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| Montana Administrative Register Notice 37-593 | No. 14 07/26/2012 | |
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BEFORE THE DEPARTMENT OF PUBLIC HEALTH AND HUMAN SERVICES OF THE STATE OF MONTANA
TO: All Concerned Persons 1. On August 20, 2012, at 10:00 a.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 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 August 13, 2012, to advise us of the nature of the accommodation that you need. Please contact Kenneth Mordan, 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 [email protected]. 3. The rules as proposed to be adopted provide as follows: NEW RULE I MEDICAID HOME AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: AUTHORITY (1) The department has been granted by the United States Department of Health and Human Services (HHS) the authority to provide Medicaid home and community children's autism services to children who are determined to have autism. The authority to implement this program is provided in 42 USC 1396n(c) and 42 CFR 441.300 441.310. These rules implement in Montana the Medicaid home and community services program for children with autism as approved by HHS as the 0667 Home and Community Services Waiver. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE II MEDICAID HOME AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: GENERALLY (1) The Medicaid home and community services program for children with autism is available to serve: (a) children who would otherwise require the level of care provided in an intermediate care facility for the mentally retarded (ICF/MR); and (b) for whom services provided will not jeopardize the child's health and safety. (2) Eligibility of applicants to be considered for acceptance into the Medicaid home and community services program for children with autism is determined as provided in [New Rule III]. (3) Acceptance into the Medicaid home and community services program for children with autism is determined as provided in [New Rule IV]. (4) Services and acceptance into the Medicaid home and community services program for children with autism are available only to the extent that the federal approval of the state's program permits and that available funding allows. (a) In accordance with current federal approval, the program has only fifty placements available. (5) The department, in order to comply with federal requirements or to limit expenditures of available funding, may: (a) reduce the number of Medicaid children that may be served through this program; (b) postpone or waive implementation of a particular service of the program; or (c) eliminate one or more of the services of the program. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE III MEDICAID HOME AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: ELIGIBILITY (1) Through the Medicaid home and community services program for children with autism, the department determines a child is eligible to be considered for acceptance into the program if the child: (a) is the age of 15 months through the age of four years; (b) is eligible for Medicaid; (c) is diagnosed as having Autism Spectrum Disorder and has adaptive disorder training needs as determined by the eligibility determination process established by the department. (2) Eligible children are placed on the waiting list in accordance with [New Rule IV]. (3) Eligible children turning five years of age are removed from the eligibility list on their fifth birthday. (4) Eligible children are not required to have a diagnosis of mental retardation. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE IV MEDICAID HOME AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: SCREENING AND ACCEPTANCE DETERMINATIONS (1) A child determined eligible to be considered for acceptance into the children's autism program will be placed on the waiting list for services through the completion of the waiting list application form. The child's application form has a number assigned to it by the program. Service opportunities for the children's autism program are awarded by means of random selection using a computer program that generates a number based on the range of numbers representing the children on the waiting list for the Developmental Disabilities Program (DDP) region of the state where the service opportunity exists. (2) Except as otherwise provided, service opportunities are only awarded to children who do not have autism services coverage through private insurance which pays for autism services at the time of entry. If the child has private insurance, then one of the following procedures apply: (a) if a child was selected for and entered the program prior to October 1, 2012 and the child has insurance which pays for autism services, then the child is allowed to remain in services for the three year period of the waiver opportunity; or (b) if a child enters the program after October 1, 2012 and at the time of entry does not have insurance that pays for autism services but subsequently receives insurance that provides coverage for autism services, then the child's eligibility is terminated and the provision of program services is discontinued. (3) A service opportunity is awarded as it becomes available. (4) The allocation of service opportunities is based proportionately on the population of each DDP region derived from US census data. (5) When the child exits the waiver, the service opportunity will stay within the DDP region except as provided for in (6). (6) In the event that unused capacity exists in a particular DDP region, an available service opportunity is allocated to the region with the lowest enrolled children per capita. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE V MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: TRANSITIONING FROM THE CHILDREN'S AUTISM WAIVER (1) A child accepted into the program may receive up to three years of available service. (a) If requested by the family, a child who is transitioning from the children's autism program and who meets the eligibility criterion for developmental disabilities services may be placed on the waiting list for the home and community-based services 0208 waiver program. (b) If requested by the family, case managers for children enrolled in the autism program shall conduct ongoing transition and other service coordination activities. