH final reimbursement is for reasonable costs of hospital services limited to 101% of allowable costs, as determined in accordance with ARM 37.86.2803(1). For cost report periods ending (2) through (8) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-113, MCA
37.86.2905 INPATIENT HOSPITAL SERVICES, GENERAL REIMBURSEMENT (1) remains the same. (2) Interim reimbursement for cost-based facilities is based on a hospital-specific Medicaid inpatient cost-to-charge ratio, not to exceed 100%. For dates of service (3) through (5) remain the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113,
37.86.2912 INPATIENT HOSPITAL PROSPECTIVE REIMBURSEMENT, CAPITAL-RELATED COSTS (1) remains the same. (2) The interim payment made to CAHs is based on the hospital-specific cost-to-charge ratio and includes capital costs. For dates of service (3) remains the same.
AUTH: 2-4-201, 53-2-201, 53-6-113, MCA IMP: 2-4-201, 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
37.86.3007 OUTPATIENT HOSPITAL SERVICES, PROSPECTIVE PAYMENT METHODOLOGY, CLINICAL DIAGNOSTIC LABORATORY SERVICES (1) Clinical diagnostic laboratory services, including automated multichannel test panels (commonly referred to as "ATPs") and lab panels, will be reimbursed on a fee basis as follows with the exception of hospitals reimbursed under ARM 37.86.3005 and specific lab codes which are paid under ARM 37.86.3020: (a) The fee for a clinical diagnostic laboratory service is the applicable percentage of the Medicare fee schedule as follows: (i) (ii) (iii) (b) and (c) remain the same. (2) For purposes of this rule, clinical diagnostic laboratory services include the laboratory tests listed in codes defined in the HCPCS and listed in the Clinical Diagnostic Fee Schedule (CLAB) published (3) remains the same.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
37.86.3109 OUTPATIENT CARDIAC AND PULMONARY REHABILITATION REIMBURSEMENT (1) Critical access hospital (CAH) interim reimbursement is based on a hospital-specific Medicaid outpatient cost-to-charge ratio, not to exceed 100%. For dates of service (2) and (3) remain the same.
37.86.3205 NONHOSPITAL LABORATORY AND RADIOLOGY (X-RAY) SERVICES, REIMBURSEMENT (1) through (3) remain the same. (4) For clinical laboratory services, the department pays the lower of: (a) remains the same. (b) (c) remains the same.
AUTH: 53-6-113, MCA
4. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (department) administers the Montana Medicaid and non-Medicaid programs to provide health care to Montana's qualified low income, elderly, and disabled residents. Medicaid is a public assistance program paid for with state and federal funds appropriated to pay health care providers for the covered medical services they deliver to Medicaid members. Pursuant to 53-6-113(3), MCA, the legislature has delegated authority to the department to set by rule, the reimbursement rates that Medicaid pays to providers for covered services.
The purpose of the proposed rule amendments is to: 1) increase provider rates effective July 1, 2018; 2) reflect the rebasing of the All Patient Refined Diagnosis Related Groups (APR-DRG) reimbursement methodology for inpatient services used by several divisions in the department which is necessary to stay within legislative appropriation; and 3) modify the adult benefit package for restoring certain high cost, extensive dental procedures and dentures.
These rules apply to services for all people and eligibility categories for Montana Medicaid, including the Montana Medicaid Health and Economic Livelihood Partnership (HELP) Program that serves the Medicaid Expansion population.
Proposed Provider Rate Increases
The department is proposing a number of provider rate increases effective July 1, 2018. The rate increases reverse across-the-board Medicaid provider rate reductions implemented in state fiscal year 2018. The provider rate increases are expected to distribute the following funds in state fiscal year (SFY) 2019.
As a part of the SFY 2019 budget restoration project, the department initially planned on raising rates prospectively. On July 31, 2018, the department filed with the Secretary of State's Office a Notice of Public Hearing on Proposed Amendment, which proposed increasing Medicaid provider rates across-the-board by 3.56% effective September 1, 2018. Over the remaining 10 months of state fiscal year 2019, a rate increase of 3.56% would have ensured providers received the equivalent of a 12-month 2.99% provider increase. That notice, MAR Notice No. 37-859, was published by the Secretary of State on August 10, 2018.
Subsequent to the filing of MAR Notice No. 37-859, the department was served a complaint and temporary restraining order requiring the department raise rates effective August 2, 2018. The department complied with the temporary restraining order, but remains concerned about the long-term impact to providers. Increasing provider rates temporarily under the direction of a restraining order may result in overpayments and require providers to refund portions of past payments to the Medicaid program.
In addition, as department staff prepared draft federal reports related to the proposed rate change, an error was noted in the fiscal impact section. The department withdrew MAR Notice No. 37-859 and prepared this replacement rule notice filing, MAR Notice No. 37-863.
