(1) The purpose of this subchapter is to implement the Montana Health and Economic Livelihood Partnership Act (HELP Act) enacted by the 64th Montana Legislature, Ch. 368, L. 2015 MT, and House Bill 658 enacted by the 66th Montana Legislature, Ch. 21, L. 2019 MT. 

(1) "American Indian and Alaska Native" means an American Indian, Alaska Native, or other individual who is eligible for health services through the Indian Health Service, tribes and tribal organizations, or urban Indian organizations.

(2) "Certification" means attestation of compliance with or exemption from community engagement activities. A participant's certification may be included as part of the Medicaid application or provided separately with a dated signature electronically, telephonically, or by mail.

(3) "Community engagement activity" means any qualifying activity identified in ARM 37.84.118 as counting towards the community engagement participation requirements outlined in ARM 37.84.116.

(4) "Department" means the Montana Department of Public Health and Human Services.

(5) "Federal poverty level (FPL)" means the poverty income guidelines published annually in the Federal Register by the U.S. Department of Health and Human Services.

(6) "Health and Economic Livelihood Partnership (HELP) program" means a Medicaid coverage program for persons as authorized at Title 53, chapter 6, part 13, MCA, and Title 39, chapter 12, part 1, MCA, and as implemented in accordance with that part, 53-2-215, MCA, 42 U.S.C. 1315 (2015), 42 U.S.C. 1396d(y) (2015), and other applicable state and federal authorities for those persons who are eligible for the HELP Program as authorized under 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) (2015).

(7) "Medicaid alternative benefit plan" means covered services available to HELP members that is equivalent to the Medicaid services described in ARM Title 37.

(8) "Medically frail" means individuals defined in 42 CFR 440.315(f) (2015).

(9) "Member" means an individual enrolled in the Montana Medicaid Program under 53-6-131, MCA, or receiving Medicaid-funded services under 53-6-1304, MCA.

(10) "Modified adjusted gross income (MAGI)" means income determined in accordance with 42 U.S.C. 1396a(e)(14) and 42 CFR 435.603 (2015).

(11) "Participant" means a member with a modified adjusted gross income at or below 138% of the federal poverty level and enrolled in Medicaid under the HELP program.

(12) "Premium" means a fee owed by an individual as a participant in the HELP Program.

(13) "Reporting period" means the required frequency for providing information to the department on community engagement activity participation. The reporting period is every six months.

(14) "Workforce program" means a program developed and administered by the Department of Labor and Industry that includes employment assessment and workforce development opportunities to members.  

(1) An individual qualifies for Medicaid coverage under the HELP Program if the person is a Montana resident who meets the eligibility criteria for Medicaid coverage as authorized at 42 U.S.C. 1396a(a)(10)(A)(i)(VIII) (2015) and 42 C.F.R. 435.119.

(2) HELP Program coverage, as specified in (1), is inclusive of a person who is 19 through 64 years of age, has a modified adjusted gross income at or below 138% of FPL as appropriate to the household size, and is not:

(a) pregnant at the time of enrollment;

(b) entitled to or enrolled in Medicare; or

(c) otherwise eligible for and enrolled in mandatory coverage under the State Plan.

(1) Coverage for a person in the HELP Program is provided through the Medicaid Alternative Benefit Plan.

(1) Coverage for a person in the HELP Program is provided through the Medicaid Benefit Plan.

(1) A HELP participant must pay a premium equal to two percent of the prorated share of the participant's annual household income. The premium will be billed in twelve equal monthly amounts.

(2) Except as provided in subsection (3), the premiums must:

(a) be set at 2% of a participant's income in the first two years the participant received coverage; and

(b) increase by 0.5% in each consecutive subsequent year that a participant receives coverage, up to a maximum of 4% of the participant's income.

(3) A participant who is exempt from the community engagement activity participation requirements as allowed under ARM 37.84.119, 37.84.120, and 37.84.121 is exempt from the premium increases in (2)(b).

(4) A participant, except as provided in (6) and (7), for whom an overdue premium is owed, will be disenrolled from coverage as provided in (5).

(5) The process for collection of overdue premiums is as follows:

(a) Within 30 days of the date a participant's premium payment was due, the department must notify the participant that the payment is overdue and that all overdue premiums must be paid within 90 days of the date the notification was sent.

(b) If payment for overdue premiums is not received, the department will notify the Department of Revenue of the sum owed.

(c) Unless the participant states the intent not to reenroll, the department may reenroll the person in the HELP Plan when the Department of Revenue assesses the unpaid premium through the participant's income tax.

(6) A participant who has an annual household income below 100 percent of the current FPL is not subject to disenrollment due to nonpayment of a premium.