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE VI MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: REIMBURSEMENT (1) The requirements governing reimbursement for Medicaid home and community children's autism services are found at ARM 37.34.3001, 37.34.3002, and 37.34.3007. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE VII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: AVAILABLE SERVICES (1) The following services may be provided by the Medicaid home and community-based autism services waiver: (a) Children's Autism Training, as provided in [New Rules XII and XIII]; (b) Waiver Funded Children's Case Management, as provided in [New Rules XIV and XV]; (c) Respite, as provided in [New Rules XVI and XVII]; (d) Adaptive Equipment, as provided in [New Rules XX and XXI]; (e) Environmental Modifications, as provided in [New Rules XVIII and XIX]; (f) Occupational Therapy, as provided in [New Rules XXII and XXIII]; (g) Physical Therapy, as provided in [New Rules XXIV and XXV]; (h) Speech Therapy, as provided in [New Rules XXVI and XXVII]; (i) Transportation, as provided in [New Rules XXVIII and XXIX]; (j) Individual Goods and Services, as provided in [New Rules XXX and XXXI]; and (k) Program Design and Monitoring, as provided in [New Rules XXXII and XXXIII]. (2) Services available to a child through the program are limited to the services specified in the child's plan of care. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE VIII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: GENERAL PROVIDER REQUIREMENTS (1) The services of the Medicaid home and community program for children with autism may be provided by one or more of the following, as determined by the department: (a) a Medicaid provider agency through contract with the department; (b) a subcontractor for a Medicaid provider agency that is recognized by the department as an "Organized Health Care Delivery System" (OHCDS); (c) an individual Medicaid provider through contract with the department; and (d) an individual Medicaid provider without a contract with the department. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE IX MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: INDIVIDUAL FAMILY SERVICE PLAN (1) The department must review and approve the individual family service plan. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE X MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: NOTICES AND FAIR HEARINGS (1) The department's notices and fair hearings are provided for in ARM 37.34.919. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XI MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: INFORMING BENEFICIARY OF CHOICE (1) The department will give the parent or legal representative of the child the opportunity to make a choice, on behalf of the child, between placement in an ICF/MR or in the Medicaid home and community services program. (2) The parent or legal representative must be informed of the feasible alternatives in the community, if any, available through the Medicaid home and community services program. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: CHILDREN'S AUTISM TRAINING, DEFINITION (1) Children's autism training is a direct training service designed to assist the child in acquiring, retaining, and generalizing the self-help, socialization, cognitive, communication, organization skills, and the positive behaviors necessary to function successfully in home and community settings. (2) Children's autism training includes: (a) social skills and related skills to enhance participation across all environments (school, home and community settings) and relationships; (b) a functional communication system which may include expressive verbal language, receptive language and nonverbal communication skills, and augmentative communication; (c) increased engagement and flexibility in the exhibition of developmentally appropriate behaviors; (d) replacement of inappropriate behaviors with more conventional and functional behaviors; (e) working with caregivers and others in the environment to promote the child's competence and positive behavior; (f) fine and gross motor skills used for age-appropriate functional activities, as needed; (g) cognitive skills relating to play activity and academic skills; (h) adaptive behavior and self-care skills to enable the child to be more independent; and (i) independent exhibition of organizational skills. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XIII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: CHILDREN'S AUTISM TRAINING, REQUIREMENTS (1) The children's autism trainer provides hands-on training using evidence-based applied behavior analysis practice and methods. Training goals are outcome-based and progress towards goals is evidenced by training data. (2) The training effort occurs where the child lives, attends child care, and/or socializes with peers. The bulk of training may occur in the child's home. Training may be delivered in group settings with same age peers or in one-to-one settings, based on the assessed needs of the child. The majority of training is delivered in one-to-one settings. (3) The trainer must complete the training requirements as outlined in ARM 37.34.2107. (4) The trainer receives training developed by the provider agency within 30 days of hire, which includes: (a) abuse reporting; (b) incident reporting; (c) client rights; (d) client confidentiality; (e) first aid training; and (f) any specialty training related to the needs of the children served as outlined in the plan of care. (5) Trainers must take the college of direct support training provided through the department, including the modules specific to autism within 30 days of hire. (6) Trainers assisting with medications must be certified in accordance with ARM 37.34.114. (7) The employer shall maintain documentation verifying that a trainer providing direct client services has had an acceptable criminal background check in accordance with ARM 