The proposed rate changes accomplish the following objectives: 1) utilize $5 million of the Senate Bill 9 department budget restoration to raise provider rates as early as possible in SFY 2019; and 2) ensure that providers will not have to return the across the board temporary rate increases if the department prevails in the aforementioned lawsuit.
The department has determined the new proposed provider rates are consistent with the efficiency, economy, and quality of care. The department believes these rates are sufficient to enlist enough providers so that care and services are available to the general population in the geographic area.
The department has posted proposed fee schedules to http://medicaidprovider.mt.gov/proposedfs.
The department has posted the Montana Developmental Disabilities Program Manual of Service Rates and Procedures of Reimbursement for Home and Community-Based Services (HCBS) 1915c, 0208, and 0667 Waiver Programs Manual (Manual) at http://dphhs.mt.gov/dsd/developmentaldisabililities/DDPratesinf.
Hospital Rates
The department proposes to adopt a new version of the APR-DRG grouper effective July 1, 2018. Version 35 of the APR-DRG grouper contains changes to DRG weights, average length of stays, and adds new DRGs. Hospital base rates are proposed to increase to meet the appropriated budget for inpatient hospitals. In addition, an increase in the conversion factor for outpatient hospitals is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases. This increase applies to free-standing birthing centers as they are paid under the outpatient hospital reimbursement methodology.
Fee Schedules
The department is proposing the adoption of fee schedules effective July 1, 2018, as revised and labeled "version 2." The rates contained within these proposed fee schedules were modified to implement the provider rate increases discussed in the preceding section titled Proposed Provider Rate Increases.
Conversion Factor
The department is proposing an increase of 3.08% to the conversion factors utilized within the Resource Based Relative Value Scale (RBRVS) reimbursement methodology, to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
Medicare Rates
Many Montana Medicaid programs utilize Medicare rates for fee schedules, cost settlements, and reimbursements. The proposed rule changes will increase reimbursement at posted Medicare rates for applicable codes. The July 1, 2018, proposed fee schedules reflect the rate increase, Medicare updates, and procedure code changes. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
Durable Medical Equipment
CMS published a final rule (CMS 1687-IFC) on May 11, 2018, that increases the Medicare fee schedule rates for certain durable medical equipment to safeguard beneficiary access for necessary items and services furnished in rural areas.
The CMS rule increases the fee schedule amounts for certain DME items in rural areas effective June 1, 2018. In order to align the fee schedule effective date with the State Plan Amendment – Introduction Page, Attachment 4, 19B, the department is proposing an effective date of July 1, 2018.
ARM 37.34.3005
The department proposes to amend this rule to incorporate a new edition of the Montana Developmental Disabilities Program Manual of Service Rates and Procedures of Reimbursement for Home and Community-Based Services (HCBS) 1915c, 0208, and 0667 Waiver Programs (Manual), effective July 1, 2018, which includes increases in the rates of reimbursement for Medicaid-funded home and community services. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
In addition to the HCBS waiver rate increase, the department proposes changes to the manual as follows:
(1) Remove on pages 24 through 26 an incorrect reference to self-directed services for all day supports and activities. The correction is necessary because the waiver renewal, effective July 1, 2018, does not include self-direct service delivery for the day supports and activities waiver service. (2) On page 33, correct the face-to-face documentation requirement reference to remove an inconsistency in the manual.
ARM 37.40.830
The department proposes to increase the hospice program rates by 3.08% and update the fee schedule date to July 1, 2018. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.104(1)(a), (b), and (d)
The department proposes updating the effective date of the mental health services plan, the 72-hour presumptive eligibility for adult crisis stabilization services, and substance use disorder services fee schedules to July 1, 2018, version 2. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.104(1)(c)
The department proposes to amend the Medicaid Youth Mental Health Fee Schedule to update the effective date to July 1, 2018.
ARM 37.85.105(2)(b)
The department proposes to update the following conversion factors in the following amounts to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases: physician services conversion factor from $36.68 to $37.81; allied services conversion factor from $22.96 to $23.67; mental health services conversion factor from $23.20 to $23.92; and anesthesia services conversion factor from $28.87 to $29.76. These changes will be effective on July 1, 2018, and therefore the RBRVS fee schedules will be made effective on that date.
