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| Montana Administrative Register Notice 37-486 | No. 18 09/24/2009 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Concerned Persons 1. On October 15, 2009, at 2:00 p.m., the Department of Public Health and Human Services will hold a public hearing in the auditorium of the Department of Public Health and Human Services Building, 111 North Sanders, Helena, Montana, to consider the proposed adoption and amendment of the above-stated rules. 2. The Department of Public Health and Human Services will make reasonable accommodations for persons with disabilities who wish to participate in this rulemaking process or need an alternative accessible format of this notice. If you require an accommodation, contact Department of Public Health and Human Services no later than 5:00 p.m. on October 6, 2009, to advise us of the nature of the accommodation that you need. Please contact Rhonda Lesofski, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail dphhslegal@mt.gov. 3. The rules as proposed to be adopted provide as follows: RULE I HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE : FAMILY SUPPORT SPECIALIST SERVICES (1) Family support specialist services provide support and interventions to parents and youth, under the guidance of the home-based therapist. These services may include: (a) assisting the therapist in family therapy by providing feedback to the in-home therapist about observable family dynamics; (b) providing education to parents regarding their child's mental illness; (c) coaching, supporting, and encouraging parenting techniques learned through parenting classes and/or family therapy; (d) providing, as necessary, parenting skills specific to the child; (e) participating in family activities in order to assist parents in applying specific parenting methods in order to change family dynamics; (f) working with youth to develop wellness recovery tools such as a wellness recovery action plan tool kit; and (g) serving as a member of the crisis intervention team. (2) Family support specialist services are provided by appropriate community agencies with the capacity to offer this service to parent or legal guardians of youth with serious emotional disturbance (SED). (3) The provider of family support specialists must: (a) ensure that its employees providing family support specialist services have a Bachelor's degree in human services; (b) be knowledgeable about family systems and dynamics; (c) have three years experience working with youth with SED and their families; (d) provide supervision of family support specialists by a licensed mental health professional (MHP); and (e) ensure that any employee providing family support services has attended a wraparound facilitation training sanctioned by the department or has been trained by someone within the community agency who has attended a wraparound facilitation training sanctioned by the department. (4) A family support specialist may be a licensed mental health professional in the state of Montana that includes one of the following: (a) licensed clinical professional counselor; (b) licensed clinical social worker; or (c) licensed clinical psychologist. (5) A family support specialist who is also a licensed mental health professional cannot provide any other waiver services or state plan services for the youth. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA RULE II HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: CAREGIVER PEER-TO-PEER SUPPORT SPECIALIST SERVICES (1) Caregiver peer-to-peer support services offer and promote support to the parent/guardian of the youth with SED. The services are geared toward promoting self-empowerment of the parent, enhancing community living skills and developing natural supports. These services include: (a) empowering parents to make informed independent choices in order to develop a network for information and support from others; (b) coaching parents in developing systems advocacy skills in order to take a proactive role in their youth's treatment and to obtain information and advocate with the school system; and (c) assisting parents in developing supports including formal and informal community supports. (2) Caregiver peer-to-peer support services are provided by appropriate community agencies with the capacity to offer this service to the parent/guardian of the youth with SED. (3) The provider of caregiver peer-to-peer support specialist services must: (a) ensure that any employee providing caregiver peer-to-peer services is a family member who has cared for a youth with SED while the youth was receiving services in the children's mental health system. The person must have experience in the direct day-to-day care of a youth with SED; (b) verify the youth is currently not enrolled as a participant in the Home and Community-Based Services Program for Youth with SED; (c) be knowledgeable of the children's mental health system as well as about other community resources; and (d) ensure that any employee providing caregiver peer-to-peer services has attended a wraparound facilitation training sanctioned by the department or has been trained by someone within the community agency who has attended a wraparound facilitation training sanctioned by the department. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA RULE III HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: WRAPAROUND FACILITATION SERVICES (1) Wraparound facilitation services are comprehensive services comprised of a variety of specific tasks and activities designed to carry out the wraparound process. These tasks include: (a) assembling the wraparound team; (b) facilitating plan of care meetings; (c) working with the department in identifying providers of services and other community resources to meet family and youth needs; (d) making necessary referrals for youth; (e) documenting and maintaining all information regarding the plan of care and the cost plan, including revisions; (f) presenting plan of care and cost plans to the plan manager for approval; (g) providing copies of the plan of care to the youth and family/guardian; (h) monitoring the implementation of the plan of care; (i) maintaining communication between all wraparound team members; (j) consulting with family and other team member to ensure the services the youth and family are receiving continue to meet the youth's needs; (k) educating new members to the wraparound process; and (l) maintaining team cohesiveness. (2) The wraparound facilitating services may be provided by a licensed mental health professional in the state of Montana that includes one of the following: (a) licensed clinical professional counselor; (b) licensed clinical social worker; or (c) licensed clinical psychologist. (3) A wraparound facilitator who is a licensed mental health professional cannot provide any other waiver services or state plan services for the youth they are facilitating. (4) The licensed mental health professional must have attended the wraparound facilitation training sanctioned by the department and is either a certified wraparound facilitator or is working towards certification. (5) A community agency that employees a wraparound facilitator must: (a) ensure that the wraparound facilitator is working under the supervision of a licensed mental health professional; (b) ensure that the wraparound facilitator has completed the wraparound facilitation training sanctioned by the department; (c) ensure all wraparound facilitators within the community agency are certified wraparound facilitators or working toward certification; and (d) document they have provided freedom of choice for all other waiver and state plan services to all waiver enrollees. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 4. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined: 37.87.1303 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: FEDERAL AUTHORIZATION AND AUTHORITY OF STATE TO ADMINISTER PROGRAM (1) The U.S. Department of Health and Human Services (HHS) has provided a grant to the Montana Department of Public Health and Human Services (department), under Section 6063 of the Deficit Reduction Act of 2005, that allows Montana to submit to the Centers for Medicare and Medicaid Services (CMS) a proposal to establish a program of Medicaid funded home and community-based services for youth who have serious emotional disturbance. That proposal has been presented to and approved by CMS. The purpose of this program is to avoid institutionalizing youth with serious emotional disturbance in residential treatment facilities. Institutionalization is avoided through the provision of mental health services and other services that support and treat those youth while residing with their families and receiving mental health treatment in the community. (2) In accordance with the state and federal statutes and rules generally governing the provision of Medicaid funded home and community-based services and any federal-state agreements specifically governing the provision of the Medicaid funded home and community-based services to be delivered through this program, and within the fiscal limitations of the funding appropriated and available for the program, the department may determine within its discretion the following features of the program: (a) through (3) remain the same. (4) The department has received federal approval to waive statewide coverage in the provision of program services. Program services may only be delivered in the following service areas for which federal approval of coverage has been received: (a) remains the same. (b) Missoula and Ravalli Counties, implementation date of August 1, 2009. (5) In (6) remains the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1305 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: ELIGIBILITY FOR PROGRAM (1) and (2) remain the same. (3) A youth is eligible to be considered for enrollment in the program if: (a) and (b) remain the same. (c) the youth requires the level of care, as determined through the certificate of need process, for a psychiatric residential treatment facility in accordance with ARM (d) and (e) remain the same. (f) the youth meets the clinical criteria of serious emotional disturbance as defined at ARM (g) through (j) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1306 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: SELECTION FOR PLACEMENT (1) through (3)(j) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1307 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: LOSS OF A SERVICE AND DISENROLLMENT (1) through (1)(d) remain the same. (2) A youth enrolled in the program may be terminated from the program by the department for the following reasons: (a) through (i) remain the same. (j) the youth no longer meets the clinical criteria of serious emotional disturbance as defined at ARM (k) remains the same. (l) the youth has attained age (m) remains the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1321 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: THE PROVISION OF SERVICES (1) through (2)(g) remain the same. (3) The following services, as defined in these rules, may be provided through the program: (a) through (d) remain the same. (e) nonmedical transportation; (f) respite care (g) family support specialist services; (h) caregiver peer-to-peer support specialist services; and (i) wraparound facilitation services. (4) through (5) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1323 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE AND PLANS OF CARE: PLAN MANAGEMENT (1) remains the same. (2) Plan management is the responsibility of the (3) Upon the youth's initial enrollment in the program, the plan of care is developed by the (4) through (7) remain the same. (8) The wraparound facilitator and/or department must provide a copy of the plan to the youth and the youth's family. (9) remains the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1325 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: COST OF PLAN OF CARE (1) through (4) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1331 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: PROVIDER REQUIREMENTS (1) through (2) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1333 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: REIMBURSEMENT (1) remains the same. (2) Program services are reimbursed at the lower of the following: (a) remains the same. (b) the fees stated in the program's (3) and (4) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1335 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: NOTICE AND FAIR HEARING (1) through (3) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1338 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: CONSULTATIVE CLINICAL AND THERAPEUTIC SERVICES, REQUIREMENTS (1) through (4) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1339 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: CUSTOMIZED GOODS AND SERVICES, REQUIREMENTS (1) Customized goods and services as a program service allows for the purchase as a program service of services or goods not typically reimbursed by Medicaid. These customized goods and services are used by the youth to facilitate access to supports designed to improve and maintain the youth in the community. (2) through (2)(c) remain the same. (3) Customized goods and services must be prior authorized and are limited in expenditure to (4) and (5) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1340 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: EDUCATION AND SUPPORT SERVICES, REQUIREMENTS (1) through (4) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1341 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: HOME-BASED THERAPY SERVICES, REQUIREMENTS (1) through (2)(e) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1342 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: NONMEDICAL TRANSPORTATION SERVICES (1) through (4) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 37.87.1343 HOME AND COMMUNITY-BASED SERVICES FOR YOUTH WITH SERIOUS EMOTIONAL DISTURBANCE: RESPITE CARE SERVICES (1) through (4)(e) remain the same. AUTH: 53-2-201, 53-6-113, 53-6-402, MCA IMP: 53-6-402, MCA 5. The Department of Public Health and Human Services (the department) is proposing the adoption of new Rules I, II, and III and the amendment of ARM 37.87.1303, 37.87.1305, 37.87.1307, 37.87.1321, 37.87.1323, 37.87.1333, and 37.87.1339, pertaining to Medicaid childrens' mental health waiver services authorized under section 1915(c) of the Social Security Act. The proposed new rules and amendments are necessary to add Missoula and Ravalli Counties as areas where home and community-based services (HCBS) for youth with serious emotional disturbance (SED) are available; to increase the maximum age for participation in the program to 18; to add family support specialist services, wraparound facilitation, and caregiver peer-to-peer support specialist services to the spectrum of HCBS for youth with SED; to increase the spending limit for customized goods and services; and to reference the fees stated in the program's Psychiatric Residential Treatment Facility Home and Community-Based Services Waiver for Youth with Serious Emotional Disturbance Provider Policy Manual dated August 2009. The department is taking this opportunity to update cross-references and to make terminology consistent throughout the subchapter. The department is proposing the amendment of ARM 37.87.1306, 37.87.1325, 37.87.1331, 37.87.1335, 37.87.1338, 37.87.1340, 37.87.1341, 37.87.1342, and 37.87.1343 by changing the word "COMMUNITY" to "COMMUNITY-BASED" in each rule title. The proposed new rules and amendments are described in detail below. Rules I, II, and III
Since October 1, 2007, the department has operated a program of Medicaid funded home and community-based services for youth who have SED. This program is authorized by the Centers for Medicare and Medicaid Services (CMS), the federal agency responsible for administering the Medicaid Medical Assistance program, under the authority of Section 6063 of the Deficit Reduction Act of 2005 (DRA). The department applied for and was awarded a grant for this purpose by CMS. The department is proposing three new rules that would add three additional services to HCBS for youth with SED. Rule I would add family support specialist services. Rule II would add caregiver peer-to-peer support services, and Rule III would add wraparound facilitation services. The experience of Medicaid waiver programs in other states with these services has been positive for youth receiving the services. These proposed rules would specify the requirements for new services that may be obtained and paid for through HCBS for youth with SED. These are recognized services provided to youth and families in other states with the same waiver. These services, as proposed, would allow for Medicaid coverage not available through the existing standard set of mental health services funded with Medicaid monies. They are designed to enhance the opportunities of youth in the program to have better outcomes and to remain in their homes and communities. ARM 37.87.1303
The amendments to this rule governing HCBS for youth with SED are necessary to implement federal authorization to administer the Medicaid Waiver program in Missoula and Ravalli Counties as of August 1, 2009. Addition of this service area will increase the service opportunities to youth and their families in this area. The proposed addition of this service area is made possible by a DRA grant conditioned on expansion of the service area. The department chose this alternative because it wanted to increase HCBS opportunities to youth in more counties. ARM 37.87.1305
The department is proposing an amendment to this rule governing eligibility to allow enrollment in the program up to a youth's 18th birthday. This will allow enrolled individuals to receive waiver services until they are old enough to qualify for adult mental health services. The existing rule creates the potential for a one-year gap in services prior to a youth's 18th birthday. The department chose this alternative after meeting with individuals and providers in Yellowstone County regarding the waiver program in that county. The department is taking this opportunity to update two obsolete cross-references in this rule. ARM 37.87.1307
