This regulation establishes Montana's Severe and Disabling Mental Illness (SDMI) Home and Community-Based Services (HCBS) Medicaid waiver program for adults 18 and older who have qualifying severe mental illness diagnoses and would otherwise require nursing facility care. It sets out eligibility criteria, enrollment and wait-list procedures, covered services (including case management, residential habilitation, supported employment, personal assistance, and others), provider requirements, person-centered recovery plan development and review obligations, reimbursement rules, and notice and fair hearing rights. Providers must be enrolled Montana Medicaid providers, meet all applicable licensing and insurance requirements, and ensure services are delivered in community settings consistent with 42 CFR 441.301(c)(4).
View official source37.90.401 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: FEDERAL AUTHORIZATION AND STATE ADMINISTRATION (1) The department has established the Severe and Disabling Mental Illness, Home and Community Based Services waiver program for members who have severe and disabling mental illness, as defined in ARM 37.90.409 , and who would otherwise have to reside in and receive Medicaid reimbursed care in a nursing facility. (2) The department, in accordance with state and federal statutes, administrative rules, federal-state agreements governing the provision of the Medicaid funded home and community-based services delivered under this program, and within the available funding appropriated for the program, may determine within in its discretion: (a) the types of services available through the program; (b) the amount, scope, and duration of the services available through the program; (c) the target population to be served through the program; (d) the total number of members who may receive services through the program; (e) delivery approach; and (f) eligibility of members for the program. (3) Enrollment in the program and the provision of services through the program are at the discretion of the department. There is no legal entitlement to enroll in the program or to receive any or all the services available through the program. (4) The Severe and Disabling Mental Illness, Home and Community Based Services waiver program is referred to throughout this subchapter as "the SDMI HCBS waiver program" or "the waiver program." Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2010 MAR p. 1538, Eff. 6/25/10; AMD, 2012 MAR p. 1265, Eff. 7/1/12; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.402 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: SERVICES (1) The services available through the waiver program are: (a) adult day health, as described in ARM 37.90.430 ; (b) behavioral intervention assistant, as described in ARM 37.90.433 ; (c) case management, as described in ARM 37.90.425 ; (d) community transition services, as described in ARM 37.90.415 ; (e) consultative clinical and therapeutic services, as described in ARM 37.90.418 ; (f) environmental accessibility adaptations, as described in ARM 37.90.414 ; (g) health and wellness, as described in ARM 37.90.417 ; (h) homemaker chore, as described in ARM 37.90.419 ; (i) life coach, as described in ARM 37.90.434 ; (j) meals, as described in ARM 37.90.426 ; (k) non-medical transportation, as described in ARM 37.90.450 ; (l) pain and symptom management, as described in ARM 37.90.416 ; (m) personal assistance service, as described in ARM 37.90.431 ; (n) personal emergency response system, as described in ARM 37.90.448 ; (o) private duty nursing, as described in ARM 37.90.447 ; (p) residential habilitation, as described in ARM 37.90.451 , 37.90.452 , 37.90.453 , 37.90.454 , and 37.90.455 ; (q) respite care, as described in ARM 37.90.438 ; (r) specialized medical equipment and supplies, as described in ARM 37.90.449 ; and (s) supported employment, as described in ARM 37.90.435 . Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2012 MAR p. 1265, Eff. 7/1/12; AMD, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2024 MAR p. 2234, Eff. 9/21/24. 37.90.403 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: DEFINITIONS (1) "Activities of daily living" (ADL) means basic personal everyday activities. (2) "Applicant" means an individual requesting services but not enrolled in the SDMI program. (3) "Community First Choice" and "Personal Assistance Service" Programs (CFC/PAS) are Medicaid state plan programs designed to provide long term supportive care in a home setting. These programs are distinct from the PAS waiver service described in ARM 37.90.431 . (4) "Critical incident" is an incident that is serious in nature and poses a risk to the health, safety, or welfare of an enrolled member or others. It is a serious occurrence that includes abuse, neglect, and exploitation, each of which are defined under 52-3-803 , MCA. (5) "Enrolled member" means an individual enrolled in the SDMI program and authorized to receive services under the SDMI program. (6) "Institutionalization" means placement in a nursing facility, a mental health nursing facility, or a state mental health hospital. (7) "Instrumental activities of daily living" (IADL) means household tasks which are limited to cleaning the area used by the member. (8) "Level of care assessment" (LOC) means a functional assessment used to determine if an individual requires the level of care normally provided in a nursing facility. (9) "Level of impairment assessment" (LOI) means an assessment used to identify areas in which a member requires long term services and supports. (10) "Mental health professional" has the meaning provided in 53-21-102 , MCA. (11) "Non-critical incidents" are minor in nature and do not pose a risk to the health, safety, or welfare of an enrolled member or others. (12) "Person-centered recovery plan" (PCRP) is a written plan that identifies the supports and services that are necessary for the enrolled member to remain out of institutional level of care, allow the enrolled member to function at the enrolled member's maximum capacity, and enable the enrolled member to achieve personal goals toward recovery. (13) "Quality improvement organization" (QIO) means the entity under contract with the department to complete agreed upon utilization review activities for Montana Medicaid services. (14) "SDMI" is used in this subchapter to refer to severe and disabling mental illness, which is described in ARM 37.90.409 . (15) "SDMI HCBS waiver program" is used in this subchapter to refer to severe and disabling mental illness home and community-based services waiver services. Authorizing statute(s): 52-3-803 , 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2012 MAR p. 1265, Eff. 7/1/12; AMD, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2024 MAR p. 2234, Eff. 9/21/24. 37.90.406 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: PROVIDER REQUIREMENTS (1) The waiver program services may only be provided by a provider that: (a) is enrolled as a Montana Medicaid provider except as provided in (2); (b) meets all facility, licensing, and insurance requirements applicable to the services offered, the service settings provided, and the professionals employed; and (c) meets the criteria as a qualified provider authorized to deliver the service as specified in this subchapter. (2) A provider of services must ensure that the services adhere to the requirements of 42 CFR 441.301 (c)(4), which permits reimbursement with Medicaid monies only for services within settings that meet certain qualities set forth under the regulation. These qualities include that the setting: (a) is integrated in and facilitates full access of the individual to the greater community; (b) ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid Home and Community-Based Services; (c) is selected by the individual from among setting options, including non-disability specific settings and an option for a private unit in a residential setting; (d) ensures the individual's rights of privacy, dignity, and respect, and freedom from coercion and restraint; (e) supports health and safety based upon the individual's needs, decisions, or desires; (f) optimizes, but does not regiment, individual initiative, autonomy, and independence in making life choices, including, but not limited to daily activities, physical environment, and with whom to interact; (g) provides an opportunity to seek employment and work in competitive integrated settings; and (h) facilitates individual choice of services and supports, and who provides them. (3) The department may authorize a contracted case management entity to issue pass-through payment for reimbursement of services rendered by a non-Medicaid provider for the following services: (a) community transition; (b) environmental accessibility adaptations; (c) health and wellness; (d) homemaker chore; (e) meals; and (f) specialized medical equipment and supplies. (4) A provider must document the completion of required training in the personnel file of the staff or in the provider's staff training files which includes: (a) title of the training; (b) the date of the training; (c) name and title of the trainer; (d) type or topic of the training; (e) the agenda of the training; (f) the hours of the training; and (g) the signature and date of the staff who received the training. (5) Providers must ensure that direct care staff are trained and capable of providing waiver program services. (6) The department adopts and incorporates by reference 42 CFR 441.301 (c)(4), as amended January 16, 2014. A copy of this regulation may be obtained at https://www.ecfr.gov/ or by contacting the Department of Public Health and Human Services, Behavioral Health and Developmental Disabilities Division, 100 N. Park, Ste. 300, P.O. Box 202905, Helena, MT 59620-2905. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2024 MAR p. 612, Eff. 3/23/24; AMD, 2024 MAR p. 2234, Eff. 9/21/24. 37.90.408 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: REIMBURSEMENT (1) The department adopts and incorporates by reference the Medicaid Home and Community-Based Services for Adults with Severe and Disabling Mental Illness fee schedule. Unless otherwise provided for in rule, the provider reimbursement rate for waiver program services is stated in the department's fee schedule as provided in ARM 37.85.105 (5)(b). These fees are calculated based on: (a) the biennial legislative appropriation; and (b) the estimated demand of covered services during the biennium. (2) Medicaid reimbursement for the SDMI HCBS waiver program will be the lesser of: (a) the provider's usual and customary charge for the service; or (b) the rate established in the department's Medicaid fee schedule adopted and incorporated into ARM 37.85.105 (5)(b). (3) The SDMI HCBS waiver program is the payor of last resort and will not reimburse a service that otherwise is or should be paid by another source. (4) The SDMI HCBS waiver program will not reimburse for services provided to individuals of an enrolled member's household or family. (5) All SDMI HCBS services, except for case management, must be prior authorized before delivery of services. Services that are delivered before prior authorization is received will not be approved and, if reimbursed, may be subject to repayment. (6) A provider must ensure that services adhere to the requirements of ARM 37.85.405 . Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2011 MAR p. 1394, Eff. 7/29/11; AMD, 2012 MAR p. 1265, Eff. 7/1/12; AMD, 2013 MAR p. 1111, Eff. 7/1/13; AMD, 2018 MAR p. 1116, Eff. 7/1/18; AMD, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2024 MAR p. 2234, Eff. 9/21/24; AMD, 2025 MAR, Notice No. 2025-523, Eff. 11/22/25. 37.90.409 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: SEVERE AND DISABLING MENTAL ILLNESS CRITERIA (1) To be found to have a qualifying SDMI diagnosis, an individual must: (a) be 18 years of age or older; (b) have a minimum of three areas of high-level impairment indicated by a score of three or higher on the Behavioral Health and Developmental Disabilities (BHDD) Severe and Disabling Mental Illness, Home and Community-Based (HCBS) Waiver, Evaluation and Level of Impairment (LOI) form; and (c) have experienced one of the following in the previous 12 months: (i) involuntarily committed because of a mental disorder to the Montana State Hospital or the Montana Mental Health Nursing Care Center for at least 30 consecutive days; or (ii) diagnosed with one of the following diagnoses, excluding mild or not otherwise specified: (A) Schizophrenia, paranoid type; (B) Schizophrenia, disorganized type; (C) Schizophrenia, catatonic type; (D) Schizophrenia, undifferentiated type; (E) Schizophrenia, residual type; (F) Delusional disorder; (G) Schizoaffective disorder; (H) Schizoaffective disorder, depressive type; (I) Bipolar I disorder, manic, moderate; (J) Bipolar I disorder, manic, severe without psychotic features; (K) Bipolar I disorder, manic, severe with psychotic features; (L) Bipolar I disorder, depressed, moderate; (M) Bipolar I disorder, depressed, severe without psychotic features; (N) Bipolar I disorder, depressed, severe with psychotic features; (O) Bipolar I disorder, mixed, moderate; (P) Bipolar I disorder, mixed, severe without psychotic features; (Q) Bipolar I disorder, severe with psychotic features; (R) Bipolar II disorder; (S) Major depressive disorder, single, moderate; (T) Major depressive disorder, single, severe without psychotic features; (U) Major depressive disorder, single, severe with psychotic features; (V) Major depressive disorder, recurrent, moderate; (W) Major depressive disorder, recurrent, severe without psychotic features; (X) Major depressive disorder, recurrent, severe with psychotic features; (Y) Post traumatic stress disorder, acute; (Z) Post traumatic stress disorder, chronic; (AA) Generalized anxiety disorder; and (BB) Borderline personality disorder. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2021 MAR p. 1555, Eff. 11/6/21; AMD, 2024 MAR p. 2234, Eff. 9/21/24. 37.90.410 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: CONSIDERATION FOR PROGRAM ELIGIBILITY AND ENROLLMENT SELECTION (1) An applicant may be considered for enrollment in the program if the applicant meets the following criteria: (a) is at least 18 years of age; (b) is Medicaid eligible; (c) requires the level of care (LOC) of a nursing facility; (d) meets the criteria in ARM 37.90.409 ; and (e) meets the following additional criteria: (i) the case management team determines that the applicant needs at least two SDMI HCBS waiver program services that can only be met through the SDMI HCBS waiver program. One of those services must be case management, and the SDMI HCBS waiver program service of meals cannot be counted as one of the two services; and (ii) the case management team determines that the service providers necessary to deliver the services requested by the applicant are available at the time of enrollment. (2) When an applicant is found eligible to receive waiver program services, the case management team will: (a) offer the applicant an available opening for program services if an opening is available; or (b) place the applicant on the wait list if an opening for program services is not available. (3) If an applicant is placed on the wait list in accordance with (2)(b), the applicant will be placed on the SDMI HCBS waiver program wait list in the service areas the applicant selects. (4) The case management team must use the applicant's combined LOC and LOI scores to determine the applicant's score for relative placement on the SDMI HCBS waiver program wait list. (5) If more than one applicant has the same combined wait list score, then each applicant is placed on the SDMI HCBS waiver program wait list based upon the applicant's wait list score as determined in (4), and thereafter in the order in which the applicant is placed on the SDMI HCBS waiver program wait list. (6) Placement on the SDMI HCBS waiver program wait list is not a guarantee an applicant will receive enrollment into the SDMI HCBS waiver program. Individuals qualified but not enrolled in another waiver program may be placed on the SDMI HCBS waiver program wait list. (7) The case management teams must review the SDMI HCBS waiver program wait list and update the SDMI HCBS waiver program wait list quarterly to ensure that individuals on the list continue to meet criteria for SDMI HCBS waiver program services. The review consists of verifying each wait list individual's ongoing need for at least two SDMI HCBS waiver program services, and continued LOC and LOI criteria. In addition, the case management teams will confirm, through the approved documentation process with the Office of Public Assistance (OPA), each individual meets the financial/non-financial Medicaid eligibility criteria prior to enrolling the individual into the SDMI program. (8) An applicant must be removed from the wait list for the following reasons: (a) the applicant's whereabouts are unknown, and the case management team has attempted to contact the applicant a minimum of once per quarter for two consecutive quarters and no response has been received from the applicant; (b) the case management team determines that the service providers necessary to deliver at least two SDMI HCBS waiver program services requested by the applicant are unavailable. Unavailable means when there is no provider who has said the provider has the staff and resources to serve the applicant in the applicant's current or requested area and who would accept the applicant if the applicant was enrolled in the SDMI program. Unavailable is established on the