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| Montana Administrative Register Notice 37-407 | No. 16 08/23/2007 | |
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Page No.: 1197 -- 1216 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Interested Persons
1. On May 24, 2007, the Department of Public Health and Human Services published MAR Notice No. 37-407 pertaining to the public hearing on the proposed amendment of the above-stated rules, at page 660 of the 2007 Montana Administrative Register, issue number 10.
2. The department has amended ARM 37.86.3705, 37.88.901, 37.88.1116, and 37.89.103 as proposed.
3. The department has amended the following rules as proposed with the following changes from the original proposal. Matter to be added is underlined. Matter to be deleted is interlined.
37.86.3701 CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, DEFINITIONS (1) through (3)(g) remain as proposed. (4) "Crisis plan" means an individualized plan for the client that identifies potential problems that, if left unaddressed, may lead to the client experiencing a mental health crisis.
(5) "Crisis response" means the immediate action taken by an individual trained to respond to mental health emergencies when a person presents as a danger to self or others. A case manager must take immediate action to contact an appropriately trained individual or emergency service responder if they believe a client presents a danger to self or others. Crisis response must be made in a manner consistent with the least restrictive alternative measures or settings available for the client's condition. Crisis response may include contact with a client's family members if necessary and appropriate. (6) through (8) remain as proposed.
IMP: 53-6-101, MCA
37.86.3702 CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, ELIGIBILITY (1) remains as proposed. (2) "Serious emotional disturbance (SED)" means with respect to a youth (a) The youth has been determined by a licensed mental health professional as having a mental disorder with a primary diagnosis falling within one of the following DSM-IV (or successor) classifications when applied to the youth's current presentation (current means within the past 12 calendar months unless otherwise specified in the DSM-IV) and the diagnosis has a severity specifier of moderate or severe: (i) through (xvii) remain as proposed. (xviii) bulimia nervosa (severe) (307.51); (xix) intermittent explosive disorder (312.34) (xx) attention deficit/hyperactivity disorder (314.00, 314.01, 314.9) when accompanied by at least one of the diagnoses listed above. (b) through (c)(vi) remain as proposed. (3) A youth must be reassessed annually by a licensed mental health professional, as to whether or not they continue to meet the criteria for having a serious emotional disturbance. For the initial or for an annual reassessment, the clinical assessment must document how the youth meets the criteria for having a serious emotional disturbance.
IMP: 53-6-101, MCA
37.88.101 MEDICAID MENTAL HEALTH SERVICES, AUTHORIZATION REQUIREMENTS (1) Mental health services for a Medicaid (a) the client has been determined to have a serious emotional disturbance as defined in ARM 37.86.3702, with the following exceptions identified in (1)(b);
(b) a youth is required to have a mental health diagnosis designated by the department, and not required to have a serious emotional disturbance to receive the following services: (i) group outpatient therapy; and (ii) the first 24 sessions per state fiscal year of individual and family outpatient therapy.
(2) through (11) remain as proposed.
IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
4. After receiving public comment, the department has amended the following rule (see comment and response #3). Matter to be added is underlined. Matter to be deleted is interlined.
37.86.3706 CASE MANAGEMENT SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE, SERVICE REQUIREMENTS (1) through (2)(h) remain the same. (3) The case plan must include a crisis plan that must minimally: (a) help the client and family identify what to do when a mental health crisis occurs; (b) identify specific resources for the client and family prior to a mental health crisis; (c) inform the client and family of the case manager's sub crisis role in responding to a crisis; (d) identify treatment team member's roles in responding to a crisis; (e) include the mental health center's crisis telephone service; and (f) assist the client and family in developing the necessary skills to manage some of their own crises. (3) and (4) remain the same but are renumbered (4) and (5).
AUTH: 53-6-113, MCA IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA
5. The department has thoroughly considered all commentary received. The comments received and the department's response to each follow:
COMMENT #1: Opposition was expressed to the proposed change and for not allowing targeted case management (TCM) to provide youth assistance in daily living. It has been the commentor's experience that many youth with a serious emotional disturbance (SED) also have developmental delays that impair their ability to learn many skills, including basic skills in daily living. Learning these skills is also important for SED youth transitioning to adult life. Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT) requires that states provide rehabilitative services. Rehabilitative services include training in basic living skills, social skills, counseling, and therapy.
The Center for Medicaid and Medicare Services (CMS) does not prohibit this service, nor does it limit case management services to the four core services listed in the proposal. Given Montana's very limited resources in rural areas, utilizing case managers to provide these rehabilitative services seems both cost effective and essential.
If the Children's Mental Health Bureau (CMHB) creates and funds an equally effective, lower cost position for teaching daily living skills to youth with SED and make it as widely available as case management, commentor would support this function being deleted from case management.
