37.34.906 0208 MEDICAID HOME AND COMMUNITY-BASED SERVICES PROGRAM: ELIGIBILITY
(1) A determination that a person is eligible to be considered for acceptance into the Medicaid Home and Community-Based Services (HCBS) Waiver Program does not entitle a person to selection and entry into the HCBS Waiver Program.
(2) A person is eligible to be considered for acceptance into the Medicaid HCBS Waiver Program if the person:
(a) is determined by the Developmental Disabilities Program (DDP) to be a person with a developmental disability in accordance with the criteria specified and approved in the waiver from the Centers for Medicare and Medicaid Services and in accordance with ARM Title 37, chapter 34, subchapter 2;
(b) applies for and meets the applicable Medicaid financial eligibility requirements found in ARM Title 37, chapter 82; and
(c) requires the level of care provided in an intermediate care facility for individuals with intellectual disability (ICF/IID), as determined by an evaluation of the person's service needs by the DDP.
(3) The level of care of an ICF/IID is needed when a person who is intellectually disabled:
(a) has severe medical problems requiring substantial care, but not to the extent that habilitation is impossible;
(b) has extreme deficits in self-care and daily living skills which require intensive training;
(c) has significant maladaptive social and/or interpersonal behavior patterns which require an on-going, supervised program of intervention; or
(d) has specialized service needs, and exhibits physical or mental limitations or changes similar to those expected in an older person.
(4) A person who has been admitted to an ICF/IID and who is discharged to enter services under the 0208 Medicaid HCBS Waiver Program for persons with developmental disabilities is considered to be of the level of care of an ICF/IID and need not be evaluated as provided in (2).
(5) For a person through the age of seven, the eligibility review panel (ERP) must make the determination of eligibility.
(6) The ERP must consist of the following members:
(a) a waiver-funded children's case manager;
(b) a provider's administrator or supervisor;
(c) a department's quality improvement specialist;
(d) a staff person who has had recent contact with the child, if applicable; and
(e) other members as determined by the panel, if applicable.
(7) The waiver-funded children's case manager must submit the following to the ERP for a determination of eligibility:
(a) a diagnostic statement from a physician; and
(b) any testing that reflects developmental delays; or
(c) a Vineland II (adaptive functioning assessment);
(d) a current psychological evaluation; and
(e) the eligibility determination form for children.
(8) For eligibility determinations made by the ERP, The Determining Eligibility for Services to Persons with Developmental Disabilities in Montana: A Staff Reference Manual does not apply to an eligibility determination for a child up to age seven.
(9) The ERP may determine a child is eligible if:
(a) the child has a diagnosis of a physical or mental condition that has a high probability of resulting in a developmental disability; or
(b) the child is experiencing developmental delays, with a 50% delay in one of the following areas or a 25% delay in two or more of the following areas:
(i) cognitive development;
(ii) physical developments, including vision and hearing;
(iii) speech and language development;
(iv) social and emotional development; or
(v) self-help skills.
(10) The department designee must annually administer a level of care re-determination.
(11) A child who has previously been determined eligible for services by the ERP must have a determination of eligibility by the department's eligibility specialist prior to the child's eighth birthday.
(12) For a person age eight and older, the department must make a determination of eligibility for consideration of acceptance into the 0208 HCBS Waiver Program.
(13) The department may make a determination of eligibility for acceptance into the 0208 HCBS Waiver Program as early as the age of six.
(14) The following documents must be submitted to the department's eligibility specialist to make a determination of eligibility for acceptance into the 0208 HCBS Waiver Program:
(a) a Vineland II;
(b) a current psychological evaluation, that for adults, is no more than ten years old; and
(c) page one of the eligibility determination form.
(15) The Determining Eligibility for Services to Persons with Developmental Disabilities in Montana: A Staff Reference Manual, as adopted in ARM 37.34.201, sets forth the requirements for eligibility of the DDP's service programs.
(16) Upon a determination of ineligibility, if the person is:
(a) on the waiting list, his or her name will be removed from the waiting list; or
(b) currently in waiver services, he or she will be exited from the 0208 HCBS Waiver Program ten days from the date of the notification letter.
History: 53-6-113, 53-6-402, MCA; IMP, 53-6-101, 53-6-402, MCA; NEW, 1992 MAR p. 1490, Eff. 7/17/92; AMD, 1995 MAR p. 1136, Eff. 6/30/95; TRANS, from SRS, 1998 MAR p. 3124; AMD, 2014 MAR p. 220, Eff. 1/31/14.