1. Request Information (2 of 3)

6. Level(s) of Care. This waiver is requested in order to provide home and community-based waiver services to individuals who, but for the provision of such services, would require the following level(s) of care, the costs of which would be reimbursed under the approved Medicaid State plan (check each that applies):
   Hospital
   Select applicable level of care

    Hospital as defined in 42 CFR §440.10

   If applicable, specify whether the State additionally limits the waiver to subcategories of the hospital level of care:

   Character Count: out of 6000

    Inpatient psychiatric facility for individuals age 21 and under as provided in42 CFR §440.160

    not selected
   Nursing Facility
   Select applicable level of care

    Nursing Facility As defined in 42 CFR §440.40 and 42 CFR §440.155

   If applicable, specify whether the State additionally limits the waiver to subcategories of the nursing facility level of care:

   Character Count: out of 6000

    Institution for Mental Disease for persons with mental illnesses aged 65 and older as provided in 42 CFR §440.140

    not selected
   Intermediate Care Facility for the Mentally Retarded (ICF/MR) (as defined in 42 CFR §440.150)
   If applicable, specify whether the State additionally limits the waiver to subcategories of the ICF/MR level of care:

   Character Count: out of 6000

1. Request Information (3 of 3)

7. Concurrent Operation with Other Programs. This waiver operates concurrently with another program (or programs) approved under the following authorities
   Select one:
    Not applicable
    Applicable
   Check the applicable authority or authorities:

   Services furnished under the provisions of §1915(a)(1)(a) of the Act and described in Appendix I

   Waiver(s) authorized under §1915(b) of the Act.

   Specify the §1915(b) waiver program and indicate whether a §1915(b) waiver application has been submitted or previously approved:

   Character Count: out of 6000

   Specify the §1915(b) authorities under which this program operates (check each that applies):

   §1915(b)(1) (mandated enrollment to managed care)

   §1915(b)(2) (central broker)

   §1915(b)(3) (employ cost savings to furnish additional services)

   §1915(b)(4) (selective contracting/limit number of providers)

   A program operated under §1932(a) of the Act.

   Specify the nature of the State Plan benefit and indicate whether the State Plan Amendment has been submitted or previously approved:

   Character Count: out of 6000

   A program authorized under §1915(i) of the Act.

   A program authorized under §1915(j) of the Act.

   A program authorized under §1115 of the Act.

   Specify the program:

   Character Count: out of 6000

   Not applicable
    not selected

2. Brief Waiver Description

3. Components of the Waiver Request

The waiver application consists of the following components. Note: Item 3-E must be completed.

1. Waiver Administration and Operation. Appendix A specifies the administrative and operational structure of this waiver.

2. Participant Access and Eligibility. Appendix B specifies the target group(s) of individuals who are served in this waiver, the number of participants that the State expects to serve during each year that the waiver is in effect, applicable Medicaid eligibility and post-eligibility (if applicable) requirements, and procedures for the evaluation and reevaluation of level of care.

3. Participant Services. Appendix C specifies the home and community-based waiver services that are furnished through the waiver, including applicable limitations on such services.

4. Participant-Centered Service Planning and Delivery. Appendix D specifies the procedures and methods that the State uses to develop, implement and monitor the participant-centered service plan (of care).

5. Participant-Direction of Services. When the State provides for participant direction of services, Appendix E specifies the participant direction opportunities that are offered in the waiver and the supports that are available to participants who direct their services. (Select one):
    Yes. This waiver provides participant direction opportunities. Appendix E is required.

    No. This waiver does not provide participant direction opportunities. Appendix E is not required.

    not selected

6. Participant Rights. Appendix F specifies how the State informs participants of their Medicaid Fair Hearing rights and other procedures to address participant grievances and complaints.

7. Participant Safeguards. Appendix G describes the safeguards that the State has established to assure the health and welfare of waiver participants in specified areas.

8. Quality Improvement Strategy. Appendix H contains the Quality Improvement Strategy for this waiver.

9. Financial Accountability. Appendix I describes the methods by which the State makes payments for waiver services, ensures the integrity of these payments, and complies with applicable federal requirements concerning payments and federal financial participation.

10. Cost-Neutrality Demonstration. Appendix J contains the State's demonstration that the waiver is cost-neutral.

4. Waiver(s) Requested

1. Comparability. The State requests a waiver of the requirements contained in §1902(a)(10)(B) of the Act in order to provide the services specified in Appendix C that are not otherwise available under the approved Medicaid State plan to individuals who: (a) require the level(s) of care specified in Item 1.F and (b) meet the target group criteria specified in Appendix B.
2. Income and Resources for the Medically Needy. Indicate whether the State requests a waiver of §1902(a)(10)(C)(i)(III) of the Act in order to use institutional income and resource rules for the medically needy (select one):
    Not Applicable

    No

    Yes

    not selected
3. Statewideness. Indicate whether the State requests a waiver of the statewideness requirements in §1902(a)(1) of the Act (select one):

   No

   Yes

   If yes, specify the waiver of statewideness that is requested (check each that applies):

   Geographic Limitation. A waiver of statewideness is requested in order to furnish services under this waiver only to individuals who reside in the following geographic areas or political subdivisions of the State.

   Specify the areas to which this waiver applies and, as applicable, the phase-in schedule of the waiver by geographic area:

   Character Count: out of 6000

   The SDMI Waiver will not be available statewide and will be located in four geographical areas based on an urban core. Those areas are Yellowstone County (including counties of big Horn, Carbon, Stillwater and Sweet Grass), Silver Bow County (including counties of Beaverhead, Deer Lodge, Granite,Powell, and Jefferson), Cascade County (including counties of Blaine, Chouteau, Glacier, Hill, Liberty, Pondera, Teton and Toole), and Missoula County.

   Limited Implementation of Participant-Direction. A waiver of statewideness is requested in order to make participant-direction of services as specified in Appendix E available only to individuals who reside in the following geographic areas or political subdivisions of the State. Participants who reside in these areas may elect to direct their services as provided by the State or receive comparable services through the service delivery methods that are in effect elsewhere in the State.