RESPONSE: Community based psychiatric rehabilitation and support (CBPRS) services are available to Medicaid SED youth, and is defined in ARM 37.88.901(5). CBPRS services include but are not limited to "(ii) assisting the consumer to develop communication skills, develop self-management of psychiatric symptoms, and develop social networks necessary to minimize social isolation and increase opportunities for a socially integrated life; (iii) assisting the consumer to develop daily living skills and behaviors necessary for maintenance of a home and family, an appropriate education, employment or vocational situation, and productive leisure and social activities."
Per ARM 37.106.1906 Mental Health Center Licensure, community based psychiatric rehabilitation and support services are one of five core services a mental health center must provide to be licensed.
The department disagrees with your interpretation of case management. The Social Security Act 1915(g) defines "case management services" as services which will assist individuals eligible under the plan in gaining access to needed medical, social, educational, and other services.
COMMENT #2: Several commentors from one agency recommended deleting "strength based" in case planning. It is already required in ARM 37.86.3706. Strength based is subjective and inconsistent with established medical necessity guidelines and incongruent with mental health center licensing rules. Prior authorization (PA) and utilization review (UR) is based on problems, symptoms, and difficulties.
RESPONSE: The department agrees that identifying the youth and families strengths and potentials is already required in ARM 37.86.3706 for the case management plan. The department wishes to emphasize the importance of focusing on the youth and family's strengths to assist them in making progress with their problems. Prior authorization and utilization review is based on the youth and family's problems, symptoms, and difficulties. Utilizing the youth and family's strengths to address and overcome their problems is a clinical tool. Strength based case management plans reframe the youth and family's problems to address or take steps to eliminate or build competencies based on the individual's skills or periods of stability. The mental health center licensing administrative rules for treatment plans do not include identifying the youth and family's strengths and potentials; however, the rules are not seen as being incongruent. Training on the development of strength based case management plans and review of the mental health center licensing rules may be beneficial.
COMMENT #3: One commentor recommended moving the crisis plan requirement from ARM 37.86.3701 to 37.86.3706.
RESPONSE: The department agrees and will move the crisis plan requirements found in ARM 37.86.3701(4)(a) through (f) to 37.86.3706. ARM 37.86.3706(3) will be renumbered to (4). The new (3) will state:
(3) The case plan must include a crisis plan that must minimally: (a) help the client and family identify what to do when a mental health crisis occurs; (b) identify specific resources for the client and family prior to a mental health crisis; (c) inform the client and family of the case manager's sub crisis role in responding to a crisis; (d) identify treatment team member's roles in responding to a crisis; (e) include the mental health center's crisis telephone service; and (f) assist the client and family in developing the necessary skills to manage some of their own crises.
COMMENT #4: The clarification of the requirement for crisis planning, sub crisis response, monitoring, follow-up, and timely action is appropriate; however, it may be irrelevant if crisis services are not available.
RESPONSE: TCMs respond to a youth and family's urgent problems that if left unaddressed could become a crisis. TCMs assist SED youth and families implement their crisis plan as needed.
COMMENT #5: The terms "sub crisis" and "timely action" should be deleted, they are subjective and unmeasureable. Many of the problems faced by our clients and their families are "urgent problems" that if left unaddressed could lead to the client experiencing a mental health crisis.
Case managers are on the front line in Montana managing crisis events with SED youth. They also thought the terms "appropriately trained individual" and "emergency responder" were unclear. This change will severely limit the ability of case managers to stabilize crisis situations.
RESPONSE: Requirements for an appropriately trained individual are defined in the mental health center (ARM 37.106.1945) Crisis Telephone Services rule. Mental health center emergency procedure requirements are found in ARM 37.106.1927, that address contacting emergency service responders. The language in the rule will be changed to emergency service responders instead of emergency responders. See responses #8, 9, and 15 regarding "sub crisis" and "timely action".
COMMENT #6: Please define a mental health emergency as defined in ARM 37.86.3701(5). What constitutes a mental health crisis in the context of working with youth and families?
RESPONSE: Mental health emergency is defined in ARM 37.89.103 under the Mental Health Services Plan section of the rule as a serious medical or behavioral condition resulting from mental illness which arises unexpectedly and manifests symptoms of sufficient severity to require immediate care to avoid jeopardy to the life or health of the member or harm to another person by the member.
COMMENT #7: Crises response service seems to be designed with the notion that Montana has a crisis service system that can be activated by a case manager. Given we do not have a crises system or any clearly identified funding, rules, or support for this type of system invoked by the rule, how should case managers really respond to crisis situations?
RESPONSE: Mental Health Center Licensure administrative rules require that the center have a plan for emergency procedures (ARM 37.106.1927) and that they provide crisis telephone services to their clients in ARM 37.106.1945.
COMMENT #8: Does a "sub-crises" response include transporting clients if necessary to avert a mental health crisis? If it does not, what actions are case managers expected to take in a "sub-crises" situation?
