Services designed to assist individuals in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in home and community based settings.
Habilitation provided in day programs includes support and functional training in use of community services, basic life skills, appropriate behaviors for the workplace and appropriate social behaviors.
Habilitation services do not include special education and related services (as defined in Section 4(a)(4) of the 1975 Amendments to the Education of the Handicapped Act (20 U.S.C. 1401(16), (17)) which otherwise are available to the individual through a State or local educational agency and vocational rehabilitation services which otherwise are available to the individual through a program funded under Section 110 of the Rehabilitation Act of 1973 (29 U.S.C. 730).
The Personal Supports Plan (PSP), based upon the results of a formal assessment and identification of needs, provides the actions and outcomes toward which training efforts are directed.
Work/day programs offer individualized services based on the support needs of service recipients. Persons served in work/day settings may include persons with pre-vocational skill training needs, persons who function as elderly with skill maintenance and social/leisure activity needs and persons with very significant behavioral, self-help or medical challenges that require enriched staffing ratios to meet habilitation and support goals. In some cases, individuals with varying services needs may be served under one roof, with staffing ratios and habilitation goals individualized to meet the needs of the recipients. Work/day programs offer one or more services conforming to the following criteria:
* Pre-vocational services are oriented toward providing training to individuals who are not expected to join the general work force in the immediate future (i.e., within a year).
Pre-vocational services include support and training in self-help skills, motor and physical development, communication skills, functional academics, community life skills, work skills, and leisure skills. These training areas are not primarily directed at teaching specific job skills but at underlying habilitative goals.
If individuals are compensated for the work they do, the compensation is less than 50 percent of the minimum wage.
* Senior day services provide health services, social services, training and supervision based on the needs of the individuals served. Senior day services entail services which provide supports and specific functional training based on the PSP.
These services are provided to older individuals whose plans of care (IP) direct training efforts and specify supports that will enable them to participate in a variety of age-appropriate activities supporting the goal of maintaining the individual's ability to function in the community and to avoid institutionalization.
* Intensive waiver-funded adult habilitation programs are oriented toward serving individuals with more severe disabilities. These individuals display fewer self-help skills and/or more severe problem behaviors than the individuals found in typical work activity centers or sheltered workshops. They have been found to have significant service and support needs based on the Montana Resource Allocation instrument and have been determined as inappropriate for placement in less restrictive adult settings.
Training and support is provided in a highly structured environment, by staff who are sophisticated in the skills of behavior management. Training focuses on the behaviors necessary to maintain the individual in the community-based service system and, if possible, move to a less restrictive setting.
Providers of day habilitation services can be reimbursed only for services delivered to recipients.
Homemaker services consist of general household activities provided by a homemaker when the person regularly responsible for these activities is unable to manage the home and care for himself/herself or others in the home, or is engaged in providing habilitation and support services to the individual with disabilities.
Services in this program include meal preparation, cleaning, simple household repairs, laundry, shopping for food and supplies and routine household care.
Homemaker services are not available under the State Plan.
Services designed to assist individuals in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in home and community-based settings.
Habilitation provided to an individual wherever he or she may live. Settings may include foster homes, group homes, congregate and non-congregate living apartments and natural homes.
All facilities covered by Section 1616(e) of the Act comply with State licensing standards that meet the requirements of 45 CFR Part 1397.
Board and room is not a covered service. Individuals served are responsible for paying for board and room through other funding sources such as Supplemental Security Income (SSI).
The plan of care, based upon the results of a formal assessment and identification of needs, provides the general goals and specific objectives toward which training efforts are directed. The plan of care (PSP or Individual Family Service Plan for Children) also specifies the appropriate residential setting in which services will be provided.
Training is provided in basic self-help skills, home and community living skills, leisure and social skills. Support is provided as necessary for the care of the individual. Each training objective is specified in the plan of care and is clearly related to the individual's long term goal and is not simply busywork or diversional in nature.
Residential habilitation services are not available to waiver recipients residing in assisted living or adult foster home settings.