37.34.2102(2). AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XIV MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: WAIVER-FUNDED CHILDREN'S CASE MANAGEMENT (1) Waiver-funded children's case management services are services furnished to assist children in gaining access to needed medical, social, education, and other services. (2) Waiver-funded children's case management includes the following assistance: (a) comprehensive assessment and periodic reassessment of the child's needs to determine the need for any medical, educational, social, or other services; (b) development and periodic revision of a specific care plan; (c) referral and related activities to help an eligible child to obtain needed services; (d) monitoring and follow-up activities including activities and contacts that are necessary to ensure the plan of care is implemented and adequately addresses the child's needs; (e) contacts with non-eligible persons that are directly related to identifying the needs and supports for helping the eligible child to access services; (f) upon request, assisting the department in scheduling meetings and providing information to department staff responsible for completing initial and ongoing level of care activities; and (g) locating suitable alternative placement, as necessary when the child's health or safety is at risk. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XV MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: WAIVER-FUNDED CHILDREN'S CASE MANAGEMENT, REQUIREMENTS (1) A case manager shall conduct a face-to-face visit with the parent or legal representative, at least monthly, for the purpose of reviewing any need for change in the plan of care, based on the changing needs of the child or the family. (2) A case manager must have a four year degree in a human services field, three years of experience in working with children with developmental disabilities, and current family support specialist certification. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XVI MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: RESPITE, DEFINITION (1) Respite care includes any services designed to meet the safety and daily care needs of the child and the needs of the child's caregiver in relation to reducing stress generated by the provision of constant care to the child receiving waiver services. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XVII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: RESPITE, REQUIREMENTS (1) Persons providing respite services will be in compliance with all state and federal respite standards. (2) Respite services are delivered in conformity with the plan of care. (3) Respite is considered an ancillary service. The sum of all ancillary service costs may not exceed $4,000 annually. (4) Respite provider is subject to approval by the family, and must possess any competencies outlined by the family in the plan of care which are related to the specific needs of the child. (5) A person providing the respite service must be 16 years of age or older. (6) Respite services are selected in collaboration with the child's parent or legal representative and are provided by persons chosen and trained by the family. (7) The amount and frequency of respite care is included in each child's plan of care. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XVIII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: ENVIRONMENTAL MODIFICATION, DEFINITION (1) Environmental modifications are physical adaptations to the home, required by the child's plan of care, which are necessary to ensure the health, welfare, and safety of the child, or which enable the child to function with greater independence in the home, and without which the child would require institutionalization. (2) Environmental modification services are measures that provide the child with accessibility and safety in the environment so as to maintain or improve the ability of the child to remain in community settings and employment. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XIX MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: ENVIRONMENTAL MODIFICATION, REQUIREMENTS (1) An environmental modification must: (a) relate specifically to and be primarily for the child's disability; (b) have utility primarily for the child who has a disability; (c) not be an item or modification that a family would normally be expected to provide for a non-disabled family member; (d) not be in the form of room and board or general maintenance; and (e) meet the specifications, if applicable, for the modification set by the American National Standards Institute (ANSI). (2) Environmental modification is considered an ancillary service; the sum of all ancillary service costs may not exceed $4,000 annually. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XX MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: ADAPTIVE EQUIPMENT, DEFINITION (1) Adaptive equipment is equipment necessary to increase independent functioning in completing activities of daily living when such equipment is not available through other sources. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXI MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: ADAPTIVE EQUIPMENT, REQUIREMENTS (1) Adaptive equipment will conform to the following criteria: (a) relate specifically to and be primarily for the child's disability; (b) have utility primarily for the child who has a disability; (c) not be an item or modification that a family would normally be expected to provide for a non-disabled family member; (d) not be in the form of room and board or general maintenance; and (e) meet the specifications, if applicable, for the modification set by the American National Standards Institute (ANSI). (2) Adaptive equipment may be provided as needed to enable family members or other caregivers to provide the care needed by the child. (3) Adaptive equipment is considered an ancillary service; the sum of all ancillary service costs may not exceed $4,000 annually. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: OCCUPATIONAL THERAPY, DEFINITION (1) Occupational therapy services are defined in 37-24-103, MCA and may include evaluation, consultation, training, and treatment.