   Specify the areas of the State affected by this waiver and, as applicable, the phase-in schedule of the waiver by geographic area:

   Character Count: out of 6000

5. Assurances

1. Health & Welfare: The State assures that necessary safeguards have been taken to protect the health and welfare of persons receiving services under this waiver. These safeguards include:

   1. As specified in Appendix C, adequate standards for all types of providers that provide services under this waiver;

   2. Assurance that the standards of any State licensure or certification requirements specified in Appendix C are met for services or for individuals furnishing services that are provided under the waiver. The State assures that these requirements are met on the date that the services are furnished; and,

   3. Assurance that all facilities subject to §1616(e) of the Act where home and community-based waiver services are provided comply with the applicable State standards for board and care facilities as specified in Appendix C.

2. Financial Accountability. The State assures financial accountability for funds expended for home and community-based services and maintains and makes available to the Department of Health and Human Services (including the Office of the Inspector General), the Comptroller General, or other designees, appropriate financial records documenting the cost of services provided under the waiver. Methods of financial accountability are specified in Appendix I.

3. Evaluation of Need: The State assures that it provides for an initial evaluation (and periodic reevaluations, at least annually) of the need for a level of care specified for this waiver, when there is a reasonable indication that an individual might need such services in the near future (one month or less) but for the receipt of home and community based services under this waiver. The procedures for evaluation and reevaluation of level of care are specified in Appendix B.

4. Choice of Alternatives: The State assures that when an individual is determined to be likely to require the level of care specified for this waiver and is in a target group specified in Appendix B, the individual (or, legal representative, if applicable) is:

   1. Informed of any feasible alternatives under the waiver; and,

   2. Given the choice of either institutional or home and community based waiver services. Appendix B specifies the procedures that the State employs to ensure that individuals are informed of feasible alternatives under the waiver and given the choice of institutional or home and community-based waiver services.

5. Average Per Capita Expenditures: The State assures that, for any year that the waiver is in effect, the average per capita expenditures under the waiver will not exceed 100 percent of the average per capita expenditures that would have been made under the Medicaid State plan for the level(s) of care specified for this waiver had the waiver not been granted. Cost-neutrality is demonstrated in Appendix J.

6. Actual Total Expenditures: The State assures that the actual total expenditures for home and community-based waiver and other Medicaid services and its claim for FFP in expenditures for the services provided to individuals under the waiver will not, in any year of the waiver period, exceed 100 percent of the amount that would be incurred in the absence of the waiver by the State's Medicaid program for these individuals in the institutional setting(s) specified for this waiver.

7. Institutionalization Absent Waiver: The State assures that, absent the waiver, individuals served in the waiver would receive the appropriate type of Medicaid-funded institutional care for the level of care specified for this waiver.

8. Reporting: The State assures that annually it will provide CMS with information concerning the impact of the waiver on the type, amount and cost of services provided under the Medicaid State plan and on the health and welfare of waiver participants. This information will be consistent with a data collection plan designed by CMS.

9. Habilitation Services. The State assures that prevocational, educational, or supported employment services, or a combination of these services, if provided as habilitation services under the waiver are: (1) not otherwise available to the individual through a local educational agency under the Individuals with Disabilities Education Act (IDEA) or the Rehabilitation Act of 1973; and, (2) furnished as part of expanded habilitation services.

10. Services for Individuals with Chronic Mental Illness. The State assures that federal financial participation (FFP) will not be claimed in expenditures for waiver services including, but not limited to, day treatment or partial hospitalization, psychosocial rehabilitation services, and clinic services provided as home and community-based services to individuals with chronic mental illnesses if these individuals, in the absence of a waiver, would be placed in an IMD and are: (1) age 22 to 64; (2) age 65 and older and the State has not included the optional Medicaid benefit cited in 42 CFR §440.140; or (3) age 21 and under and the State has not included the optional Medicaid benefit cited in 42 CFR § 440.160.

7. Contact Person(s)

1. The Medicaid agency representative with whom CMS should communicate regarding the waiver is:

   Last Name:
   First Name:
   Title:
   Agency:
   Address:
   Address 2:
   City:
   State:	Montana
   Zip:
   Phone:	Ext: TTY
   Fax:
   E-mail:

2. If applicable, the State operating agency representative with whom CMS should communicate regarding the waiver is:

   Last Name:
   First Name:
   Title:
   Agency:
   Address:
   Address 2:
   City:
   State:	Montana
   Zip:
   Phone:	Ext: TTY
   Fax:
   E-mail:

Attachment #1: Transition Plan

Additional Needed Information (Optional)

Appendix A: Waiver Administration and Operation

7. Distribution of Waiver Operational and Administrative Functions. In the following table, specify the entity or entities that have responsibility for conducting each of the waiver operational and administrative functions listed (check each that applies):
   In accordance with 42 CFR §431.10, when the Medicaid agency does not directly conduct a function, it supervises the performance of the function and establishes and/or approves policies that affect the function. All functions not performed directly by the Medicaid agency must be delegated in writing and monitored by the Medicaid Agency. Note: More than one box may be checked per item. Ensure that Medicaid is checked when the Single State Medicaid Agency (1) conducts the function directly; (2) supervises the delegated function; and/or (3) establishes and/or approves policies related to the function.

   Function	Medicaid Agency	Contracted Entity
   Participant waiver enrollment
   Waiver enrollment managed against approved limits
   Waiver expenditures managed against approved levels
   Level of care evaluation
   Review of Participant service plans
   Prior authorization of waiver services
   Utilization management
   Qualified provider enrollment
   Execution of Medicaid provider agreements
   Establishment of a statewide rate methodology
   Rules, policies, procedures and information development governing the waiver program
   Quality assurance and quality improvement activities

Appendix A: Waiver Administration and Operation

Quality Improvement: Administrative Authority of the Single State Medicaid Agency

1. Methods for Discovery: Administrative Authority
   The Medicaid Agency retains ultimate administrative authority and responsibility for the operation of the waiver program by exercising oversight of the performance of waiver functions by other state and local/regional non-state agencies (if appropriate) and contracted entities.