Respite care includes any services (e.g., traditional respite hours, recreation or leisure activities for the recipient and care giver; summer camp) designed to meet the safety and daily care needs of the recipient and the needs of the recipient's care giver in relation to reducing stress generated by the provision of constant care to the individual receiving waiver services. These services are selected in collaboration with the parents and are provided by persons chosen and trained by the family. Persons providing respite services will be in compliance with all state and federal respite standards. Respite services are delivered in conformity with an individualized plan of care.
Respite services may be provided in licensed adult day care centers. Licensed adult day care centers may choose to receive payment directly from the DDP in accordance with the terms of a DDP contract, or be reimbursed for respite services by an agency designated as an OHCDS in their DDP contract. The respite reimbursement paid by the Department will not exceed the currently approved rate for the service for either reimbursement option.
The amount and frequency of respite care (with the exception of emergencies) is included in each individual's plan of care.
FFP (Federal Financial Participation) will not be claimed for the cost of room and board except when provided as part of respite care furnished in a facility approved by the State that is not a private residence.
Respite is only available to primary caregivers in family settings, including adult foster homes. Respite is available when a primary caregiver is not compensated for providing some or all of the support or supervision needed by the client.
Supported employment is for persons with developmental disabilities who, because of their disabilities, need intensive ongoing support to perform in a work setting.
Supported employment provides the opportunity to: work for pay in regular employment; integrate with non-disabled persons who are not paid care givers; and receive long-term support services in order to retain the employment. The service is designed for individuals with developmental disabilities facing severe impediments to employment due to the nature and complexity of their disabilities.
Supported employment may include the following types of activities designed to assist eligible individuals to access and maintain employment:
a. Pre-placement activities: Pre-placement activities consist of gathering information, conducting employee assessment and completing any steps necessary to implement the job placement process.
b. Job Market Analysis/Job Development: Job market analysis and job development involve identifying and locating potential jobs.
c. Job Match/Screening: Job match and screening involves establishing job requirements and selecting/matching potential employees to jobs.
e. Job Placement/Training: Training is directed toward development of all the skills necessary to succeed in the particular paid job that the individual is hired to do. Training occurs within the actual job environment and addresses naturally occurring demands and contingencies. The trainer assists the employee in completing the job until all the tasks can be performed at the standard established by the employer
f. Ongoing Assessment and Support and Service Coordination: Ongoing assessment and support involves monitoring the status of the job environment and the employee, and providing interventions as needed to maintain job placement.
g. Transportation: Transportation of a work crew and its equipment to and from the job site may be provided.
Supported employment will be funded under the waiver when not available under Section 110 of the Rehabilitation Act of 1973, as amended, (19 U.S.C. 730).
Waiver–funded children’s case management (WCCM) services are services furnished to assist individuals in gaining access to needed medical, social, educational and other services. Case management includes the following assistance:
Comprehensive assessment and periodic reassessment of individual needs to determine the need for any medical, educational, social or other services. These assessment activities include
• taking client history;
• identifying the individual’s needs and completing related documentation; and gathering information from other sources such as family members, medical providers, social workers, and educators (if necessary), to form a complete assessment of the individual.
Case management may include contacts with non-eligible individuals that are directly related to identifying the needs and supports for helping the eligible individual to access services.
For plans that provide case management services to assist individuals who reside in medical institutions to transition to the community: Case management services are coordinated with and do not duplicate activities provided as a part of institutional services and discharge planning activities. Billing for services is limited to a maximum of 60 days prior to the HCBS placement, and provider reimbursement follows waiver enrollment.
For persons who choose to self-direct: Case management may provide assistance to a recipient and/or unpaid primary care giver in the recruiting, co-hiring (the agency of choice is the legal employer) and scheduling of direct support workers.
Level of care activities: Case management is responsible for assisting the Department, as requested, in scheduling meetings and providing information as requested to Department staff responsible for completing initial and ongoing level of care activities.
Crisis Supports: Case management will provide assistance to the recipient and family, as necessary, in locating suitable alternative placement when the individual’s health or safety is at risk.
Case Management does not include the following:
• Case management activities that are an integral component of another covered Medicaid service;
• The direct delivery of an underlying medical, educational, social, or other service to which an eligible individual has been referred.
