Administrative Rules of the State of Montana

BEFORE THE DEPARTMENT OF PUBLIC

HEALTH AND HUMAN SERVICES OF THE

STATE OF MONTANA

In the matter of the adoption of New Rule I and II and the amendment of ARM 37.79.102, 37.79.326, 37.79.503, and 37.79.505 pertaining to Healthy Montana Kids

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NOTICE OF PUBLIC HEARING ON PROPOSED ADOPTION AND AMENDMENT

TO: All Concerned Persons

1. On November 17, 2010, at 10:30 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 adoption and amendment of the above-stated rules.

2. The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require an accommodation, contact Department of Public Health and Human Services no later than 5:00 p.m. on November 8, 2010, to advise us of the nature of the accommodation that you need. Please contact Rhonda Lesofski, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail [email protected].

3. The rules as proposed to be adopted provide as follows:

NEW RULE I PREMIUM ASSISTANCE (1) The department may pay employer-sponsored plan premiums for an HMK eligible child with access to an employer-sponsored group health plan if the premiums are cost effective and the coverage is equivalent to a benchmark plan.

(a) The child must apply for HMK coverage and meet all eligibility requirements for the HMK coverage group to qualify for premium assistance.

(b) Premium assistance reimbursement may be paid to either the employer or directly to the insured coverage group member.

(c) The employer or insured group member must provide the department with proof of premiums paid in order to receive reimbursement.

(d) The employer must contribute at least 40 percent of the cost of the premium for the employee for an HMK eligible child to receive premium assistance.

(2) In order for a child to continue receiving premium assistance, the child must be redetermined annually as eligible for the HMK coverage group and meet all premium assistance criteria.

(3) An HMK eligible child may choose to end their participation in the premium assistance program at month end and seamlessly transfer to the HMK coverage group effective the first of the following month.

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

IMP: 53-4-1007, 53-4-1108, MCA

NEW RULE II PRESUMPTIVE ELIGIBILITY (1) A family applies for a period of presumptive eligibility (PE), defined as temporary enrollment in the HMK coverage group not to exceed two consecutive calendar months within a 12-month period, for all of their uninsured children less than 19 years of age.

(a) To apply for PE, a parent or guardian submits a PE application to a qualified entity (QE).

(i) The parent or guardian must complete the entire PE application and sign it as indicated.

(b) The QE makes a determination of PE based on self-declared information provided by the applicant on the PE application including family size, gross monthly income, citizenship, and residency.

(i) PE determinations are effective beginning the date a QE makes the determination through the earlier of:

(A) the last day of the month following the PE determination month; or

(B) the date the department makes an eligibility determination.

(ii) If the children are approved for PE, the QE provides the parent or guardian with an HMK Plan application and explains how to submit the application and all needed documentation to HMK.

(iii) If the child(ren) are determined ineligible for PE, the QE provides the parent or guardian with the specific reason for the PE denial.

(c) The parent or guardian is responsible for submitting a completed HMK application and all needed documentation to HMK no later than the last day of the month following the month of the PE determination.

(d) The department makes the HMK coverage group determination based on information provided on a completed HMK Plan application that includes documentation. If eligible, a child remains enrolled in the HMK Plan. If ineligible, the child is disenrolled.

(e) Presumptively eligible children receive the same benefits as all children in the HMK coverage group.

(f) Children may not have more than one PE period during a 12-month span. The 12-month span begins with the date a QE determines eligibility.

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

IMP: 53-4-1004, 53-4-1102, 53-4-1103, 53-4-1104, 53-4-1105, 53-4-1108, MCA

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

37.79.102 DEFINITIONS Definitions as used in this subchapter, unless expressly provided otherwise, the following definitions apply:

(1) through (3) remain the same.

(4) "Benchmark plan" means a health benefit plan which is actuarially equivalent to the state of Montana employee group health plan.

(4) through (6) remain the same but are renumbered (5) through (7).

(8) "Cost effective" means the total amount paid in expenses on behalf of a child under an employer-sponsored plan is less than the department would pay for equivalent services for a child enrolled in HMK.

(7) through (9)(c) remain the same but are renumbered (9) through (11)(c).

(12) "Employer-sponsored plan" means any plan, including a self-insured plan, that meets HMK requirements for creditable coverage and provides health care to employees, former employees, or the families of such employees.

