Montana Waiver

Montana – Montana Big Sky Home and Community Based Waiver (0148.R06.00), HCBW for Individuals w/DD (0208.R06.00); Behavioral Health Severe and Disabling Mental Illness Home and Community Based Services (0455.R02.00)

Waiver Title

Montana Big Sky Home and Community Based Waiver (0148.R06.00), HCBW for Individuals w/DD (0208.R06.00); Behavioral Health Severe and Disabling Mental Illness Home and Community Based Services (0455.R02.00)

Description of Emergency

On March 13, 2020, as authorized under the Robert T. Stafford Disaster Relief and Emergency Assistance Act (the “Stafford Act”), President Donald J. Trump declared a state of emergency resulting from the ongoing Coronavirus Disease 2019 (COVID-19) pandemic. On January 31, 2020, pursuant to the Public Health Services Act, Secretary of Health and Human Services (HHS) Alex Azar declared a public health emergency. On March 12, 2020, Governor Steve Bullock issued an executive order declaring a state of emergency related to the continued spread of COVID-19 to allow the governor to direct a coordinated response to the outbreak of communicable disease. This includes mobilizing all available state resources, such as emergency funds or personnel from the National Guard. It also allows the governor to take additional steps to ease regulatory requirements, continue federal and multi-state coordination, and ensure continued access to critical services for the State’s most vulnerable. The novel COVID-19 pandemic has already begun to place unprecedented burdens on Montana’s health care programs and systems. Per the Centers for Disease Control and Prevention (CDC), as of March 31, 2020, there are 177 reported COVID-19 cases; this number is expected to grow as more people become tested and the virus spreads to other communities in Montana, increasing the risk of exposure for the State’s residents. Montana has three approved 1915(c) waivers with 5400 participants, many of which are among the most vulnerable and susceptible to COVID-19. Health care workers caring for patients with COVID-19, individuals who have had close contact with persons with COVID-19, and travelers returning from affected international locations where community spread is occurring are all at elevated risk of exposure. Montana’s knowledge of COVID-19 is still rapidly evolving. Montana has received approval to waive certain Medicaid and the Children’s Health Insurance Program (CHIP) requirements to ensure sufficient health care items and services are available to meet the needs of individuals under 1135 of the Social Security Act. A number of requirements Montana has committed to in its Medicaid state plan and waiver applications are dependent on staff and provider ability to perform tasks. Due to the evolving nature of this crisis, we may reach a point where we must adjust service delivery methods, suspend home visits, and shift workload priorities due to staff shortages to in order to meet immediate health and safety needs. This amendment will apply waiver-wide for each waiver included in this Appendix, to all individuals impacted by the virus or the response to the virus.

Waiver Description

Montana Big Sky Home and Community Based Waiver (0148.R06.00): Provides adult day health, case management, community first choice/personal assistance and specially trained attendant care, day habilitation, homemaker, prevocational services, residential habilitation, respite, supported employment, audiology, respiratory therapy, financial management services, community supports, community transition, consultative clinical and therapeutic services, consumer goods and services, dietetic services, environmental accessibility adaptations, family training and support, health and wellness, homemaker chore, non-medical transportation, nutrition, occupational therapy, pain and symptom management, personal emergency response systems, physical therapy, post-acute rehabilitation services, private duty nursing, senior companion, specialized child care for medically fragile children, specialized medical equipment and supplies, speech therapy, supported living, vehicle modifications for aged individuals 65- no max age and individuals with physical disabilities and other disabilities ages 0 – 64; HCBW for Individuals w/DD (0208.R06.00): Provides day supports and activities, homemaker, residential habilitation, respite, supported employment – follow along support, nutritionist services, occupational therapy, physical therapy, private duty nursing, speech therapy, supports brokerage, adult foster support, assisted living, behavioral support services, caregiver training and support, community transition services, companion services, environmental modifications, individual goods and services, meals, personal care, personal emergency response system (PERS), personal supports, psychological evaluation, counseling and consultation services, remote monitoring equipment, remote monitoring, retirement services, specialized medical equipment and supplies, supported employment – co-worker support, supported employment – individual employment support, supported employment – small group employment support, transportation for individuals w/IDD/DD ages 0 – no max age; Behavioral Health Severe and Disabling Mental Illness Home and Community Based Services (0455.R02.00): Provides adult day health, case management, homemaker, prevocational services, residential habilitation, respite, supported employment, community transition, consultative clinical and therapeutic services, environmental accessibility adaptations, habilitation aide, health and wellness, homemaker chore, life coach, meals, non-medical transportation, pain and symptom management, peer support, personal assistance attendant, personal emergency response system, private duty nursing/ registered nurse supervision, specialized medical equipment and supplies, specially trained attendant for individuals w/mental illness ages 18 – no max age

Start Date

27-01-20

End Date

27-07-20

Description of Transition Plan

Individuals will transition to pre-emergency service status as soon as circumstances allow. Individual needs will be reassessed, as necessary, on a case by case basis following the return to pre-emergency services.