date of the quarterly review. The SDMI HCBS waiver program meals service does not count towards the two services; (c) the applicant's needs cannot be met by the SDMI HCBS waiver program, as determined by the case management team; (d) the applicant has reported he or she will not or cannot pay any Medicaid spend down; (e) the applicant has moved out of state; (f) the applicant requests to be removed from the wait list; (g) the Office of Public Assistance has determined the applicant does not meet established financial and resource criteria; or (h) the applicant's death is confirmed. (9) An applicant must not remain on the wait list for more than six consecutive months. Exceptions may be made with prior approval from SDMI program staff. (10) The case management team must provide an enrolled member with written notice ten working days before termination of services due to a determination of program ineligibility. An enrolled member may be removed from the SDMI HCBS waiver program for the following reasons: (a) a determination by a mental health professional that the enrolled member no longer meets the SDMI diagnosis criteria set forth in ARM 37.90.409 ; (b) the enrolled member fails to select or does not actively participate in at least two services in the waiver program within 30 calendar days from the date the enrolled member agrees to and signs the PCRP. The service of meals cannot be counted as one of the two services; (c) the department determines that the enrolled member has failed to utilize or to attempt to utilize at least two waiver services, in 30 days, with repeated attempts documented by the case management team to engage the enrolled member; (d) the enrolled member no longer requires the level of care of a nursing facility as determined by the QIO under contract with the department; (e) the case management team or program staff received written notification from the Office of Public Assistance confirming Medicaid ineligibility; (f) insufficient SDMI HCBS waiver program funds; (g) the enrolled member moved out of state; (h) the enrolled member refuses to sign or participate in the completion of the PCRP or quarterly review; (i) the enrolled member's behavior creates serious risk to the member, caregivers, or others, or substantially impedes the delivery of services as established in the PCRP; (j) the enrolled member's death; (k) the enrolled member's failure to use services as established in the PCRP; (l) the enrolled member's needs cannot be met through the SDMI HCBS waiver program; (m) the enrolled member's written request to withdraw from the program; (n) the health of the enrolled member deteriorates or in some manner places the enrolled member at serious risk of harm; (o) the enrolled member is admitted to a nursing facility or hospital for a stay exceeding 30 days; (p) the service providers necessary for the delivery of services are unavailable; or (q) the services are no longer appropriate or effective in relation to the enrolled member's needs as determined by the case management team. (11) Eligibility for consideration for the waiver program does not entitle an individual to selection and entry into the program. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2010 MAR p. 1538, Eff. 6/25/10; AMD, 2012 MAR p. 1265, Eff. 7/1/12; AMD, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2024 MAR p. 2234, Eff. 9/21/24. 37.90.412 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: PERSON-CENTERED RECOVERY PLAN (1) The PCRP is developed by the enrolled member and the case management team to meet the enrolled member's identified needs as well as cost of identified services. (2) All services must be specifically authorized in writing in the enrolled member's PCRP. (3) Each PCRP must be developed, reviewed, and revised by the CIO case management team. The case management team must: (a) develop an initial PCRP upon the enrolled member's enrollment into the SDMI HCBS waiver program which is the date the enrolled member begins receiving services under the SDMI HCBS waiver program; (b) ensure the initial PCRP includes all aspects of (5)(a) through (m) based on the LOC, LOI, and the information obtained by the case management team; (c) initiate the strength assessment upon the enrolled member's enrollment into the SDMI HCBS waiver program to determine the enrolled member's strengths, needs, preferences, goals, and desired outcomes, along with his/her health status and risk factors; (d) complete the strength assessment within three months of the enrolled member's enrollment into the program. Upon completion of the strength assessment, the PCRP is finalized; (e) have monthly telephone contact with the enrolled member consisting of monthly monitoring calls; (f) conduct in-person reviews of the PCRP with the enrolled member every three months. Any issues with the PCRP and the delivery and implementation of services are to be discussed at this time. The review is conducted at the enrolled member's place of residence, place of service, or other appropriate setting, as determined by the enrolled member's needs. This is an opportunity for case management teams to monitor the health and welfare of the enrolled member and evaluate the delivery of services to the enrolled member. This review includes evaluating and assessing strategies for meeting the needs, preferences, and goals of the enrolled member. It also includes evaluating and obtaining information concerning the enrolled member's satisfaction with the services, the effectiveness of services being provided, changes in the enrolled member's function, and cost effectiveness of the services. (g) update the PCRP to reflect any changes to the information listed in (5)(a) through (j); and (h) complete an annual review of the PCRP with the enrolled member and update the PCRP if there are any changes to the information listed in (5)(a) through (j). (4) The case management team must develop the PCRP in consultation with: (a) the enrolled member or the enrolled member's legal representative; (b) the enrolled member's treating professional and other appropriate health care professionals; and (c) others who have knowledge of the enrolled member's needs. (5) The PCRP must include: (a) the primary SDMI diagnosis and any other diagnosis of the enrolled member that are relevant to the services provided; (b) the enrolled member's symptoms, complaints, and complications indicating the need for services; (c) the enrolled member's strengths, areas of concern, goals, objectives, and required interventions; (d) the SDMI HCBS waiver program services that will be provided; (e) all other services the enrolled member requires including Montana Medicaid state plan services and community-based services and supports. However, including non-program services in the PCRP does not obligate the department to pay for the non-program services or ensure their delivery or quality; (f) a description of how each service addresses each of the enrolled member's functional needs outlined in the Severe and Disabling Mental Illness, Home and Community Based Services, Evaluation and Level of Impairment form; (g) a crisis plan; (h) physicians' orders; (i) a discharge plan; (j) the projected annual cost of SDMI Home and Community-Based Services (HCBS) waiver program services provided; (k) the signature of the enrolled member or the enrolled member's legal representative which signifies the participation in and agreement of the PCRP; (l) the names and signatures of all individuals who participated in the development of the PCRP which signifies the participation in and agreement of the PCRP; and (m) the enrolled member's bill of rights that informs enrolled members they have the right to choose from the full range of services available in the waiver if appropriate and that services will be delivered by a qualified provider of the enrolled member's choice. (6) The case management team must provide a copy of the plan to the recipient. (7) The case management team must retain all of the enrolled member's records in accordance with ARM 37.85.414 . (8) The PCRP must be approved by the department initially and then annually. The annual review must ensure compliance with this rule and federal guidance. If the initial PCRP is found to meet program criteria, the department must approve the PCRP within 30 days of enrollment into the care management system. (9) The department reviews all initial and annual PCRP and at any time there is a change. (10) The PCRP is subject to review by the department at any time. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2024 MAR p. 2234, Eff. 9/21/24. 