(7) A participant is not subject to disenrollment for failure to pay a premium if the participant meets two of the following criteria:

(a) discharge from the United States military within the previous 12 months;

(b) enrollment in any Montana university system unit, a tribal college, or an accredited Montana college offering at least an associate degree. A participant cannot claim the education exemption for more than four years;

(c) participation in a workforce program or activity established under the authority of 39-12-101 through 39-12-107, MCA; or

(d) participation in any of the following health behavior activities developed by a health care provider or approved by the department:

(i) a Medicaid health home;

(ii) a patient-centered medical home;

(iii) a cardiovascular disease, obesity, or diabetes prevention program;

(iv) a program requiring the member to obtain primary care services from a designated provider and to obtain prescriptions from a designated pharmacy;

(v) a Medicaid primary care case-management program established by the department;

(vi) a tobacco use prevention or cessation program; or

(vii) a substance abuse treatment program.

(8) A participant may reenroll at any time by payment of the premium.

(9) A participant is exempt from paying a premium if the individual:

(a) has a modified adjusted gross income under 50% of the federal poverty level;

(b) has been determined to be medically frail;

(c) is American Indian or Alaska Native;

(d) is receiving Medicaid services under a presumptive eligibility program; or

(e) is pregnant.

(10) The department shall implement and enforce (2) and (3) only upon receiving approval from the U.S. Secretary of Health and Human Services of the department's 1115 waiver application filed August 30, 2019, and in accordance with the terms and conditions of the approval.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

This rule has been repealed.

(1) A participant shall participate in a minimum average of 80 hours per month of qualifying community engagement activities each reporting period unless exempt from participation as defined in (2).

(2) A participant is not subject to the community engagement activity participation requirements if the participant meets any of the following:

(a) is 55 years of age or older;

(b) qualifies for an income-based exemption as provided under ARM 37.84.119;

(c) qualifies for a standard exemption under ARM 37.84.120; or

(d) qualifies for a hardship exemption under ARM 37.84.121.

(3) A participant may communicate exemption from or compliance with community engagement activity participation to the department electronically, telephonically, or by mail.

(4) The department shall implement and enforce this rule only upon receiving approval from the U.S. Secretary of Health and Human Services of the department's 1115 waiver application filed August 30, 2019, and in accordance with the terms and conditions of the approval.

(1) The department shall make reasonable efforts to review available electronic data sources on a monthly basis to identify and document compliance with or exemption from community engagement activity participation requirements.

(2) The department shall only request supportive documentation or certification from a participant if no electronic data verification is available to demonstrate compliance with or an exemption from community engagement activity participation as required in ARM 37.84.118, 37.84.119, 37.84.120, and 37.84.121.

(3) This information will be used only for community engagement activity participation tracking. All information required to be reported by the member to other programs must continue to be reported according to those program rules and policies.

(4) The department shall implement and enforce this rule only upon receiving approval from the U.S. Secretary of Health and Human Services of the department's 1115 waiver application filed August 30, 2019, and in accordance with the terms and conditions of the approval.

(1) Time spent in one or more of the following qualifying activities may be counted toward the community engagement activity participation requirements as provided under ARM 37.84.116:

(a) employment;

(b) work readiness or workforce training activities which include, but are not limited to, an education, training, coaching, or other related workforce readiness activity intended to support preparation for workforce participation;

(c) secondary, postsecondary, or vocational education including time spent completing assignments and preparing for exams;

(d) substance abuse education or substance use disorder treatment including prevention, treatment, medication assisted treatment, and recovery;

(e) other work or community engagement activities that promote work or work readiness or advance the health purpose of the Medicaid program;

(f) community service or volunteer activities; or

(g) any other activity required by the Centers for Medicare and Medicaid Services for the purpose of obtaining necessary waivers under HB 658, section 1, Ch. 1, L. 2019 MT.

(2) The department shall implement and enforce this rule only upon receiving approval from the U.S. Secretary of Health and Human Services of the department's 1115 waiver application filed August 30, 2019, and in accordance with the terms and conditions of the approval.

(1) A participant is exempt from community engagement activity participation requirements if a participant's income exceeds an amount equal to or above the average of 80 hours per month multiplied by the minimum wage for each reporting period.

(2) The department shall review available electronic data sources on a monthly basis to identify an exemption under this subsection.

(3) If the department is unable to verify an income-based exemption through data review, a participant may provide documentation to meet the exemption under this subsection. Such documents may include:

(a) documentation of income, including pay stubs or other means of employment certification; or

(b) income tax forms, financial statements, or other supporting income documentation of self-employment.

(4) The department shall implement and enforce this rule only upon receiving approval from the U.S. Secretary of Health and Human Services of the department's 1115 waiver application filed August 30, 2019, and in accordance with the terms and conditions of the approval.

(1) A participant is exempt from the community engagement activity participation requirements if the participant is:

(a) medically frail consistent with 42 C.F.R. 440.315.