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXIII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: OCCUPATIONAL THERAPY, REQUIREMENTS (1) Occupational therapy must meet the requirements for occupational therapy services required by ARM 37.86.606, except that under the Medicaid home and community services program: (a) maintenance therapy is reimbursable and there are no limitations on visits for maintenance therapy; (b) training for persons providing direct care is reimbursable; and (c) participation in the interdisciplinary team planning process is reimbursable. (2) Occupational therapy is considered an ancillary service. The sum of all ancillary service costs may not exceed $4,000 annually. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXIV MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: PHYSICAL THERAPY, DEFINITION (1) Physical therapy services are defined in 37-11-101(7), MCA. (2) Physical therapist may provide treatment training programs that are designed to: (a) preserve abilities for independent function; and (b) prevent, insofar as possible, irreducible or progressive disabilities. (3) Therapists may also provide consultation and training to staff or caregivers who work directly with waiver children. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXV MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: PHYSICAL THERAPY, REQUIREMENTS (1) Physical therapy must meet the requirements for physical therapy services required by ARM 37.86.606, except that under the Medicaid home and community services program: (a) maintenance therapy is reimbursable and there are no limitations on visits for maintenance therapy; (b) training for persons providing direct care is reimbursable; and (c) participation in the interdisciplinary team planning process is reimbursable. (2) Physical therapy is considered an ancillary service. The sum of all ancillary service costs may not exceed $4,000 annually. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXVI MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: SPEECH THERAPY, DEFINITION (1) Speech therapy services are defined in 37-15-102(8), MCA and may include evaluation, consultation, training, and treatment. (2) Speech therapy services may include: (a) screening and evaluation of children with respect to speech and hearing functions; (b) comprehensive speech and language evaluations when indicated by screening results; (c ) participation in the continuing interdisciplinary evaluation of children for purposes of beginning, monitoring, and following up on individualized habilitation programs; and (d) treatment services as an extension of the evaluation process, which include consultation with appropriate people involved with the child for speech improvement and speech education activities to design specialized programs for developing each child's communication skills in comprehension, including speech, reading, auditory training, and skills in expression. (3) Therapists may also provide consultation and training to staff or caregivers who work directly with waiver children. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXVII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: SPEECH THERAPY, REQUIREMENTS (1) Speech therapy must meet the requirements for speech therapy services required by ARM 37.86.606, except that under the Medicaid home and community services program: (a) maintenance therapy is reimbursable and there are no limitations on visits for maintenance therapy; (b) training for persons providing direct care is reimbursable; and (c) participation in the interdisciplinary team planning process is reimbursable. (2) Speech therapy is considered an ancillary service. The sum of all ancillary service costs may not exceed $4,000 annually. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXVIII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: TRANSPORTATION, DEFINITION (1) Transportation services are offered in order to enable children served on the waiver to gain access to waiver and other community services, activities, and resources specified by the plan of care. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXIX MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: TRANSPORTATION, REQUIREMENTS (1) Transportation services through the waiver must be offered in accordance with the plan of care. (2) Persons providing transportation must be licensed, insured, and drive a registered vehicle in accordance with the motor vehicle laws of the state of Montana. (3) Reimbursement for rides provided a legally responsible person or others must be related to the specific disability needs of a child, as outlined in the plan of care. (4) Under no circumstances will medically necessary transportation be reimbursed through the waiver if the service is reimbursable through Medicaid state plan transportation. (5) Transportation is considered an ancillary service. The sum of all ancillary service costs may not exceed $4,000 annually. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXX MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: INDIVIDUAL GOODS AND SERVICES, DEFINITION (1) Individual goods and services are services, supports, or goods that enhance opportunities to achieve outcomes related to living arrangements, relationships, inclusion in the community, and work as clearly identified and documented in the plan of care. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXXI MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: INDIVIDUAL GOODS AND SERVICES, REQUIREMENTS (1) Items covered through individual goods and services must meet the following requirements: (a) the item or service is designed to meet the child's functional, medical, or social needs and advance the desired outcomes in the plan of care; (b) the item or service is not prohibited by federal or state statutes or regulations; (c) the item or service is not available through another source; (d) the service does not include experimental goods or services; and (e) one or more of the following additional criteria are met: (i) the item or service would increase the child's functioning related to the disability; (ii) the item or service would increase the child's safety in the home environment; or (iii) the item or service would increase independence from other Medicaid services. (2) Recreational activities provided through individual goods and services may be covered only to the degree that they are not diversional in nature and are included in a planning objective related to a specific therapeutic goal. (3) Individual goods and services are reimbursable only if: (a) individual goods and services must be approved by the planning team prior to purchase; and (b) goods and services purchased on behalf of the child by nonemployees acting on behalf of the child are reimbursable only if receipts for such purchases are submitted to the agency that has a contract with the department. (4) The department assures that services, goods, or supports provided for through this definition are not available through the Individuals with Disabilities Education Act (IDEA) or Section 110 of the Rehabilitation Act or available through any other public funding mechanism. (5) Individual goods and services is considered an ancillary service. The sum of all ancillary service costs may not exceed $4,000 annually. Individual goods and services projected to exceed an annual aggregate amount of $2,000 require approval by the program regional manager. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXXII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: PROGRAM DESIGN AND MONITORING, DEFINITION (1) Program design and monitoring is designed to provide the formal training protocols and methods used by the children's autism trainer in helping the child acquire, retain, and generalize the self-help, socialization, cognitive, communication, organizational skills, and the positive behaviors necessary to function successfully in home and community-based settings. (2) Training goals must be outcome-based and progress toward goals will be evidenced by training data. (3) Training efforts will occur in the customary and usual community locations where the child lives, plays, and socializes with peers. Training may be delivered in group settings with same aged peer or in one-to-one settings, based on the assessed needs of the child. The majority of training will be delivered in one-to-one training. AUTH: 53-6-402, MCA IMP: 53-6-402, MCA NEW RULE XXXIII MEDICAID AND COMMUNITY SERVICES CHILDREN'S AUTISM PROGRAM 0667: PROGRAM DESIGN AND MONITORING, REQUIREMENTS (1) Staff providing program design and monitoring(PDM) must have a family support specialist certification with an autism endorsement or be a Board Certified Behavioral Analyst. (2) Staff providing PDM shall provide the following services: (a) develop and monitor the implementation of formal and informal training methods and provide training specific to the formal training plan and the informal interaction techniques used by the children's autism trainer, family members and others who work with or interact with the child; and (b) provide general assistance and support to individuals who provide unpaid support, training, companionship or supervision to the child.
AUTH: 53-6-402, MCA IMP: 53-6-402, MCA 4. STATEMENT OF REASONABLE NECESSITY The Department of Public Health and Human Services (department) is proposing the adoption of New Rules I through XXXIII pertaining to Children's Autism Waiver (CAW). The implementation of these new rules serves to define and deliver the services available.
