BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
TO: All Concerned Persons
1. On October 14, 2015, at 10:00 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, 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 October 7, 2015, 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 firstname.lastname@example.org.
3. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
37.86.3503 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, SEVERE DISABLING MENTAL ILLNESS
(1) "Severe disabling mental illness" means with respect to a person who is 18 or more years of age that the person meets the requirements of (1)(a), (b), or (c)
, or d. The person must also meet the requirements of (1) (e)(d). The person:
(a) has been involuntarily hospitalized for at least 30 consecutive days because of a mental disorder at Montana State Hospital
(Warm Springs campus) at least once; or
(b) has recurrent thoughts of death, recurrent suicidal ideation, a suicide attempt, or a specific plan for committing suicide; or
(c) except for excluding "mild, not otherwise specified (NOS)," or due to "physiological disturbances and physical factors," has a
DSM-IV-TR DSM diagnosis of:
schizophrenic disorder (295) schizophrenia, schizophrenia spectrum, and other psychotic disorders;
other psychotic disorder (293.81, 293.82, 295.40, 295.70, 297.1, 297.3, 298.9) bipolar spectrum disorder;
mood disorder (293.83, 296.22, 296.23, 296.24, 296.32, 296.33, 296.34, 296.40, 296.42, 296.43, 296.44, 296.52, 296.53, 296.54, 296.62, 296.63, 296.64, 296.7, 296.80, 296.89) depressive disorder;
(iv) amnestic disorder (294.0, 294.8);
(v) disorder due to a general medical condition (293.0, 310.1);
(vi) pervasive developmental disorder not otherwise specified (299.80) when not accompanied by mental retardation;
(vii) (iv) anxiety disorders; (300.01, 300.21, 300.3); or
(viii) (v) posttraumatic stress disorders (309.81).;
(d) has a DSM-IV-TR diagnosis of personality disorder (301.00, 301.20, 301.22, 301.4, 301.50, 301.6, 301.81, 301.82, 301.83, or 301.90); and
(vi) borderline personality disorder; or
(vii) autism spectrum disorders; and
(e) (d) has ongoing functioning difficulties because of the mental illness for a period of at least six months or for an a obviously predictable period over six months, as indicated by the presence of at least two three of the following indicators:
(i) remains the same.
(ii) the person is unable to work in a full-time competitive situation because of mental illness;
(ii) an inability to care for personal needs, e.g., meals, bathing, dressing, and daily chores, due to mental illness;
(iii) an inability to maintain housing due to mental illness;
(iv) an inability to maintain competitive employment or education process due to mental illness;
(v) an inability to sustain interpersonal relationships due to mental illness;
(iii) (vi) the person has been determined to be disabled due to mental illness by the social security administration;
(iv) (vii) the person maintains a living arrangement only with ongoing supervision, is homeless, or is at imminent risk of homelessness due to mental illness; or
(v) (viii) the person has had or will predictably have repeated episodes of decompensation.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, MCA
37.88.101 MEDICAID MENTAL HEALTH SERVICES FOR ADULTS, AUTHORIZATION REQUIREMENTS (1) Mental health services for a Medicaid adult under the Montana Medicaid program will be reimbursed only if the client is 18 or more years of age and has been determined to have a severe disabling mental illness as defined in ARM
(2) For mental health services provided to an adult Medicaid client under the Montana Medicaid program, a maximum of 24 sessions may be reimbursed per state fiscal year for individual and family outpatient therapy billed under 2015 Current Procedure Terminology
4th Edition (CPT4) codes 90804, 90806, 90846, and 90847 90832, 90833, 90834, 90836, 90837, 90838, 90846, and 90847 only. Prior authorization must be obtained for additional sessions.
(3) Adult intensive outpatient therapy services may be medically necessary for a person with safety and security needs who has demonstrated the ability and likelihood of benefit from continued outpatient therapy. The person must meet the requirements of (3)(a) or (b). The person must also meet the requirements of (3)(c). The person has:
(a) a DSM
-IV diagnosis with a severity specifier of moderate or severe of mood disorder (293.31, 293.33, 293.34, 293.83, 295.70, 296.7, 296.22, 296.23, 296.24, 296.32, 296.33, 296.34, 296.42, 296.43, 296.44, 296.80, 296.89) bipolar spectrum or depressive disorder; or
(b) a DSM
-IV diagnosis borderline personality disorder (301.83), personality disorder NOS (301.9) with prominent features of 301.83; and
(c) through (4) remain the same.
(5) The prior authorization requirement
shall will not be waived except as provided in this rule.
(6) remains the same.
(7) Review of authorization requests by the department or its designee will be made with consideration of the adult intensive outpatient therapy services
c Clinical m Management g Guidelines (2006) (2015). A copy of the a Adult iIntensive oOutpatient tTherapy sServices cClinical mManagement gGuidelines (2006) (2015) can be obtained from the following web site: https://montana.fhsc.com/ or department by a request in writing to the Department of Public Health and Human Services, Addictive and Mental Disorders Division, Mental Health Services Bureau, 555 Fuller, P.O. Box 202905, Helena, MT 59620-2905.