• Activities integral to the administration of foster care programs;
• Activities, for which an individual may be eligible, that are integral to the administration of another non-medical program, except for case management that is included in an individualized education program or individualized family service plan consistent with section 1903(c) of the Social Security Act.
Waiver-funded children's case management services are available to persons from 0 through 21 years of age, inclusive.
These services will be provided through direct contact between therapist and waiver recipient as well as between the therapist and other people providing services to the individual.
Occupational therapists may provide evaluation, consultation, training and treatment.
Occupational therapy services under the State Plan are limited. Maintenance therapy is not reimbursable, nor is participation in the interdisciplinary planning process.
These services will be provided through direct contact between therapist and waiver recipient as well as between the therapist and other people providing services to the individual. Physical therapists may provide treatment training programs that are designed to:
1. Preserve and improve abilities for independent function, such as range of motion, strength, tolerance, coordination and activities of daily living; and
2. Prevent, insofar as possible, irreducible or progressive disabilities through means such as the use of orthotic prosthetic appliances, assistive and adaptive devices, positioning, behavior adaptations and sensory stimulation.
Therapists will also provide consultation and training to staff or caregivers who work directly with waiver recipients.
Physical therapy services under the State Plan are limited.
Maintenance therapy is not reimbursable, nor is participation in the interdisciplinary planning process.
Psychological and counseling services are those services provided by a licensed psychologist, licensed professional counselor or a licensed clinical social worker within the scope of the practice of the respective professions.
Psychological and counseling services may include individual and group therapy; consultation with providers and care givers directly involved with the individual; development and monitoring of behavior programs; participation in the individual planning process; and counseling for primary care givers (i.e., family members and foster parents) when their needs are related to problems dealing with the child with the disability. Psychological and counseling services available under the Montana State Plan will be used before billing under the waiver.
Psychological and counseling services under the State Plan are limited. Under the waiver, this service is available to adults when the service is recommended by a qualified treatment professional, approved by the planning team and written into the plan of care.
These services will be provided through direct contact between therapist and waiver recipient as well as between the therapist and other people providing services to the individual.
Speech therapy services may include:
1. Screening and evaluation of individuals with respect to speech and hearing functions;
2. Comprehensive speech and language evaluations when indicated by screening results;
3. Participation in the continuing interdisciplinary evaluation of individuals for purposes of beginning, monitoring and following up on individualized habilitation programs; and
4. Treatment services as an extension of the evaluation process, which include:
Consultation with appropriate people involved with the individual for speech improvement and speech education activities to design specialized programs for developing each individual's communication skills in comprehension, including speech, reading, auditory training, and skills in expression.
Therapists will also provide training to staff and caregivers who work directly with waiver recipients.
Speech therapy services under the State Plan are limited. Maintenance therapy is not reimbursable, nor is participation in the interdisciplinary planning process.
Non-medical care, supervision and socialization, provided to a functionally impaired individual. Companions may assist or supervise the individual with such tasks as meal preparation, laundry and shopping, but do not perform these activities as discrete services. The provision of companion services does not entail hands-on nursing care. Providers may also perform light housekeeping tasks which are incidental to the care and supervision of the individual. This service is provided in accordance with a therapeutic goal in the plan of care, and is not purely diversional in nature.
Companion services are not available to persons receiving 24/7 DDP waiver funded supports and supervision (e.g., persons residing in a DD group home or in assisted living).
This service pays for extraordinary supervision and support by a principal care giver licensed as an adult foster care provider who lives in the home. The total number of service recipients (including participants served in the waiver) living in the adult foster home, who are unrelated to the principal care provider, cannot exceed four persons (ARM 37.100.121).
Residential skill acquisition training is available to recipients of the adult foster support service. Skill acquisition training, if needed, will be provided in the adult foster home in accordance with assessed needs and desires of the individual as outlined in the plan of care. This training will be delivered by staff meeting the qualified provider standards for residential training support. The RTS service recipient receives training to increase independence in health care, self care, safety and access to and use of community services. The individual plan of care, based upon the results of formal assessment and identification of needs, provides the general goals and specific objectives toward which training efforts are directed. Each training objective is specified in the plan of care and is clearly related to the individual's long term goal and is not simply busywork or diversional in nature.