(10) through (17) remain the same but are renumbered (13) through (20).

~~(18)~~ (21) "Healthy Montana Kids (HMK) Plan" means the two health care coverage groups, Healthy Montana Kids (HMK) and Healthy Montana Kids ~~(HMK)~~ Plus (HMK Plus), which pay for covered health care services to qualified individuals until their 19th birthday. The HMK coverage group was formerly referred to as CHIP and the provisions of Title 53, chapter 4, part 10, MCA apply. The HMK Plus coverage group is also referred to as children's Medicaid and the provisions of Title 53, chapter 6, MCA apply.

(19) through (29) remain the same but are renumbered (22) through (32).

(33) "Premium assistance" means a program to help subsidize the purchase of qualified employer-sponsored health care coverage for children eligible for the HMK coverage group.

(34) "Presumptive eligibility (PE)" means a temporary period of HMK medical assistance not to exceed two consecutive calendar months in a 12-month period for uninsured children through the month of their 19th birthday, pending a decision of HMK Plan eligibility.

(30) remains the same but is renumbered (35).

(36) "Qualified entity (QE)" means a health care facility, individual, or other approved entity designated and trained by HMK to make a presumptive eligibility determination for a child on behalf of HMK.

(31) through (36) remain the same but are renumbered (37) through (42).

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

IMP: 53-4-1003, 53-4-1004, 53-4-1009, 53-4-1103, 53-4-1104, 53-4-1105, 53-4-1108, MCA

37.79.326 DENTAL BENEFITS (1) The maximum dental benefits paid under the basic dental plan will be 85 percent of the billed services received. up Up to $1,200 in basic dental care will be paid per benefit year for each enrollee. For example, $1,412 in services received ~~would result~~ results in $1,200 paid.

(a) through (2) remain the same.

(3) The following procedures are not a benefit of the HMK coverage group Dental Program:

(a) remains the same.

~~(b) D6000 through D6199 implant services;~~

(4) remains the same.

(5) Enrollees with significant dental needs beyond those covered in the basic dental plan may, with prior authorization, receive additional services through the HMK coverage group Extended Dental Plan (EDP). The EDP program is dependent on legislative appropriation for the program.

(a) remains the same.

(b) The ~~type of~~ services covered by the EDP are the same ~~type of~~ services covered under the basic dental plan.

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

IMP: 53-4-1003, 53-4-1004, 53-4-1005, 53-4-1009, 53-4-1104, 53-4-1105, MCA

37.79.503 ENROLLMENT (1) through (3)(b) remain the same.

(4) For presumptively eligible children, enrollment begins the date the qualified entity (QE) determines eligibility and may not exceed two consecutive calendar months in a 12-month period.

(a) The QE will give the enrollee a copy of the signed presumptive eligibility (PE) determination to verify PE for service providers during the enrollment period.

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

IMP: 53-4-1003, 53-4-1004, 53-4-1007, 53-4-1009, 53-4-1103, 53-4-1104, 53-4-1105, MCA

37.79.505 DISENROLLMENT (1) through (1)(b) remain the same.

(2) Disenrollment takes effect, at the earliest, the first day of the month after the department receives the request for disenrollment, but no later than the first day of the second calendar month after the request for disenrollment is received.

(a) The enrollee remains enrolled in the HMK coverage group and the HMK coverage group program is responsible for benefits covered under the contract until the effective date of disenrollment, which is ~~always~~ the first day of a month.

(b) The department will disenroll a presumptively eligible child the earlier of:

(i) the last day of the month following the PE determination month; or

(ii) the date the department makes an eligibility determination.

(3) remains the same.

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

IMP: 53-4-1003, 53-4-1004, 53-4-1009, 53-4-1103, 53-4-1104, 53-4-1105, MCA

5. The Department of Public Health and Human Services (the department) is proposing the adoption of New Rule I and II and the amendment of ARM 37.79.102, 37.79.326, 37.79.503, and 37.79.505 pertaining to Healthy Montana Kids.