(8) and (9) remain the same.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
37.89.103 MENTAL HEALTH SERVICES PLAN, DEFINITIONS As used in this subchapter, unless expressly provided otherwise, the following definitions apply:
(1) and (2) remain the same.
(3) "Correctional or detention facility" means:
(a) the Montana State Prison, including any correctional facility located on the Warm Springs
correctional facilities campus;
(b) through (e) remain the same.
(4) "Covered diagnosis" means a diagnosis for which the Mental Health Services Plan provides covered services to members who have a severe disabling mental illness, as specified in ARM
(5) through (15) remain the same.
(16) "Severe disabling mental illness" is defined in ARM
(17) remains the same.
(18) The department adopts and incorporates by reference the
ICD-9-CM ICD-10-CM diagnosis codes with meanings found in the Ingenix ICD-9-CM ICD-10-CM Code Book (2006) published by Ingenix (2015) published by the American Medical Association. A copy of the code book may be obtained at: http://www.ama-assn.org/ama. The department also adopts and incorporates by reference the DSM -IV diagnosis codes with meanings found in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Fifth Edition Text Revision (2000) (2013), published by the American Psychiatric Association of Washington, D.C. A copy of the DSM may be obtained at: http://www.medicalcodingbooks.com/. These systems of coding provide the codes and meanings of the diagnostic terms commonly used by treating professionals and are incorporated in order to provide common references for purposes of the provision of services through the Mental Health Services Plan. Copies of applicable portions of the ICD-9-CM and the DSM-IV may be obtained from the Department of Public Health and Human Services, Addictive and Mental Disorders Division, Mental Health Services Bureau, 555 Fuller, P.O. Box 202905, Helena, MT 59620-2905.
AUTH: 41-3-1103, 52-1-103, 53-2-201, 53-6-113, 53-6-131, 53-6-701, 53-21-703, MCA
IMP: 41-3-1103, 52-1-103, 53-1-601, 53-1-602, 53-1-603, 53-2-201, 53-6-101, 53-6-113, 53-6-116, 53-6-117, 53-6-131, 53-6-701, 53-6-705, 53-21-139, 53-21-201, 53-21-202, 53-21-701, 53-21-702, MCA
37.89.114 MENTAL HEALTH SERVICES PLAN, COVERED SERVICES
(1) through (3) remain the same.
(4) The plan covers the medically necessary psychotropic medications listed in the department's mental health services plan drug formulary if medically necessary with respect to a covered diagnosis. The department may revise the formulary from time to time. A copy of the current formulary may be obtained from the Department of Public Health and Human Services, Addictive and Mental Disorders Division,
555 Fuller, P.O. Box 202905, Helena, MT 59620-2905.
(5) through (9) remain the same.
AUTH: 41-3-1103, 52-1-103, 52-2-603, 53-2-201, 53-6-113, 53-6-131, 53-6-706, 53-21-703, MCA
IMP: 41-3-1103, 52-1-103, 52-2-603, 53-1-405, 53-1-601, 53-1-602, 53-1-603, 53-2-201, 53-6-101, 53-6-113, 53-6-116, 53-6-701, 53-6-705, 53-6-706, 53-21-139, 53-21-202, 53-21-701, 53-21-702, MCA
37.89.509 72-HOUR PRESUMPTIVE ELIGIBILITY FOR ADULT CRISIS STABILIZATION SERVICES: CLAIMS AND REIMBURSEMENT (1) through (7) remain the same.
(8) If reimbursement is denied because services were delivered to an individual within seven days following discharge from crisis stabilization services delivered by another provider, the provider may request a review to determine whether payment is warranted. A written request for review must be received by the Department of Public Health and Human Services, Addictive and Mental Disorders Division,
555 Fuller, P.O. Box 202905, Helena, MT 59620-2905 within 30 days after the date of a notice denying a claim. The department will conduct an informal administrative review and may grant full or partial reimbursement for services if it determines that:
(a) complications have arisen because of premature discharge, treatment errors, or omissions in the previous crisis stabilization plan;
(b) the crisis stabilization services are for a condition that could not have been treated during the previous crisis stabilization plan; or
(c) the provider could not have discovered the previous stabilization plan using due diligence.
AUTH: 53-6-101, 53-6-113, MCA
IMP: 53-6-101, MCA
4. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services, Mental Health Services Bureau (the department) proposes to amend ARM 37.86.3503, 37.88.101, 37.89.103, 37.89.114, and 37.89.509. These rules specify the program and member eligibility requirements for adult Medicaid mental health services and they define the basis and procedure the department will use to reimburse these services. The proposed amendments implement the new ICD-10 requirements mandated by the Centers for Medicare and Medicaid (CMS) and to make general housekeeping edits.
The proposed amendments incorporate a new definition of severe disabling mental illness (SDMI) that uses the new ICD-10-CM diagnoses. The new definition necessitates the removal of the old ICD-9 diagnosis codes and replacement of those diagnosis codes with the general conditions of the diagnosis codes. The department proposes to eliminate medical and physical conditions such as amnestic disorder, disorders due to medical conditions, and pervasive developmental disorder because such conditions are not considered to be a severe disabling mental illness. The department proposes to take the mood disorder diagnosis codes and replace them with depressive disorders; broaden the schizophrenia, schizophrenia spectrum, and other psychotic disorders to include some of the psychotic and mood disorders; and the bipolar spectrum disorder including mood disorder. The department proposes to add, specifically, borderline personality disorder and autism spectrum disorders.
