BEFORE THE DEPARTMENT OF PUBLIC
HEALTH AND HUMAN SERVICES OF THE
STATE OF MONTANA
In the matter of the amendment of ARM 37.85.204 pertaining to member copayment
NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT
TO: All Concerned Persons
1. On December 12, 2019, 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 rule.
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 December 9, 2019, to advise us of the nature of the accommodation that you need. Please contact Gwen Knight, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail email@example.com.
3. The rule as proposed to be amended provides as follows, new matter underlined, deleted matter interlined:
37.85.204 MEMBER REQUIREMENTS, COST SHARING (1)
Except as provided in this rule each member must pay cost share to the provider of service as described below. Effective for claims paid on or after January 1, 2020, members covered under Medicaid or Medicaid Expansion will not be assessed a copayment, as defined in ARM 37.84.102, for any covered service.
(2) The cost share applied to a service or item is not to exceed the Medicaid allowed amount.
(3) A member with income at or below 100% of the federal poverty level (FPL) is responsible for the following copayments:
(a) inpatient hospital - $75 per discharge;
(b) pharmacy-preferred brand drugs - $4 per prescription;
(c) pharmacy-nonpreferred brand drugs - $8 per prescription;
(d) outpatient hospital services - $4 per visit;
(e) podiatry services - $4 per visit;
(f) physical therapy services - $4 per visit;
(g) speech therapy services - $4 per visit;
(h) audiology services - $4 per visit;
(i) hearing aid services - $4 per visit;
(j) occupational therapy services - $4 per visit;
(k) home health services - $4 per visit;
(l) ambulatory surgical center services - $4 per visit;
(m) public health center services - $4 per visit;
(n) dental treatment services - $4 per visit;
(o) denturist services - $4 per visit;
(p) durable medical equipment - $4 per visit;
(q) optometric and optician services - $4 per visit;
(r) professional services - $4 per visit;
(s) federally qualified health center services - $4 per visit;
(t) rural health clinic services - $4 per visit;
(u) dialysis clinic services - $4 per visit;
(v) independent diagnostic testing facility services - $4 per visit;
(w) home infusion therapy services - $4 per therapy;
(x) mental health clinic services - $4 per visit; and
(y) chemical dependency services - $4 per visit
(4) A member with income above 100 percent of the FPL, except as noted in (a) and (b) is responsible for cost share of 10% of the provider reimbursed amount. A member is responsible for cost share for outpatient pharmacy services as follows:
(a) preferred brand drugs - $4 per prescription;
(b) nonpreferred brand drugs - $8 per prescription.
(5) Members with the following statuses are exempt from cost sharing:
(a) persons under 21 years of age;
(b) pregnant women;
(c) American Indians/Alaska Natives who are eligible for, currently receiving, or have ever received an item or service furnished by:
(i) an Indian Health Service (IHS) provider;
(ii) a Tribal 638 provider;
(iii) an IHS Tribal or Urban Indian Health provider; or
(iv) through referral under contract health services.
(d) persons who are terminally ill receiving hospice services;
(e) persons who are receiving services under the Medicaid breast and cervical cancer treatment category;
(f) institutionalized persons who are inpatients in a skilled nursing facility, intermediate care facility, or other medical institution if the person is required to spend for the cost of care all but their personal needs allowance, as defined in ARM 37.82.1320.
(6) Cost sharing may not be charged to members for the following services:
(a) emergency services;
(b) family planning services;
(c) hospice services;
(d) home and community based waiver services;
(e) transportation services;
(f) eyeglasses purchased by the Medicaid program under a volume purchasing arrangement;
(g) early and periodic screening, diagnostic and treatment (EPSDT) services;
(h) provider preventable health care acquired conditions as provided for in 42 CFR 447.26(b);
(i) generic drugs;
(j) preventive services as approved by CMS through the Health and Economic Livelihood Partnership (HELP) Medicaid 1115 waiver;
(k) services for Medicare crossover claims where Medicaid is the secondary payer under ARM 37.85.406(18). If a service is not covered by Medicare but is covered by Medicaid, cost sharing will be applied; and
(l) services for third party liability (TPL) claims where Medicaid is the secondary payor under ARM 37.85.407. If a service is not covered by the TPL but is covered by Medicaid, cost sharing will be applied.
(7) Cost share may not be charged to the member until the claim has been processed through the claims adjudication process and the provider has been notified of payment and amount owing.
(8) (2) The total of Medicaid or Medicaid Expansion cost share, as defined in ARM 37.84.102, premiums and cost sharing incurred by a Medicaid or Medicaid Expansion household may not exceed an aggregate limit of five percent of the family's income applied quarterly. There may not be further cost sharing applied to the household members in a quarter once a household has met the quarterly aggregate cap.
(9) remains the same but is renumbered (3).
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-6-101, 53-6-113, 53-6-141, MCA
4. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (department) is proposing to amend ARM 37.85.204, pertaining to member copayment, effective January 1, 2020.
The following introductory explanation represents the reasonable necessity for the proposed amendments. The department administers the Montana Medicaid and non-Medicaid program 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.
The rule amendments are necessary to implement the elimination of copayment for Medicaid Expansion members in accordance with House Bill 658, which was passed by the 2019 Legislature and explicitly prohibits the department from requiring Medicaid Expansion members to make a copayment. The department is proposing to expand the elimination of copayment to Medicaid members to keep reimbursement policies consistent. Copayments for Medicaid members account for less than 10% of yearly copayment assessment. Applying the same copayment methodology to Medicaid and Medicaid expansion members is anticipated to reduce the administrative burden placed on providers, while increasing access to healthcare services and prescription drugs for Medicaid members. The rule amendments are proposed to be effective for all claims paid on or after January 1, 2020.
The proposed amendments in ARM 37.85.204(1) implement House Bill (HB) 658 by revising rule language to state effective January 1, 2020, all paid claims will not have a copayment assessed and refer to the definition of "copayment" in ARM 37.84.102.
ARM 37.85.204(2) through (7)
ARM 37.85.204(2) through (7) are proposed to be removed to implement HB 658 and eliminate copayments for Medicaid members.
ARM 37.85.204(8) is proposed to be renumbered ARM 37.85.204(2). In addition, a reference to the definition of "cost sharing" has been added.
ARM 37.85.204(9) is proposed to be renumbered ARM 37.85204(3).
The following table displays the fiscal impact of State general funds for State Fiscal Year (SFY) 2020 and SFY 2021 for the proposed amendments
State Fiscal Year
State General Fund Impact
Federal Funds Impact
The department intends to apply the rule amendments retroactively to January 1, 2020. A retroactive application does not result in a negative impact to any affected party.
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: Gwen Knight, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail firstname.lastname@example.org, and must be received no later than 5:00 p.m., December 20, 2019.
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, apply and have been fulfilled. The primary bill sponsor was notified by email on November 12, 2019.
9. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment of the above-referenced rule 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.
/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 November 12, 2019.