(i) The department shall review healthcare claims on a monthly basis for receipt of services including, but not limited to, a personal care service or a diagnosis of severe and disabling mental or physical illness to identify an exemption under this subsection.

(ii) If the department is unable to verify a medical frailty exemption through a data review, a participant may provide a certification to meet an exemption under this subsection.

(b) blind or disabled.

(i) A blind or disabled individual shall include:

(A) Social Security Disability Insurance recipients;

(B) individuals who, as defined under the Americans with Disability Act, Section 50 or Section 1557, are unable to comply with the community engagement requirements due to disability-related reasons; or

(C) recipients of a state or federal benefit program due to a disability.

(ii) The department shall review available data sources on a monthly basis to identify an exemption under this subsection.

(iii) If the department is unable to verify a blind or disabled exemption through a data review, a participant may provide documentation to meet an exemption under this subsection.

(c) pregnant or up to six months post-partum.

(i) The department shall review healthcare claims on a monthly basis to identify an exemption under this subsection.

(ii) If the department is unable to verify pregnancy or up to six months post-partum through a data review, a participant may provide documentation or a certification to meet an exemption under this subsection.

(d) experiencing an acute medical condition.

(i) A participant who experiences a medical condition that requires medical treatment or that temporarily impacts activities of daily living shall meet an exemption under this subsection.

(ii) A participant shall provide documentation from a registered or licensed provider to meet an exemption under this subsection.

(e) unable to work due to a mental or physical condition.

(i) A participant shall provide documentation to meet an exemption under this subsection. Documentation may include:

(A) temporary or permanent disability benefits issued by governmental or private sources; or

(B) a statement provided by a physician, licensed or certified psychologist, physician assistant, nurse, nurse practitioner, designated representative of the physician's office, licensed or certified psychologist, social worker, or any other medical personnel.

(f) a primary caregiver of a person who is unable to provide self-care which shall include a child under the age of 19 residing in the household or an individual who is unable to provide self-care, regardless of age.

(i) A participant may provide a certification to meet an exemption under this subsection.

(ii) Only one participant may be deemed the primary caregiver for an individual.

(g) a foster care or kinship care provider.

(i) The department shall review available electronic records on a monthly basis to identify an exemption under this subsection.

(ii) If the department is unable to verify if a participant is a foster care or kinship care provider through a data review, a participant may provide documentation or a certification to meet an exemption under this subsection.

(h) Engaged in secondary, postsecondary, or vocational education.

(i) A participant in high school shall satisfy the requirements of this exemption.

(ii) A participant enrolled in the equivalent of at least six credits of community college or pursuing an associate degree, four-year undergraduate program, or post-graduate masters or doctoral program shall satisfy the requirements of this exemption.

(iii) A participant enrolled in the equivalent of at least six credits in a trade school, college, or career center program that provides specialized skills training shall satisfy the requirements of this exemption.

(iv) The department shall review available electronic records on a monthly basis to identify an exemption under this subsection.

(v) If the department is unable to verify if a participant is engaged in secondary, postsecondary, or vocational education through a data review, a participant may provide documentation to meet an exemption under this subsection.

(vi) A participant satisfies this exemption if they are participating in-person or virtually and such participation may be inside or outside of the State of Montana.

(i) Participating in or exempt from the work requirements of the Temporary Assistance for Needy Families or Supplemental Nutrition Assistance Program.

(i) The department shall review available electronic records on a monthly basis to identify an exemption under this subsection.

(ii) If the department is unable to verify if a participant is exempt from or compliant with Temporary Assistance for Needy Families or Supplemental Nutrition Assistance Program work requirements through a data review, a participant may provide documentation to meet an exemption under this subsection.

(j) Under the supervision of the Department of Corrections, a county jail, or another entity as directed by the court, the Department of Corrections, or the Board of Pardons and Parole.

(i) The department shall review available electronic records on a monthly basis to identify an exemption under this subsection.

(ii) If the department is unable to verify if a participant is under the supervision of the Department of Corrections, a county jail, or another entity as directed by the court, a participant may provide documentation to meet an exemption under this subsection.

(k) Experiencing chronic homelessness.

(i) Experiencing chronic homelessness includes a participant who:

(A) lacks a fixed and regular nighttime residence;

(B) primarily resides at nighttime in a supervised shelter designed to provide temporary accommodations;

(C) resides for no more than 90 days in the residence of another individual; or

(D) resides in a location that is not designed for, or ordinarily used to, accommodating individuals for sleep, home, or meals, including but not limited to hallways, bus station, or lobbies.

(I) The department shall review available data on a monthly basis to identify an exemption under this subsection.

(II) If the department is unable to verify if a participant is chronically homeless through a data review, the participant may provide a certification to meet an exemption under this subsection.

(l) A victim of domestic violence as defined by the Personal Responsibility and Work Opportunity Reconciliation Act of 1996, 42 U.S.C. 601, et seq.