37.90.413 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: COST OF PERSON-CENTERED RECOVERY PLAN (1) In order to maintain the program cost within the appropriated federal and state funds, the cost of a member's Person-Centered Recovery Plan (PCRP) may be limited by the department. (2) The total annual cost of services for each member, except as approved by the department, may not exceed a maximum amount set by the department. (3) The department may limit the services members receive under the waiver program based upon the appropriation of funding by the legislature. (4) The cost of services in the PCRP must be determined prior to implementation of the PCRP and may be revised as necessary by the department or the department's designee. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.414 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: ENVIRONMENTAL ACCESSIBILITY ADAPTATIONS (1) Environmental accessibility adaptations are modifications to a member's home that are necessary to increase accessibility, independence, and prevent the need for a higher level of care. (2) The member's need for the adaptation must be documented by an individual with the appropriate licensure, certification, or experience with home modification to document the member's need for the adaptation to increase accessibility, independence, and prevent the need for a higher level of care. (3) The provision of environmental accessibility adaptations may include the provision of consultation regarding the appropriateness of the equipment or supplies. (4) The waiver program does not cover: (a) additions to the square footage of the home; (b) services that are for comfort or convenience; (c) services that are not a direct and specific benefit for the member; and (d) services that are for maintenance, repair, or building code compliance that is the responsibility of the homeowner. (5) Environmental accessibility adaptations must: (a) ensure the health, welfare, and safety of the member in their home; and (b) allow the member to function with greater independence in their home. (6) Environmental accessibility adaptations must be provided in accordance with applicable state and local building codes by individuals licensed through the Montana Department of Labor and Industry to do home modifications. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.415 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: COMMUNITY TRANSITION SERVICES (1) Community transition services are nonrecurring set-up expenses for members who are transitioning from an institutional setting into a community living setting or a private residence and are necessary to coordinate and purchase to establish a basic household. (2) The department may approve community transition services on a case-by-case basis from other settings in circumstances that address a member's health or safety. (3) The case management team must complete a needs assessment prior to implementation of the service. (4) The needs assessment must demonstrate community transition services are required to: (a) address a health or safety concern; and (b) discharge from or avert institutionalization. (5) Allowable expenses are those necessary to enable a person to establish a basic household and may include: (a) customary security deposits that are required to obtain a lease on an apartment or home; (b) essential household items; (c) moving expenses incurred directly from the moving, transport, provision, or assembly of household furnishings for the residence; (d) customary setup fees or deposits for utility or service access, including telephone landline or cell phone, electricity, heating, and water; (e) services necessary for a member's health and safety; and (f) fees associated with obtaining legal or identification documents necessary for housing applications. (6) Community transition services do not include monthly rental or mortgage expenses, food, and diversion/recreational expenses. (7) Refunded security deposits must be paid to the department. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2012 MAR p. 1265, Eff. 7/1/12; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.416 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: PAIN AND SYMPTOM MANAGEMENT (1) Pain and symptom management is defined as a service that provides traditional and nontraditional methods of pain reduction or management. (2) Allowable non-traditional or mind-body therapies include: (a) acupuncture; (b) reflexology; (c) massage therapy; (d) craniosacral therapy; (e) hypnosis; (f) biofeedback; and (g) pain mitigation counseling/coaching. (3) Allowable traditional therapies include: (a) chiropractic therapy; and (b) nursing services by a nurse specializing in pain and symptom management. (4) The service must be prescribed by a licensed health care professional. (5) The service must be documented in the member's Person-Centered Recovery Plan and: (a) address the member's chronic or acute symptoms, complaints, or complications indicating the need for services; (b) include the number of authorized sessions; and (c) document the expected outcomes of the provision of the service. (6) Services must be provided by a person licensed or certified to provide the service. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2012 MAR p. 1265, Eff. 7/1/12; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.417 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: HEALTH AND WELLNESS (1) Health and wellness services are services that assist a member in acquiring, retaining, and improving self-help, socialization, and adaptive skills to reside successfully in the community. (2) The services include: (a) classes on weight loss, smoking cessation, and healthy lifestyles; (b) health club memberships and exercise classes; (c) art, music, and dance classes; (d) costs associated for participating in adaptive sports and recreational activities; (e) classes on managing disabilities; and (f) hippotherapy. (3) The service must be prescribed by a licensed health care professional. (4) The service must be documented in the member's Person-Centered Recovery Plan and: (a) address the member's symptoms, complaints, or complications indicating the need for services; (b) include the number of authorized sessions; and (c) document the expected outcomes of the provision of the service. (5) Services may be provided in a setting appropriate to the provision of the service. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2012 MAR p. 1265, Eff. 7/1/12; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.418 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: CONSULTATIVE CLINICAL AND THERAPEUTIC SERVICES (1) Consultative clinical and therapeutic services provide comprehensive expertise, training, and technical assistance to improve the ability of providers and caregivers to carry out therapeutic interventions and reduce challenges that may be interfering with a member's daily functioning, independence, and quality of life. (2) Consultative clinical and therapeutic services include: (a) a clinical/functional evaluation; (b) implementation of positive behavioral supports as part of the member's Person-Centered Recovery Plan (PCRP); (c) training and technical assistance for the member's paid and non-paid caregivers to implement the positive behavioral supports; and (d) monitoring the member's response to the positive behavioral supports and updating the PCRP if necessary. (3) Consultative clinical and therapeutic services must meet a documented behavioral need that cannot be addressed through other waiver or state plan services. (4) Consultative clinical and therapeutic services may be provided by a: (a) psychiatrist; (b) psychologist; (c) neuropsychiatrist; (d) licensed clinical professional counselor; or (e) licensed clinical social worker. (5) Training must be aimed at assisting the provider and caregiver in meeting the needs of the member and must include instruction to implement the positive behavioral supports outlined in the member's PCRP. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.419 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: HOMEMAKER CHORE (1) Homemaker chore services are extensive cleaning beyond the scope of general household cleaning under Community First Choice/Personal Assistance Service (CFC/PAS) state plan and is needed to return a residence to a sanitary and safe environment. (2) Homemaker chore may be provided by: (a) entities that provide deep cleaning, yard, trash removal, and moving services; (b) home health providers; and (c) CFC/PAS providers. (3) Homemaker chore is provided when neither the member nor other community resources are available to provide the service. (4) Moving expenses must be prior authorized by the department. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.420 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: NOTICE AND FAIR HEARING (1) The department provides written notice to a member when a determination is made by the department concerning: (a) Medicaid eligibility; (b) eligibility for the SDMI HCSB waiver program; and (c) changes to a member's Person-Centered Recovery Plan (PCRP). (2) The department provides a member with notice ten working days before termination of services due to a determination of ineligibility. (3) Requirements for administrative review and fair hearings are provided for in ARM Title 37, chapter 5, subchapter 3. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.425 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: CASE MANAGEMENT (1) Case management means case management as defined in the Code of Federal Regulations (CFR) at 42 CFR 440.169 (d)(e). (2) Case management services offered under the Severe and Disabling Mental Illness, Home and Community Based waiver program are provided through a selective contract for conflict free case management under the authority of a 1915(b)(4) waiver authorized under Section 1915(b) of the Social Security Act. (3) A case management team must consist of: (a) a case manager with a bachelor's level education in the field of human services; and (b) a registered nurse, licensed practical nurse, licensed clinical social worker, or licensed clinical professional counselor to provide clinical supervision for every two case managers. (4) Case management teams submit annual report cards to the SDMI HCBS waiver program staff as well as monthly utilization reports to ensure that quality assurance measures are met in accordance with performance measures. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2012 MAR p. 1265, Eff. 7/1/12; AMD, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2024 MAR p. 2234, Eff. 9/21/24. 37.90.426 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: MEALS (1) Meal service is the provision of hot or cold meals to a member up to twice daily. (2) Meals may be provided by: (a) a non-profit entity or public agency that provides congregate or home-delivered meals on a regular basis to individuals who are unable to gain access to meals due to age or disability; (b) entities that provide home-delivered meals that are transported from a preparation site to the member's residence; or (c) meal preparation entities. (3) Members must need special assistance to ensure adequate nutrition due to: (a) special nutritional needs; or (b) the member's inability to gain access to proper nutrition due to a disability. (4) The provider must follow the rules that govern the provision of meal services at ARM 37.41.306 through 37.41.315 . (5) If meals are provided during the provision of another service, the total combined meals provided to the member may not exceed two meals per day. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.430 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: ADULT DAY HEALTH (1) Adult day health is a supervised daytime program that offers health and social services for adults with severe and disabling mental illness to ensure optimal functioning of the member and enrichment activities through engaging social community but who do not require the intervention or services of a registered nurse or licensed rehabilitative therapist onsite. (2) An entity providing adult day health services must be licensed as an adult day care center as provided at ARM 37.106.301 , et seq. (3) Adult day health services are furnished in an outpatient setting that does not include overnight residential services. (4) Adult day health includes the following service components: (a) meals as described in ARM 37.106.2616 ; (b) health, nutritional, recreational, and social habilitation; and (c) transportation between the member's place of residence and the adult day health center. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.431 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: PERSONAL ASSISTANCE SERVICE (1) Personal assistance service (PAS) is the provision of long term service and supports in a member's home and in the community tailored to each member's needs and living situation. (2) PAS may be provided by: (a) a home health agency provider; (b) a community first choice/personal assistance service (CFC/PAS) provider; or (c) a member self-directing the service, as described in ARM 37.90.439 . (3) PAS may be provided only when the services available in CFC/PAS are insufficient to meet the following needs of the member: (a) the member has a documented physical need that requires hours in addition to the 42 bi-weekly hours available under CFC/PAS; or (b) the member requires services outside of their residence that cannot be provided by CFC/PAS. (4) PAS may not be provided in a residential habilitation. (5) PAS includes the following service components: (a) activities of daily living; (b) instrumental activities of daily living; and (c) non-medical transportation. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.433 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: BEHAVIORAL INTERVENTION ASSISTANT (1) Behavioral Intervention Assistant service is provided when the PAS available in the waiver and CFC/PAS provided in the state plan are insufficient in meeting the needs of the enrolled member due to challenging behaviors and assistance is required to improve or restore function in ADLs, IADLs, or social and adaptive skills. (2) Behavioral intervention assistant service is provided by entities that are licensed and insured to deliver personal care services. If an enrolled member chooses to self-direct their services as a co-employer, the enrolled member must use an agency providing personal assistance, behavioral intervention assistance, or life coach type services, with the goal of ensuring the enrolled member is successful with the self-direction experience. (3) Behavioral intervention assistants must: (a) have at least eight hours of mental health training within six months of hire and annually thereafter, in order to develop and maintain specialized skills to address the challenging behaviors of enrolled members; (b) be at least 18 years of age; (c) receive training, within 30 days of hire in: (i) abuse reporting; (ii) incident reporting; (iii) client confidentiality; and (iv) any specialty training required or needed to sufficiently address the entire needs of the enrolled member, to provide whole person care; (d) possess the ability to complete the documentation requirements of the program; and (e) possess a valid driver's license and proof of auto liability insurance if transporting the enrolled member. (4) Behavioral intervention assistants provide instructive assistance, cueing to prompt, and supervision, to assist the enrolled member in completion of ADLs, IADLs, and community integration activities. (5) Behavioral intervention assistant services may not be provided concurrently with personal assistance services or supported employment services. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2024 MAR p. 2234, Eff. 9/21/24. 37.90.434 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: LIFE COACH (1) Life coach focuses on social determinants of health (SDoH) that impact a enrolled member's overall health and well-being, and addresses the obstacles that impede an enrolled member's progress towards self-sufficiency, improved health, and well-being. (2) Life coach services may be provided by: (a) independent living centers; (b) personal care entities; (c) other entities approved by the department; or (d) a member self-directing the service, as described in ARM 37.90.439 . (3) Life coaches must have at least eight hours of specialized behavioral health training annually approved by the department. (4) All life coach providers must complete and submit the designated application to the department. (5) An enrolled member must have a SDoH assessment with identified needs and established goals in their PCRP. (6) Life coach services must include at least one of the following social determinants of health: (a) economic stability; (b) neighborhood and physical environment; (c) education; (d) regular and consistent access to healthy foods, education on nutrition, and overall health impacts; (e) access to needed healthcare; and (f) community and social context. (7) Life coach services may not duplicate services provided under behavioral intervention assistant. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2024 MAR p. 2234, Eff. 9/21/24. 