RESPONSE: TCM may transport a client to avert a mental health crisis. However, the travel time is not reimbursable by Medicaid Mental Health Services. In a sub crisis or urgent situation, the TCM may request prior authorization from Medicaid Transportation Services and if authorized receive reimbursement for mileage. For emergency transportation, authorization is requested after the transportation has been provided within the time frame allotted by Medicaid Transportation.
Sub crisis means urgent. TCMs respond to sub crisis situations and problem-solve the youth or family's presenting urgent problem or assist them to implement the crisis plan.
COMMENT #9: What is the definition of timely action? Does this suggest some level of responsibility to provide direct services in some circumstances? If so, the rule needs to articulate how and when this responsibility should be met.
RESPONSE: There are times when a TCM will need to assist the family in accessing needed services quickly, within a day or two. The wording does not intend to suggest that the TCM has a responsibility to provide direct services, it means the coordination and referral to needed services must be timely, based on the needs of the youth and family.
COMMENT #10: The current definition of SED found in ARM 37.86.3702(2) includes attention deficit hyperactivity disorder (ADHD) if accompanied by one of the other diagnoses in (2)(a)(i) through (xix). Commentor would like the department's response to address that the removal of ADHD does not mean it should go untreated when the condition occurs concurrently with one of more of the conditions in (2)(a)(i) through (xix) of the SED definition.
RESPONSE: The department agrees, and for the reasons stated above will leave ADHD in the rule.
COMMENT #11: One commentor opposed removing ADHD from the list of qualifying SED diagnoses. The rationale for dropping ADHD was because it was redundant. Commentor does not believe as the rule currently exists, that ADHD needs to be moderate or severe and that ADHD can be the primary diagnosis when accompanied by one of the qualifying diagnoses.
RESPONSE: The department disagrees with part of the comment. Current administrative rule requires all the diagnoses in the SED definition found at ARM 37.86.3702(2)(a) to have a severity specifier of moderate or severe, even ADHD. However, ADHD may be the primary diagnoses if accompanied by at least one of the other qualifying SED diagnoses.
COMMENT #12: What is the state policy with regards to treating children suffering from ADHD or attention deficit disorder (ADD)?
RESPONSE: Attention deficit/hyperactivity disorder with a severity specifier of moderate or severe when accompanied by at least one of the diagnoses listed in ARM 37.86.3702(2)(a) is a covered SED diagnosis. Attention deficit disorder is not.
COMMENT #13: The rationale in the proposed rule notice was incorrect for removing the other agency service needs in the SED definition. Currently the SED definition requires the youth to meet (2)(a) and either (2)(b) or (2)(c). In the proposed rule notice it would appear to interpret the current language of ARM 37.86.3702 to require that the student meet (2)(a), (2)(b), and (2)(c).
The proposed change would affect the definition of SED by removing (2)(c) as an option for meeting the criteria for eligibility in circumstances where the student does not meet the criteria in (2)(b). This change could have a significant impact on the number of children eligible for services. We would ask that the department reconsider the removal of (2)(c). If the department chooses to eliminate (2)(c) as proposed, then we would strongly encourage the department to add the following language to (2)(b): "(vii) has been determined eligible for special education as a student having emotional disturbance under 10.16.3015, MCA." (sic)
RESPONSE: The department agrees that the language in the proposed rule notice rationale could have been stated more clearly. Currently the SED definition requires the youth to meet (2)(a) and either (2)(b) or (2)(c). The department is proposing to eliminate (2)(c) and not make the youth wait to receive needed mental health services until they need the special services of another state agency. The department believes youth meeting the criteria for an emotional disturbance for special education in ARM (not MCA) 10.16.3015 may meet the functional impairment requirement in the SED definition without adding the proposed language. For youth that meet the criteria for having an emotional disturbance for special education and not the functional impairment for SED, some outpatient therapy services are available for non-SED youth.
COMMENT #14: One commentor was concerned with the omission of children ages three to five that were previously served.
RESPONSE: Children under six are still in the new SED definition in ARM 37.86.3702(2)(c) through (c)(vi). Children under six were previously addressed in (2)(d) through (d)(vi). (2)(d) through (d)(vi) were renumbered (2)(c) through (c)(vi).
COMMENT #15: A crisis plan in the case management plan is appropriate; however, there needs to be further clarification between "crisis" and "sub-crisis" response. A functional description should be added. Timely action should include the number of days for crisis, sub crisis and regular referrals as well as "appropriately trained individual" and "crisis responder". Consideration should be given to deleting "sub-crisis response" due to its subjectivity.
RESPONSE: The department disagrees with deleting sub crisis response. Sub crisis response means responding to urgent problems and crisis response means responding to a client who presents a danger to self or others. The department does not believe a functional definition is necessary. Please refer to response #5 for the definition of an "appropriately trained individual" and "emergency responder".