In order to identify gaps or needs in the service system for children with The children's autism waiver provides intensive early autism intervention training (about 20 hours per week) for improving skills in the areas of communication, socialization, academics, and activities of daily living while reducing difficult or socially unacceptable behaviors. Eligible children are between the ages of 15 months through 7 years old and may receive services for a maximum of three years. Eight agencies across the state provide program design and training individualized for each child, case management services, and other supports to children and their families. Applied behavior analysis (ABA) training models and evidence-based practice are the basis for these services. The hours of training provided are required to be evidence-based practices of behavioral intervention. The department ensures these Medicaid expenditures pay for practices that have clear scientific evidence which demonstrate their effectiveness. Treatment strategy is developed and directed by a certified behavior specialist, documented in an individualized autism training plan, and provided by a direct support person trained in providing behavioral support to children with autism. Providers receive reimbursement for the waiver services at a standardized rate set by the department and based on the rates reimbursement methodology used to establish rates for other department services. Services provided by staff with the required experience and at the intensity required cost approximately $45,000 per individual per year. It is anticipated that these costs may be more than offset by a decreased need for assistance by the child later in life. To evaluate the program a variety of types of measures (i.e., norm referenced, curriculum-based measures) across a number of variables (i.e., symptom-related, development, and functional) were measured. The department will conduct a comprehensive evaluation of the project when children complete the program (meaning receive three years of Children's Autism Waiver services); however, the department has preliminary data and report of this data is available at: http://www.dphhs.mt.gov/dsd/ddp/autism.shtml. Previously reported data indicate that in the developmental domains most affected by autism (i.e., social skills, communication skills, and adaptive functioning) all children were making progress. Most notably, in these three domains, norm-reference tests indicated that on average participating children's rate of development nearly tripled. It is not known if this rate will hold steady through the children's participation in the program. Four children have exited due to age and preliminary outcome data suggests that the percentage of treatment goals mastered by these children ranged from 85% to 73%.
Based on this preliminary data, as many as 20% of the children receiving Children's Autism Wavier services may achieve what is known as a "best outcome." Autism is considered a life-long developmental disability and as such there is no cure. "Best outcome" describes children who demonstrate a normal IQ, can access the general education curriculum, and whose autism symptoms have decreased to the extent that they no longer fall in the clinical scale of autism. Thus far, two children have met these criteria. The average lifetime cost for serving an individual with autism is approximately $2 million. Using this average for each child obtaining a best outcome, the state could save approximately $2 million in lifetime costs per child for those children who achieve a best outcome. Appropriations to the department to serve 50 individuals for one year of this waiver total $2.1 million. New Rule I New Rule I provides the authority for the department to provide Medicaid home and community children's autism services. The department has the authority to apply for waiver funds through the Medicaid home and community-based program and applied for the waiver in order to meet the needs of children with autism. The department believes this is the most fiscally responsible option for meeting those needs. Another option available is to provide these services fully through state funds. The department believes this is a much less responsible option due to the severe limitations placed on the state budget and the fact that the department would be able to serve far fewer individuals. New Rule II The department is proposing New Rule II as it is the goal of the department to provide services to those in need at the least restrictive levels available and it is the department's contention that early autism intervention reduces the risk of placement into an ICF/MR as an adult. This program provides opportunity for children with autism to maximize their level of independence by providing early autism intervention training. The state provides services in accordance with Medicaid home and community services standards and available funding. In order to participate in the Medicaid waiver program, the department has no other option but to strictly comply with these regulations or face the loss of the federal funding. New Rule III The department is proposing New Rule III to define the criteria for eligibility into the Children's Autism Waiver. Unlike eligibility for other services funded by the department the defining characteristic of a child eligible for this waiver is the diagnosis of autism spectrum disorder (ASD) in conjunction with significant deficits in adaptive behavior. Because ASD has different manifestations than other disabilities related to developmental disabilities, it is not necessary for the child found eligible for this waiver to meet the developmental disability, mental retardation, or intellectual disability definitions. The department retained the services of an expert on autism who has available the scientific data which demonstrates that early and intense intervention has the greatest likely effect for a child with autism. The department begins its eligibility for this waiver at 15 months. Once the child enters into the waiver, the services continue for three years. The department chose this model over other options because of its demonstrated effectiveness. New Rule IV New Rule IV defines the process used by the department to randomly select individuals for service opportunities in the department. The numbers of service opportunities are allocated by population density in the 5 developmental disability program regions in Montana. Once a child is determined eligible a computer program assigns the child a random number. When a service opening occurs, the computer