37.90.435 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: SUPPORTED EMPLOYMENT (1) Supported employment services assist members to prepare for, find, and keep competitive jobs that exist in the open labor market, pay at least minimum wage, and are in a variety of integrated work settings. (2) Supported employment services are provided by public or private employment agencies, Independent Living Centers, organizations that provide support for individuals with disabilities, Mental Health Centers, or a self-employed individual with at least: (a) an associate degree in vocational rehabilitation, career development, or disability services; (b) an Individual Placement Services (IPS) certification; or (c) two years of experience in vocational rehabilitation, career development, or disability services and receive an IPS certification within six months of hire. (3) A supported employment provider must have at least eight hours of specialized behavioral health training annually approved by the department. (4) Supported employment services are for members who have previously been unable to succeed in competitive employment due to significant disabilities or challenging behaviors and need intensive, ongoing job supports to maintain long-term employment. (5) The need for supported employment must be documented in the member's Person-Centered Recovery Plan and individualized to meet the identified need. (6) Supported employment may: (a) continue for as long as the member wants and needs support; and (b) be provided in conjunction with other employment services. (7) Supported employment may be provided only in a competitive employment setting. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.438 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: RESPITE CARE (1) Respite care is planned or emergency care provided to a member with need for support and supervision in order to provide temporary relief to the unpaid caregiver of the member. (2) Respite care services may be provided in: (a) a member's place of residence; (b) an alternative private residence; or (c) a residential habilitation setting or a nursing facility. (3) Respite care is provided for members who: (a) in the absence of respite care, would require institutional level of care; (b) are unable to care for themselves; and (c) have an unpaid caregiver as the member's primary caregiver. (4) A person providing respite care services must be: (a) physically and mentally qualified to provide this service to the member; (b) aware of emergency assistance systems and CPR-certified; and (c) able to follow the positive behavioral supports that are in place. (5) A person who provides respite care services to a member may be required by the case management team to have the following when the member's needs so warrant: (a) knowledge of the physical and mental conditions of the member; (b) knowledge of common medications and related conditions of the member; and (c) ability to administer basic first aid. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.439 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: SELF-DIRECTED SERVICES (1) Enrolled members in the waiver program must be offered an opportunity to utilize self-directed services as a co-employer. Once an enrolled member's comprehensive assessment and PCRP process have been completed and needed waiver services are identified, the enrolled member may select the specific services they wish to self-direct from the list of services indicated in (10). The enrolled member may also receive some of the services in their PCRP through traditional supports and services from a provider agency, as long as no services are duplicated. The entities responsible for supporting self-direction include case managers, the QIO, and the provider agencies. (2) Services may be directed by: (a) an enrolled member who has the capacity to self-direct, as determined by the department or the department's designee; (b) a legal representative of the enrolled member, including a parent, spouse, or legal guardian; or (c) a nonlegal representative freely chosen by the enrolled member or the enrolled legal representative. (3) The person directing the services must: (a) be 18 years of age or older; (b) successfully complete required training for self-direction; and (c) if acting in the capacity of a representative, demonstrate understanding of the enrolled member's needs and preferences. (4) If an enrolled member indicates an interest in the self-directed option, the case management team is responsible for referring the enrolled member to the QIO. The QIO must assign a health care professional to: (a) conduct a capacity interview over the telephone; and (b) certify that the enrolled member, legal representative, or nonlegal personal representative is capable of managing the tasks and understands the risks involved. An approved capacity determination is required to self-direct services. (5) The case management teams must: (a) assist the enrolled member to develop an emergency backup plan, identifying and mitigating risks or potential risks, and monitor the health and safety of the enrolled member. Agency-based PAS managed by provider agencies under agreement with Medicaid are not available to enrolled members who are participating in the self-directed program. The use of PAS managed by provider agencies is permissible only if the enrolled member's backup plan fails; (b) educate enrolled members regarding self-directed opportunities; (c) meet with enrolled members to detail the self-directed service options during the intake process, annual visit, as well as throughout their service plan year as indicated through assessed need; (d) provide assistance for informed decision-making by enrolled members and their families/representatives about the election of self-direction with information and training on the roles, risks, and responsibilities assumed by those who choose self-direction; (e) inform enrolled members they are able to assist with the development of formal/informal supports, plan development, as well as available resources for self-direction; and (f) oversee the service delivery in the self-direct option. (6) The enrolled member, the enrolled member's legal representative, or the nonlegal personal representative must: (a) be capable of making choices about activities of daily living, understand the impact of their choices, and assume responsibility for those choices; (b) be capable of managing all tasks related to service delivery including recruiting, hiring, scheduling, training, directing, and dismissal of attendants; and (c) understand the shared responsibility between the enrolled member and the provider agency. (7) Enrolled members will be able to choose from several agencies providing personal assistance type services, ensuring members are successful with the self-direction experience. The provider agency must: (a) advise, train, and support the enrolled member, as identified in the member's PCRP; (b) assist with recruiting, interviewing, hiring, training, managing, paying, and dismissing workers; and (c) assist with monitoring the health and welfare of the enrolled member. (8) Self-directed services can be terminated when: (a) the enrolled member chooses not to self-direct; or (b) the case management team or the department identifies an instance where the self-directed option is not in the best interest of the enrolled member, and a corrective action does not improve the situation. (9) The enrolled member must be informed in writing of the plan to transfer to an agency-based service delivery. (10) The following services may be self-directed as a co-employer: (a) personal assistance services; (b) behavioral intervention assistance; and (c) life coach. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2024 MAR p. 2234. 37.90.447 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: PRIVATE DUTY NURSING (1) Private duty nursing are medically necessary nursing services delivered to a member in their place of residence. (2) Private duty nursing may be provided by: (a) a licensed registered nurse (RN); or (b) a licensed practical nurse (LPN) under the supervision of a RN, physician, dentist, osteopath, or podiatrist authorized by the state of Montana to prescribe medication. (3) Private duty nurses may be employed by a home health care provider or self-employed. (4) Private duty nursing may be provided when Home Health Agency services under state plan, defined in ARM 37.40.701 , are not appropriate or available. (5) Private duty nursing must be prescribed by an appropriately licensed medical professional. (6) Private duty nurses must comply with the Montana Nurse Practice Act. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.448 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: PERSONAL EMERGENCY RESPONSE SYSTEMS (1) A personal emergency response system (PERS) is an electronic device used to secure assistance in an emergency situation to allow a member to gain greater independence. (2) A PERS must be connected to an emergency response unit with the capacity to activate emergency personnel. (3) The provision of a personal emergency response system as a service does not include the purchase, installation, or routine monthly charges of a telephone. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.449 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: SPECIALIZED MEDICAL EQUIPMENT AND SUPPLIES (1) Specialized medical equipment and supplies service is the provision of items of medical equipment and supplies to an enrolled member for the purpose of maintaining and improving the enrolled member's ability to reside at home and to function in the community. (2) Specialized medical equipment and supplies must: (a) be functionally necessary and relate specifically to the enrolled member's disability; (b) substantively meet the enrolled member's needs for accessibility, independence, health, or safety; (c) be likely to improve the enrolled member's functional ability or the ability of a caregiver or service provider to maintain the enrolled member in the enrolled member's home; and (d) be the most cost-effective item that can meet the needs of the enrolled member. (3) Specialized medical equipment and supplies service does not include: (a) items used for leisure and recreational purposes only; (b) items of clothing; (c) basic household furniture; (d) educational items including computers, software, and books unless such items are purchased in conjunction with an environmental control unit; or (e) coverage for dentistry or dental-related procedures, services, equipment or supplies. This includes any 'D' procedure code definitions identified in the current American Medical Association's Common Procedural Terminology (CPT) manual or identified as dental pursuant to Medicare, the American Dental Association, and/or Montana Medicaid. (4) Specialized medical equipment and supplies service includes service animals as defined in ARM 37.90.463 . (5) Certain items of medical equipment or supplies for short term use, as specified by the department, may be leased or rented instead of purchased. (6) The department may require a consultation prior to the purchase of certain equipment and supplies. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2020 MAR p. 1173, Eff. 7/1/20; AMD, 2024 MAR p. 2234, Eff. 9/21/24. 37.90.450 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: NONMEDICAL TRANSPORTATION (1) Nonmedical transportation is the provision to a member of transportation through common carrier or private vehicle for access to social or other nonmedical activities. (2) Nonmedical transportation services are provided only after volunteer transportation services, or transportation services funded by other programs, have been exhausted. (3) Nonmedical transportation may be provided by accessible transportation providers, cabs, personal care provider agencies, and Life Coaches. Nonmedical transportation providers must show proof of: (a) a valid Montana driver's license; and (b) adequate automobile insurance. (4) Nonmedical transportation services must be: (a) provided by the most cost-effective mode; and (b) provided only after all volunteer, state plan, or other publicly funded transportation programs have been exhausted or determined inappropriate. (5) Nonmedical transportation services are available only for the transport of members to and from activities identified in the member's Person-Centered Recovery Plan. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2006 MAR p. 2665, Eff. 10/27/06; AMD, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.451 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: RESIDENTIAL HABILITATION, ASSISTED LIVING (1) Residential habilitation, assisted living, provides 24-hour services and supports designed to ensure the health, safety, and welfare of a member and assist the member acquiring and improving behaviors necessary to live and participate in the community. (2) Assisted living facilities must be licensed in accordance with ARM Title 37, chapter 106, subchapter 28. (3) Assisted living includes the following service components: (a) personal care; (b) social and recreational activities; (c) medication management and oversite; (d) medical escort; (e) non-medical transportation; (f) meals; and (g) 24-hour onsite awake staff. (4) A provider of adult residential care must report serious occurrences, as defined in ARM 37.90.403 , to the department. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.452 HOME AND COMMUNITY BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: RESIDENTIAL HABILITATION, INTENSIVE MENTAL HEALTH GROUP HOME (1) Residential habilitation, intensive mental health group home, provides 24-hour care designed to ensure the health, safety, and welfare of a member and provide supervision for the member to live and participate in the community. (2) Intensive mental health group homes must be licensed in accordance with ARM Title 37, chapter 106, subchapter 19. (3) Only the Montana State Hospital, the Montana Mental Health Nursing Care Center, or the Addictive and Mental Disorders Division may refer a member for intensive mental health group home services under the waiver program. (4) An intensive mental health group home must: (a) be a licensed mental health center with a group home endorsement; (b) be approved by the Addictive and Mental Disorders Division; and (c) be knowledgeable about commitment and recommitment processes, as well as the process for use of involuntary medications. (5) Intensive mental health group homes consist of the following staff: (a) a program supervisor, .5 FTE, who provides clinical supervision as described in the member's Person-Centered Recovery Plan; (b) a residential manager, 1.0 FTE; and (c) 24 hour onsite awake staff with at least a 1:3 staffing ratio for at least 16 hours per day during awake hours and at least one staff for eight hours during sleeping hours, as determined by the provider. (6) The member must: (a) have a history of repeated unsuccessful placements in less intensive community-based programs; (b) have at least one full year combined of institutionalization within the past three years; and (c) exhibit an inability to perform activities of daily living in an appropriate manner due to the member's Severe and Disabling Mental Illness (SDMI) diagnosis. (7) Intensive mental health group homes must offer the following service components: (a) assistance with activities of daily living and instrumental activities of daily living, as needed; (b) medication management, administration, and oversite; (c) medical escort; (d) crisis stabilization services as needed by the member; (e) close supervision and support of daily living activities; (f) access to community involvement; (g) care coordination; (h) discharge planning; and (i) transportation and supervision, if appropriate, to suitable community resources. (8) A provider of adult residential care must report serious occurrences, as defined in ARM 37.90.403 , to the department. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.453 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: RESIDENTIAL HABILITATION, MENTAL HEALTH GROUP HOME (1) Residential habilitation, mental health group home, provides 24 hours of available services and supports designed to ensure health, safety, and welfare of a member and assist the member in the acquisition and improvement of behaviors necessary to live and participate in the community. (2) A mental health group home must be a licensed mental health center with a group home endorsement. (3) Mental health group homes consist of the following staff: (a) a program supervisor, .5 FTE, who provides clinical supervision as determined in the member's Person-Centered Recovery Plan; (b) a residential manager, 1.0 FTE; and (c) 24-hour onsite awake staff with a minimum 1:4 staffing ratio for at least 16 hours per day during awake hours and at least one staff for eight hours during sleeping hours, as determined by the provider. (4) The member must have: (a) a history of repeated unsuccessful placements in less intensive rehabilitative community-based programs; (b) impaired interpersonal or social functioning; (c) impaired occupational functioning; (d) impaired judgment; (e) poor impulse control; or (f) a lack of family or other community or social supports. (5) The member must exhibit: (a) an inability to perform activities of daily living in an appropriate manner due to the member's SDMI diagnosis; and (b) symptoms related to the SDMI severe enough that a less intensive level of service would be insufficient to support the member in an independent living environment and requires a structured treatment environment to be successfully treated in a less restrictive setting. (6) Mental health group homes must offer the following service components: (a) assistance with activities of daily living and instrumental activities of daily living as needed; (b) medication management, administration, and oversite as needed; (c) medical escort; (d) crisis stabilization services as needed by the member; (e) supervision and support of daily living activities; (f) assistance with medications, including administration of medications as necessary; (g) skills building in areas of community reintegration and independent living; (h) care coordination; (i) discharge planning for transition to a less restrictive setting; and (j) transportation and supervision, if appropriate, to suitable community resources. (7) A provider of adult residential care must report serious occurrences, as defined in ARM 37.90.403 , to the department. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.454 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: RESIDENTIAL HABILITATION, ADULT GROUP HOME (1) Residential habilitation, adult group home, provides 24-hour available services and supports designed to ensure health, safety, and welfare of a member and assist the member in the acquisition and improvement of behaviors necessary to live and participate in the community. (2) An adult group home must be provided in the setting as defined in ARM Title 37, chapter 88, subchapter 9. (3) Placement in an adult group home must be supported by the member's level of impairment and strengths assessment found in the Person-Centered Recovery Plan. (4) Adult group home is a bundled service that includes: (a) personal care; (b) homemaker services; (c) social activities; (d) recreational activities; (e) medication management and oversite; (f) medical escort; (g) nonmedical transportation; and (h) 24-hour onsite awake staff to meet the needs of the members and provide supervision for safety and security. (5) Members in an adult group home may not receive the following services under the Home and Community Based Services, Adults with Severe and Disabling Mental Illness Waiver Program: (a) personal assistance; (b) homemaker chore; (c) respite care; (d) environmental accessibility adaptations; or (e) meals. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.455 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: RESIDENTIAL HABILITATION, FOSTER CARE (1) Residential habilitation, foster care, provides 24-hour services and supports designed to ensure the health, safety, and welfare of a member and assist the member in acquiring and improving behaviors necessary to live and participate in the community. (2) Residential habilitation, foster care, must be licensed in accordance with ARM Title 37, chapter 106, subchapter 20. (3) Residential habilitation, foster care, includes the following components: (a) personal care; (b) social activities; (c) recreational activities; (d) medication management and oversite; (e) medical escort; (f) nonmedical transportation; (g) meals; and (h) 24-hour on-site supervision to meet the needs of the member for safety and security. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2020 MAR p. 1173, Eff. 7/1/20. 37.90.462 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: PROVISION OF SERVICES BY LEGALLY RESPONSIBLE INDIVIDUALS (1) A legally responsible individual (LRI) is an enrolled member's spouse or a court-appointed guardian for the enrolled member. (2) The following services may be provided by a LRI: (a) private duty nursing; (b) personal assistance; (c) non-medical transportation; (d) respite; and (e) behavioral intervention assistant. (3) In order for a LRI to receive payment for services, it has to be demonstrated that services provided meet the following criteria: (a) be a service/support identified in the approved SDMI HCBS waiver program application; (b) be necessary to avoid institutionalization; (c) be a service or support that is specified in the enrolled member's PCRP ; (d) be provided by a LRI who meets the provider qualifications and training standards specified in the waiver for that service; (e) be paid at a rate that does not exceed what is allowed by the department for the payment of similar services; and (f) be extraordinary care, as provided in (4). (4) The CMT must assess the enrolled member's need for extraordinary care using the following criteria: (a) the activity is one that exceeds the range of activities that a legally responsible individual would ordinarily perform in the household on behalf of a person without a disability or chronic illness of the same age, and which are necessary to assure the health and welfare of the enrolled member and meet either (i) or (ii) as listed below: (i) the enrolled member scores as severely or gravely impaired on the Behavioral Health and Developmental Disabilities (BHDD) Severe and Disabling Mental Illness (SDMI) Home and Community Based Services (HCBS) Waiver Evaluation and Level of Impairment (LOI) Form in Areas One, Two, or Seven; or (ii) the enrolled member scores a 4 (total dependence) in the Activities of Daily Living/Instrumental Activities of Daily Living section on the Level of Care form. (5) An enrolled member must be offered a choice of providers. If the enrolled member or the enrolled member's authorized representative chooses a relative or legal guardian as a care provider, the choice must be documented on the PCRP. In addition to case management, monitoring, and reporting activities required for all waiver services, the following requirements are applied when a relative or legal guardian is paid as a care provider: (a) quarterly face-to-face reviews with the enrolled member of expenditures, and the enrolled member's health, safety, and welfare status; (b) monthly reviews by the provider agency of hours billed for relative provided care; (c) a relative or legal guardian who is an enrolled member's authorized representative may not also be paid to provide services; and (d) an enrolled member's spouse employed by a personal care agency may not be reimbursed directly to provide personal care to the enrolled member. (6) A relative or legal guardian may not provide more than 40 hours of paid time in a seven-day period. (7) The CMT checks in with the LRI to see if there are concerns regarding the risk factors. A back-up plan is part of the PCRP plan that would provide relief to the caregiver in the event they are at risk. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2024 MAR p. 2234, Eff. 9/21/24. 37.90.463 HOME AND COMMUNITY-BASED SERVICES FOR ADULTS WITH SEVERE AND DISABLING MENTAL ILLNESS: SPECIALIZED MEDICAL EQUIPMENT AND SUPPLIES –SERVICE ANIMALS (1) A service animal is an animal trained to undertake a particular task or tasks on behalf of an enrolled member that the enrolled member cannot perform and that are necessary to meet the enrolled member's needs for accessibility, independence, health, or safety. A service animal is limited to a dog trained to perform a task or tasks directly related to the enrolled member's disability. (2) The following requirements must be met prior to the department approving and paying for a service animal: (a) the enrolled member must be evaluated by a physician to determine if the member would benefit from a service animal in maintaining and improving the enrolled member's ability to reside at home and to function in the community; (b) the evaluating physician must provide a recommendation for a service animal for the enrolled member and must identify the work or task the service animal will perform for the enrolled member and whether and how the work or task relates to the enrolled member's SDMI; (c) the work or task performed by the service animal must relate to the enrolled member's SDMI as defined in ARM 37.90.403 ; and (d) the enrolled member's case management team must determine that a service animal is a practical means of meeting the enrolled member's need and that there exists no alternative method of meeting the enrolled member's need that is significantly less expensive than a service animal. (3) A service animal does not include any of the following: (a) pets, companion animals, emotional support animals, and therapy animals; (b) guard dogs, rescue dogs, sled dogs, tracking dogs, or any other animal not specifically designated as a service animal; or (c) wild, exotic, or any other animals not specifically designated as a service animal. (4) The following expenses will be covered by the program: (a) supplies necessary for the service animal to perform work or tasks for the enrolled member; (b) veterinary care, transportation to veterinary care, licensing or registering of service animal, and grooming if the enrolled member or the enrolled member's primary care giver is unable to groom the service animal; (c) training of service animal to undertake the particular tasks on behalf of an enrolled member as long as a qualified trainer has assessed the service animal and determined the animal to have the behavioral characteristics to successfully complete training. (5) The program does not pay for food for the service animal. (6) The department may require a consultation prior to the purchase of certain equipment and supplies. Authorizing statute(s): 53-2-201 , 53-6-402 , MCA Implementing statute(s): 53-6-402 , MCA History: NEW, 2024 MAR p. 2234, Eff. 9/21/24.