   1. Performance Measures

      For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

      For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

      Performance Measure: % of LOC determinations completed by MPQH that are reviewed by AMDD. Denominator is the number of Level of Care (LOC) determination Numerator is the number of LOCs reviewed by AMDD Data Source (Select one): Other If 'Other' is selected, specify: Report submitted to AMDD by Mountain Pacific Quality Health. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: The Case Management Team will follow the protocol described in policies and procedures. 100% of files for each Case Management Team will be reviewed. Numerator is the demonstration of case management teams following protocols as defined in quality assurance review Denominator is the total number of files reviewed. Data Source (Select one): Record reviews, on-site If 'Other' is selected, specify: Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: Percent of the Level II evaluations completed by CMHC within 10 days from request by MPQH. Numerator is the time from referral to completion Denominator is the number of Level II evaluations Data Source (Select one): Reports to State Medicaid Agency on delegated If 'Other' is selected, specify: Monthly report sent from MPQH to AMDD Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: MPQH Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      Performance Measure: % of waiver providers with a signed agreement with the Medicaid agency. Numerator is the number of signed provider agreements. Denominator is the number of Waiver providers. Data Source (Select one): Other If 'Other' is selected, specify: Reports from ACS - report card Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: ACS Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
2. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
      Character Count: out of 6000
      AMDD/Mental Health Services Bureau (MHSB) has total oversight over the waiver. The MHSB Central Office and the CPOs act at the local and statewide level to provide routine and ongoing waiver oversight of the waiver program quality measures and waiver providers. At the local level the CPO, in their Quality Assurance reviews, provide ongoing oversight of the SDMI waiver consumers and providers. Training is provided to consumers and providers, as needed, for policy/program changes and when issues are identified. Discovery - AMDD has total oversight over the waiver. The MPQH, Community Mental Health Centers, ACS,Case Management Teams, Senior and Long Term Care Division, and Quality Assurance Division have operational responsibilities and activities with the waiver. The AMDD Program Manager and Community Program Officers (CPO) act at the local and statewide level to provide routine and ongoing waiver oversight. At the quarterly Quality Management Committee meetings the Program Manager and CPOs provide regular statewide oversight of the waiver program quality measures and providers. At the local level the CPO and Program Manager provide oversight in the annual quality reviews. The CPO provides ongoing oversight of the case management teams, consumers and providers. Training is provided to consumers and providers, as needed, for policy/program changes and when issues are identified. Remediation - The Community Program Officers (CPO) and Program Manager will review 100% of the waiver consumer files. Reviews include examination of case notes, plan of care (with amendments and changes), Level of Care determination, Level of Care re-evaluation documentation, prior authorization for services and support, monthly expenditures, Cost Sheet, admittance form, serious occurrence reports, and documentation of training. The CPO will respond to any immediate concerns. Data collected in the review will result in a report that will be submitted to the Case Management Agency and to AMDD.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

      Responsible Party (check each that applies):	Frequency of data aggregation and analysis (check each that applies):
      State Medicaid Agency	Weekly
      Operating Agency	Monthly
      Sub-State Entity	Quarterly
      Other Specify:	Annually
      	Continuously and Ongoing
      	Other Specify:

3. Timelines
   When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Administrative Authority that are currently non-operational.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Administrative Authority, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-1: Specification of the Waiver Target Group(s)

1. Target Group(s). Under the waiver of Section 1902(a)(10)(B) of the Act, the State limits waiver services to a group or subgroups of individuals. Please see the instruction manual for specifics regarding age limits. In accordance with 42 CFR §441.301(b)(6), select one waiver target group, check each of the subgroups in the selected target group that may receive services under the waiver, and specify the minimum and maximum (if any) age of individuals served in each subgroup:

   Target Group	Included	Target SubGroup	Minimum Age	Maximum Age
   				Maximum Age Limit	No Maximum Age Limit
   Aged or Disabled, or Both - General
   		Aged
   		Disabled (Physical)
   		Disabled (Other)
   Aged or Disabled, or Both - Specific Recognized Subgroups
   		Brain Injury
   		HIV/AIDS
   		Medically Fragile
   		Technology Dependent
   Mental Retardation or Developmental Disability, or Both
   		Autism
   		Developmental Disability
   		Mental Retardation
   Mental Illness
   		Mental Illness
   		Serious Emotional Disturbance
   not selected

2. Additional Criteria. The State further specifies its target group(s) as follows:

   Character Count: out of 12000
   “Severe disabling mental illness" means with respect to a person who is 18 or more years of age that the person meets the requirements of (a) or (b) or (c). The person must also meet the requirements of (d): (a) has been involuntarily hospitalized for at least 30 consecutive days because of a mental disorder at Montana State Hospital at least once; or (b) has a DSM-IV diagnosis of (i) schizophrenic disorder (295); (ii) other psychotic disorder (295.40, 295.70, 297.1, 297.3, 298.9, 293.81, 293.82); (iii) mood disorder (296.2x, 296.3x, 296.40, 296.4x, 296.5x, 296.6x, 296.7, 296.80, 296.89, 293.83); (iv) amnesic disorder (294.0, 294.8); (v) disorder due to a general medical condition (310.1); or (vi) pervasive developmental disorder not otherwise specified (299.80) when not accompanied by mental retardation; (vii) anxiety disorder (300.01, 300.21, 300.3) or (c) has a DSM-IV diagnosis of personality disorder (301.00, 301.20, 301.22, 301.4, 301.50, 301.6, 301.81, 301.82, 301.83, or 301.90) which causes the person to be unable to work competitively on a full-time basis or to be unable to maintain a residence without assistance and support by family or a public agency for a period of at least 6 months (or for an obviously predictable period over 6 months); and (d) has ongoing functioning difficulties because of the mental illness for a period of at least 6 months (or for an obviously predictable period over 6 months), as indicated by at least two of the following: (i) medical professional with prescriptive authority has determined that medication is necessary to control the symptoms of mental illness; (ii) the person is unable to work in a full-time competitive situation because of mental illness; (iii) the person has been determined to be disabled due to mental illness by the Social Security Administration; (iv) the person maintains a living arrangement only with the ongoing supervision , is homeless, or is at risk of homelessness due to mental illness; or (v) the person has had or will predictably have repeated episodes of decompensation. An episode of decompensation includes: -increased symptoms of psychosis -self-injury -suicidal or homicidal intent, or -psychiatric hospitalization. Licensed mental health professionals determine whether an individual meets SDMI criteria.