program randomly draws one of the numbers assigned to the eligible children in that region. If all eligible children within a region are currently receiving services, the department will allocate the service opportunity to the region containing the largest waiting list of children when compared with the general population of the region. The department allocates service opportunities based upon population density and believes this is the most equitable process for selecting individuals served by the waiver. Effective October 1, 2012, children who have autism coverage through private insurance will no longer be found eligible for the waiver. As stated above, the department is conducting comprehensive evaluations of the project and in order to maintain consistency in the implementation of the evidence-based practices of the program services and ensure the integrity of data that is derived from the services, the department must regulate the services provided. The department does not regulate or control services provided through private insurers. Therefore, it is proposed that the children's autism waiver services will not be available to those who have private insurance that covers autism services. New Rule V The department is proposing New Rule V to describe the process whereby a child receiving children's autism services will transition from the waiver after three years of service or upon reaching the age of eight. Upon the request of the family, if the child is determined eligible for developmental disabilities services the family has the option of placing the child on the waiting list for the comprehensive services waiver. If the child is ineligible for developmental disabilities services, the case manager will review requirements for agencies serving children with a substantial handicapping condition due to either a physical disability, traumatic brain injury, diagnosis of serious emotional disturbance, or a combination of any of these with the child's family and will refer the child's family to other appropriate programs and services. New Rule VI New Rule VI directs individuals to the department's reimbursement rules as adopted in August 2011. ARM 37.34.3001 governs the requirements and limitations for provider reimbursement for services or items delivered to persons currently receiving services. ARM 37.34.3002 defines and describes the Individual Cost Plans (ICP) for individual persons. ARM 37.34.3007 sets forth the reimbursement for the provision of services or items funded through the 0667 Autism Program of Home and Community Services waiver. New Rule VII New Rule VII is being proposed to provide a comprehensive list of the services available through the Medicaid and Community Services Children's Autism Program 0667. Items (a), (b), and (k) are core services provided by the children's autism waiver. Items (c) and (d) through (j) are ancillary services. New Rule VIII New Rule VIII specifies which providers may provide Medicaid home and community-based services. Contracted services may include: initial and ongoing level of care activities, case management duties, available services, registered nurses, and other services determined by the department. New Rule IX New Rule IX specifies that the department reviews and approves the individual family service plans. New Rule X New Rule X references the administrative rule that defines the responsibilities of the department for appropriate notice to applicants regarding an individual's level of care and selection or denial for placement. A person who disagrees with an adverse action relating to services rendered, including such actions as suspension, reduction or termination of services, the denial of a requested service, or an adverse action resulting from the individual planning process, may appeal the decision through a fair hearing procedure available through the authority of the Montana Administrative Procedure Act. A fair hearing officer from the Department of Public Health & Human Services' Office of Fair Hearings conducts a hearing. Both the person who is appealing a decision and representatives from the department may present testimony and evidence at that hearing through witnesses and documents. New Rule XI New Rule XI maintains the department's obligation to meet the federal assurance of informing an individual of their freedom of choice, as provided in 42 CFR Section 441.302(d). The department's Waiver-5 Freedom of Choice form is part of the Children's Autism Waiver application. Upon entry into the waiver, a department staff member completes the form during the initial face-to-face level of care evaluation and then on an annual basis, with a parent or legal representative for children receiving the waiver. New Rules XII and XIII New Rules XII and XIII address the definition and requirements of Children's Autism Training. Children's Autism Training is a direct training service designed to assist the child in acquiring, retaining and generalizing the self-help, socialization, cognitive, communication, organizational skills, and the positive behaviors necessary to function successfully in home and community settings. The training methods are based on practices with a strong scientific basis and the protocols use evidence-based training approaches based upon applied behavior analysis to improve a child's functioning and performance. The training plan governs the activities of the autism trainer and reflects the assessed needs of the child. The needs of the child determine the assessment tools used and the use of multiple assessments helps ensure that the child's individual needs are met. Training protocols most likely to help the child achieve goals based upon the assessments, and set by the planning team, guide the activity of the staff person delivering the program services. Participation in the Children's Autism Waiver will require a general willingness on the part of the parent(s) or legal representative(s) to support the goals and objectives specific to the child's disability training needs. The training needs of the child may involve education of the parent(s) or legal representative(s) and others in terms of specific training and interaction protocols likely to be most beneficial to the child. The treatment plan may also provide guidance to others who live with or work with the child. Positive outcomes for the family and the child are contingent upon the cooperation of all planning team members in working together toward mutually agreed upon goals. New Rules XIV and XV New Rules XIV and XV defines Waiver-Funded Children's Case Management and provides the requirements.
