BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

 

In the matter of the amendment of ARM 37.27.136, 37.27.137, 37.27.138, 37.27.902, 37.27.903, 37.86.3515, 37.88.101, 37.88.907 and the repeal of ARM 37.27.906, 37.86.3501, 37.86.3502, 37.86.3503, 37.86.3505, 37.86.3506, 37.86.3507, 37.88.110, 37.88.201, 37.88.205, 37.88.206, 37.88.301, 37.88.305, 37.88.306, 37.88.601, 37.88.605, 37.88.606, 37.88.901, 37.88.903, 37.88.906, 37.88.908, 37.88.909 pertaining to Adult Mental Health and Substance Use Disorder

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NOTICE OF PUBLIC HEARING ON PROPOSED AMENDMENT AND REPEAL

 

TO: All Concerned Persons

 

            1. On March 1, 2018, at 10:00 a.m., the Department of Public Health and Human Services will hold a public hearing in the auditorium of the Department of Public Health and Human Services Building, 111 North Sanders, Helena, Montana, to consider the proposed amendment and repeal 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 February 16, 2018, 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 dphhslegal@mt.gov.

 

3.  The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:

 

            37.27.136 OUTPATIENT COMPONENT REQUIREMENTS (1) Patient Individual placement criteria shall must address the following:

            (a) Persons able to receive services on a nonresidential and less intensive basis shall be admitted to this component. Persons needing detoxification, inpatient or intermediate care services shall be referred to an appropriate treatment program. Persons manifesting signs and symptoms of a condition that warrants acute medical care shall not be admitted but shall be referred to a hospital.

            (b) Persons should demonstrate stable physical or emotional/behavioral conditions, sufficient motivation, and supportive environmental factors to participate in this component. This level of care involves weekly sessions usually supplemented by involvement in self help groups. The intensity typically does not exceed 9 contact hours per week.

            (a) referrals to a hospital for individuals manifesting signs and symptoms of a condition that warrants acute medical care; and

            (b) discharge criteria that demonstrates successful completion of treatment or justification for either an extension or a transfer.

            (c) Persons who have recently completed a more intensive level of care may utilize this level for aftercare services. This level of care also may be appropriate for protracted evaluation of patients who require some additional time to make a commitment to a more intensive recovery effort.

            (d) Dimensional admission criteria must demonstrate compliance with the preceding descriptions and encompass the dimensions delineated in ARM 37.27.120(1)(j)(i) through (vi).

            (e) Continued stay criteria shall be based on the above criteria to justify continuance at this level of care or transfer to a more restrictive treatment environment. A continued stay/utilization review must be documented at 45 days.

            (f) Discharge criteria shall be based on previous dimensional criteria to demonstrate successful completion of treatment or justification for an extension or transfer.

            (2) Outpatient services shall must include:

            (a) Admission and screening services in accordance with dimensional admission criteria which substantiates the appropriateness of treatment based on a biopsychosocial assessment corresponding to the dimensional admission criteria via utilization review.

            (b) Crisis intervention, screening evaluation, individual, group and family counseling, intervention services, structured educational presentation, referral and transportation services, discharge, and follow-up services.

            (a) sufficient staff coverage 24 hours a day, seven days a week; and

            (b) treatment plan assessment and staffing every 30 days.

            (c) A plan for outreach activities which includes: target groups, methodology, and special emphasis programs.

            (d) Availability of 24-hour, seven-day a week coverage.

            (e) Assessments and evaluations shall be conducted by a certified chemical dependency counselor based on at least three cross-referenced diagnostic tools.

            (f) A minimum of 2.5 counseling contacts per month.

            (g) Treatment plan assessment/staffing every 45 days.

            (3) Staff requirements:

            (a) Counseling staff shall be certified and trained in the field of chemical dependency counseling and education and shall demonstrate an ability to work with clients and a knowledge of the etiology of chemical dependency.

            (b) Sufficient staff shall be available to provide 24-hour on-call services.

            (c) Staff shall be familiar with community resources for referral, including medical, social, vocational, mental health, alcoholics anonymous, etc.

            (4) (3)  The program shall must develop policies and procedures to address the above listed services, staff requirements, and the criteria in ARM 37.27.115.

            (5) Client recordkeeping and reporting requirements specific to the outpatient care component shall include:

            (a) ADIS admission/discharge forms.

            (b) Date of admission.

            (c) Admission note/utilization review which justifies the admission to this level of care based on compliance with dimensional admission criteria are results of diagnostic tools, if applicable.

            (d) Biopsychosocial assessment.

            (e) Dimensional admission criteria checklist.

            (f) Medical history.

            (g) Documentation of all supportive service contacts.

            (h) Individualized treatment plan which is reviewed and updated at least every 45 days and responds to ARM 37.27.120(g).

            (i) Progress notes shall be written following each contact (a minimum of once a month) and respond to ARM 37.27.120(h).

            (j) Discharge summary that includes: compliance with dimensional criteria or transfer, an account of the client's response to treatment which reviews the treatment plan and documents the client's progress in accomplishing treatment goals and a follow-up plan.

