Mont. Admin. R. 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;
(b)
shopping;
(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; and
(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:
(a)
dates;
(b) times;
(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.
Notes
53-2-201, MCA IMP: 53-2-201, 53-6-113, MCA;
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