Case management includes completing a comprehensive assessment by taking client history and identifying the child's needs, completing related documentation, and gathering information from other sources such as family members, medical providers, social workers, and educators to form a complete assessment of the child. The case manager develops a plan of care based on the information collected through the assessment and specifies goals and actions to address the medical, social, educational, and other services needed by the child. The case manager also provides referrals for needed services and monitors the activities and contacts that are necessary to ensure the care plan is implemented and adequately addresses the child's needs. The case manager is responsible for assisting the department, as requested, in scheduling meetings and providing information as requested to department staff responsible for completing initial and ongoing level of care activities. New Rules XVI through XXXI New Rules XVI through XXXI describe the ancillary services provided through the children's autism waiver. The sum of all ancillary services may not exceed $4000 and may include one or more services defined in New Rules XVI through XXXI. In collaboration, the parent(s) or legal representative(s) and the planning team select the services and persons chosen by the family supply the service. The Children's Autism Waiver is designed to provide hands on training using evidence-based applied behavioral analysis practices and methods. Ancillary services are chosen based on the specific needs of the child and their family in order to meet the goals defined in the child's plan of care. Ancillary services may be necessary to ensure the health and safety of an individual or enable the individual to function with greater independence. Ancillary services provided through the Children's Autism Waiver play an essential role in providing a holistic approach for services to children and their families. New Rules XXXII and XXXIII The department is proposing New Rules XXXII and XXXIII to provide definitions and the requirements for Program Design and Monitoring. Program Design and Monitoring (PDM) specialists develop the training methods based on practices with a strong scientific basis, as written in a formal training plan. The specialist providing PDM services may use the skill-based interventions and treatments of Applied Behavior Analysis (ABA), Discrete Trial Training (DTT), Pivotal Response Training (PRT), and Learning Experiences: An Alternative Program for Preschoolers and Parents (LEAP). This waiver service is designed to provide the formal training protocols and methods used by the children's autism trainer in helping the child acquire, retain, and generalize the self-help, socialization, cognitive, communication, organizational skills, and the positive behaviors necessary to function successfully in home and community-based settings. PDM specialists work with caregivers and others in their environment to implement accommodations and supports to promote the child's competence and positive behavior. Fiscal Impact There is no fiscal impact due to this rulemaking. 5. The department intends the proposed rule changes to be applied effective October 1, 2012. 6. 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: Kenneth Mordan, 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 [email protected], and must be received no later than 5:00 p.m., August 23, 2012. 7. The Office of Legal Affairs, Department of Public Health and Human Services, has been designated to preside over and conduct this hearing. 8. 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 6 above or may be made by completing a request form at any rules hearing held by the department. 9. 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. 10. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
/c/ Cary B. Lund /s/ Anna Whiting Sorrell Rule Reviewer Anna Whiting Sorrell, Director Public Health and Human Services Certified to the Secretary of State July 16, 2012.
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