            (6) (4)  Program effectiveness and quality assurance efforts which include individual case review and utilization and effectiveness review. as described below.

            (a) Individual case review is a procedure for monitoring a client's progress and is designed to ensure the adequacy and appropriateness of the services provided to that client and shall:

            (i) Be designed to ensure that the care provided to clients is evaluated and updated every 45 days, according to the needs of each client.

            (ii) Be accomplished through staff meetings and/or quarterly staff reviews. All involved treatment staff must participate. In small rural programs with only one staff member, files shall be reviewed by that staff member.

            (b) (a)  Utilization and effectiveness - review is a process of using patient placement criteria to evaluate the necessity and appropriateness of allocated services and resources to ensure confirm that the programs services are necessary, cost efficient, and effectively utilized. Utilization and effectiveness reviews shall must:

            (i) Utilize patient placement criteria to justify the necessity of admissions, continued stay, transfer and discharge at timely intervals and to document justification via a utilization review note.

            (ii) Ensure the collection, analysis and utilization of information which collect, analyze, and utilize the information to demonstrates program effectiveness. This shall include, but not be limited to, completion of goals and objectives, average monthly caseloads, average contacts per client per month, completion ratios, employment and follow-up data.

 

AUTH: 53-24-204, 53-24-208, MCA

IMP: 53-24-208, MCA

 

            37.27.137 DAY TREATMENT COMPONENT REQUIREMENTS (1) Patient placement criteria shall be developed and address the following:

            (a) Persons requiring a more intensive treatment experience than intensive outpatient treatment but do not require inpatient care. This level of care provides at least five hours of contact time per day for at least four days per week, for a total of 20 to 40 hours per week.

            (b) Persons admitted to this level of care require the presence of minimal, if any symptoms of substance withdrawal; the ability to safely respond to and benefit from ambulatory detoxification, if necessary; the absence of significant or unstable physical or emotional/behavioral complicating conditions; the presence of a current impending episode of loss of control or a current threat of loss of control in a previously successful patient. Due to significant life disruptions and/or lack of social supports the patient requires an intensive outpatient treatment free from the distractions of work, school, family, and/or social problems to focus on recovery. Although the patient may acknowledge a need for change, ambivalence about treatment and problems in several dimensions require the resources of a multidisciplinary team.

            (c) Dimensional admission criteria shall be developed to demonstrate compliance with the preceding descriptions and encompass dimensions delineated in ARM 37.27.120(1)(j)(i) through (vii).

            (d) Continued stay criteria shall be developed based on the above criteria to justify continuance at this level of care or transfer to a more or less restrictive treatment environment. A continued stay/utilization review shall be documented at least once, preferably at ten days.

            (e) Discharge criteria shall be developed based on the previous dimensional criteria to demonstrate successful completion of treatment or justification for an extension or transfer.

            (2) (1)  Day treatment services will may be offered within an inpatient setting and all of the corresponding standards pursuant to inpatient care will be applied with exception of 24 hour supervision and residential requirements. 

 

AUTH: 53-24-208, MCA

IMP: 53-24-208, MCA

 

            37.27.138 INTENSIVE OUTPATIENT TREATMENT COMPONENT REQUIREMENT (1) Patient placement criteria shall be developed and address the following:

            (a) Persons should have only minimal (if any) continuing symptoms of intoxication or withdrawal; the presence of stable physical and emotional/behavioral conditions (if any); a recent history of behavioral deterioration with increasing life impairment. The client requires structured outpatient counseling involving ten to 30 hours of program contact time per week in order to provide the necessary intensity of services without an inpatient placement. The client must be sufficiently accepting of treatment and have an environment which is adequate to support recovery efforts. This level of care affords the client the opportunity to interact with the real world environment while still benefiting from a programmatic structured therapeutic milieu.

            (b) Persons Individuals needing detoxification withdrawal management, inpatient, or intermediate care residential services shall must be referred to an appropriate treatment program.

            (2) Persons Individuals manifesting signs and symptoms of a condition that warrants acute medical care shall not be admitted but must be referred to a hospital.

            (c) Dimensional admission criteria shall demonstrate compliance with the preceding descriptions and encompass the dimensions delineated in ARM 37.27.120(1)(j)(i) through (vii).

            (d) Continued stay criteria shall be developed based on the above criteria to justify continuance at this level of care or transfer to a more or less restrictive treatment environment. A continued stay/utilization review shall be documented at three weeks following admission or as needed.

            (e) Discharge criteria shall be developed based on previous dimensions to demonstrate successful completion of treatment which includes 90% completion of all required sessions or justification for an extension or transfer.

            (2) (3)  Intensive outpatient services shall must include: referral, transfer, discharge, aftercare, and follow-up services that ensure a continuity of care.