3. Transition of Individuals Affected by Maximum Age Limitation. When there is a maximum age limit that applies to individuals who may be served in the waiver, describe the transition planning procedures that are undertaken on behalf of participants affected by the age limit (select one):

   Not applicable. There is no maximum age limit

   The following transition planning procedures are employed for participants who will reach the waiver's maximum age limit.

   Specify:

   Character Count: out of 12000

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (1 of 2)

1. Individual Cost Limit. The following individual cost limit applies when determining whether to deny home and community-based services or entrance to the waiver to an otherwise eligible individual (select one) Please note that a State may have only ONE individual cost limit for the purposes of determining eligibility for the waiver:
    No Cost Limit. The State does not apply an individual cost limit. Do not complete Item B-2-b or item B-2-c.
    Cost Limit in Excess of Institutional Costs. The State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed the cost of a level of care specified for the waiver up to an amount specified by the State. Complete Items B-2-b and B-2-c.

   The limit specified by the State is (select one)

    A level higher than 100% of the institutional average.

   Specify the percentage:

    Other

   Specify:

   Character Count: out of 6000

    not selected
    Institutional Cost Limit. Pursuant to 42 CFR 441.301(a)(3), the State refuses entrance to the waiver to any otherwise eligible individual when the State reasonably expects that the cost of the home and community-based services furnished to that individual would exceed 100% of the cost of the level of care specified for the waiver. Complete Items B-2-b and B-2-c.
    Cost Limit Lower Than Institutional Costs. The State refuses entrance to the waiver to any otherwise qualified individual when the State reasonably expects that the cost of home and community-based services furnished to that individual would exceed the following amount specified by the State that is less than the cost of a level of care specified for the waiver.

   Specify the basis of the limit, including evidence that the limit is sufficient to assure the health and welfare of waiver participants. Complete Items B-2-b and B-2-c.

   Character Count: out of 6000

   The cost limit specified by the State is (select one):

    The following dollar amount:

   Specify dollar amount:

   The dollar amount (select one)

    Is adjusted each year that the waiver is in effect by applying the following formula:

   Specify the formula:

   Character Count: out of 6000

    May be adjusted during the period the waiver is in effect. The State will submit a waiver amendment to CMS to adjust the dollar amount.

    not selected

    The following percentage that is less than 100% of the institutional average:

   Specify percent:

    Other:

   Specify:

   Character Count: out of 6000

    not selected
    not selected

Appendix B: Participant Access and Eligibility

B-2: Individual Cost Limit (2 of 2)

2. Method of Implementation of the Individual Cost Limit. When an individual cost limit is specified in Item B-2-a, specify the procedures that are followed to determine in advance of waiver entrance that the individual's health and welfare can be assured within the cost limit:
   Character Count: out of 12000
3. Participant Safeguards. When the State specifies an individual cost limit in Item B-2-a and there is a change in the participant's condition or circumstances post-entrance to the waiver that requires the provision of services in an amount that exceeds the cost limit in order to assure the participant's health and welfare, the State has established the following safeguards to avoid an adverse impact on the participant (check each that applies):
   The participant is referred to another waiver that can accommodate the individual's needs.
   Additional services in excess of the individual cost limit may be authorized.

   Specify the procedures for authorizing additional services, including the amount that may be authorized:

   Character Count: out of 12000
   Other safeguard(s)

   Specify:

   Character Count: out of 12000

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (1 of 4)

1. Unduplicated Number of Participants. The following table specifies the maximum number of unduplicated participants who are served in each year that the waiver is in effect. The State will submit a waiver amendment to CMS to modify the number of participants specified for any year(s), including when a modification is necessary due to legislative appropriation or another reason. The number of unduplicated participants specified in this table is basis for the cost-neutrality calculations in Appendix J:

   Table: B-3-a

   Waiver Year	Unduplicated Number of Participants
   Year 1
   Year 2
   Year 3
   Year 4 (renewal only)
   Year 5 (renewal only)

2. Limitation on the Number of Participants Served at Any Point in Time. Consistent with the unduplicated number of participants specified in Item B-3-a, the State may limit to a lesser number the number of participants who will be served at any point in time during a waiver year. Indicate whether the State limits the number of participants in this way: (select one):

   The State does not limit the number of participants that it serves at any point in time during a waiver year.

   The State limits the number of participants that it serves at any point in time during a waiver year.

   The limit that applies to each year of the waiver period is specified in the following table:

   Table: B-3-b

   Waiver Year	Maximum Number of Participants Served At Any Point During the Year
   Year 1
   Year 2
   Year 3
   Year 4 (renewal only)
   Year 5 (renewal only)

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (2 of 4)

3. Reserved Waiver Capacity. The State may reserve a portion of the participant capacity of the waiver for specified purposes (e.g., provide for the community transition of institutionalized persons or furnish waiver services to individuals experiencing a crisis) subject to CMS review and approval. The State (select one):

   Not applicable. The state does not reserve capacity.

   The State reserves capacity for the following purpose(s).

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served (3 of 4)

4. Scheduled Phase-In or Phase-Out. Within a waiver year, the State may make the number of participants who are served subject to a phase-in or phase-out schedule (select one):

   The waiver is not subject to a phase-in or a phase-out schedule.

   The waiver is subject to a phase-in or phase-out schedule that is included in Attachment #1 to Appendix B-3. This schedule constitutes an intra-year limitation on the number of participants who are served in the waiver.

5. Allocation of Waiver Capacity.

   Select one:

   Waiver capacity is allocated/managed on a statewide basis.