Area(s) Affected

Area Affected

Statewide

Access and Eligibility

Increase Cost Limits

N/A

Modify Targeting Criteria

N/A

Services

Modify Scope or Coverage

N/A

Exceed Service Limitations

Implement a temporary increase in the amount or duration and waive limits of prior authorization on the following services within the waivers necessary to address issues related to the COVID-19 pandemic. MT-0208.R06.03 Montana Home and Community Based Waiver for Individuals with Developmental Disabilities (Respite); MT-0148.R06.03 Montana Big Sky Home and Community Based Waiver (Companion, Respite, Personal Assistance Services, Non-Medical Transportation); MT 0455 R02 06 Montana Behavioral Health Severe Disabling Mental Illness Home and Community Based Services (Homemaker Chore); Note: Respite limits may be extended beyond 30 days annually without requesting a variance in order to meet the immediate health and safety needs of participants. The state has mechanisms in place to prevent duplicate billing for both institutional and HCB services when respite exceeds 30 days, specifically in institutional settings.

Add Services

The state seeks to add the service Mental Health Group Home to MT 0455 R02 05 (Montana Behavioral Health Severe Disabling Mental Illness Home and Community Based Services). See attached Section A.

Expand Settings

Permit the following services to be delivered in a participant’s home environment or alternative provider or community setting: MT-0208.R06.03 Montana Home and Community Based Waiver for Individuals with Developmental Disabilities (Day Supports & Activities, Retirement Services, Supported Employment-Follow Along Support and Individual Employment Support, Personal Care, Companion, Personal Supports, Homemaker, Residential Habilitation); MT-0148.R06.03 Montana Big Sky Home and Community Based Waiver (Adult Day Health, Day Habilitation, Supported Living); MT 0455 R02 06 Montana Behavioral Health Severe Disabling Mental Illness Home and Community Based Services (Adult Day Health). Additional settings include: The private home of the participant or a family member of the participant; A provider owned or controlled or extended family home; The private home of a direct care provider; Community center or designated community gathering center; Hotel/paid lodging; Newly rented room; Other residential setting; or Telework settings.

Provide Service Out of State

N/A

Allow Payment for Services by Families

For services that currently allow Relative and Legal Guardian to deliver the service, the state will add Legally Responsible Person as an allowable caregiver to be paid for the following services: MT-0208.R06.03 Montana Home and Community Based Waiver for Individuals with Developmental Disabilities (Day Supports and Activities, Homemaker, Residential Habilitation, Respite, Companion Services, Personal Care, Personal Supports, Retirement Services, Specialized Child Care for Medically Fragile Children, Supported Employment-Follow Along Support, Supported Employment- Co-Worker Support, Supported Employment- Individual Employment Support, Supported Employment- Small Group Employment); MT-0148.R06.03 Montana Big Sky Home and Community Based Waiver (Day Habilitation); MT 0455 R02 06 Montana Behavioral Health Severe Disabling Mental Illness Home and Community Based Services * (Personal Assistant Attendant, Specially Trained Attendant) * SDMI waiver will ensure payment to family caregivers or legally responsible individuals by authorizing case management team to issue pass thru payments to the provider.