The department administers the Healthy Montana Kids (HMK) Plan, which is funded by the state and federal government to pay for covered health care services to low income Montana children. The department is proposing amendments and additions to the rules to amend current rules to comply with requirements of the Patient Protection and Affordable Care Act of 2010 (PPACA), to adopt or amend current rules to reflect requirements and options of the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009, to adopt or amend current rules to reflect requirements and recommendations in Montana I-155, the Healthy Montana Kids Plan, and to amend current rules to reflect program policy changes.

New Rule I

This new rule is necessary to enable premium assistance for HMK eligible children who have access to one or more qualified employer sponsored health insurance plans. Premium assistance allows an HMK eligible child access to employer sponsored insurance on a family policy if, without assistance, the family cannot afford the portion of the premium designated for the child's coverage. In addition, a premium assistance option provides an opportunity for families to evaluate the benefits and costs of the employer sponsored plan compared to the benefits and costs of HMK, and select the best choice for their family if there is no additional cost to the state. HMK proposes to implement premium assistance in accordance with recommendations found in the Children's Health Insurance Program Reauthorization Act (CHIPRA) of 2009, Public Law 111-3, Title III(A)(301)(a), and Montana Initiative 155 (Healthy Montana Kids Plan).

New Rule II

Section 53-4-1105, MCA, directs the department to provide for presumptive eligibility. The HMK coverage group proposes to pay the cost of covered health care services during a period of presumptive eligibility, not to exceed more than two consecutive calendar months, for previously unenrolled children less than 19 years of age who meet specified eligibility requirements. Children are determined presumptively eligible by a qualified entity certified by the state. The determination is based upon a child's estimated gross monthly family income after simple disregards. Presumptive eligibility allows children access to health care services pending the screening and final determination of plan eligibility. Presumptive eligibility assures payment to HMK participating providers for covered services. The implementation date is January 1, 2011.

ARM 37.79.102

The department proposes to add definitions for benchmark plan, cost effective, group health plan, premium assistance, presumptive eligibility, and qualified entity.

The new definitions will clarify the meaning of terminology used in the proposed rules.

ARM 37.79.326

The department proposes to amend this rule to add coverage for medically necessary dental implants with prior authorization. The change will delete language stating dental implants are a noncovered service. This change is necessary to align HMK dental benefits with those of the state of Montana employee dental plan. HMK uses the state's dental benefit plan as a benchmark for its benefit structure. HMK is required by Children's Health Insurance Program Reauthorization Act (CHIPRA) to maintain equal or superior benefits to retain its designation as a benchmark plan.

ARM 37.79.503

The department proposes to amend this rule to add enrollment for a presumptively eligible child begins the date the qualified entity determines eligibility and may not exceed two consecutive calendar months. The new language provides the specific enrollment requirements for presumptive eligibility.

ARM 37.79.505

The department proposes to amend this rule to delete language stating the effective date of disenrollment is always the first day of a month. The department will disenroll a presumptively eligible child on the date the child is determined ineligible. The new language will clarify the difference between the HMK coverage group disenrollment rule and the new date requirement for presumptive eligibility.

Proposed changes are necessary to come into compliance with CHIPRA, the Patient Protection and Affordable Care Act (PPACA) of 2010 and Montana Initiative 155 (Healthy Montana Kids Plan).

Fiscal Impact

It is estimated that 19,000 HMK enrollees and approximately 5,808 HMK participating providers may be impacted by the proposed rule amendments. The annual fiscal impact of these changes will be $309,398 in state fiscal year 2011 and $1,241,986 in state fiscal year 2012. The annual fiscal impact of these changes will be $590,522.40 in federal fiscal year 2011 and $1,053,273.60 in federal fiscal year 2012.

6. The department intends the rule amendments to be applied effective January 1, 2011.

7. Concerned persons may submit their data, views, or arguments either orally or in writing at the hearing. Written data, views, or arguments may also be submitted to: Rhonda Lesofski, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail [email protected], and must be received no later than 5:00 p.m., November 26, 2010.

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

9. 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 7 above or may be made by completing a request form at any rules hearing held by the department.

10. An electronic copy of this proposal notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. The Secretary of State strives to make the electronic copy of the notice conform to the official version of the notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the notice and the electronic version of the notice, only the official printed text will be considered. In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems.

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

/s/ Geralyn Driscoll /s/ Anna Whiting Sorrell

Rule Reviewer Anna Whiting Sorrell, Director

Public Health and Human Services

Certified to the Secretary of State October 18, 2010.