COMMENT #16: Please clarify ARM 37.86.3705, as it is confusing because the definition of crisis response suggests that case managers don't do crisis response but refer clients to those who do.
RESPONSE: Per the definition of "crisis response" in ARM 37.86.3701(5) a case manager must take immediate action to contact an appropriately trained individual or emergency service responder if they believe a client presents a danger to self or others.
COMMENT #17: The language is confusing regarding outpatient therapy for non-SED youth except CSCT and prior authorized services. Perhaps there is a way to rewrite this section by stating in a separate section the services that are available for youth who have not yet been identified as SED.
RESPONSE: The department agrees and has revised the language for clarity to read:
"(1) Mental health services for a Medicaid youth under the Montana Medicaid program will be reimbursed only if the following requirements are met: (a) the client has been determined to have a serious emotional disturbance as defined in ARM 37.86.3702, with exceptions identified in (1)(b); (b) a youth is required to have a mental health diagnosis designated by the department, and not required to have a serious emotional disturbance to receive the following services: (i) group outpatient therapy; and (ii) the first 24 sessions per state fiscal year of individual and family outpatient therapy. (c) the department has determined prior to treatment on a case by case basis that treatment is medically necessary for early intervention and prevention of a more serious emotional disturbance. . ."
COMMENT #18: How will the department determine if a youth has a serious emotional disturbance.
RESPONSE: Providers will continue to be required to determine whether or not a youth has a serious emotional disturbance. The proposed language will be changed to "verified" and ARM 37.88.101(1)(b) renumbered to (1)(d) and read: "(d) for prior authorized services, the serious emotional disturbance has been verified by the department or it's designee."
COMMENT #19: Several commentors do not support allowing non-SED Medicaid youth to access outpatient therapy. They agree it is a positive benefit but is it at the expense of other services like case management? What is the projected cost for reestablishing this benefit? This service was cut in 2002 due to budget constraints. Why add a costly Medicaid service when financial concerns seem to be driving the proposal to prior authorize case management services.
Is the change to serve non-SED youth a result of the department abdicating its responsibility to monitor providers of outpatient therapy services to ensure youth are SED?
What is the evidence that this benefit alone will affect utilization rates of case management? If early intervention is the intended outcome of the change, the proposed change should support a concurrent benefit of case management as an effective strategy for treatment and management of milder mental health diagnoses.
RESPONSE: Allowing Medicaid reimbursement for outpatient therapy for non-SED youth is a preventive approach to intervene early so problems or conditions with youth do not become more serious.
It is not the intent of the department to abdicate their responsibility to monitor providers to ensure the youth they serve are SED.
It is not the department's intent to affect case management utilization rates by allowing outpatient therapy to non-SED youth.
COMMENT #20: One commentor supported the rule change allowing some outpatient therapy services to be provided to non-SED youth. This effort is consistent with Early Periodic Screening, Diagnosis, and Treatment (EPSDT) requirements that Medicaid eligible children have access to all medically necessary services regardless of diagnosis or disability. The earlier we can provide appropriate community supports and services to children at risk, the more likely we can resolve issues before they become crises or long term problems.
While several commentors opposed providing outpatient therapy service to non-SED youth at this time due to the proposal that TCM services be prior authorized, they did acknowledge the benefit of early intervention for youth with mental health issues.
RESPONSE: Thank you for your support. The department agrees that early intervention through outpatient therapy to non-SED youth can mitigate problems from becoming more severe.
COMMENT #21: The amended rule to allow individual, group, or family therapy without an initial diagnosis of SED will allow for earlier intervention and treatment. The lowering of the criteria for SED youth to qualify for CM services certainly enables providers to serve youth in a preventative manner but it must be recognized that both of these changes will result in higher numbers of youth served and potentially more cost to the system.
RESPONSE: The rule change allows a non-SED youth to receive group outpatient therapy services without limit. The rule change allows a non-SED youth to receive individual and family outpatient therapy up to 24 sessions per SFY. The youth needs to be SED to receive individual and family outpatient therapy services beyond 24 sessions in a SFY. The rule change does NOT allow non-SED youth to receive TCM services prior to the 60 unit TCM authorization requirement.
COMMENT #22: Several commentors disagree with the proposed change to prior authorize case management. What are the costs associated with implementing a prior authorization and UR system for case management? This managed care approach had abysmal results, 1997-2000, creating artificial barriers in accessing needed levels of care, disruption in continuity of care, expensive managed care decisions, higher out-of-home placements, diversion of youth into parallel systems and hospital emergency rooms, less investment in developing community based alternatives. Several commentors who oppose prior authorization believe TCM services are a central and necessary component for a system of care.
RESPONSE: The cost of prior authorization has been factored into the cost savings in the proposed rule notice. TCM services will be available for SED youth who meet the medical necessity criteria established. TCM services may play a central role in a system of care. One of the key components in developing a system of care is supporting and empowering parents. Some parents are capable of accessing needed services for their SED youth.
