37.40.1001 AGENCY-BASED AND SELF-DIRECTED COMMUNITY FIRST CHOICE SERVICES: DEFINITIONS
(1) "Activities of daily living" (ADL) means basic personal everyday activities limited to bathing, personal hygiene, transferring, positioning, eating, dressing, toileting, assistance with exercise routine performed in home, self-administered medication, including medication reminders, and meal preparation.
(2) "Agency-based services" means services provided by a qualified personal care provider agency. The agency works with the member to establish the schedule for service provision and provides the trained staff necessary for the delivery of care.
(3) "Annual review" means a member review conducted by a licensed nurse from the designated quality improvement organization once every 365 days. The review of the member's health status includes the completion of a functional assessment and service profile.
(4) "Case manager" means a nurse or social worker who is responsible for managing services provided to eligible members under the Home and Community Based Services (HCBS Waiver) Program. These case managers plan, implement, and monitor the delivery of services available through the program to the member.
(5) "Community First Choice Program" (CFCP) means a program developed in accordance with 1915(k) of the Social Security Act, which allows states the option of providing home and community-based attendant services and supports through an approved state plan. The CFC Program is developed to deliver attendant-based services through the use of a person-centered planning process that includes service coordination and member involvement to provide long-term services and supports (LTSS) to individuals in their homes or communities rather than in institutional settings.
(6) "Community First Choice Services" (CFCS) means the delivery of medically necessary in-home and community-based services provided to Medicaid eligible members whose health conditions cause them to be functionally limited in performing activities of daily living and instrumental activities of daily living.
(7) "Department" means the Montana Department of Public Health and Human Services.
(8) "Direct-Care Wage" means funding which is a supplemental payment made to Community First Choice service providers for the purpose of providing direct-care wage increases, benefits, or lump-sum payments to workers that provide direct services. These funds are distributed proportionately based on a pro rata share of appropriated funding to participating providers of CFCS. The distribution is based on the number of units of Medicaid CFCS provided by each provider agency for the distribution year relative to the total number of units provided statewide by all providers of CFCS.
(9) "Functional assessment" means an assessment that is performed by the designated quality improvement organization licensed nurse to determine if the member qualifies for CFCS and requires assistance with activities of daily living, instrumental activities of daily living, and health maintenance activities.
(10) "Health Care for Health Care Workers" means funding which is designated for the purpose of Medicaid provider rate increases when health insurance is provided for direct-care workers in the Community First Choice, personal assistance services and private duty nursing programs. The funds must be used to cover premiums for health insurance that meet defined benchmark criteria established by the department. These funds are distributed proportionately based on a pro rata share of appropriated funding to participating providers of CFCS based on the number of units of Medicaid CFCS provided by each provider for the distribution year relative to the total number of units provided statewide by all providers of service.
(11) "Health care professional" means a medical doctor, certified physician assistant, nurse practitioner or registered nurse, occupational therapist or a medical social worker, who is familiar with the member's activities of daily living. The health care professional may not be a paid employee of the CFCS provider agency.
(12) "Health maintenance activities" means health-related tasks that may be reimbursed through the Nurse Practice Act exemption in accordance with ARM 24.159.1616 and 37-8-103, MCA. These tasks are limited to bowel programs, wound care, urinary system management, and administration of medication. These activities are delivered by the member's personal care attendant when the activities, in the opinion of the physician or other health care professional, can be performed by the person if the person were physically capable and if the procedure could be safely performed in the home. A member is only able to receive these services from a personal care attendant using the self-direct model.
(13) "Instrumental activities of daily living" means activities which are limited to activities provided in accordance with the service plan, which are directly related to the member's person-centered needs. These activities are limited to the following:
(a) household tasks which are limited to cleaning the area used by the
member, changing the member's bed linens, and doing the member's laundry;
(c) community integration which provides assistance so the member can
participate in recreational and community activities;
(d) yard hazard removal which provides safe access to the member's home;
(e) correspondence assistance which provides a member, capable of
directing the service, with assistance opening mail, filing records, and completing paperwork.