The proposed amendments are:
(1) The proposed amendments clarify that a person with severe disabling mental illness only needs to have one of the conditions identified in (1)(a), (b), or (c). Section (1) was deleted from the definition and (1)(d) was added.
(1)(c) The DSM-IV-TR was updated to DSM. The exclusion to the diagnosis codes was added for mild, not otherwise specified or due to physiological disturbances and physical factors.
(1)(c)(i) The ICD-9-CM codes are no longer valid and are replaced with general conditions of schizophrenia, schizophrenia spectrum, and other psychotic disorders.
(1)(c)(ii) The ICD-9-CM codes are no longer valid and are replaced with the general conditions of the bipolar spectrum.
(1)(c)(iii) The invalid ICD-9-CM codes were deleted for mood disorder and replaced with general conditions of depressive disorder.
(1)(c)(iv) Amnestic disorder is deleted entirely because this is a physical condition and is not considered a severe disabling mental illness condition.
(1)(c)(v) The disorder due to a general medical condition is deleted because it is a medical condition and is not considered a severe disabling mental illness.
(1)(c)(vi) The diagnosis was deleted because it is not considered a severe disabling mental illness condition.
(1)(c)(iv) Formerly (1)(c)(viii), the invalid ICD-9-CM codes are deleted. The general condition of anxiety disorders remains.
(1)(c)(v) Formerly (1)(c)(viii), the invalid ICD-9-CM codes are deleted. The general conditions of posttraumatic stress disorders remain.
(1)(c)(vi) Borderline personality disorder was added as a qualifying diagnosis. This had been incorporated in the personality disorder ICD-9-CM codes. People with this particular diagnosis have been shown to be high utilizers of expensive services such as emergency room and inpatient services. They also have a higher incidence of suicidal ideation. The department believes that people with this qualifying diagnosis need to have services available for their own safety.
(1)(c)(vii) Autism spectrum disorders were added to the qualifying diagnosis for severe disabling mental illness. Many providers have given the department examples of how the debilitating effects of autism spectrum disorders on adults impact their ability to function in activities expected from adults.
(1)(d) The new (1)(d) is an amendment of the current (1)(e). The amendments reflect an alignment of the "functioning areas" to those of other states. The department added four functioning areas and increased the eligibility requirement from meeting two out of five to three out of eight functional area difficulties. The department believes that (1)(d), as proposed, will provide a more objective evaluation of the difficulties an affected person may have in functioning in daily life.
(1) The proposed amendment corrects an error in the identification of the appropriate rule.
(2) The added statement, "without prior authorization" clarifies that only 24 therapy sessions will be reimbursed per state fiscal year unless prior authorization is obtained. The date of 2015 was added to the Standard Current Procedure Terminology and the "4th edition (CPT4)" was deleted. The outdated 90804, 90806, 90846, and 90847 codes were deleted and replaced with 2013 CPT codes, which are 90832, 90833, 90936, 90837, 90838, 90846, and 90847.
(3)(a) The invalid DSM IV codes were deleted and replaced with "bipolar spectrum or depressive disorder" and a clarifying "or."
(3)(b) The invalid DSM IV codes were deleted.
(7) The date for Clinical Management Guidelines was updated to 2015. The method for obtaining the guidelines was updated with current information.
(4) The incorrect citation to ARM 37.86.3501 was corrected.
(16) The incorrect citation to ARM 37.86.3501 was corrected.
(18) Coding references were updated. The DSM Fifth Edition has the ICD-10-CM codes that are valid effective October 1, 2015. The department no longer furnishes coding reference documents. Persons needing to use these coding references must obtain a copy elsewhere.
(4) The street address for the Addictive and Mental Disorders Division is no longer valid and is being deleted.
(8) The street address for the Addictive and Mental Disorders Division is no longer valid and is being deleted.
The department believes there is some risk that the ICD-10-CM and new diagnoses could increase the number of individuals determined to have a severe disabling mental illness and increase the expenditures. It is unknown if providers will adjust diagnosis coding and claims submission that could result in a fiscal impact. At this time the fiscal impact is not expected to be substantial.
5. The department intends to apply these rule amendments retroactively to October 1, 2015. A retroactive application of the proposed rule amendments does not result in a negative impact to any affected party.
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: 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 email@example.com, and must be received no later than 5:00 p.m., October 22, 2015.
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.
11. 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.
12. 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 amendments presented in this notice implement federal law and otherwise reflect no substantive changes and thus are exempt from the performance-based measures requirement of 53-6-196, MCA.
/s/ Susan Callaghan /s/ Richard H. Opper
Susan Callaghan, Attorney Richard H. Opper, Director
Rule Reviewer Public Health and Human Services
Certified to the Secretary of State September 14, 2015.