ARM 37.85.105(2)(d)
The department is proposing to reinstate the provider payment to charge percentage to 47%. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(2)(i)
The department proposes to update reimbursement for physician-administered drugs as determined at 42 CFR 414.904 (2016). The department is proposing an increase in the percentage of average sales price (ASP) paid for physician-administered drugs. This increase is to reinstate the Medicare reimbursement of 106% of ASP. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(2)(j)
The department proposes to increase the fee schedule for vaccines effective July 1, 2018, by 3.08%, to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(a)(i)
The department proposes to update and revise the APR-DRG fee schedule for inpatient hospitals as provided in ARM 37.86.2907 effective July 1, 2018. The base rates will be increased to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(a)(ii)
The department adopts and incorporates by reference the APR-DRG Table of Weights and Thresholds effective July 1, 2018, and updates the APR-DRG grouper version 34 to version 35. The department proposes these changes to include the revisions to the weights, thresholds, and DRGs proposed in version 35 of the APR-DRG grouper. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(b)(ii)
The department proposes to revise the conversion factor for outpatient hospital services on or after July 1, 2018, from $49.46 to $50.98. The conversion factor for outpatient hospital services is being increased to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(b)(iv)
The department proposes to revise the composite Rate for Dialysis from $244.47 to $252.00 effective July 1, 2018. The change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(c)
The department proposes to increase the hearing aid services fee schedule by 3.08% effective July 1, 2018, to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(d)
The department proposes to revise the relative value for dentists publish date to 2018 and revise the fee schedule effective date to July 1, 2018. This change is required to incorporate the most recently published relative value units for dentists. In addition, the department proposes to increase the dental conversion factor from $32.77 to $33.78. The changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(e)
The department proposes to update the fee schedules for dental services to reinstate coverage of certain high cost, extensive dental procedures, and dentures for adults. These reinstated dental services are effective on October 1, 2018, and thus providers will be reimbursed for these reinstated services only after that date. The department proposes to update the Dental and Denturist Program Provider Manual effective October 1, 2018, to reflect changes outlined in ARM 37.86.1006.
ARM 37.85.105(3)(f)
The department proposes to revise the effective date regarding the outpatient drugs reimbursement dispensing fee ranges to July 1, 2018. The department is increasing the maximum dispensing fees by 3.08%. The change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(f)(i)
The department proposes to revise the maximum dispensing fees for pharmacies with prescription volumes between 0 and 39,999 from $14.55 to $15.00. The change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(f)(ii)
The department proposes to revise the maximum dispensing fee for pharmacies with prescription volumes between 40,000 and 69,999 from $12.61 to $13.00. The change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(f)(iii)
The department proposes to revise the maximum dispensing fee for pharmacies with prescription volumes greater than 70,000 from $10.67 to $11.00. The change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(h)
The department proposes to revise the outpatient drugs reimbursement vaccine administration fee, as provided in ARM 37.86.1105(6), from $20.68 to $21.32 for the first vaccine, and from $13.42 to $13.83, for each additional administered vaccine effective July 1, 2018. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(j)
The department proposes to revise the effective date of the home infusion therapy services fee schedule to July 1, 2018 increasing rates by 3.08%. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(k)
The department proposes to revise the effective date of the reference to the Region D Supplier Manual to July 1, 2018. The department will remove the 2.99% reductions to the 2018 Medicare rates, department set fees, and MSRP rates. Effective date of the revised fee schedule is July 1, 2018. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(l)
The department proposes to revise the effective date regarding the Early Periodic Screening, Diagnostic, and Treatment (EPSDT) fee schedule for nutrition, and orientation and mobility specialists to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(o)
The department proposes to revise the effective date regarding the ambulance services fee schedule to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(p)
The department proposes to revise the effective date for the audiology services fee schedule to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(q)
The department proposes to revise the effective date of the fee schedule for occupational therapists, physical therapists, and speech therapists to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(r)
The department proposes to revise the effective date of the optometric fee schedule to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(s)
The department proposes to revise the effective date of the chiropractic fee schedule to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(t)
The department proposes to revise the effective date of the lab and imaging fee schedule to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(v)
The department proposes to revise the effective date of the Targeted Case Management for Children and Youth with Special Health Care Needs fee schedule to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(w)
The department proposes to revise the effective date of the Targeted Case Management for High Risk Pregnant Women fee schedule to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(x)
The department proposes to revise the effective date of the mobile imaging fee schedule to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(3)(y)
The department proposes to revise the effective date of the licensed direct entry midwife fee schedule to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(4)(a)
The department proposes to increase the fee schedule date for Home and Community Based Services (HCBS) Waiver program to July 1, 2018. A rate increase (excluding member mileage) of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(4)(b)
The department proposes to update the fee schedule date for Home Health Services to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(4)(c) and (d)
The department proposes to update the fee schedule date for Personal Assistance and Self-directed Personal Assistance Services to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(4)(e)
The department proposes to update the fee schedule date for Community First Choice program services to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(5)(a)
The department proposes to update the fee schedule date for mental health center services to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(5)(b)
The department proposes to update the fee schedule date for home and Community-based services to July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(5)(c)
The department proposes to update the fee schedule for a reference for substance use disorder services reimbursement with an effective date of July 1, 2018. A rate increase of 3.08% is proposed. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.105(6)
The department proposes to update the fee schedule date to July 1, 2018. A rate increase of 3.08% is proposed. It is necessary for the department to incorporate new assigned relative values to implement rates set by Montana Medicaid's RBRVS reimbursement for psychologists, social workers, and professional counselors. The RBRVS is located in ARM 37.85.212.