COMMENT #23: Are TCM services limited to 60 units per year? It is inconceivable to understand how the proposed 60 unit annual benefit can achieve the goals of resiliency and recovery in so short a period of time. To propose such a limited benefit is to misunderstand the amount of time needed to stabilize crises and to develop therapeutic relationships with SED youth and families.
RESPONSE: It appears the commentor does not understand the proposed rule change. TCM services need to be authorized at 60 units before more can be provided. Sixty units is not an annual benefit.
COMMENT #24: Use existing retrospective review processes rather than prior authorization for TCM services. It will be more cost efficient.
RESPONSE: Prior authorization is being proposed to manage the appropriate use of TCM services. Retrospective reviews would be conducted after a youth and family receive TCM services. If the department used retrospective reviews to manage the appropriate use of TCM services and found inappropriate services had been provided, the department would need to take back money from the providers. The department disagrees that retrospective reviews are less expensive. However, the department has the authority to conduct retrospective reviews of Medicaid paid services at any time.
COMMENT #25: Per the department's rationale, prior authorization and UR would provide "an effective way to assure the efficient use of funds". The commentor questions if these methods are effective for residential treatment center (RTC) and therapeutic group home (TGH) services given that closer monitoring of TGH and RTC services through prior authorization and utilization review has not resulted in a decrease in utilization. This would contradict the notion that this process would demonstrate cost effectiveness for TCM services.
RESPONSE: If prior authorization of TCM services does not prove to be an effective management tool, the department will not continue to use it.
COMMENT #26: The state of Montana demonstrated an ability to develop a well funded continuum of care for SED youth in the community between 1994-1997. The aggressive application of this philosophy developed an effective community based system of care that resulted in a dramatic reduction in the utilization of higher levels of care. CMHB needs to incentivize local communities to develop community based systems of care for SED youth.
RESPONSE: The department does provide incentives for the development of local systems of care with the SAMHSA Children's Mental Health Initiative or System of Care grant, with the development of local Kid's Management Authorities; and with the Community-Based Alternative to Psychiatric Residential Treatment Facilities Project from the Deficit Reduction Act Grant of 2005. The Medicaid Mental Health program also provides an array of community based mental health services for youth and families.
COMMENT #27: Prior authorization and UR will disrupt the "first line of defense" for SED youth and their families and defeat the design of targeted youth case management which is to empower parents to learn to become advocates for themselves and their youth. Proposing to manage the utilization of the "first line of defense" in order to decrease its availability seems antithetical to system of care principles and should not be implemented. (TCM as the "first line of defense" was referenced from the Children's Mental Health Bureau (CMHB) 2007 Block Grant application.)
RESPONSE: The "first line of defense" is not prior authorized until 60 units. TCM services will be available to SED youth who meet the established medical necessity criteria. The prior authorization process will be designed to minimize disruption regarding the SED youth's continuation of case management services. The department believes TCM services can be an effective service for SED youth and their families, particularly those with multi-agency needs. The department also believes that parents provided with some support and knowledge of the system are capable of accessing services for their SED youth.
COMMENT #28: The department should develop a standardized form for all providers to document SED eligibility to include diagnoses, functional impairment, and justification, which would make retrospective reviews easier and ensure providers are aware of eligibility criteria.
Piggybacking SED eligibility and prior authorization together will create redundancies in that multiple providers will be required to provide SED eligibility information with their PA request. This will increase costs for the department and mental health centers.
RESPONSE: The department is not proposing a standardized SED eligibility form for providers at this time and believes the SED definition found in ARM 37.86.3702(2) is quite clear. Rather than proposing a standardized SED eligibility form the department will clarify the process in ARM 37.86.3702 and add the following language: "(3) Youth must be reassessed annually by a licensed mental health professional, as to whether or not they continue to meet the criteria for having a serious emotional disturbance. For the initial or for an annual reassessment, the clinical assessment must document how the youth meets the criteria for having a serious emotional disturbance." Mental health centers are required in Licensure Rule to complete a clinical intake assessment, ARM 37.106.1915.
The department is developing a standardized tool for prior authorization. This form will request information from the provider that documents how the youth meets the SED definition and medical necessity criteria for TCM services.
The department understands the concerns regarding SED verification for all prior authorized services and will develop a process for implementing the SED verification on prior authorization forms. The department will inform and educate the service providers of the new requirements before implementing the SED verification.
COMMENT #29: Requiring prior authorization beyond 60 units is not reasonable. The commentor recommended unlimited case management services for the first 90 days of care or 30 hours, whichever comes first. Please see the response to comment #25.
RESPONSE: The average TCM client received 125 units of service in SFY 2006. In essence, the commentor's proposal would keep the service as it is. The department does not agree with this for reasons stated above.
COMMENT #30: If case managers are required to submit continued stay requests will this function be a billable event?
