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In the matter of the adoption of New Rules I and II and the amendment of ARM 37.87.903, 37.87.1401, 37.87.1402, 37.87.1407, 37.87.1408, and 37.87.1410 pertaining to home support services (HSS) program redesign
NOTICE OF PUBLIC HEARING ON PROPOSED ADOPTION AND AMENDMENT
1.  On November 30, 2020, at 2:00 p.m., the Department of Public Health and Human Services will hold a public hearing via remote conferencing to consider the proposed adoption and amendment of the above-stated rules. Because there currently exists a state of emergency in Montana due to the public health crisis caused by the coronavirus, there will be no in-person hearing. Interested parties may access the remote conferencing platform in the following ways:
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 the Department of Public Health and Human Services no later than 5:00 p.m. on November 20, 2020, to advise us of the nature of the accommodation that you need. Please contact Heidi Clark, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; telephone (406) 444-4094; fax (406) 444-9744; or e-mail dphhslegal@mt.gov.
3. The rules as proposed to be adopted provide as follows:
NEW RULE I HOME SUPPORT SERVICES (HSS), PROVISIONS OF SERVICE (1) Home support services (HSS) providers must support the strengths of youth and caregivers by:
(a) identifying behavioral health abilities and needs across key areas such as school, family, social, community, and vocational environments;
(b) identifying strengths that can form the basis of the treatment plan in the areas of school, family, social, community, and vocational functioning; and
(c) prioritizing the most critical behavioral health needs and concerns as the focus of the treatment planning and delivery.
(2) HSS providers must engage in treatment planning that:
(a) clearly states the treatment goals identified in the clinical eligibility recommendation;
(b) is based on the functional assessment conducted pursuant to the manual adopted and incorporated by reference in ARM 37.87.903;
(c) is a collaborative process that involves youth and caregivers in developing a treatment plan with a manageable number of prioritized needs along with goals and strategies for addressing each need and goal;
(d) includes goals with measurable and observable outcomes;
(e) includes monthly summaries and updates every 90 days, which include outcome measurements of treatment goals; and
(f) unifies treatment plans with a targeted case manager, if applicable, and identifies all services and supports to caregivers.
(3) The provider must conduct a treatment team meeting with the caregiver to develop an individualized treatment plan in accordance with ARM 37.106.1916.
(4) The provider must measure progress on individualized treatment goals, using both the department-approved standardized assessment and treatment goal indicators to measure progress from baseline. Progress towards individualized treatment goals must be considered as part of discharge planning.
(5) The provider must collaborate and coordinate with the TCM provider, if youth and caregivers are engaged in TCM services.
(6) The provider must collaborate with youth and caregivers to identify and address suicidality, risk, and safety concerns at home, in school, and in the community to develop an individualized safety plan for each youth. Individual safety plans must be completed within 21 days of admission to HSS and must be reviewed monthly and after crisis with updates as necessary. Individual safety plans must contain the following components:
(a) delineate required safety planning and processes, youth and caregiver involvement, and plan dissemination;
(b) identification of what is considered a crisis for youth and caregivers;
(c) natural supports currently accessible to the youth and caregivers;
(d) current resources and skills accessible to the youth and caregivers;
(e) crisis escalation patterns and triggers;
(f) de-escalation strategies that are easily understood and can be implemented by the youth and caregivers;
(g) if indicated by suicidality screening, a specific plan to address suicidal thoughts or ideations;
(h) when to call the HSS team; and
(i) when to call 911.
(7) The provider must maintain requirements for crisis response as defined in ARM 37.106.1945. Individual treatment and safety plans must be immediately available to mental health center employees engaged in crisis response.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, MCA
NEW RULE II HOME SUPPORT SERVICES (HSS), PROVIDER REQUIREMENTS (1) The HSS provider must be a mental health center as described in ARM Title 37, chapter 106, subchapter 19.
(2) HSS teams should consist of a family support specialist (FSS) and a clinical lead.
(3) HSS providers must ensure caseload sizes are sufficiently small to permit home support teams to respond flexibly to differing service needs of youth and families, including frequency of contact. FSS caseloads may vary between 4 to 14 families.
(4) HSS providers must provide coaching to an FSS on in-home behavioral health skills. The clinical lead shall provide feedback based on observation of practice, review of plans of care and other documentation, and progress for each youth and caregiver. The FSS must meet with their clinical lead regularly. Frequency must be at least once a week, or more frequently based on documented skills and competencies.
