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Montana Administrative Register Notice 37-508 No. 8   04/29/2010    
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BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.79.135, 37.79.201, 37.79.303, 37.79.316, 37.79.317, and 37.79.325 pertaining to Healthy Montana Kids Plan

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT

 

TO:  All Concerned Persons

 

            1.  On May 27, 2010, at 1:30 p.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 Department of Public Health and Human Services no later than 5:00 p.m. on May 18, 2010, to advise us of the nature of the accommodation that you need.  Please contact Rhonda Lesofski, 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:

 

            37.79.135  PROSPECTIVE PAYMENT SYSTEM FOR FEDERALLY QUALIFIED HEALTH CENTER (FQHC) REIMBURSEMENT  (1)  The Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA) requires states with separate or combined CHIP programs to pay federally qualified health centers (FQHCs) and rural health centers (RHCs) using the Medicaid outpatient prospective payment system (OPPS) as described in ARM 37.86.4413.  An OPPS rate for the HMK coverage group will be developed by the department.  The existing CHIP provider rate will be used for the HMK coverage group until the department establishes the OPPS rate The department adopts the Medicaid OPPS rate for children enrolled in the HMK coverage group.

 

AUTH:  53-4-1105, MCA

IMP:  53-4-1104, 53-4-1105, MCA

 

            37.79.201  ELIGIBILITY  (1)  An applicant may be eligible for covered services under the HMK coverage group if:

            (a) through (g) remain the same.

            (h)  the applicant does not have or has not had creditable health insurance coverage for three months prior to becoming eligible for the HMK coverage group.  This three month period does not apply if the parent or guardian providing the insurance:

            (i) through (vii) remain the same.

            (viii)  paid more than 50% of the insurance premium; or

            (ix)  has insurance coverage that is not accessible (e.g. coverage is through an HMO in another state).; or

            (x)  loses Tricare military health insurance.

            (2) through (5)(d) remain the same.

            (6)  An applicant whose HMK coverage group enrollment ended because his or her parent was activated into military service and who was insured through Tri-care, which is the insurance available to active duty and retired military families during the parent's military activation period, is not subject to the minimum three month waiting period for previous creditable health insurance and will be enrolled in the HMK coverage group if he or she continues to be eligible for the HMK coverage group.  Upon notification that the parent was deactivated and the applicant loses Tri-care coverage, the applicant may be re-enrolled:

            (a)  the month after HMK Plan is notified, if the family has an open family span; or

            (b)  the month after a completed application is received and the applicant requalifies for HMK coverage group.

            (7) through (13) remain the same but are renumbered (6) through (12).

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.303  BENEFITS NOT COVERED  (1)  In addition to any exclusions noted elsewhere in these rules, the following services are not covered benefits:

            (a) through (v) remain the same.

            (w)  cochlear implants and associated components;

            (w) and (x) remain the same but are renumbered (x) and (y).

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.316  MENTAL HEALTH BENEFITS  (1)  Mental health benefits include:

            (a) and (b) remain the same.

            (2)  Mental health benefits are limited to:

            (a)  21 days of inpatient mental health care per benefit year;

            (b)  partial hospitalization benefits which are exchanged for inpatient days at a rate of two partial treatment days for one inpatient day; and

            (c)  20 outpatient visits per year which can be furnished in community based settings or in a mental hospital.

            (3)  Mental health benefits will not be limited for enrollees with the following disorders:

            (a)  schizophrenia;

            (b)  schizoaffective disorder;

            (c)  bipolar disorder;

            (d)  major depression;

            (e)  panic disorder;

            (f)  obsessive-compulsive disorder; and

            (g)  autism.

            (4) through (5) remain the same but are renumbered (2) through (3).

 

AUTH:  53-4-1009, MCA

IMP:  53-4-1003, MCA

 

            37.79.317  CHEMICAL DEPENDENCY BENEFITS SUBSTANCE USE DISORDER BENEFITS  (1) remains the same.

            (2)  The combined benefit for inpatient and outpatient treatment for alcoholism and drug addiction, excluding costs for medical detoxification, is subject to a maximum benefit of $6,000 in a 12-month period.  The life inpatient time maximum benefit is $12,000.  If the inpatient lifetime maximum benefit is met, the annual outpatient benefit is reduced to $2,000.

            (3) (2)  Benefits for medical detoxification treatment will be paid the same as any illness and are not subject to the annual and lifetime limits stated above.

            (4) remains the same but is renumbered (3).

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            37.79.325  AUDIOLOGY BENEFITS  (1) and (2) remain the same.

            (3)  Hearing aids and specified supplies are a covered benefits. and prior Prior authorization is required for hearing aids.