RESPONSE: No.
COMMENT #31: The department should begin to pursue the possibility of performance based contracts to ensure quality results and limit cost.
RESPONSE: The department agrees and would appreciate the commentor's assistance in moving to outcome based TCM services.
COMMENT #32: In response to the department's rationale for prior authorizing TCM services, several commentors from one agency said that given only 36% of Medicaid eligible individuals under 18 years of age identified as having a serious emotional disturbance are receiving case management services, it would appear that those youth with the greatest need are in fact the ones accessing the service. The department's rationale was that "over the past several years, the costs related to TCM for SED youth have increased at a rate greater than the corresponding increase in the total number of SED youth served." What specifically are those rates? In SFY 2002, 4,035 Medicaid youth received case management services and in SFY 2006, approximately 3,456; a decrease of 421 youth. In 2002 there were 56,500 children under the age of 19 enrolled in Medicaid. Between 2000 and 2004 the number of Medicaid eligible youth in Montana grew by 9,494. One could assume a similar rate of increase between 2004 and 2007. This would indicate far fewer SED youth are receiving case management services and those children and families getting TCM services are presenting with a myriad of more complex, pervasive challenges given that costs related to TCM services have increased. To propose a decrease or limit the amount of TCM services a youth and family receive ignores the reality of these client's situations and implies youth and families are receiving more TCM services than they require. From the SFY 2005 Montana Consumer Satisfaction Project it would appear families would prefer more case management contact, not less.
RESPONSE: The following data is from Medicaid paid claims and indicates:
Targeted Case Management (TCM) Services:
* As of June, 31, 2007, with 365 days to bill Medicaid. **Date of Payment
* As of June 31, 2007, with 365 days to bill Medicaid. **Date of Payment
COMMENT #33: Several commentors disagreed with the implication that ineffective case management services are responsible for the increase in out-of-home and residential psychiatric care and the department's rationale that if TCM services were being used effectively, it could be expected that the number of youth in out-of-home and residential psychiatric care would be decreasing. One commentor points out other reasons for an increase in residential psychiatric care that includes clients being more disturbed and the limited room and board payment available for community based therapeutic living services. Another asks if there is research to support the department's rationale.
RESPONSE: The department's rationale is based on Medicaid paid claim reports, our knowledge of service requirements, and working with local treatment teams and providers. TCM service requirements include serving the client in the least restrictive and most culturally appropriate therapeutic environment possible for the client. The department acknowledges as valid some of the commentor's additional reasons for increases in residential psychiatric care.
COMMENT #34: At the same time the department is proposing to limit the number of TCM hours to SED youth and families, the department is increasing the paperwork requirements by adding a "crisis plan" requirement in rule, and a "transition plan" in the TCM contract, along with the prior authorization paperwork. This means less time to provide TCM services. Will there be any cost savings by adding additional paperwork for prior authorization, at both the State and Mental Health Center level?
RESPONSE: The department is proposing to prior authorize TCM units beyond 60 in a state fiscal year. The intent is to "manage" and not simply "limit" TCM services. Some SED youth and their families will easily meet the medical necessity criteria for continued services.
Both the crisis and transition plan are new required components of the TCM plan. One is covered in the rule and one is covered in the TCM contract. In working with SED youth and their families, urgent or crisis situations should be anticipated and planned for, as a result of the TCMs role in coordination, referral, and crisis response. In providing TCM services to older adolescents, the TCM should anticipate their transitional needs if the TCM services are individualized and based on the adolescent's needs. The department is taking this opportunity to clarify with the new crisis plan requirement in the case management plan what is meant by coordination, referral, sub crisis, and crisis response.
COMMENT #35: It currently takes a week or longer for prior authorization determinations to be made. With adding the SED eligibility determination, I am concerned the time frame will be longer and will leave providers in the position of continuing services that may not be reimbursed. With managed care in the 1990s, we learned the authorization of case management resulted in disrupted care, barriers to accessing medically necessary services, and harm to clients.
RESPONSE: The department will follow up with the utilization review contractor regarding the length of time it currently takes to receive prior authorization. It should not take a week or longer to receive authorization, if all the clinical information requested on the form is submitted. The department is always willing to review problems regarding the prior authorization process with providers. The department will develop a prior authorization process that allows a request to be made prior to youth having received 60 units of TCM.
COMMENT #36: Without knowing more about the prior authorization review process and authorization spans beyond the initial 60 units it is hard to respond to this proposed rule change. It appears the goal is to reduce access and save money currently spent on case management. The cost of implementing this plan is likely to outweigh the state's projected savings unless the cost is anticipated to be shifted to providers for uncompensated care.
RESPONSE: The goal is to reduce Medicaid funds paid to mental health centers providing services to non-SED youth receiving TCM services or SED youth who do not meet the medical necessity criteria established by the department for TCM services. It is not the department's intent for mental health centers to provide uncompensated care.