            (a) Admission and screening in accordance with dimensional admission criteria which substantiate the appropriateness of treatment based on a biopsychosocial assessment corresponding to the dimensional admission criteria via utilization review. Additionally, assessments shall include at least three cross-referenced diagnostic/assessment tools confirming a determination of chemical dependency. This assessment must be conducted by a certified chemical dependency counselor.

            (b) Structured outpatient counseling equaling ten to 30 hours per week consistent with the individualized treatment plan. The content of this service must be similar to inpatient treatment and offer the same foundations for recovery.

            (c) A minimum of two skilled treatment services per day at least three times per week. One of the skilled treatment services must be group counseling of at least two to three hours in duration. Skilled treatment services may include group counseling, individual counseling, family counseling, and educational presentations (lectures).

            (d) The structured educational series shall be presented in a logical, progressive format which contains the essential elements necessary for recovery.

            (e) One session of documented individual counseling per week with a certified or eligible chemical dependency counselor.

(f) Other support services as necessary.

            (g) Availability of professional consultation including medical.

            (h) Direct affiliation with more intensive levels of care. This may be offered as part of the overall program or via contract/agreement.

            (i) Encouragement of clients to attend A.A. twice weekly.

            (j) Periodic assessment review and treatment plan update every two weeks.

(k) Provision of family services as appropriate.

            (l) Referral, transfer, discharge, aftercare, and follow-up services that ensure a continuity of care.

            (3) (4)  Staff requirements: The program must provide availability of professional counseling services 24 hours per day, 7 days per week.

            (a) Counseling staff shall be certified or eligible and trained in the field of chemical dependency counseling. Counselors conducting the IAP program shall demonstrate an ability to work with clients, a knowledge of the etiology of chemical dependency, and expertise in group skills.

            (b) Availability of professional counseling services 24 hours per day, seven days per week.

            (c) The program shall provide sufficient staff to provide for all aspects of this service.

            (d) Staff shall be familiar with community resources for referral including medical, social, vocational, mental health, spiritual, alcoholics anonymous, and etc.

            (4) (5)  Required policies and procedures: The program shall must develop policies, procedures, and plans to address the above-listed services, staff requirements, and criteria requirements.

            (5) Client recordkeeping and reporting requirements specific to the intensive outpatient component shall include:

(a) ADIS admission/discharge forms;

(b) Date of admission;

            (c) Admission note/utilization review, which justifies the admission to this level of care based on compliance with dimensional admission criteria and results of diagnostic tools.

(d) Biopsychosocial assessment;

(e) Dimensional admission criteria checklist;

(f) Documentation of all supportive service contacts;

            (g) Individualized treatment plan, which is reviewed and updated every two weeks and responds to ARM 37.27.120(h).

            (h) continued stay/utilization review note which justifies continuation of IOP or transfer based on dimensional criteria;

            (i) Progress notes written at a minimum of three times a week, reflecting required services i.e. ten to 30 hours per week and responding to ARM 37.27.120(h).

            (j) Discharge summary that includes: compliance with dimensional criteria or transfer; an account of the clients response to treatment; a review of the treatment plan and corresponding progress; reason for discharge and aftercare plan.

            (6) Program effectiveness and quality assurance shall include must:

            (a) Individual case review is a procedure for monitoring a client's progress and is designed to ensure the adequacy and appropriateness of the services provided to that client and shall:

            (i) (a)  Bbe designed to ensure that the care provided to clients individuals is evaluated and updated every month, according to the needs of each client individual.

            (ii) (b)  Bbe accomplished through reviews, which all involved treatment staff attend.

            (b) (7)  Utilization and eEffectiveness review is a process of using patient placement criteria to evaluate the necessity and appropriateness of patient placement, allocated services and resources to ensure the program's services are necessary, cost efficient, and effectively utilized. Utilization and eEffectiveness reviews shall must:

            (i) Utilize patient placement criteria to justify the necessity of admissions, continued stay, transfer and discharge at timely intervals and document justification via a utilization review note.

            (ii) (a)  Bbe designed to achieve cost efficiency, increase effective utilization of program's services, and ensure verify the necessity of services provided;

            (iii) (b)  Aaddress under-utilization, over-utilization, and inefficient scheduling as well as over-utilization of the program's resources.

            (iv) (c) Eensure methods for identifying and monitoring utilization and effectiveness related problems including analysis of the appropriateness and necessity of admission, caseload, continued stays, recidivism, completion ratios, frequency of services, and delays in the provision of services, effectiveness of the aftercare plan based on verification of referrals and results of follow-up, as well as utilization of the findings of related quality assurance activities and all current relevant documentation. 

 

AUTH: 53-24-208, MCA

IMP: 53-24-208, MCA

 

37.27.902 MEDICAID SUBSTANCE USE DISORDER SERVICES: PURPOSE AUTHORIZATION REQUIREMENTS (1) remains the same.

(2) In addition to the requirements contained in rule, the department has developed and published the Addictive and Mental Disorders Division, Medicaid Services Provider Manual for Adult Mental Health and Substance Use Disorder (Manual), dated April 1, 2018, which it adopts and incorporates by reference.  The purpose of the Manual is to implement requirements for utilization management and services.  A copy of the Manual may be obtained from the department by a request in writing to the Department of Public Health and Human Services, Addictive and Mental Disorders Division, 100 N. Park, Ste. 300, P.O. Box 202905, Helena, MT 59620-2905 or at http://dphhs.mt.gov/amdd.aspx.