Residential training supports delivered in the context of an adult foster home will be invoiced, reimbursed and reported as a separate service, and rolled back into the adult foster support service for the purpose of Federal reporting.
Payments for adult foster support are not made for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep and improvement. Payment for adult foster support does not include payments made, directly or indirectly, to members of the participant’s immediate family. The methodology by which the costs of room and board are excluded from payments for adult foster support is described in Appendix I.
Payment to an adult foster care provider is available to assist in placing and maintaining persons with extraordinary support needs in licensed adult foster care settings. Reimbursements are based on assessments completed by the Adult Targeted Case Manager. Payments are based on the service recipient meeting a required threshold in the hours of direct support and supervision required of the foster care provider.
The net effect of this service option is to strengthen the foster home network available to serve adults with developmental disabilities who would otherwise require services in more restrictive and costly service settings (e.g., an ICF-MR or an adult group home).
DDP will reimburse the adult foster care provider for no more than four people. Persons with varying supervision needs can be served with adult foster supports, but the adult foster support reimbursement to a single foster home cannot exceed the adult foster supports reimbursement rate for serving one person with intensive support needs.
Residential training supports delivered in the context of an adult foster home will be invoiced, reimbursed and reported as a separate and distinct service from the adult foster support service. Reimbursements for the service will be rolled into the cost of AFS for the purpose of Federal reporting.
Provision has been made in the AFS qualified provider standards for the Adult Foster Care provider to provide AFS only, or both AFS and RTS. In the event the AFS provider is not qualified to provide RTS, RTS will be made available by a qualified employee of an agency with a DDP contract.
Separate payment is not made for homemaker or chore services furnished to a participant receiving adult foster care services, since these services are integral to and inherent in the provision of adult foster care services.
Payments for services rendered in an assisted living facility, including personal care, homemaker services, medication oversight, social and recreation activities, 24 hour on site response staff to meet the unpredictable needs of recipients and supervision for safety and security. Separate payment will not be made for those services integral to and inherent in the provision of the personal care facility service.
Payments for assisted living facility services are not made for room and board, items of comfort or convenience, or the costs of facility maintenance, upkeep or improvements. Payment for personal care facility support does not include payments made, directly or indirectly, to members of the recipient’s immediate family.
This service is targeted only for those individuals with developmental disability who function as elderly due to age and/or specific handicapping condition and/or physically handicapping conditions or impairment precluding placement in a less restrictive setting. Persons with DD will have similar handicapping conditions to other persons in this service; generally this means persons who would otherwise be unable to safely and cost-effectively remain at home. Persons in this service option are not precluded from attending DD waiver-funded work/day or supported employment options.
Separate payment is not made for homemaker or chore services or personal care services furnished to a participant receiving assisted living services, since these services are integral to and inherent in the provision of assisted living services. Residential training supports and residential habilitation are not available to a person residing in an assisted living setting.
The Board Certified Behavior Analyst (BCBA) functions include the following:
1. Designing behavioral assessments and functional analyses of behavior and interpreting assessment and evaluation results for staff and unpaid caregivers providing services to enrolled waiver recipients.
2. Designing, monitoring and modifying written behavior intervention procedures and skill acquisition procedures. Written plans of intervention developed by the BCBA generally require the collection of data by staff or unpaid caregivers providing direct support. Decisions made by the BCBA in designing, monitoring and modifying behavior intervention and skill acquisition procedures are generally based on the review and analysis of collected data.
3. Training staff and unpaid caregivers in the implementation of formal and informal procedures designed to reduce problem behaviors and/or to increase appropriate behaviors.
4. Attending planning meetings for purpose of providing guidance and information to planning team members in the setting of appropriate goals and objectives for persons who need BCBA services.
In general, the BCBA is able to effectively develop and implement appropriate assessment and intervention methods for use in unfamiliar situations and for a range of cases of all ages. The BCBA teaches others to carry out ethical and effective behavior interventions based on published research, and designs and delivers instruction in behavior analysis. The BCBA may supervise the work of others who develop and implement behavior interventions. All behavior intervention procedures developed by the BCBA are in compliance with the Administrative Rules of Montana governing the use of restrictive procedures.