These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.85.106(2)
The department proposes to amend this rule and update the fee schedule for targeted case management for adult and children's mental health services. The updated provider rates reflect a 3.08% increase to implement the provider rate increases outlined in the section titled Proposed Provider Rate Increases.
The department is proposing that the Montana Medicaid program pays the following for audiology and hearing aid services: the lowest of 1) the provider's usual and customary charge for the service; 2) the department fee schedule for each respective service; or 3) 100% of the Medicare Region D allowable fee.
This change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.86.1006
The department proposes to reinstate dental coverage of certain high cost, extensive dental procedures, and dentures for the adult Medicaid population. These reinstated dental services are effective on October 1, 2018, and thus providers will be reimbursed for these reinstated services only after that date. The Dental and Denturist Program Provider Manual informs providers of the requirements applicable to the delivery of services. Copies of the manual are available on the Montana Medicaid provider web site at http://medicaidprovider.mt.gov and from the Department of Public Health and Human Services, Health Resources Division, 1400 Broadway, P.O. Box 202951, Helena, MT 59620-2951.
ARM 37.86.1101
The department proposes to eliminate the 2.99% reduction to Wholesale Acquisition Cost (WAC) reimbursements made when Average Acquisition Cost (AAC) is not available. This change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.86.1105
The department proposes to eliminate the 2.99% reduction to WAC, within the clotting factor reimbursement calculation when dispensed by specialty pharmacies, hemophilia treatment centers, or centers of excellence. This increase is to both 340B and non-340B dispensed drugs. This change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.86.1406
The department proposes to reinstate reimbursement for ambulatory surgical centers services at 100% of the Medicare allowable amount. This change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.86.1807
The department proposes to modify the department's DMEPOS Fee Schedule for items other than those billed under generic or miscellaneous to 100% of the Medicare region D allowable fee. The department proposes to multiplicatively modify the Medicaid fee for all items for which there is no Medicare allowable fee available. The department is modifying the reimbursement percentage of the provider's usual and customary charge to 75%, effective July 1, 2018. In addition, for items that have no product retail list price, the department is proposing a reimbursement of 75% of the provider's usual and customary charge, effective July 1, 2018. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.86.805, 37.86.2005, and 37.86.2605
The department proposes to change the percentage of the manufacturer's suggested retail price that is considered reasonable when there is no established Medicare or Medicaid fee to 75%. For items without a manufacturer's suggested retail price, the charge will be considered reasonable if the provider's acquisition cost from the manufacturer is at least 50% of the charge amount effective July 1, 2018. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.86.2803, 37.86.2806, 37.86.2905, 37.86.2912, and 37.86.3109
The department proposes to increase the final cost settlement for critical access hospitals amount to 101%. In addition, the department proposes to increase the interim payment for all Critical Access Hospitals (CAHs) to their individual cost to charge ratios. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.86.3007
The department proposes to increase the percentage of the prevailing Medicare fee schedule for clinical diagnostic laboratory services. The revised percentages are as follows: 60% for a birthing center or where a hospital laboratory acts as an independent laboratory; 62% for a hospital designated as a sole community hospital; and 60% for a hospital that is not designated as a sole community hospital. These changes are proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
ARM 37.86.3205
The department proposes to increase the percentage of the Medicare fee schedule for nonhospital laboratory services to 60%. This change is proposed to implement the provider rate increases outlined in the preceding section titled Proposed Provider Rate Increases.
FISCAL IMPACT
The following table displays the fiscal impact as well as number of providers affected by the proposed changes.
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: Todd Olson, 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 the dphhslegal@mt.gov, and must be received no later than 5:00 p.m., October 5, 2018.
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. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
9. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment of the above-referenced rules will not significantly and directly impact small businesses.
10. 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 not appropriate for performance-based measurement and therefore are not subject to the performance-based measures requirement of 53-6-196, MCA.
11. With the exception of the amendments to ARM 37.85.105(3)(e) and 37.86.1006, the department intends to apply these rule amendments retroactively to July 1, 2018. The department intends to apply the amendments to ARM 37.85.105(3)(e) and 37.86.1006 retroactively to October 1, 2018. A retroactive application of the proposed rule amendments does not result in a negative impact to any affected party.
/s/ Brenda K. Elias /s/ Sheila Hogan Brenda K. Elias Sheila Hogan, Director Rule Reviewer Public Health and Human Services
Certified to the Secretary of State August 28, 2018. |
A directory of state agencies is available online at http://www.mt.gov/govt/agencylisting.asp.
For questions about the organization of the ARM or this web site, contact sosarm@mt.gov.