Modify Provider Qualifications

Modification of Provider Qualifications

All Waivers: Expand provider pool by allowing any enrolled waiver provider to work in all three waivers. Temporarily extend deadlines for all training requirements for 60 days from the original due date. All direct care staff should continue to receive training on the participant’s plan of care for whom they are providing support. Training on the plan of care must consist of basic health and safety support needs for that individual. Providers must continue to ensure that direct care staff are able to demonstrate competency in the skills and techniques necessary to perform their assigned tasks under the participant’s plan of care. MT-0208.R06.03 Montana Home and Community Based Waiver for Individuals with Developmental Disabilities Services included in modification of provider qualifications (Day Supports and Activities, Homemaker, Residential Habilitation, Respite, Companion Services, Personal Care, Personal Supports, Retirement Services, Supported Employment-Follow Along Support, Supported Employment- Co-Worker Support, Supported Employment- Individual Employment Support, Supported Employment- Small Group Employment); MT-0148.R06.03 Montana Big Sky Home and Community Based Waiver: Temporarily suspend the training requirements for the duration of COVID 19 at the provider’s discretion (Personal Assistance Services, Day Habilitation, Adult Day Health); MT 0455 R02 06 Montana Behavioral Health Severe Disabling Mental Illness Home and Community Based Services: Temporarily suspend the training requirements for the duration of COVID 19 at the provider’s discretion (Personal Assistance Services, Specially Trained Attendant, Habilitation Aide).

Modify Provider Types

All Waivers: Expand provider types for specialized equipment and supplies to purchase items from nontraditional vendors who have necessary items in stock when supply or cost impacts occur due to COVID 19 on a case by case basis. MT 0455 R02 06 Montana Behavioral Health Severe Disabling Mental Illness Home and Community Based Services: Mental Health Centers will provide services in the proposed Mental Health Group Home Service in Section A. This will allow Mental Health Centers to provide this service without having to become a HCBS provider type.

Modify Licensure/Requirements for Waiver Settings

Suspend periodic licensing and quality reviews of provider agencies throughout the duration of the pandemic. Allow provider flexibility in daytime staffing levels as long as care quality is retained.

Modification LOC Eval and Re-Eval Processes

Temporarily modify processes for initial level of care for waiver eligibility to allow evaluations to be conducted via telephone or other interactive electronic communication. Telephonic or other remote methods will be conducted with HIPAA requirements, to the extent possible, but with recognition of the Office of Civil Rights is not enforcing certain requirements for good faith communications during the period of the national emergency.

Increase Payment Rates

N/A

Modifications of ISP

Allow assessments to be modified to contain information that can be completed through telephonic and/or electronic interview/observations, allow meetings to be conducted virtually including telephonic or other electronic methods and permit electronic signatures. The state will ensure the person-centered service Plan of Care is modified to allow for additional supports/and or services to respond to the COVID-19 pandemic. The specificity of such services including amount, duration and scope will be appended as soon as possible to ensure that the specific service is delineated accordingly to the date it began to be received. The Plan of Care will be updated no later than 30 days from the date the service was initiated. Plans of Care that are due to expire within the next 60 days require case management contact to the participant using allowable remote contact methods to verify with the participant or representative that the current Plan of Care assessment and service, including providers, remain acceptable and approvable for the upcoming year. The state will verify by obtaining electronic signatures from service providers and the individual or representative, in accordance with the state’s HIPAA requirements. Allow Plan of Care teams to temporarily suspend actions or activities that do not compromise the health and welfare of participants with the informed consent of the individual. If requested and/or necessary, modifications to the Plan of Care may be made, as driven by individualized participant need, circumstance, and consent reviewed on an individualized basis, without the input of the entire Plan of Care team.

Modify Incident Reporting/Med Management Safeguards

MT-0208.R06.03 Montana Home and Community Based Waiver for Individuals with Developmental Disabilities: Require reporting of suspected exposure, symptoms of, and/or confirmation of diagnosis of COVID 19 in incident management data systems. Incidents that meet critical threshold will be reported within 8 hours. Incidents that meet reportable threshold will be entered into the data management system within 48 hours. COVID 19 related incidents shall be reviewed daily by regional managers. Recommended safeguards and precautions will be discussed with the members service providers. Allow medication assistance to be delivered telephonically or via electronic communication for those members who can respond to verbal prompting. Extend medication certification for 60 days past the current individual expiration date. Re-certification will be completed as soon as possible once the emergency is declared over, but not longer than 90 days following the end of the declared emergency. MT-0148.R06.03 Montana Big Sky Home and Community Based Waiver: Require reporting of suspected exposure, symptoms of, and/or confirmation of diagnosis of COVID 19 in incident management data systems within 2 days. The incident tracking system has been updated to include a COVID-19 indicator. MT 0455 R02 06 Montana Behavioral Health Severe Disabling Mental Illness Home and Community Based Services: Require reporting of suspected exposure, symptoms of, and/or confirmation of diagnosis of COVID 19 in incident management data systems within 2 days. The incident tracking system has been updated to include a COVID-19 indicator. All Waivers: Montana would like to delay 372 reporting, quality reporting, and other reporting, for 60 days.