This service is not available under the Montana State Plan. The BCBA service will not supplement or supplant services available to children under IDEA, or otherwise available to a school age child.
Caregiver training and support are services for individuals who provide unpaid support, training, companionship or supervision to participants. For purposes of this service, individual is defined as any person, family member, neighbor, friend, companion, or co-worker who provides uncompensated care, training, guidance, companionship or support to a person served on the waiver. This service may not be provided in order to train paid caregivers. Training includes instruction about treatment regimens and other services included in the service plan, use of equipment specified in the service plan, and includes updates as necessary to safely maintain the participant at home. Support must be aimed at assisting the unpaid caregiver in meeting the needs of the participant. All training for individuals who provide unpaid support to the participant must be included in the participant’s service plan.
• Training furnished to persons who provide uncompensated care and support to the participant must be directly related to their role in supporting the participant in areas specified in the service plan.
• Counseling similarly must be aimed at assisting unpaid individuals who support the participant to understand and address participant needs.
• FFP is available for the costs of registration and training fees associated with formal instruction in areas relevant to participant needs identified in the service plan. FFP is not available for the costs of travel, meals and overnight lodging to attend a training event or conference.
Services to be provided do not duplicate case management services. The role of the staff person providing Caregiver Training and Support is defined by the planning team.
This service is only available to persons living in a family setting or private non-congregate residence where support and supervision is provided by unpaid care givers. It is not available to persons living in group homes, assisted living facilities, or foster homes when the foster care provider is paid for support and supervision.
Community Transition Services are non-recurring set-up expenses for individuals who are transitioning from an institution to a DDP waiver funded HCBS residential service. Allowable expenses are those necessary to enable a person to establish a basic household that do not constitute room and board and may include:
a. Security deposits required to obtain a lease on an apartment or home.
b. Essential household furnishings and moving expenses required to occupy and use a community domicile, including furniture, window coverings, food preparation items and bath/bed linens.
c. Set-up fees or deposits for utility or services access, including telephone, electricity, heating and water.
d. Services necessary for the individual’s health and safety, such as pest eradication and one-time cleaning prior to occupancy.
e. Moving expenses.
f. Necessary home accessibility adaptations.
g. Activities to assess need, arrange for and procure needed resources.
Community transition services are furnished only to the extent that they are reasonable and necessary through the service plan development process, clearly identified in the service plan and the person is unable to meet such expense or when the services cannot be obtained from other sources. Community transition services do not include monthly rental or mortgage expense; food, regular utility charges; and/or household appliances or items that are intended for purely diversional/recreational purposes, such as television, cable TV access or VCRs.
This service is capped at $3,000 per person, per transition. This service is not available to persons transitioning into residential settings that are owned or leased by a DDP funded service provider, rather, the residential setting must be owned, leased, or rented by the individual and must be considered his or her private residence.
These services provided by a registered dietitian or licensed nutritionist include meal planning, consultation with and training for care givers, and education for the individual served. The service does not include the cost of meals. Dietitian services are not available under Montana's State Plan.
This service must be cost effective and necessary to prevent institutionalization.
These services may include:
* Environmental Modifications:
Those physical adaptations to the home, required by the individual's plan of care, which are necessary to ensure the health, welfare and safety of the individual, or which enable the individual to function with greater independence in the home, and without which, the individual would require institutionalization. Such adaptations may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems which are necessary to accommodate the medical equipment and supplies which are necessary for the welfare of the individual.
In addition to the above, environmental modifications services are measures that provide the recipient with accessibility and safety in the environment so as to maintain or improve the ability of the recipient to remain in community settings and employment. Environmental modifications may be made to a recipient's home or vehicle (wheelchair lift, wheelchair lock down devices, adapted driving controls, etc) for the purpose of increasing independent functioning and safety or to enable family members or other care givers to provide the care required by the recipient. An environmental modification provided to a recipient must:
Excluded are those adaptations or improvements to the home which are of general utility, and are not of direct medical or remedial benefit to the individual, such as carpeting, roof repair, central air conditioning, etc. Adaptations which add to the total square footage of the home are excluded from this benefit. All services shall be provided in accordance with applicable State or local building codes.
