(1) The department may consider for eligibility in and may enroll in the program persons who the department determines qualify for enrollment in accordance with the criteria in ARM 37.90.410.
(2) In order to be considered by the department for eligibility in the program, a person must be determined to qualify for enrollment in accordance with the criteria in this rule.
(3) A person is qualified to be considered for enrollment in the program if the person meets the following criteria:
(a) is at least 18 years of age and, if under the age of 65, has been determined to be disabled according to the Social Security Administration;
(b) is Medicaid eligible;
(c) requires the level of care of a nursing facility as determined in accordance with the preadmission screening provided for in ARM 37.40.202, 37.40.205, and 37.40.206;
(d) does not currently reside in a hospital or a nursing facility;
(e) has needs that can be met through the program;
(f) meets the severe disabling mental illness definition at ARM 37.89.103; and
(g) resides in one of the following service areas for which federal approval of coverage has been received:
(i) Yellowstone County Region, inclusive of the counties of Yellowstone, Big Horn, Carbon, Stillwater, and Sweet Grass;
(ii) Cascade County Region, inclusive of the counties of Cascade, Blaine, Chouteau, Glacier, Hill, Liberty, Pondera, Teton, and Toole;
(iii) Butte-Silver Bow County Region, inclusive of the counties of Butte-Silver Bow, Beaverhead, Deer Lodge, Granite, Powell, and Jefferson; and
(iv) Missoula County.
(4) The department may consider for an available opening for program services a person who, as determined by the department:
(a) meets the criteria of ARM 37.90.410;
(b) is actively seeking services;
(c) is in need of the services available;
(d) is likely to benefit from the available services; and
(e) has a projected total cost of plan of care that is within the limits specified in ARM 37.90.413.
(5) The department offers an available opening for program services to the applicant, as determined by the department, who is:
(a) most in need of the available services;
(b) most likely to benefit from the available services; and
(c) whose projected total cost plan of care is within the applicable limits specified in ARM 37.90.413.
(6) Factors to be considered in the determination of whether a person is:
(a) in need of the available program services;
(b) likely to benefit from those services; and
(c) which person is most likely to benefit from the available services include, but are not limited to, the following:
(i) medical condition;
(ii) degree of independent mobility;
(iii) ability to be alone for extended periods of time;
(iv) presence of problems with judgment;
(v) presence of a cognitive impairment;
(vi) prior enrollment in the program;
(vii) current institutionalization or risk of institutionalization;
(viii) risk of physical or mental deterioration or death;
(ix) willingness to live alone;
(x) adequacy of housing;
(xi) need for adaptive aids;
(xii) need for 24 hour supervision;
(xiii) need of person's caregiver for relief;
(xiv) appropriateness for the person, given the person's current needs and risks, of services available through the program;
(xv) status of current services being purchased otherwise for the person; and
(xvi) status of support from family, friends, and community.
(7) A recipient may be removed from the program by the department. Bases for removal from the program include, but are not limited to the following:
(a) a determination by the case management team that the services, as provided for in the plan of care, are no longer appropriate or effective in relation to the person’s needs;
(b) the failure of the person to use the services as provided for in the plan of care;
(c) the behaviors of the person place the person, the person's caregivers, or others at serious risk of harm or substantially impede the delivery of services as provided for in the plan of care;
(d) the health of the person is deteriorating or in some other manner placing the person at serious risk of harm;
(e) a determination by the case management team that the service providers necessary for the delivery of services to the person, as provided for in the plan of care, are unavailable;
(f) a determination that the total cost of the person’s plan of care is not within the limits specified at ARM 37.90.413;
(g) the person no longer requires the level of care of a nursing facility as determined in accordance with the preadmission screening provided for in ARM 37.40.202, 37.40.205, and 37.40.206; and
(h) the person no longer resides in one of the counties specified in ARM 37.90.410.