   Waiver capacity is allocated to local/regional non-state entities.

   Specify: (a) the entities to which waiver capacity is allocated; (b) the methodology that is used to allocate capacity and how often the methodology is reevaluated; and, (c) policies for the reallocation of unused capacity among local/regional non-state entities:

   Character Count: out of 12000
6. Selection of Entrants to the Waiver. Specify the policies that apply to the selection of individuals for entrance to the waiver:
   Character Count: out of 12000
   Individuals must: • Be Medicaid eligible; • Meet SDMI criteria; • Be age 18 or older; • Meet nursing facility level of care; • Choose to receive waiver services; and • Reside in an area within the state where the HCBS waiver is available and there’s capacity within the waiver. Entrance into the waiver will be on a first-come, first-served basis for those who meet the above-listed criteria. Once a waiting list has been established, the case management teams will use the Wait List Criteria Tool when an opening occurs. The Wait List Criteria Tool scores individuals eligible for the waiver according to criteria, including cognitive impairment, risk of medical and/psychiatric deterioration without services, risk of institutional placement or death, need for supervision, need for formal paid services, assessment of informal supports, assessment of relief needed for primary caregiver, need for adaptive aides, and assessment of health and safety issue that place the individual at risk. The case managers will manage the waitlist, which will be submitted to a database at the Addictive and Mental Disorders Division of the Department of Public Health and Human Services. On a quarterly basis, the CPOs will monitor waiting lists in the geographic area where the waiver is available and forward the information to the Mental Health Services Program Manager who will determine when to reallocate unused capacity to areas where additional capacity may be needed. Reallocation will occur following the review of the waiting list information sent quarterly by the CPOs. Any unused slots will be reallocated based on the prioritized need as established by the criteria in the Waiting List Criteria Tool. The tool scores individuals eligible for the waiver according to eleven criteria, including risk of psychiatric deterioration without services, cognitive impairment, risk of institutional placement, need to obtain/maintain stable residence, need for more formal services, need for adaptive aids, and health and safety issues that place the individual at risk.

Appendix B: Participant Access and Eligibility

B-3: Number of Individuals Served - Attachment #1 (4 of 4)

Appendix B: Participant Access and Eligibility

B-4: Eligibility Groups Served in the Waiver

1. 1. State Classification. The State is a (select one):
       §1634 State
       SSI Criteria State
       209(b) State
       not selected
   2. Miller Trust State.
      Indicate whether the State is a Miller Trust State (select one):
       No
       Yes
       Unknown
2. Medicaid Eligibility Groups Served in the Waiver. Individuals who receive services under this waiver are eligible under the following eligibility groups contained in the State plan. The State applies all applicable federal financial participation limits under the plan. Check all that apply:
   Eligibility Groups Served in the Waiver (excluding the special home and community-based waiver group under 42 CFR §435.217)
   Low income families with children as provided in §1931 of the Act
   SSI recipients
   Aged, blind or disabled in 209(b) states who are eligible under 42 CFR §435.121
   Optional State supplement recipients
   Optional categorically needy aged and/or disabled individuals who have income at:

   Select one:

    100% of the Federal poverty level (FPL)

    % of FPL, which is lower than 100% of FPL.

   Specify percentage:

    not selected
   Working individuals with disabilities who buy into Medicaid (BBA working disabled group as provided in §1902(a)(10)(A)(ii)(XIII)) of the Act)
   Working individuals with disabilities who buy into Medicaid (TWWIIA Basic Coverage Group as provided in §1902(a)(10)(A)(ii)(XV) of the Act)
   Working individuals with disabilities who buy into Medicaid (TWWIIA Medical Improvement Coverage Group as provided in §1902(a)(10)(A)(ii)(XVI) of the Act)
   Disabled individuals age 18 or younger who would require an institutional level of care (TEFRA 134 eligibility group as provided in §1902(e)(3) of the Act)
   Medically needy
   Medically needy in 209(b) States (42 CFR §435.330)
   Medically needy in 1634 States and SSI Criteria States (42 CFR §435.320, §435.322 and §435.324)
   Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

   Specify:

   Character Count: out of 6000

   PICKLE, DAC
   Special home and community-based waiver group under 42 CFR §435.217) Note: When the special home and community-based waiver group under 42 CFR §435.217 is included, Appendix B-5 must be completed
    No. The State does not furnish waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217. Appendix B-5 is not submitted.

    Yes. The State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217.

    not selected

   Select one and complete Appendix B-5.

    All individuals in the special home and community-based waiver group under 42 CFR §435.217

    Only the following groups of individuals in the special home and community-based waiver group under 42 CFR §435.217

    not selected

   Check each that applies:

   A special income level equal to:

   Select one:

    300% of the SSI Federal Benefit Rate (FBR)

    A percentage of FBR, which is lower than 300% (42 CFR §435.236)

   Specify percentage:

    A dollar amount which is lower than 300%.

   Specify dollar amount:

    not selected

   Aged, blind and disabled individuals who meet requirements that are more restrictive than the SSI program (42 CFR §435.121)

   Medically needy without spenddown in States which also provide Medicaid to recipients of SSI (42 CFR §435.320, §435.322 and §435.324)

   Medically needy without spend down in 209(b) States (42 CFR §435.330)

   Aged and disabled individuals who have income at:

   Select one:

    100% of FPL

    % of FPL, which is lower than 100%.

   Specify percentage amount:

    not selected

   Other specified groups (include only statutory/regulatory reference to reflect the additional groups in the State plan that may receive services under this waiver)

   Specify:

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (1 of 4)

In accordance with 42 CFR §441.303(e), Appendix B-5 must be completed when the State furnishes waiver services to individuals in the special home and community-based waiver group under 42 CFR §435.217, as indicated in Appendix B-4. Post-eligibility applies only to the 42 CFR §435.217 group. A State that uses spousal impoverishment rules under §1924 of the Act to determine the eligibility of individuals with a community spouse may elect to use spousal post-eligibility rules under §1924 of the Act to protect a personal needs allowance for a participant with a community spouse.