(i) A victim of domestic violence shall include a participant who is a victim of physical, sexual, financial, mental, or emotional abuse by a person with whom the individual lives or has lived with in the last 24 months;

(ii) A participant may provide a certification to meet an exemption under this subsection.

(m) Living in an area with a high poverty designation which shall include a participant residing in a zip code area in Montana with a poverty rate greater than the U.S. poverty rate, for individuals in the age range of 18 to 64 years, as determined by the U.S. Census Bureau, estimated for the most current year available.

(i) The department shall review available data to identify an exemption under this subsection.

(ii) If the department is unable to verify if a participant is living in an area with a high poverty designation through a data review, the participant may provide documentation or certification to meet an exemption under this subsection.

(n) A member of an entity organized under 26 U.S.C. 501(d). A participant shall provide a certification to meet an exemption under this subsection.

(o) An American Indian or Alaska Native.

(i) The department shall review available data on a monthly basis to identify an exemption under this subsection.

(ii) If the department is unable to verify if a participant is a member of a federally recognized tribe through a data review, the participant may provide a certification to meet an exemption under this subsection.

(p) Otherwise exempt under federal law.

(2) The department shall implement and enforce this rule only upon receiving approval from the U.S. Secretary of Health and Human Services of the department's 1115 waiver application filed August 30, 2019, and in accordance with the terms and conditions of the approval. 

(1) A participant is exempt from community engagement activity participation requirements if the participant:

(a) is hospitalized or is caring for an immediate family member who has been hospitalized;

(i) the department shall review healthcare claims on a monthly basis for receipt of services that include an inpatient hospitalization to identify an exemption under this subsection;

(ii) if the department is unable to verify if a participant is hospitalized through a data review, a participant may provide a certification to meet the exemption under this subsection. A participant shall provide documentation of caring for a family member who has been hospitalized to meet the exemption under this subsection.

(b) has a serious illness or is caring for an immediate family member who has a serious illness. A participant shall provide documentation to meet an exemption under this subsection;

(c) is incapacitated or is caring for an immediate family member who is incapacitated. A participant shall provide documentation to meet an exemption under this subsection; or

(d) is experiencing a catastrophic event or hardship that prevents

the participant from complying with the community engagement activity participation requirements. A catastrophic event or hardships includes, but is not limited to, public health emergencies, natural or human-caused disasters, or an unforeseen personal crisis. A participant may request a temporary reporting exemption for an unforeseen personal hardship.

(2) The department shall implement and enforce this rule only upon receiving approval from the U.S. Secretary of Health and Human Services of the department's 1115 waiver application filed August 30, 2019, and in accordance with the terms and conditions of the approval.

(1) A participant who does not meet the age-based exclusion found in ARM 37.84.117(2)(a) or an income, standard, or hardship exemption and fails to comply with the community engagement activity participation requirements will have a grace period of 180 days after the end of the reporting period to come into compliance.

(2) A participant who does not come into compliance within the 180-day grace period will have their coverage suspended.

(3) The suspension period will end 180 days after the date of suspension or upon determination by the department that the participant is:

(a) exempt from community engagement activity participation requirements;

(b) compliant with community engagement activity participation requirements for 30 days; or

(c) eligible for another category not subject to community engagement activity participation requirements.

(4) A participant who has their coverage reinstated during a suspension period shall be monitored by the department to ensure continued compliance.

(5) Upon the end of the suspension period, a participant shall have coverage reinstated so long as the participant continues to be eligible for the HELP program.

(6) Prior written notice of an adverse action, which shall include information on how to come into compliance with community engagement activity participation requirements, will be sent to a participant informing them of the pending suspension of coverage.

(7) The department shall implement and enforce this rule only upon receiving approval from the U.S. Secretary of Health and Human Services of the department's 1115 waiver application filed August 30, 2019, and in accordance with the terms and conditions of the approval.

(1) On a quarterly basis, the Quality Assurance Division shall prepare, plan, and execute an audit to test compliance with community engagement participation requirements from a random sample of participants subject to community engagement participation requirements.

(2) Participants who are found to be out of compliance with community engagement participation requirements will be notified in writing with information on how to become compliant. Participants who are out of compliance with community engagement reporting requirements are subject to the provisions of ARM 37.84.122.

(3) The Quality Assurance Division shall provide audit results to the Human and Community Services Division for program improvement and corrective action plans when appropriate.

(4) The Human and Community Services Division shall provide corrective action plans to the Quality Assurance Division, which shall use the plans along with audit results to assess risk and plan future quarterly audit cycles.

(5) The department shall implement and enforce this rule only upon receiving approval from the U.S. Secretary of Health and Human Services of the department's 1115 waiver application filed August 30, 2019, and in accordance with the terms and conditions of the approval.