(14) "Level of care" means a functional assessment performed by the department or the department's designee to determine if an individual requires nursing facility or intermediate care facility for person with intellectual disabilities level of service. Level of care process is defined in ARM 37.40.201.
(15) "Member" means a person eligible for and enrolled as a participant in the Montana Medicaid Program.
(16) "Nurse supervisor" means a licensed nurse employed by an agency-based CFCS provider agency who completes the service plan with the member and oversees the training and orientation of personal care attendants in the delivery of CFCS.
(17) "Personal Assistance Services" (PAS) means the delivery of medically necessary in-home services provided to Medicaid eligible members whose health conditions cause them to be functionally limited in performing activities of daily living. A member must have a medical need for hands-on assistance in order to receive PAS.
(18) "Personal care attendants" means individuals who assist members with their activities of daily living, instrumental activities of daily living, and other health care needs.
(19) "Person-centered plan" means a department-generated form that is utilized in the identification of the member's goals, strengths, and preferences for service delivery. The form is developed using a person-centered planning process that focuses on learning what is important to a member and how they want to live. The ultimate goal of the person-centered planning process is increased member choice, participation, and independence, while also ensuring health and safety.
(20) "Personal Emergency Response System" (PERS) means a service which provides members with an electronic, telephonic, or mechanical system used to summon assistance in an emergency situation. The system alerts medical professionals, support staff, or other designated individuals to respond to the member's emergency request.
(21) "Personal representative" means an individual designated by a member to act on the member's behalf to hire, direct, schedule, and train personal care attendants in performing self-directed CFCS.
(22) "Plan Facilitator" means the person designated by the department to be responsible for developing and coordinating the member's person-centered plan. The plan facilitator is either a qualified case manager, when one exists, or an individual appointed by the provider agency who is responsible for development of the plan in situations where there is no qualified case manager.
(23) "Oversight staff" means the person employed by a self-directed CFCS provider agency that completes the service plan with the member and oversees the member's participation in the program.
(24) "Provider agency" means a Medicaid-enrolled provider who provides attendant-based services.
(25) "Quality Improvement Organization" (QIO) means a department-contracted entity who is responsible for completing the functional assessments for members accessing CFCS.
(26) "Self-directed services" means a service delivery option for CFCS. In this option the member, or a personal representative, takes responsibility of managing the CFCS. Under the self-directed option, the member or personal representative must hire, fire, supervise, and manage the personal care attendants. In this service option personal care attendants are employed by the provider agency.
(27) "Service Delivery Record" means a form used to document the personal care attendants' delivery of CFCS on a daily basis. The form includes:
(c) location, when not in the home; and
(d) types of tasks provided by the personal care attendant.
(28) "Service plan" means a department-generated form that captures the scope and frequency of CFCS based on the functional assessment of a member's needs for service and support.
(29) "Service profile" means a form that summarizes the member's functional need for CFCS. A licensed quality improvement organization nurse completes the service profile form. The service profile identifies the member's level of impairment, frequency and need for assistance with activities of daily living, instrumental activities of daily living, and health maintenance activities. The profile also provides the member's total authorization for CFCS on a biweekly basis.
(30) "Skill acquisition advocate" means someone who has the capacity to assess the necessity and appropriateness of a member to acquire the skills necessary to achieve independence in performing a CFCS. The skill acquisition advocate may be an occupational therapist, speech therapist, physical therapist, physician, nurse practitioner, physician assistant, registered nurse, behavior specialist, or any other qualified professional approved by the department.
(31) "Skill acquisition letter of endorsement" means a department-generated letter that is signed by a skill acquisition health advocate. The letter outlines the member's plan for receiving skill acquisition service and provides endorsement by the skill acquisition health advocate that the member is capable of achieving independence in performing the service.
(32) "Skill acquisition, maintenance, and enhancement" means a service that may be authorized in the CFCP and is designed to promote member independence. The service enables a member to receive additional support from a personal care attendant to acquire the skills necessary to achieve independence in performing a CFCS.
History: 53-2-201, MCA; IMP, 53-2-201, 53-6-113, MCA; NEW, 2014 MAR p. 3075, Eff. 12/25/14.