COMMENT #37: Has the department projected the uncompensated cost to providers of implementing the prior authorization process? Is this cost a factor in the rulemaking process? As a provider, we have not had any inquiries into these costs nor can they be fully projected until the state has a plan for implementation. The impact of the rule for prior authorization on consumers, providers, and the state cannot be evaluated given the information currently available or at least the information currently being publicly shared.
RESPONSE: No. Administrative costs are built into the reimbursement rate for TCM services. With existing Medicaid and Mental Health Center Licensure requirements, the TCM provider should already have most if not all of the client information available to them that will be requested by the department for the prior authorization of TCM services beyond 60 units. Prior authorization will require some additional paperwork on the part of the TCM providers.
COMMENT #38: On what basis does the department assume 10% of client services do not meet medical necessity criteria?
RESPONSE: The cost of TCM services increased 12% in SFY 2006. The total number of Medicaid eligible SED youth served for this time period remained relatively the same. Ten percent is an estimate.
COMMENT #39: Montana has few crisis support services for children and limited mental health services. Montana is experiencing a crisis due to the lack of child psychiatrists, psychiatrists, and qualified mental health practitioners in general and this is especially true for those who accept Medicaid reimbursement. Case management performs necessary intervention services when other providers are unavailable or inaccessible.
EPSDT only allows certain utilization controls if they do not delay the delivery of care and are consistent with the preventative thrust of EPSDT. Prior authorization almost always delays the provision of services.
RESPONSE: There is no authorization requirement for the first 60 units of TCM services per state fiscal year. The prior authorization process developed will allow providers enough time to request additional TCM services without a gap in service, if the information requested is submitted timely, the youth is SED and meets the established medical necessity criteria. Delays in authorization are generally due to the provider not submitting the required information necessary to make a determination of medical necessity.
The department agrees that TCMs provide a valuable service to SED youth and their families by responding to urgent problems that if left unaddressed could lead to the youth experiencing a crisis. The department agrees that the crisis service needs for SED youth and their families are different than the service needs for SDMI adults and that TCMs play an important role in addressing urgent problems before they develop into a crisis. The department contracts with mental health centers to provide TCM services. All mental health centers are required to provide crisis telephone services to their clients. This is a TCM scope of practice issue and not meant to meet all the crisis needs of SED youth and their families.
COMMENT #40: Case management is a cost effective service available across Montana in circumstances and locations where access to other support services may be delayed, limited, or inaccessible. CMHB notes that case management has not reduced the reliance on residential treatment or out-of-state placements. It is quite likely that many other factors significantly affect and are responsible for the state's reliance on high-cost treatment options. Other reasons for the state's reliance on these high cost placements include: an increase in autism spectrum disorders (ASD), children becoming more violent and sexualized at earlier ages, and the methamphetamine epidemic. Cutting case management is focusing on the wrong solution to reduce residential treatment and out-of-state placements. The children's mental health system has other failures that contribute to the state's reliance on residential or out-of-state placements and include the department's failure to develop low-cost, effective community based support and crisis services for youth.
RESPONSE: Please see the response to comment #39.
COMMENT #41: One commentor opposes ARM 37.88.101(2)(d) because it allows for changes to case management rule "as provided for in other rules." The rules should be available in one readily accessible source, the Administrative Rules of Montana. Private in-house rules that only become known when a conflict develops are not appropriate, efficient, or a fair way to allocate state resources. Nor do they allow for public input so that the rules reflect all the relevant issues. RESPONSE: The department believes the commentor is referencing ARM 37.88.101(2)(d), which is the Medicaid Mental Health Services Authorization Requirement rule and not the TCM section of the administrative rule. Subsection (2)(d) references other administrative rules that pertain to authorization requirements and not private in-house rules.
COMMENT #42: Services to children have protective priority when cuts must be made. Per 53-6-101, MCA, the Legislature has directed the department to administer the Medicaid program by protecting those persons who are most vulnerable and in need, protecting the quality of care of services, and giving priority to services that employ the science of prevention to reduce disability and illness. Per 53-6-101(3)(g), MCA, the Legislature has prioritized the Medicaid services of highest priority, which include EPSDT services for children under 21. Therefore, if cuts must be made in the Medicaid budget, they should not be made in children's services.
RESPONSE: The department believes the commentor is referring to the department's proposed rule change to lower the age of eligibility from "up to 21" to "up to 20" in ARM 37.88.901 and 37.89.103, and our proposal to prior authorize TCM services after 60 units in ARM 37.88.101.
Prior authorizing TCM services is an attempt to protect services for those most in need of these services. SED youth are the most vulnerable. The department believes there may be some mismanagement of TCM services by the mental health centers and that some youth receiving TCM services are not SED. TCM services are being prior authorized after 60 units, not cut. TCM services to non-SED youth will not be provided, nor will services be provided to youths who do not meet the established medical necessity criteria.