 

AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, MCA

IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, MCA

 

            37.27.903 MEDICAID SUBSTANCE USE DISORDER SERVICES: GENERAL REQUIREMENTS (1) and (2) remain the same.

            (3) Medicaid substance use disorder services include:

(a) screening and assessment;

(b) individual therapy;

(c) group therapy;

(d) family therapy;

(e) multiple-family group therapy;

(f) targeted case management for substance use disorders as defined in ARM 37.86.3301 through 37.86.3306 and ARM 37.86.4001 through 37.86.4010;

(g) nonhospital inpatient substance use disorder detoxification;

(h) nonhospital inpatient substance use disorder residential treatment; and

(i) nonhospital inpatient substance use disorder residential day treatment.

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

 

AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, MCA

IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, MCA

 

            37.86.3515 TARGETED CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, REIMBURSEMENT (1) Targeted Ccase management services for adults with severe disabling mental illness will be reimbursed on a fee per unit of service basis as follows. For purposes of this rule, a unit of service is a period of 15 minutes.

            (2) The department adopts the method of establishing rates for mental health case manager providers approved by the Centers for Medicare and Medicaid Services (CMS) on February 1, 2011. That method is:

            (a) The department determined the total costs of providing case management services by using case management provider reports of the most recent wage costs, benefit costs, and other case management costs.

            (b) The department used actual time units billed from the providers of the most complete fiscal year.

            (c) The department determined yearly wage cost per case manager full-time employee (FTE) added to the yearly benefit costs per case manager FTE, and yearly other costs per FTE. The total costs are divided by the average units billed per FTE. This final calculation will be the rate per 15-minute unit.

            (d) The department will update the rate setting methodology every three years or whenever significant changes in services occur.

            (3) (2) The department adopts and incorporates by reference the department's fee schedule which sets forth the reimbursement rates for targeted case management. The provider reimbursement rate for targeted case management services for persons adults with severe disabling mental illness is stated in the department's fee schedule as provided in ARM 37.85.105(5) 106.

            (4) The department may, in its discretion, designate a single provider of case management services in a designated geographical region.  Any provider designated as the sole case management provider for a designated geographical region must, as a condition of such designation, agree to serve the entire designated geographical region.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-113, 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 37.86.3503.

            (2) 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 (2)(a) or (b). The person must also meet the requirements of (2)(c). The person has:

            (a) a DSM diagnosis with a severity specifier of moderate or severe bipolar I disorder, bipolar II disorder, or major depressive disorder; or

            (b) a DSM diagnosis borderline personality disorder;

            (c) ongoing difficulties in functioning because of mental illness for a period of at least six months or for an obviously predictable period over six months, as indicated by:

            (i) dysregulation of emotion, cognition, behavior, and interpersonal relationships;

            (ii) resulting in recurrent suicidal, parasuicidal, serious self-damaging impulsive behaviors, or serious danger to others;

            (iii) a history of treatment at a higher level of care, and

            (iv) evidence that lower levels of care are inadequate to meet the needs of the client.

            (2) In addition to the requirements contained in rule, the department has developed and published the Addictive and Mental Disorders Division, Medicaid Services Provider Manual for Adult Mental Health and Substance Use Disorder (Manual), dated April 1, 2018, which it adopts and incorporates by reference.  The purpose of the Manual is to implement requirements for utilization management and services.  A copy of the Manual may be obtained from the department by a request in writing to the Department of Public Health and Human Services, Addictive and Mental Disorders Division, 100 N. Park, Ste. 300, P.O. Box 202905, Helena, MT 59620-2905 or at http://dphhs.mt.gov/amdd.aspx.

            (3) Medicaid reimbursement for mental health services will be the lowest of:

            (a)  the provider's actual (submitted) charge for the service; or

            (b)  the rate established in the department's fee schedule.  Reimbursement fees are as provided in ARM 37.85.105(5) and 37.85.106(2)(c).

            (3) and (4) remain the same, but are renumbered (4) and (5).

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.88.907 MENTAL HEALTH CENTER SERVICES FOR ADULTS, REIMBURSEMENT (1) The department adopts and incorporates by reference the Medicaid Adult Mental Health and the Adult Mental Health Services Plan fee schedule as provided in ARM 37.85.105(5). A copy of the department's fee schedule is posted at the Montana Medicaid provider web site at www.dphhs.mt.gov/amdd/services/index.shtml. A copy may be obtained from the Department of Public Health and Human Services, Addictive and Mental Disorders Division, PO Box 202905, Helena, MT 59620-2905. Medicaid reimbursement for mental health center services will be the lowest of:

            (a) through (2)(b) remain the same.

