Current through Register Vol. 18, September 20, 2024
(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.
AUTH:
53-2-201,
53-6-402, MCA; IMP:
53-6-402,
MCA