1. Use of Spousal Impoverishment Rules. Indicate whether spousal impoverishment rules are used to determine eligibility for the special home and community-based waiver group under 42 CFR §435.217 (select one):

   Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (2 of 4)

2. Regular Post-Eligibility Treatment of Income: SSI State.

   Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (3 of 4)

3. Regular Post-Eligibility Treatment of Income: 209(B) State.

   Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-5: Post-Eligibility Treatment of Income (4 of 4)

4. Post-Eligibility Treatment of Income Using Spousal Impoverishment Rules

   The State uses the post-eligibility rules of §1924(d) of the Act (spousal impoverishment protection) to determine the contribution of a participant with a community spouse toward the cost of home and community-based care if it determines the individual's eligibility under §1924 of the Act. There is deducted from the participant’s monthly income a personal needs allowance (as specified below), a community spouse's allowance and a family allowance as specified in the State Medicaid Plan.. The State must also protect amounts for incurred expenses for medical or remedial care (as specified below).

   Answers provided in Appendix B-4 indicate that you do not need to submit Appendix B-5 and therefore this section is not visible.

Appendix B: Participant Access and Eligibility

B-6: Evaluation/Reevaluation of Level of Care

1. Reasonable Indication of Need for Services. In order for an individual to be determined to need waiver services, an individual must require: (a) the provision of at least one waiver service, as documented in the service plan, and (b) the provision of waiver services at least monthly or, if the need for services is less than monthly, the participant requires regular monthly monitoring which must be documented in the service plan. Specify the State's policies concerning the reasonable indication of the need for services:

   1. Minimum number of services.

      The minimum number of waiver services (one or more) that an individual must require in order to be determined to need waiver services is:
   2. Frequency of services. The State requires (select one):
       The provision of waiver services at least monthly
       Monthly monitoring of the individual when services are furnished on a less than monthly basis

      If the State also requires a minimum frequency for the provision of waiver services other than monthly (e.g., quarterly), specify the frequency:

      Character Count: out of 4000
       not selected
2. Responsibility for Performing Evaluations and Reevaluations. Level of care evaluations and reevaluations are performed (select one):
    Directly by the Medicaid agency
    By the operating agency specified in Appendix A
    By an entity under contract with the Medicaid agency.

   Specify the entity:

   Character Count: out of 4000

   Mountain Pacific Quality Health
    Other
   Specify:

   Character Count: out of 4000
    not selected
3. Qualifications of Individuals Performing Initial Evaluation: Per 42 CFR §441.303(c)(1), specify the educational/professional qualifications of individuals who perform the initial evaluation of level of care for waiver applicants:

   Character Count: out of 6000
   Registered Nurse or Licensed Practical Nurse, licensed in the State of Montana
4. Level of Care Criteria. Fully specify the level of care criteria that are used to evaluate and reevaluate whether an individual needs services through the waiver and that serve as the basis of the State's level of care instrument/tool. Specify the level of care instrument/tool that is employed. State laws, regulations, and policies concerning level of care criteria and the level of care instrument/tool are available to CMS upon request through the Medicaid agency or the operating agency (if applicable), including the instrument/tool utilized.

   Character Count: out of 12000
   The Mountain Pacific Quality Health will complete a PASRR Determination including a Functional Assessment to determine if the individual meets level of care requirements for enrollment into the waiver. Preadmission determination and functional assessment involves telephone interviews based on established protocols. A Level I screen will also be completed to determine if the individual has Mental Retardation or Mental Illness as part of PASARR requirements. Community Mental Health Centers will complete Level II screens to determine if an individual with Mental Illness identified through the Level I screen requires active treatment. Active treatment in Montana is provided by inpatient care at: A) Local community hospitals with psychiatric units; or B) The Montana State Hospital (MSH); or C) Montana Mental Health Nursing Care Center (MMHNCC). MSH and MMHNCC are Institutions for Mental Disease.
5. Level of Care Instrument(s). Per 42 CFR §441.303(c)(2), indicate whether the instrument/tool used to evaluate level of care for the waiver differs from the instrument/tool used to evaluate institutional level of care (select one):
    The same instrument is used in determining the level of care for the waiver and for institutional care under the State Plan.
    A different instrument is used to determine the level of care for the waiver than for institutional care under the State plan.

   Describe how and why this instrument differs from the form used to evaluate institutional level of care and explain how the outcome of the determination is reliable, valid, and fully comparable.

   Character Count: out of 12000
    not selected
6. Process for Level of Care Evaluation/Reevaluation: Per 42 CFR §441.303(c)(1), describe the process for evaluating waiver applicants for their need for the level of care under the waiver. If the reevaluation process differs from the evaluation process, describe the differences:

   Character Count: out of 12000
   A level of care screening is performed to evaluate the medical, psychological and social needs of an individual. The Functional Assessment is a review of impairments in walking, bathing, grooming, dressing, toileting, transferring, feeding, bladder incontinence, bowel incontinence, special sense impairments (such as speech or hearing), mental and behavioral dysfunctions. Nursing facility or waiver level of care is authorized if the individual’s needs are greater than personal level of care. The reevaluation process is the same.
7. Reevaluation Schedule. Per 42 CFR §441.303(c)(4), reevaluations of the level of care required by a participant are conducted no less frequently than annually according to the following schedule (select one):
    Every three months
    Every six months
    Every twelve months
    Other schedule
   Specify the other schedule:

   Character Count: out of 4000

   The reevaluation schedule is every 12 months and when there is significant change within the year.
    not selected
8. Qualifications of Individuals Who Perform Reevaluations. Specify the qualifications of individuals who perform reevaluations (select one):
    The qualifications of individuals who perform reevaluations are the same as individuals who perform initial evaluations.
    The qualifications are different.
   Specify the qualifications:

   Character Count: out of 6000
    not selected
9. Procedures to Ensure Timely Reevaluations. Per 42 CFR §441.303(c)(4), specify the procedures that the State employs to ensure timely reevaluations of level of care (specify):

   Character Count: out of 6000
   The case Management Teams will use their own internal systems to track participants enrolled in the waiver and alert the Mountain Pacific Quality Health when a participant is due for a reevaluation of level of care. The quality assurance process will include a review by regional Community Program Officers to ensure the timeliness of reevaluation in accordance with quality assurance standards.
10. Maintenance of Evaluation/Reevaluation Records. Per 42 CFR §441.303(c)(3), the State assures that written and/or electronically retrievable documentation of all evaluations and reevaluations are maintained for a minimum period of 3 years as required in 45 CFR §92.42. Specify the location(s) where records of evaluations and reevaluations of level of care are maintained:

    Character Count: out of 6000
    The Mountain Pacific Quality Health will maintain all evaluations and re-evaluations for a minimum of three years as required in 45 CFR §74.53.