* Adaptive Equipment:
Adaptive equipment necessary to obtain and retain employment or to increase independent functioning in completing activities of daily living when such equipment is not available through other sources may be provided. Adaptive equipment as needed to enable family members or other care givers to provide the care needed by the individual.
A comprehensive list is not possible because sometimes items are created (invented) to meet the unique adaptive needs of the individual, for example, an adult-sized "changing table" to enable a care giver to diaper and dress a person who has severe physical limitations; or specially designed switches that an individual with physical limitations can use to accomplish other tasks. Adaptive equipment will conform to the following criteria:
Individual Goods and Services are services, supports or goods that enhance opportunities to achieve outcomes related to living arrangements, relationships, inclusion in the community and work as clearly identified and documented in the service plan. Items or services under individual goods and services fall into the following categories:
*Membership/Fees: fitness memberships, tuition/classes, summer day programs, social membership (for example: Sierra Club, outdoor clubs, rotary club, friendship clubs and girl scouts) and socialization supports (for example: fees associated with participating in Special Olympics and community events such as the annual pancake breakfast, community picnics, fairs, art shows and cultural events and
*Devices/Supplies: batteries for hearing aids and batteries for assistive technology devices, nutritional supplements, diapers, instructional supplies, instructional books and computers.
Items covered under individual goods and services must meet the following requirements:
- The item or service is designed to meet the participant's functional, medical or social needs and advance the desired outcomes in his/her plan of care;
- The item or service is not prohibited by Federal or State statutes or regulations;
- One or more of the following additional criteria are met:
1. The item or service would increase the participants functioning related to the disability;
2. The item or service would increase the participants safety in the home environment; or
3. The item or service would decrease dependence on other Medicaid services;
- The item or service is not available through another source; and
- The service does not include experimental goods/services.
Recreational activities provided under Individual Goods and Services may be covered only to the degree that they are not diversional in nature and are included in a planning objective related to a specific therapeutic goal.
Montana assures that services, supports or goods provided under this definition are not covered under the Individuals with Disabilities Education Act (IDEA) or Section 110 of the Rehabilitation Act or available through any other public funding mechanism.
Individual goods and services must be approved by the planning team prior to purchase and reimbursement. In addition, goods and services purchased on behalf of the recipient by legal guardians, legally responsible persons, or other non-employees acting on behalf of the recipient are reimbursable only if receipts for such purchases are submitted to the agency with a DDP contract. The receipts are reimbursable only if all the requirements listed above have been met.
Goods and services projected to exceed $2,000 (annual aggregate) require prior approval by the DDP Regional Manager.
This service provides hot or other appropriate meals once or twice a day, up to seven days a week. A full nutritional regimen (three meals per day) will not be provided, in keeping with the exclusion of room and board as covered services.
Some individuals need special assistance with their diets and the special meals service can help ensure that these individuals would receive adequate nourishment. This service will only be provided to individuals who are not eligible for these services under any other source, or need different or more extensive services than are otherwise available. This service must be cost effective and necessary to prevent institutionalization.
Personal Care Services Include:
1. Assistance with personal hygiene, dressing, eating and ambulatory needs of the individual; and
2. Performance of household tasks incidental to the person's health care needs or otherwise necessary to contribute to maintaining the individual at home;
3. Supervision for health and safety reasons.
Payment will not be made for personal care services furnished by a member of the individual's family.
Frequency or intensity will be as indicated in the plan of care.
Personal care services under the State plan differ in service definition or provider type from the services to be offered under the waiver. Under the waiver, RN supervision of the personal care worker is not required.
This service is available under the waiver only if the scope, amount or duration of the available Medicaid State Plan Personal Care is insufficient in meeting the needs of the recipient. Personal care may be bundled with other services when delivered as a component of Self-Directed Services and Supports (SDSS) and is therefore not available as a discrete service to persons receiving SDSS.