The department is proposing an amendment to the enrollment termination criteria that would raise the age of eligibility to 18. This would make this rule consistent with the amendments proposed for ARM 37.87.1305. For more details please see the discussion of amendments to ARM 37.87.1305 above. The department is taking this opportunity to update an obsolete cross reference in this rule. ARM 37.87.1321
The department is proposing an amendment to this rule that would add family support specialist services, caregiver peer-to-peer support specialist services, and wraparound facilitation services to the list of services available through the Home and Community-Based Waiver Services Program for Youth with SED. This would make it consistent with proposed new Rules I, II, and III. For more details please see the discussion of Rules I, II, and III above. ARM 37.87.1323 The department is proposing amendments to this rule that would make a wraparound facilitator responsible for management of an individual's plan of care. This function is currently being performed by the plan manager who is an employee of the department. The plan of care would be developed by the wraparound facilitator in collaboration with the plan manager, the youth and the youth's parent(s) or caregiver, appropriate health care professionals, and others who treat or have knowledge of the youth's mental health and related needs. ARM 37.87.1333
The department is proposing an amendment to this rule that would adopt and incorporate by reference an updated "fee schedule" reflecting the changes proposed in this notice. The name of the fee schedule has been changed to the "Psychiatric Residential Treatment Facility Home and Community-Based Services Waiver for Youth with Serious Emotional Disturbance Provider Policy Manual" (manual) and is dated August 2009. A copy of the manual can be obtained by writing the department's Children's Mental Health Bureau, 1400 Broadway, Room A-113, Helena, MT 58620 or by visiting the department's web site, http://www.dphhs.mt.gov/mentalhealth/children/ No substantive changes to rates of provider reimbursement are intended, except for addition of the three new services. ARM 37.87.1339 The department is proposing an amendment to this rule that would increase the limit on expenditures for customized goods and services for youths under the HCBS waiver. Recommendations from the youth and families receiving these services in Yellowstone County indicate that the limit of $200 is too restrictive. Consequently, the department is proposing a limit of $1,000 to cover the cost of reasonable customized goods and services while managing the HCBS Waiver program in a fiscally responsible manner. Fiscal effect
The department expects no increase or decrease in the cost of benefits for recipients of HCBS waiver services and no overall change in reimbursement levels for providers. Budget projections indicate no increases or decreases in federal or state expenditures should be expected as a result of the new rules and amendments proposed in this notice. Benefit effects
The department does not expect the changes proposed in this notice to affect the overall level of mental health services Medicaid eligible youths would receive. However, the department expects outcomes to improve for youth participating in the HCBS Waiver program.
Entities affected
There are at least three mental health centers plus numerous mental health providers in Missoula and Ravalli Counties eligible to provide HCBS mental health waiver services and approximately 35 to 50 youth may be eligible for those services. All could be affected by the proposed new rules and amendments. 6. The department intends the rule amendments to be applied retroactively to August 1, 2009. No negative effects on providers or recipients are anticipated as a result of a retroactive application of this proposal. 7. Concerned persons may submit their data, views, or arguments either orally or in writing at the hearing. Written data, views, or arguments may also be submitted to: Rhonda Lesofski, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail dphhslegal@mt.gov, and must be received no later than 5:00 p.m., October 22, 2009. 8. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing. 9. The department maintains a list of interested persons who wish to receive notices of rulemaking actions proposed by this agency. Persons who wish to have their name added to the list shall make a written request that includes the name, e-mail, and mailing address of the person to receive notices and specifies for which program the person wishes to receive notices. Notices will be sent by e-mail unless a mailing preference is noted in the request. Such written request may be mailed or delivered to the contact person in 7 above or may be made by completing a request form at any rules hearing held by the department. 10. An electronic copy of this Proposal Notice is available through the Secretary of State's web site at http://sos.mt.gov/ARM/Register. The Secretary of State strives to make the electronic copy of the Notice conform to the official version of the Notice, as printed in the Montana Administrative Register, but advises all concerned persons that in the event of a discrepancy between the official printed text of the Notice and the electronic version of the Notice, only the official printed text will be considered. In addition, although the Secretary of State works to keep its web site accessible at all times, concerned persons should be aware that the web site may be unavailable during some periods, due to system maintenance or technical problems. 11. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
/s/ John Koch /s/ Anna Whiting Sorrell Rule Reviewer Anna Whiting Sorrell, Director Public Health and Human Services Certified to the Secretary of State September 14, 2009.
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A directory of state agencies is available online at http://www.mt.gov/govt/agencylisting.asp.
For questions about the organization of the ARM or this web site, contact sosarm@mt.gov.