COMMENT #43: The department should reconsider its proposal to lower the age of eligibility and proposed new language for the definition of child or adolescent. Under the provisions of 20-5-101, MCA, schools have the option to admit individuals who are 19 years of age or older. The new language would leave schools to serve some 20 and 21 year olds with a serious emotional disturbance on their own. The loss of publicly funded mental health services could pressure schools to limit enrollment to age 19. While there are few individuals with a serious emotional disturbance ages 20 and above still enrolled in public school, the impact of the proposed change could be significant for those few cases. State law defines a youth's age, for the purpose of enrollment in a public school, as the age of the student on or before September 10, for the entire school year. The proposed new language would also avoid the student losing eligibility for mental health services in the middle of the school year. The proposed new language would read: "Child or adolescent means a person 17 years of age and younger or a person who is enrolled in a public secondary school."
RESPONSE: It is the department's understanding that most public schools already limit the age of individuals enrolled to age 19. The department is attempting to be consistent with current practices. Early and Periodic Screening, Diagnostic, and Treatment Services (EPSDT) requirements would address exceptions to this rule. Also, EPSDT does not differentiate between youth and adult services.
COMMENT #44: One commentor opposed the reduction in the age of children eligible for mental health services under the Medicaid and the State Plan from "under 21 years of age" to "under 20 years of age" and the requirement that they are still in school. EPSDT provides that children receiving Medicaid receive all medically necessary services offered to anyone in the state plan until age 21. Per 53-6-101(3)(g), MCA, there is no requirement that the child or youth still be in school. Inconsistencies between federal EPSDT rules, state EPSDT rules, and CMHB requirements lead to confusion and barriers in accessing medically necessary services and wasted resources. Commentor supports keeping "under 21 years of age."
RESPONSE: The requirement that youth are still in school is not a new proposal. The proposed changes were made to bring consistency to the definition of "child or adolescent" in Medicaid ARM 37.88.901 and "youth" in Mental Health Service Plan (MHSP) ARM 37.89.103. The Medicaid definition said "is enrolled in secondary school" and the MHSP definition said "is enrolled in a special education program". For young adults age 18 to 21, not in school, with a qualifying SDMI diagnosis, it is generally more appropriate for them to receive services from the adult mental health system. EPSDT requirements do not differentiate between youth and adult mental health services.
COMMENT #45: What is the projected cost of Utilization Review for TCM services? What is the cost to the CMHB per authorization review for case management services? What is the projected cost of SED eligibility determination? What is the projected cost of allowing outpatient therapy for non-SED Medicaid eligible children and youth? What is the percentage of budget overrun attributable to TCM services on page 14 of the proposed rule notice as compared to residential treatment, therapeutic group home, and inpatient hospital care?
RESPONSE: The department is still negotiating with our utilization review contractor to prior authorize TCM services after 60 units and to verify SED eligibility. An estimated cost of $145,500 was used in projecting the cost savings in the proposed rule notice in the "Estimated Budget Effects" section on page 17, for prior authorization. The department is considering combining the cost of the TCM prior authorization review and SED verification.
The department is reviewing previous SFY financial reports and making projections on the cost of offering individual, family, and group outpatient therapy to non-SED youth.
Page 15 of the proposed rule notice indicated that residential psychiatric care (or RTC) was up 17% from SFY 2005 to SFY 2006. The rate of reimbursement for in-state RTCs was increased 6% during this time period. Fewer youth were served by in-state RTCs and more youth were served by out-of-state RTCs.
Inpatient hospital care increased 72% from SFY 2005 to SFY 2006, from $1,953,915 to $3,679,543. There are a number of reasons for the increase in inpatient hospital care: 1) different billing practices with 365 days to bill Medicaid; 2) inpatient hospital costs include both physical and psychiatric care; 3) an increase in the number of youth receiving inpatient hospital services in out-of-state facilities; 4) inpatient hospital costs were down 45% from SFY 2004 to SFY 2005.
Therapeutic youth group home services increased 4% from SFY 2005 to SFY 2006. They had a 6% rate increase for this time period.
COMMENT #46: One commentor had several comments about the TCM contract, one regarding strengthening the Kids Management Authority language and one concern about softening the requirement regarding face-to-face contact with youth and families.
RESPONSE: The comments are outside the scope of the proposed administrative rule changes. However, the department appreciates the commentor's recommendations and concerns and looks forward to working with the commentor on the next TCM contract.
COMMENT #47: The department should strengthen its commitment to ongoing monitoring and evaluation of case management providers to ensure quality and compliance.
RESPONSE: The department agrees and appreciates the support for monitoring, evaluation, and quality services.
/s/ Russell E. Cater /s/ Russell E. Cater for Rule Reviewer Director, Public Health and Human Services
Certified to the Secretary of State August 13, 2007. |
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