Private Duty Nursing service is to provide medically necessary nursing services to individuals when these services exceed the established Medicaid limits or are different from the service provided under the State Plan. They will be provided where they are needed, whether in the home or in the individual's day activity setting.
Services may include medical management, direct treatment, consultation, and training for the individual and/or his caregivers.
Nursing services provided under the home health requirement of the State Plan are limited and are only available to individuals considered "home bound" and in need of acute nursing care. Nursing services other than direct treatment are not available through a home health agency. Waiver recipients, particularly those coming out of the State's ICF's/MR, may be quite medically involved. State Plan nursing services may only be provided in group homes or other places of residence, while some waiver beneficiaries need nursing services in day programs or otherwise outside the home. Nursing homes are no longer service options for the vast majority of people with developmental disabilities.
Nursing services must be specified in the plan of care. It must be ordered in writing by the individual's physician and it must be delivered by a registered nurse (RN) or a licensed practical nurse (LPN). Waiver nursing services will be used after the home health nursing limits have been reached, or if the service required is different from that authorized under the State Plan.
These services are provided by a licensed respiratory therapist and may include direct treatment to the individual, ongoing assessment of the person's medical conditions, equipment monitoring and upkeep, and pulmonary education and rehabilitation. Without these services, individuals with severe pulmonary conditions would have to be institutionalized.
This service must be cost effective and necessary to prevent institutionalization.
Service offered in order to enable individuals served on the waiver to gain access to waiver and other community services, activities and resources, specified by the plan of care. This service is offered in addition to medical transportation required under 42 CFR 431.53 and transportation services under the State plan, defined at 42 CFR 440.170(a) (if applicable), and shall not replace them. Transportation services under the waiver shall be offered in accordance with the plan of care. Whenever possible, family, neighbors, friends, or community agencies that can provide this service without charge will be utilized.
Legally responsible persons, relatives, legal guardians and other persons who are not employees of agencies with a DDP contract may be reimbursed for the provision of rides. In these cases, reimbursement will be less than or equal to the mileage rate set by the Department for a State employee operating a personal vehicle. The mileage rate is based on the operational expense of a motor vehicle and does not include reimbursement for work performed, or the driver’s time. Reimbursement for rides provided by legally responsible persons or others must be related to the specific disability needs of a recipient, as outlined in the plan of care. Persons providing transportation must be licensed, insured and drive a registered vehicle, in accordance with the motor vehicle laws of the State of Montana.
Note: Rates for services in residential settings and work/day settings in which paid, on-site primary care givers provide routine, non-medically necessary transportation (community outings, picnics, etc) may include cost of these integrated transportation services.
Transportation services are not reimbursable in residential and work/day settings, if the transportation service is folded into the rates for these residential and/or work/day settings. Under no circumstances will medically necessary transportation (transportation to medical services reimbursed under the State Plan) be reimbursed under the waiver if the service is reimbursable under State Plan transportation.
Personal Emergency Response System (PERS) is an electronic device that enables waiver participants to secure help m an emergency. The participant may also wear a portable “help” button to allow for mobility. The system is connected to the participant’s phone and programmed to signal a response center once a “help” button is activated. The response center is staffed by trained professionals.
PERS services may be appropriate for individuals who live alone, or who are alone for parts of the day, and have no regular caregiver for periods of time.
Because of the limitations of the PERS service, a cell phone may be a more flexible, cost effective solution in ensuring health and safety for some individuals. Cell phones are not for convenience or general purpose use.
Guidelines for the use of cell phones include:
1. The individual requires access to assistance or supports and is frequently beyond the range of coverage of a PERS system.
2. Cell phone plans will be basic plans and will not include features unrelated to health and safety issues, such as web access or music services.
3. Individuals may elect to add a usage control feature to their basic plan to eliminate the potential for fee overage.
4. Individuals who do not elect to add a usage control feature and who exceed the fees associated with their plan may require the implementation of a usage control feature to prevent future overages. In all cases of an overage the case manager will be notified.
5. These cell phone guidelines will be reviewed with the individual prior to or at the annual planning meeting.
Installation, maintenance and monthly fees associated with PERS services and cell phone services may be reimbursed with waiver funds as outlined in the plan of care.