 

AUTH:  53-4-1004, 53-4-1009, 53-4-1105, MCA

IMP:  53-4-1003, 53-4-1004, 53-4-1009, 53-4-1104, 53-4-1105, MCA

 

            4.   The Department of Public Health and Human Services (the department) is proposing the amendment of ARM 37.79.135, 37.79.201, 37.79.303, 37.79.316, 37.79.317, and 37.79.325 pertaining to the Healthy Montana Kids Plan. 

 

The department administers the Healthy Montana Plan, which is funded by the state and federal government to pay for covered health care services to low income Montana children.  The plan has two coverage groups referred to as HMK and HMK Plus.  The HMK Plus coverage group is administered through the Montana Medicaid program.  The HMK coverage group is administered as a self-funded health coverage program that makes direct payment to providers for service delivered to eligible enrollees.  The department contracts with a third party administrator (TPA) to maintain a provider network and pay claims for the HMK coverage group.  Provider rates are generally set as a percentage of the TPA's rate schedule. 

 

In November, 2008, the Montana voters approved Initiative 155 that enacted the Healthy Montana Kids (HMK) Plan Act.  The Healthy Montana Kids Plan Act is now codified at Title 53, chapter 4, part 11, MCA.  Congress also enacted significant changes in the CHIP program in Children's Health Insurance Program Reauthorization Act of 2009 (CHIPRA), Public Law 111-3.  Changes in the administrative rules implementing HMK and HMK Plus are necessary because of changes resulting from both Acts.  The first phase of rule changes went into effect October 1, 2009.  This is the second phase of rule changes.

 

ARM 37.79.135

 

The department adopted this rule prior to receiving guidance from the federal Department of Health and Human Services Centers for Medicare and Medicaid (CMS).  CMS has advised the department that the Medicaid outpatient prospective payment system (OPPS) rate applies to federally qualified health centers (FQHCS) for services to the HMK and HMK Plus coverage group therefore the department is proposing to adopt Medicaid's prospective payment system (PPS) and rate for FQHCS and rural health centers (RHC) services for children enrolled in HMK.  This rule change will bring HMK into compliance with federal Children's Health Insurance Program Reauthorization Act (CHIPRA) requirements.

 

ARM 37.79.201

 

The department proposes to move ARM 37.79.201(6) and include it as one of the exceptions to the three-month waiting period listed in ARM 37.79.201(1)(h).  This clarification would not change the intent the rule; it will provide better structure.

 

ARM 37.79.303

 

The department proposes the following addition to the list of benefits not covered:  cochlear implants and related components.  Cochlear implants and/or related cochlear components are not hearing aid benefits. 

 

ARM 37.79.316

 

The department proposes to amend this rule to comply with requirements of CHIPRA.  CHIPRA (Section 502) prohibits separate state child health plans that provide mental health benefits from imposing annual and lifetime dollar limits on mental health benefits more restrictive than those applicable to medical and surgical benefits. 

 

ARM 37.79.317

 

The department proposes to amend this rule to comply with requirements of CHIPRA.  CHIPRA (Section 502) prohibits separate state child health plans that provide substance use disorder benefits from imposing annual and lifetime dollar limits on substance use disorder benefits that are more restrictive than those applicable to medical and surgical benefits.  Current rule limits the combined benefit for inpatient and outpatient treatment for alcoholism and drug addiction, excluding costs for medical detoxification, to a maximum of $6,000 in a 12-month period.  The lifetime inpatient benefit is $12,000 and if the lifetime maximum is met, the annual outpatient benefit is reduced to $2,000.

 

ARM 37.79.325

 

The department proposes to clarify the current rule and explain hearing aid services and supplies are a covered benefit.  Current rule does not indicate covered benefits include services and supplies affiliated with hearing aids.

 

This proposed change will affect approximately 20 members per benefit year.  Fiscal impact with this change will be minimal, as the HMK coverage group currently covers hearing aid services and supplies.

 

Fiscal Impact

 

It is estimated that approximately 19,000 HMK enrollees and approximately 4,600 HMK participating providers may be impacted by the proposed rule amendments.  The annual fiscal impact of this will be approximately $541,000 in fiscal year 2011 and  $573,000 in fiscal year 2012.  The state fiscal year 2011 federal cost is $416,000 and the state cost is $125,000.  The state fiscal year 2012 federal cost is approximately $441,000 and the state cost is $132,000.

 

            5.  The department intends the proposed rule changes to be applied effective July 1, 2010.

 

            6.  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: Rhonda Lesofski, 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., May 28, 2010.

 

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

 

8.  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 6 above or may be made by completing a request form at any rules hearing held by the department.

 

9.  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.

 

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

 

 

 

 

/s/  John Koch                                                /s/  Anna Whiting Sorrell                              

Rule Reviewer                                               Anna Whiting Sorrell, Director

                                                                        Public Health and Human Services

           

Certified to the Secretary of State April 19, 2010.

 

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