            (3) For day treatment, program of assertive community treatment, and crisis intervention services, Medicaid will not reimburse a mental health center provider for more than one fee per treatment day per individual. This does not apply to practitioner services to the extent such services are separately billed in accordance with these rules.

            (4) For purposes of Medicaid billing and reimbursement of day treatment services, a "half day" means that the individual has attended the day treatment program for a minimum of two hours during the treatment day.

            (5) For purposes of meeting the minimum hours required in (3), the provider may not include time during which the individual is receiving practitioner services that are billed separately as practitioner services under ARM 37.88.906, up to a maximum of four hours during the treatment day.

            (6) Services billed as community-based psychiatric rehabilitation and support may not be counted toward the time requirements for any other service or billed by the provider as any other type or category of service.

            (7) Reimbursement will be made to a provider for reserving an adult foster care or mental health adult group home bed only if:

            (a) the individual's plan of care documents the medical need for a therapeutic visit as part of a therapeutic plan;

            (b) the individual is temporarily absent on a therapeutic visit;

            (c) the provider clearly documents staff contact and individual achievements or regressions during and following the therapeutic visit; and

            (d) no more than 14 patient days per individual in each rate year will be reimbursed for therapeutic visits.

            (8) remains the same, but is renumbered (3).

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            4. The department proposes to repeal the following rules:

 

            37.27.906 MEDICAID SUBSTANCE USE DISORDERS SERVICES: TREATMENT REQUIREMENTS is found on page 37-6091 of the Administrative Rules of Montana.

 

AUTH: 53-6-113, 53-24-204, 53-24-208, 53-24-209, MCA

IMP: 53-6-101, 53-24-204, 53-24-208, 53-24-209, MCA

 

            37.86.3501 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, DEFINITIONS is found on page 37-20631 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, MCA

 

            37.86.3502 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, ELIGIBILITY is found on page 37-20632 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, 53-21-703, MCA

IMP: 53-6-101, 53-21-701, MCA

 

            37.86.3503 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, SEVERE DISABLING MENTAL ILLNESS is found on page 37-20633 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, MCA

 

            37.86.3505 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, SERVICE COVERAGE is found on page 37-20635 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-113, MCA

 

            37.86.3506 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, SERVICE REQUIREMENTS is found on page 37-20637of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, MCA

 

            37.86.3507 CASE MANAGEMENT SERVICES FOR ADULTS WITH SEVERE DISABLING MENTAL ILLNESS, PROVIDER REQUIREMENTS is found on page 37-20639 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.88.110 TEMPORARY RATE ADJUSTMENT is found on page 37-21539 of the Administrative Rules of Montana.

 

AUTH: 53-6-113, 53-21-201, MCA

IMP: 53-6-101, 53-6-113, 53-21-201, MCA

 

            37.88.201 LICENSED CLINICAL SOCIAL WORK SERVICES, DEFINITIONS is found on page 37-21549 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.88.205 LICENSED CLINICAL SOCIAL WORK SERVICES, REQUIREMENTS is found on page 37-21553 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.88.206 LICENSED CLINICAL SOCIAL WORK SERVICES, REIMBURSEMENT is found on page 37-21555 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, 53-21-703 MCA

IMP: 53-1-601, 53-1-602, 53-1-603, 53-6-101, 53-6-113, 53-21-202, 53-21-701, 53-21-702, MCA

 

            37.88.301 LICENSED PROFESSIONAL COUNSELOR SERVICES, DEFINITIONS is found on page 37-21575 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.88.305 LICENSED PROFESSIONAL COUNSELOR SERVICES, REQUIREMENTS is found on page 37-21581 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.88.306 LICENSED PROFESSIONAL COUNSELOR SERVICES, REIMBURSEMENT is found on page 37-21583 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, 53-21-703, MCA

IMP: 53-1-601, 53-1-602, 53-1-603, 53-6-101, 53-6-113, 53-21-201, 53-21-202, 53-21-701, 53-21-702, MCA

 

            37.88.601 LICENSED PSYCHOLOGIST SERVICES, DEFINITIONS is found on page 37-21633 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-6-101, MCA

 

            37.88.605 LICENSED PSYCHOLOGIST SERVICES, REQUIREMENTS is found on page 37-21637 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.88.606 LICENSED PSYCHOLOGIST SERVICES, REIMBURSEMENT is found on page 37-21638 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, 53-21-703, MCA

IMP: 53-1-601, 53-1-602, 53-1-603, 53-6-101, 53-6-113, 53-21-202, 53-21-701, 53-21-702, MCA

 

            37.88.901 MENTAL HEALTH CENTER SERVICES FOR ADULTS, DEFINITIONS is found on page 37-21667 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.88.903 MENTAL HEALTH CENTER SERVICES FOR ADULTS, DEFINED is found on page 37-21671 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, MCA

 

            37.88.906 MENTAL HEALTH CENTER SERVICES FOR ADULTS, COVERED SERVICES is found on page 37-21679 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, 53-6-113, MCA

 

            37.88.908 MENTAL HEALTH CENTER SERVICES FOR ADULTS, PROGRAM OF ASSERTIVE COMMUNITY TREATMENT (PACT) is found on page 37-21682 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, MCA

 

            37.88.909 MENTAL HEALTH CENTER SERVICES FOR ADULTS, INTENSIVE COMMUNITY-BASED REHABILITATION FACILITY is found on page 37-21683 of the Administrative Rules of Montana.