The payment for the additional costs of rent and food that can reasonably be attributed to an unrelated live-in caregiver who resides in the same household as the waiver participant. Payment will not be made when the participant lives in the caregiver’s home, or in a residence that is owned or leased by the provider of Medicaid services.
The staff person providing this service is an employee of an agency with a DDP contract. The service is provided by staff qualified to deliver residential habilitation. This service is limited to adult service recipients. Services are not billable when the caregiver is sleeping. Specific terms and conditions of the service are specified in a written Live-In Caregiver Agreement between the provider agency, the live-in caregiver and the service recipient and require Department approval. Additional residential support required by the recipient exceeding the value of the live-in caregiver reimbursement must be prior authorized by the Regional Manager and delivered in accordance with the plan of care and Live-In Caregiver Agreement.
The service must include an approved backup plan in the event of a service disruption. The backup system must include an on call system in the event that emergency assistance is needed when the caregiver is not available. Reimbursement for paid backup support (e.g., the live-in caregiver takes a two week annual vacation) would require the backup agency staff person to meet the qualified provider requirements for residential habilitation. In this event, the backup staff person’s services would be reimbursed based on the prevailing hourly rate for residential habilitation.
Legal guardians, parents of adult recipients, and legally responsible persons (e.g., the spouse of an adult recipient) may not provide the service. Other relatives (e.g., siblings, aunts/uncles, grandparents, cousins, sons/daughters) may provide this service.
This service is capped at $9,000/year. Only one agency staff person can be designated as, and reimbursed for, the provision of live-in caregiver services to the service recipient.
The personal supports worker assists the participant in carrying out daily living tasks and other activities essential for living in the community. Services may include assistance with homemaking, personal care, general supervision and community integration. Personal supports activities are generally defined in the plan of care and are flexible in meeting the changing needs of the recipient. Personal supports workers do not provide formal training to a participant, but workers may be assigned activities that involve informal training, mentorship, and activities designed to maintain skills. Personal supports workers may be required to provide transportation to a participant for activities as outlined in the plan of care, including community integration activities, rides to medical appointments, work or school and other community functions.
Personal supports is available to a participant only when the planning team has approved a back-up plan, serving to ensure the health and safety of the participant in the event of a service disruption. Respite and agency based residential habilitation are available to a participant receiving personal supports, but waiver-funded adult companion, agency based homemaker services, and personal care services (except for State Plan funded personal care services) are not available to a person receiving personal supports services. These service exclusions ensure the non-duplication of waiver-funded services.
Personal supports services are only available to participants who self-direct some or all of their services with employer authority. The personal supports worker is hired by the designated employer, and is the employee of the participant, family member or representative with employer authority.
A person receiving personal supports is self-directing this service with employer authority.
Other waiver services that may overlap with the activities of the personal supports worker are prohibited. These include live in care giver services, adult companion, extended personal care services and homemaker.
Personal supports services are only available to participants who self-direct some or all of their services with employer authority. The personal supports worker is hired by the participant or the participant’s representative, and is an employee of the participant or the participant's representative.
Service/function that assists the participant (or the participant's family, or representative, as appropriate) in arranging for, directing and managing services. Serving as the agent of the participant or family, the service is available to assist in identifying immediate and long-term needs, developing options to meet those needs and accessing identified supports and services. Practical skills training is offered to enable families and participants to independently direct and manage waiver services. Examples of skills training include providing information on recruiting and hiring personal care workers, managing workers and providing information on effective communication and problem-solving. The service/function includes providing information to ensure that participants understand the responsibilities involved with directing their services. The extent of the assistance furnished to the participant or family is specified in the service plan.
This service may include the performance of activities that nominally overlap the provision of case management services. Where the possibility of duplicate provision of services exists, the participant’s service plan should clearly delineate responsibilities for the performance activities.
This service is capped annually at $6000 or 20% of value of service recipients cost plan, whichever is smaller. These values can be exceeded for a limited time period in extraordinary circumstances, with the prior approval of the DDP program director.
Page last updated 03/28/2012