Appendix B: Evaluation/Reevaluation of Level of Care

Quality Improvement: Level of Care

1. Methods for Discovery: Level of Care Assurance/Sub-assurances
   1. Sub-Assurances:

      1. Sub-assurance: An evaluation for LOC is provided to all applicants for whom there is reasonable indication that services may be needed in the future.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: Number of waiver participants who received a LOC determination prior to enrollment Denominator is the number of enrolled participants Numerator is the number of enrolled participants who received an LOC prior to enrollment Data Source (Select one): Other If 'Other' is selected, specify: Report submited to AMDD from Mountain Pacific Quality Health. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Mountain Pacific Quality Health Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      2. Sub-assurance: The levels of care of enrolled participants are reevaluated at least annually or as specified in the approved waiver.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: % of waiver participants whose LOCs are reevaluated at least annually Numerator is the number of participants whose LOCs are reevaluated annually Denominator is all waiver participants Data Source (Select one): Record reviews, on-site If 'Other' is selected, specify: Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

      3. Sub-assurance: The processes and instruments described in the approved waiver are applied appropriately and according to the approved description to determine participant level of care.

         Performance Measures

         For each performance measure/indicator the State will use to assess compliance with the statutory assurance complete the following. Where possible, include numerator/denominator. Each performance measure must be specific to this waiver (i.e., data presented must be waiver specific).

         For each performance measure, provide information on the aggregated data that will enable the State to analyze and assess progress toward the performance measure. In this section provide information on the method by which each source of data is analyzed statistically/deductively or inductively, how themes are identified or conclusions drawn, and how recommendations are formulated, where appropriate.

         Performance Measure: % of initial LOC determinations for waiver applicants completed timely by MPQH. Numerator is the number of LOC determinations initiated within three working days. Denominator is the total number of LOC determinations. Data Source (Select one): Other If 'Other' is selected, specify: Report to the AMDD provided by Mountain Pacific Quality Health. Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Mountain Pacific Quality Health Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Source (Select one): Record reviews, on-site If 'Other' is selected, specify: Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: % of accurate initial LOCs MPQH completed. Numerator is the number of initial LOCs done accurately Denominator is the total numbers of initial LOC determinations Data Source (Select one): Other If 'Other' is selected, specify: Report sent to AMDD from Mountain Pacific Quality Health Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Mountain Pacific Quality Health Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify: Reviews conducted at MPQH every three years.

         Performance Measure: % of LOC re-determinations that were done accurately Numerator is the number of LOC re-determinations completed accurately. Denominator is the total number of SDMI LOC re-determinations completed. Data Source (Select one): Other If 'Other' is selected, specify: Report sent to AMDD from MPQH Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: MPQH Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Source (Select one): Record reviews, on-site If 'Other' is selected, specify: Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: % of LOC re-determinations completed within 10 working days of the request by MPQH Numerator is the number of LOC re-determinations completed within 10 working days Denominator is the number of LOC re-determinations completed. Data Source (Select one): Other If 'Other' is selected, specify: Report sent to AMDD from MPQH Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: MPQH Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

         Performance Measure: % of Level IIs conducted by Community Mental Health Centers (CMHCs) completed within 10 working days of request by MPQH. Numerator is the number of Level IIs completed within 10 working days. Denominator us the number of Level IIs completed. Data Source (Select one): Other If 'Other' is selected, specify: Report sent to AMDD from MPQH Responsible Party for data collection/generation(check each that applies): Frequency of data collection/generation(check each that applies): Sampling Approach(check each that applies): State Medicaid Agency Weekly 100% Review Operating Agency Monthly Less than 100% Review Sub-State Entity Quarterly Representative Sample Confidence Interval = Other Specify: MPQH Annually Stratified Describe Group: Continuously and Ongoing Other Specify: Other Specify: Data Aggregation and Analysis: Responsible Party for data aggregation and analysis (check each that applies): Frequency of data aggregation and analysis (check each that applies): State Medicaid Agency Weekly Operating Agency Monthly Sub-State Entity Quarterly Other Specify: Annually Continuously and Ongoing Other Specify:

   2. If applicable, in the textbox below provide any necessary additional information on the strategies employed by the State to discover/identify problems/issues within the waiver program, including frequency and parties responsible.
      Character Count: out of 6000
      MPQH will submit a management report to MHSB on a monthly basis. This report will capture data on the Level of Care evaluations completed prior to the receipt of waiver services, participants notified of the Level of Care determinations within the state required timeframes and timeframes for redeterminations. CPOs will review Level of Care determinations and re-determinations as part of their annual QA reviews. CPOs will review 100% of LOC denials and take action if an inappropriate denial was made. All persons denied are notified in writing of the denial and process of requesting a Fair Hearing.
2. Methods for Remediation/Fixing Individual Problems
   1. Describe the State’s method for addressing individual problems as they are discovered. Include information regarding responsible parties and GENERAL methods for problem correction. In addition, provide information on the methods used by the State to document these items.
      Character Count: out of 6000
      MHSB will review monthly and monitor the MPQH management reports to assure that LOCs occur prior to receipt of waiver services and that participants are notified within the required timeframes. Reports will also be monitored monthly to assure that a re-determination occurs with in the specified timeframes of the approved waiver. CPOs and Program Manager will review Level of Care determinations and re-determinations as a part of their annual QA reviews. CPOs will review 100% of LOC denials and take action if an inappropriate denial was made. MHSB provides ongoing monitoring of MPQH LOC activities and provides additional training as needed. All individuals must be informed of his/her right to Fair Hearing in writing as part of the waiver entrance process. A request for a Fair Hearing must be in writing within 90 days of the mailing date of notice of denial of LOC. Level of Care Determinations Discovery - Mountain Pacific Quality Health (MPQH) will submit a management report to AMDD on a monthly basis. This report will capture data on the Level of Care evaluations completed prior to the receipt of waiver services, participants notified of the Level of Care Determinations within state required timeframes and timeframes for re-determinations. CPOs and Waiver Program Manager will review Level of Care determinations and re-determinations as part of the annual QA reviews. Remediation - AMDD will review monthly and monitor the MPQH management reports to assure that the LOCs occur prior to receipt of waiver services and participants are notified within the required timeframes. Reports will also be monitored to assure that a re-determination occurs within the specified time frames of the approved waiver. The CPOs and Program Manager will review Level of Care determinations and re-determinations as a part of their annual QA reviews. The CPOs review 100% of LOC denials and take action if an inappropriate denial was made. The AMDD will identify if the inappropriate denials are from a particular reviewer. AMDD will request the reviewer receive further training on LOC determinations. If the problem is not resolved the AMDD can suspend payments until resolved or may terminate contract with MPQH if training and suspension of payments does not resolve the matter. Level II Evaluations Discovery – Mountain Pacific Quality Health (MPQH) will submit a management report to AMDD on a monthly basis. The report includes dates of Level II referrals to the Community Mental Health centers. Mental Health Centers are required by contract to complete the Level II evaluation within 10 working days from the referral. The MPQH report includes the date the Level II was completed and sent to MPQH. If the Mental Health Center fails to complete the Level IIs within the 10 working day timeframe within 25% of the time, the AMDD will request a corrective plan of action which needs to be completed within 30 days. The AMDD needs to approve the plan. Inability to comply with the plan could result in loss of contract. CPOs and Program Manager will review Level II evaluations as part of the annual QA reviews. Remediation - AMDD will review and monitor the MPQH management reports to assure that the Level IIs occur prior to receipt of waiver services and that MPQH is notified of the Level II results within the required timeframes. If there is no exigency or risk of harm to persons from continued performance, the AMDD, at its discretion, may impose penalties and/or provide notice to Mental Health Center of the failure to perform Level IIs within the prescribed time frame. AMDD will allow the mental health center 30 days to remedy the performance. If the performance is not remedied within the 30 day period, the AMDD may terminate the contract with the Mental Health Center for Level II reviews.
   2. Remediation Data Aggregation
      Remediation-related Data Aggregation and Analysis (including trend identification)

      Responsible Party (check each that applies):	Frequency of data aggregation and analysis (check each that applies):
      State Medicaid Agency	Weekly
      Operating Agency	Monthly
      Sub-State Entity	Quarterly
      Other Specify:	Annually
      	Continuously and Ongoing
      	Other Specify:

3. Timelines
   When the State does not have all elements of the Quality Improvement Strategy in place, provide timelines to design methods for discovery and remediation related to the assurance of Level of Care that are currently non-operational.

    No

    Yes

    not selected
   Please provide a detailed strategy for assuring Level of Care, the specific timeline for implementing identified strategies, and the parties responsible for its operation.

   Character Count: out of 6000

Appendix B: Participant Access and Eligibility

B-7: Freedom of Choice

1. Procedures. Specify the State's procedures for informing eligible individuals (or their legal representatives) of the feasible alternatives available under the waiver and allowing these individuals to choose either institutional or waiver services. Identify the form(s) that are employed to document freedom of choice. The form or forms are available to CMS upon request through the Medicaid agency or the operating agency (if applicable).
   Character Count: out of 12000
   During the preadmission screening determination, the Mountain Pacific Quality Health Foundation will inform eligible individuals of the feasible alternatives available under the waiver and allow individuals to choose either institutional or waiver services, as long as the individuals reside in areas where the waiver is available (the SDMI Waiver will not be available statewide) and there is capacity. The Screening Determination form documenting choice will be maintained on file.
2. Maintenance of Forms. Per 45 CFR §92.42, written copies or electronically retrievable facsimiles of Freedom of Choice forms are maintained for a minimum of three years. Specify the locations where copies of these forms are maintained.
   Character Count: out of 4000
   The Mountain Pacific Quality Health Foundation will maintain the Screening Determination Form, including all documentation regarding freedom of choice, for a minimum of three years.

Appendix B: Participant Access and Eligibility

B-8: Access to Services by Limited English Proficiency Persons

Appendix C: Participant Services

C-1: Summary of Services Covered (1 of 2)

1. Waiver Services Summary. List the services that are furnished under the waiver in the following table. If case management is not a service under the waiver, complete items C-1-b and C-1-c:

   Service Type	Service
   Statutory Service	Adult Day Health
   Statutory Service	Case Management
   Statutory Service	Day Habilitation
   Statutory Service	Homemaker
   Statutory Service	Prevocational Services
   Statutory Service	Residential Habilitation
   Statutory Service	Respite
   Statutory Service	Supported Employment
   Extended State Plan Service	Occupational Therapy
   Other Service	Adult Residential Care
   Other Service	Chemical Dependency Counseling
   Other Service	Chore
   Other Service	Dietician/Nutrition/Meals
   Other Service	Habilitation Aide
   Other Service	Illness Management and Recovery
   Other Service	Non-Medical Transportation
   Other Service	Personal Assistance Service and Specially Trained Attendant Care
   Other Service	Personal Emergency Response System
   Other Service	Private Duty Nursing (and Registered Nurse Supervision)
   Other Service	Psychosocial Rehabilitation
   Other Service	Specialized Medical Equipment and Supplies
   Other Service	Supported Living
   Other Service	Wellness Recovery Action Plan (WRAP)