 

AUTH: 53-2-201, 53-6-113, MCA

IMP: 53-2-201, 53-6-101, 53-6-111, MCA

 

            5. STATEMENT OF REASONABLE NECESSITY

 

The Department of Public Health and Human Services (department) administers the Montana Medicaid and non-Medicaid programs to provide health care to Montana's qualified low income, elderly, and disabled residents.  Medicaid is a public assistance program paid for with state and federal funds appropriated to pay health care providers for the covered medical services they deliver to Medicaid members.  Non-Medicaid programs are funded primarily with state funds or grants.  The legislature delegates authority to the department to set the reimbursement rates Montana pays providers for covered services.

 

In November of 2017, the governor called a special session to address the variances in revenue and high fire season expenditures.  The governor and the legislature worked together to reach a compromise to bring the budget into balance. That compromise included a number of proposed spending reductions and a reduction to the department budget of $49 million general fund dollars.

 

Medicaid rates and services are stated in administrative rule.  The rule amendments in this notice of proposed rulemaking implement the necessary spending reductions. The rule amendments in this notice of proposed rulemaking are proposed to implement the mandatory spending reductions under 17-7-140, MCA.  The proposed rule amendments include program reductions in services and the implementation of utilization management.  In proposing any rates of reimbursement in this notice, the department primarily considered the availability of appropriated funds, as provided in 53-6-113(3), MCA.  In considering any service reductions proposed in this rulemaking, the department considered the factors set forth in 53-6-101, MCA as follows:

 

a.  protecting those persons who are most vulnerable and most in need, as defined by a combination of economic, social, and medical circumstances;

 

b.  giving preference to the elimination or restoration of an entire Medicaid program or service, rather than sacrifice or augment the quality of care for several programs or services through dilution of funding; and

 

c.  giving priority to services that employ the science of prevention to reduce disability and illness, services that treat life-threatening conditions, and services that support independent or assisted living, including pain management, to reduce the need for acute inpatient or residential care.

 

The following summaries describe in detail the proposed rule amendments to be made:

 

The department is proposing to adopt and incorporate into administrative rule a provider manual entitled, Addictive and Mental Disorders Division, Medicaid Services Provider Manual for Adult Mental Health and Substance Use Disorder (Manual), effective April 1, 2018. The department also is proposing the following rule amendments and repeals to simplify the rules for both adult mental health and substance use disorder and to align the language in the Manual with the current practice of the department. 

 

Amendments to Utilization Management

 

The department is proposing to add utilization management to the following covered services:

(1) acute inpatient hospital services for out of state facilities will continue to require prior authorization;

(2) intensive community based rehabilitation (ICBR), program for assertive community treatment (PACT), and therapeutic group home (TGH) will now require prior authorization and continued stay reviews;

(3) secure crisis diversion, also known as crisis intervention facility, will continue to require continued stay reviews, however the timeline will change from seven days to five days;

(4) community based psychiatric rehabilitation and supports (CBPRS) will implement a limit of two hours per day (eight units per day);

(5)  targeted case management (TCM) will implement a limit of 24 hours per state fiscal year (96 units per state fiscal year);

(6) Outpatient (OP) therapy more than 12 sessions for individual therapy and 12 sessions of group therapy will require the member to have either a severe disabling mental illness (SDMI) or substance use disorder (SUD) for OP therapy more than 12 sessions diagnosis.

(7) SUD medically monitored intensive inpatient (ASAM 3.7), SUD clinically managed high-intensity residential (ASAM 3.5), and SUD Clinically managed low-intensity residential (ASAM 3.1) will now requirement prior authorization and continued stay reviews.

 

Amendments to the SDMI Eligibility Requirements

 

The department is proposing to move the definition of SDMI from ARM 37.86.3503 to the Manual, align diagnoses to the current DSM-V and ICD-10 coding standards, and update for accuracy.  This is necessary to ensure accurate reimbursement for services to members diagnosed with SDMI.  The department proposes to make the following amendments to the current SDMI definition:

 

(1) Remove F20.3 (schizophrenia, undifferentiated type) because unspecified/undifferentiated diagnoses are not reimbursable by Montana Medicaid;

(2) Update the diagnosis code for obsessive compulsive disorder from F42 to F42.2 for accuracy.  This billing code was updated between the 2015 and 2018 version of the ICD-10 manual.

(3) Add diagnosis codes F44.0, F44.1, F44.2, F44.81 for dissociative disorder.  This diagnostic category was added to the SDMI criteria because when an adult is diagnosed with this type of disorder, the symptoms are of a severe nature. Symptoms cause clinically significant distress or impaired social and/or occupational functioning.