Allow Payment for Services During Acute Care Hospital/Short Term Institutional Stay

Allow for payment of services for the purpose of supporting a participant when temporarily institutionalized in a nursing facility, swing bed, critical access hospital or acute care hospital, for a COVID 19-related illness. This is specifically for the purpose of providing additional supports for communication, behavior and/or extensive personal supports and such services are not covered in such settings. MT-0208.R06.03 Montana Home and Community Based Waiver for Individuals with Developmental Disabilities (Residential Habilitation, Day Supports and Activities, Retirement Services, Personal Supports, Companion, Adult Foster). MT 0455 R02 06 Montana Behavioral Health Severe Disabling Mental Illness Home and Community Based Services (Specially Trained Attendant, Life Coach).

Inclusion of Retainer Payments

Add or increase retainer payments for waiver providers of services identified as habilitation services that include a component of personal care and/or personal care. Retainer payments shall be available when the participant is hospitalized or otherwise unavailable to participate in habilitative services for the duration of COVID 19 related absences. The retainer time limit will not exceed the lesser of 30 consecutive days or the number of days for which the state authorizes a payment for “bed hold” in nursing facilities. MT-0208.R06.03 Montana Home and Community Based Waiver for Individuals with Developmental Disabilities (Adult Foster, Assisted Living, Companion Services, Day Supports and Activities, Personal Care Services, Residential Habilitation, Retirement Services, Supported Employment Follow Along Support*, Supported Employment Individual Employment Support*, Supported Employment- Small Group Employment*). MT-0148.R06.03 Montana Big Sky Home and Community Based Waiver (Residential Habilitation, Post-Acute Rehabilitation Services, Supported Living, Adult Day Health, Day Habilitation, Personal Care Services, Private Duty Nursing); MT 0455 R02 06 Montana Behavioral Health Severe Disabling Mental Illness Home and Community Based Services (Residential Habilitation, Personal Care Services, Specially Trained Attendant, Private Duty Nursing).* Supported employment includes habilitation services that include a component of personal care needed to stabilize and maintain a member in a competitive, customized, or self- employment.

Institute/Expand Opportunities for Self-Direction

N/A

Increase Factor C

N/A

Other Changes Necessary

MT-0208.R06.03 Montana Home and Community Based Waiver for Individuals with Developmental Disabilities: Providers may be reimbursed for tiered services at the tier that is prior authorized for the service list below, provided that daytime staffing hours never fall below 80% of the lower end of the tier threshold. (Residential Habilitation- Congregate Living, Residential Habilitation- Supported Living, Day Supports and Activities, Retirement Services, Supported Employment- Small Group Employment, Supported Employment- Follow Along).

Addendum

HCBS Regulations

Not comply with the HCBS settings requirement at 42 CFR 441.301(c)(4)(vi)(D) that individuals are able to have visitors of their choosing at any time, for settings added after March 17, 2014, to minimize the spread of infection during the COVID-19 pandemic.

Services

Add Electronic Method of Service Delivery

Case management, personal care services that only require verbal cueing, in-home habilitation, monthly monitoring

Add Home Delivered Meals

N/A

Add Medical Supplies, Equipment and Appliances

N/A

Add Assistive Technology

N/A

Conflict of Interest

Other Changes Necessary

Provider Qualifications

Allow Spouses and Parents of Minor Children to Provide Personal Care Servcies

Allow a Family Member to be Paid to Render Services to an Individual

Allow Other Practitioners in Lieu of Approved Providers Within the Waiver

Modify Service Providers for Home-Delivered Meals to Allow for Additional Providers, Including Non-Traditional Providers

Processes

Allow an Extension for Reassessments and Reevaluations for up to One Year Past the Due Date

Allow the Option to Conduct Evaluations, Assessments, and Person-Centered Service Planning Meetings Virtually/Remotely in lieu of Face-to-Face Meetings

Adjust Prior Approval/Authorization Elements Approved in Waiver

Adjust Assessment Requirements

Add an Electronic Method of Signing Off on Required Documents Duch As The Person-Centered Service Plan

Link To Application

Montana Appendix K Application (PDF)

Link to Approval Letter

Montana Appendix K Approval Letter (PDF)