(4) Add diagnosis code F41.1 for generalized anxiety disorder.  This diagnosis was added to assist transitional age youth with a serious emotional disturbance into an adult with a SDMI mental health services and due to the nature of the chronicity of the symptoms.

(5) Add diagnosis code F34.1 for persistent depressive disorder (dysthymia).  This diagnosis was added to assist transitional age youth with a serious emotional disturbance into an adult with a SDMI mental health services and due to the nature of the chronicity of the symptoms.

(6) Add diagnosis codes F50.01, F50.02, F50.2 for feeding and eating disorders.  This diagnosis was added to assist transitional age youth with a serious emotional disturbance into an adult with a SDMI mental health services and due to the nature of the chronicity of the symptoms.

(7) Add diagnosis F64.8 for gender dysphoria. This diagnosis was added to assist transitional age youth with a serious emotional disturbance into an adult with a SDMI mental health services and due to the nature of the chronicity of the symptoms as well as national statistics reflecting a high suicide rate in this population.

(8) The department is proposing to implement a level of impairment worksheet (LOI). This is necessary to provide a consistent means to determine the level of impairment of a member.  Providers will be required to complete this worksheet when determining the SDMI eligibility of a member. The SDMI eligibility of a member must be determined annually.

 

Amendments to Administrative Rules of Montana. Specifically, the department is proposing the following:

 

ARM 37.27.136

 

The department is proposing to amend ARM 37.27.136. This is necessary to update requirements to align with current practice as outlined in The American Society of Addiction Medicine (ASAM) Criteria, remove language that is duplicative with The ASAM Criteria and ARM 37.27.120, and move pertinent requirements for this service to the Manual. Due to the fact the rule pertains to both Medicaid and non-Medicaid providers and services, some information was maintained in rule that may be duplicative with the Manual, which is specific to Medicaid providers and services.

 

ARM 37.27.137

 

The department is proposing to amend ARM 37.27.137(1). This is necessary to update requirements to align with current practice and because applicable language has been moved to the Manual and updated for accuracy.

 

ARM 37.27.138

 

The department is proposing to amend ARM 37.27.138. This is necessary to update requirements to align with current practice and because applicable language has been moved to the Manual. In addition, the language in (2) is duplicative of ARM 37.27.116 through 37.27.120, the language in (3) is duplicative of ARM 37.27.115 and ARM 37.27.120, and the language in (5) is duplicative of ARM 37.27.120.

 

ARM 37.27.902

 

The department is proposing to amend ARM 37.27.902 to adopt and incorporate the Manual, effective April 1, 2018.

 

ARM 37.27.903

 

The department is proposing to amend ARM 37.27.903 to strike (3) and move the language to the Manual and align to current practice and update for accuracy.

 

ARM 37.86.3515

 

The department is proposing to amend ARM 37.86.3515. This is necessary to amend the service name to targeted case management in (1) and strike (2) and (4) because the language is outdated and no longer applicable.  In addition, the department is proposing to amend (3) to correct the reference to the department’s fee schedule for targeted case management for adults with a severe disabling mental illness from ARM 37.85.105 to ARM 37.85.106, which was recently promulgated in MAR Notice No. 37-801.

 

ARM 37.88.101

 

The department proposes to amend ARM 37.88.101 to adopt and incorporate the Manual.  The language pertaining to intensive outpatient therapy has been transferred to the Manual and the name corrected to dialectical behavioral therapy.  In addition, the department proposes to align the service language in the Manual with the current practice.  The department proposes to move the language from ARM 37.88.206(2) to this rule and update the language because the requirements outlined are not specific to only licensed clinical social work service but are applicable to all Montana Medicaid adult mental health programs.

 

ARM 37.88.907

 

The department is proposing to amend ARM 37.88.907; this is necessary to correct the reference in (1) to the adult mental health service plan fee schedule, which is adopted and incorporated in ARM 37.85.104 and 37.89.125, respectively.  In addition, the department proposes to remove (3), (4), (5), (6), and (7) because the requirements were moved to the Manual and updated for accuracy.

 

Repeals of certain Administrative Rules of Montana. Specifically, the department is proposing the following:

 

ARM 37.27.906

 

The department is proposing to repeal ARM 37.27.906. This is necessary because medical necessity criteria and references to The ASAM Criteria and ICD-10 were moved to the Manual and updated for accuracy.

 

ARM 37.88.110

 

The department is proposing to repeal ARM 37.88.110. This is necessary because this rule applied specifically to the timeframe of January 11, 2002 through June 30, 2002.

 

ARM 37.88.201, ARM 37.88.301, and ARM 37.88.601

 

The department is proposing to repeal ARM 37.88.201, 37.88.301, and 37.88.601. This is necessary because licensed clinical social work services (LCSW), licensed professional counselor services (LCPC), and licensed psychologist services are already defined in Title 37, chapter 22, MCA; Title 37, chapter 23, MCA; and Title 37, chapter 17, MCA, respectively.  In addition, LCPCs and LCSWs are further defined in ARM Title 24, chapter 219; therefore, these rules are repetitive.

 

ARM 37.88.205, ARM 37.88.305, ARM 37.88.605

 

The department is proposing to repeal ARM 37.88.205, 37.88.305, and 37.88.605.  This is necessary because the language contained in these rules are duplicative of other administrative rules and applicable to other Medicaid programs in which LCPCs, LCSWs, and licensed psychologists provide services.

 

ARM 37.88.206, ARM 37.88.306, ARM 37.88.606

 

The department is proposing to repeal ARM 37.88.206, 37.88.306, and 37.88.606.  This is necessary because the information regarding billing codes, modifiers, and Healthcare common procedure coding system (HCPCS) is contained in the fee schedule adopted and incorporated in ARM 37.85.105.  In addition, the department proposes to move and update the language contained in (2) to ARM 37.88.101.  This is necessary because the requirements outlined are applicable to all Montana Medicaid mental health programs.

 

ARM 37.88.901

 

The department is proposing to repeal ARM 37.88.901.  This is necessary because applicable definitions were moved to the Manual and outdated definitions removed.

 

ARM 37.88.903

 

The department is proposing to repeal ARM 37.88.903.  This is necessary because mental health center service definitions and requirements are now located in the Manual.

 

ARM 37.88.905

 

The department is proposing to repeal ARM 37.88.905.  This is necessary because the language is duplicative of language in ARM Title 37 chapter 106, subchapter 19 and ARM 37.85.414.

 

ARM 37.88.906

 

The department is proposing to repeal ARM 37.88.906.  This is necessary because the language is duplicative of language in ARM Title 37 chapter 106, subchapter 19.

 

ARM 37.88.908

 

The department is proposing to repeal ARM 37.88.908.  This is necessary because the language was moved to the Manual and updated for accuracy.

 

ARM 37.88.909

 

The department is proposing to repeal ARM 37.88.909 because the language was moved to the Manual and updated for accuracy.

 

ARM 37.86.3501

 

The department is proposing to repeal ARM 37.86.3501.  This is necessary because pertinent information contained in this rule is now located in the Manual in the section pertaining to TCM.

 

ARM 37.86.3502

 

The department is proposing to repeal ARM 37.86.3502.  This is necessary for general housekeeping purposes because the rules referenced are proposed to be repealed in this rulemaking.

 

ARM 37.86.3503

 

The department is proposing to repeal ARM 37.86.3503.  This is necessary because the SDMI definition and criteria were moved to the Manual, diagnoses aligned to the current DSM-V and ICD-10 coding standards, and updated for accuracy.

 

ARM 37.86.3505

 

The department is proposing to repeal ARM 37.86.3505.  This is necessary because pertinent information contained in this rule is now located in the Manual in the section pertaining to TCM.

 

ARM 37.86.3506

 

The department is proposing to repeal ARM 37.86.3506. This is necessary because pertinent information contained in this rule is now located in the Manual in the section pertaining to TCM.

 

ARM 37.86.3507

 

The department is proposing to repeal ARM 37.86.3507, as it is duplicative of ARM 37.106.1902 and the provider requirements in the Manual.

 

 

 

FISCAL IMPACT

 

The proposed Manual includes the addition of utilization management to select services.  Historically, there has been no utilization management requirements for these services; therefore, any fiscal impact is unquantifiable. The department lost approximately one-eighth of its Medicaid appropriation for the biennium and although this decrease was specified for targeted case management, the department has chosen to retain this service and instead, instituting utilization management to achieve those cost savings over the last 15 months of the biennium. 

 

Utilization management will be applied to the following services:

 

Therapeutic group home;

Program for assertive community treatment;

Intensive community based rehabilitation;

Substance use disorder (SUD) ASAM 3.1, ASAM 3.5, and ASAM 3.7;

An annual limit of 24 hours (96 unit) on adult mental health targeted case management (TCM) and SUD TCM for adult and youth;

An annual limit on outpatient mental health therapy requiring a prior authorization asserting severe disabling mental illness status or an ASAM 2.0 or higher acuity to receive more than 12 sessions per year for individual and 12 sessions per year for group;

A daily limit of two hours (eight units) for individual and two hours (eight units) of group community based psychiatric rehabilitation and supports (CBPRS); and

A decrease in the number of days a member can receive secure crisis diversion services before getting a continued stay review from seven days to five days.

 

            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 dphhslegal@mt.gov, and must be received no later than 5:00 p.m., March 9, 2018.

 

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

 

10. With regard to the requirements of 2-4-111, MCA, the department has determined that the amendment and repeal of the above-referenced rules will significantly and directly impact small businesses.

 

11. 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/ Jorge Quintana                                       /s/ Sheila Hogan                                         

Jorge Quintana                                            Sheila Hogan, Director

Rule Reviewer                                             Public Health and Human Services

 

 

Certified to the Secretary of State January 30, 2018.