(5) Coaching and mentoring must be skills-based and include coaching to promote competencies in key skill sets such as safety planning, behavior management, cognitive behavioral interventions, caregivers and systemic interventions, and psychoeducation.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, MCA
4. The rules as proposed to be amended provide as follows, new matter underlined, deleted matter interlined:
37.87.903 MEDICAID MENTAL HEALTH SERVICES FOR YOUTH, AUTHORIZATION REQUIREMENTS (1) through (6) remain the same.
(7) In addition to the requirements contained in rule, the department has developed and published a provider manual entitled Children's Mental Health Bureau, Medicaid Services Provider Manual (Manual), dated March 1, 2020 January 1, 2021, for the purpose of implementing requirements for utilization management. The department adopts and incorporates by reference the Children's Mental Health Bureau, Medicaid Services Provider Manual, dated March 1, 2020 January 1, 2021. A copy of the manual may be obtained from the department by a request in writing to the Department of Public Health and Human Services, Developmental Services Division, Children's Mental Health Bureau, 111 N. Sanders, P.O. Box 4210, Helena, MT 59604-4210 or at http://dphhs.mt.gov/dsd/CMB/Manuals.aspx.
(8) and (9) remain the same.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, 53-6-111, MCA
37.87.1401 HOME SUPPORT SERVICES AND THERAPEUTIC FOSTER CARE, SERVICES REIMBURSEMENT (1) and (2) remain the same.
(3) HSS and The TFC providers are is reimbursed a daily rate.
(a) To receive the daily rate for HHS, the provider must have contact as described in ARM 37.87.1410(6). The department will not reimburse the daily rate for any telephone contacts that exceed the number of face-to-face contacts reimbursed in a four-week period. Reimbursement is limited to one contact per day.
(b) For TFC services, the department will reimburse the providers the daily rate for every day of a four-week period if the provider meets the minimum number of contacts as described in ARM 37.87.1410(6) during the four-week period.
(4) The HSS provider is reimbursed on a fee per unit of service basis. For purposes of this rule, a unit of service is based on a 15-minute unit increment. A unit of service is a period of 15 minutes as follows:
(a) one unit of service is equal to 8 minutes but fewer than 23 minutes;
(b) two units of service are greater than or equal to 23 minutes but fewer than 38 minutes;
(c) three units of service are greater than or equal to 38 minutes but fewer than 53 minutes;
(d) four units of service are greater than or equal to 53 minutes but fewer than 68 minutes;
(e) five units of service are greater than or equal to 68 minutes but fewer than 83 minutes;
(f) six units of service are greater than or equal to 83 minutes but fewer than 98 minutes;
(g) seven units of service are greater than or equal to 98 minutes but fewer than 113 minutes; and
(h) eight units of service are greater than or equal to 113 minutes but fewer than 128 minutes.
(4) remains the same but is renumbered (5).
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, MCA
37.87.1402 HOME SUPPORT SERVICES (HSS) AND THERAPEUTIC FOSTER CARE (TFC), DEFINITIONS  (1) and (2) remain the same.
(3) "Clinical lead" means a person who is an employee of the provider agency who is responsible for the supervision and overall provision of treatment services to youth in HSS and TFC. Effective January 31, 2014, the The clinical lead must be a licensed mental health professional as defined in ARM 37.87.102 or an individual providing in-training mental health services as defined in ARM 37.87.702.
(4) remains the same.
(5) "Family support specialist" (FSS) means a person who is an employee of the provider agency who provides therapeutic interventions to youth who are receiving HSS and TFC. The FSS must have a bachelor's degree in a human services field or a combination of experience and education equivalent to a bachelor's degree. For an FSS, six years of human services experience equates to a bachelor's degree, and each year of post-secondary education in human services equates to one year of experience.
(5) (6) "Home support services (HSS)" is defined in the Manual adopted and incorporated by reference in ARM 37.87.903 and "therapeutic foster care (TFC)" means medically necessary, intensive in-home services delivered by providers with specialized training and experience working with caregivers and youth in their homes, with temporary services available when a youth is homeless for less than 90 days.
(6) "Home support services specialist" means a person who is an employee of the provider agency who provides therapeutic interventions to youth who are receiving HSS and TFC. The home support services specialist (HSS-S) must have a bachelor's degree in a human services field, or a combination of experience and education equivalent to a bachelor's degree. For a HSS-S, six years of human services experience equates to a bachelor's degree and each year of post-secondary education in human services equates to one year experience.
(7) "Natural supports" means relationships and supports that occur within the community in everyday life including but not limited to relationships with family members, friends, neighbors, and community acquaintances.
(8) "Therapeutic foster care (TFC)" means medically necessary, intensive in-home services delivered by a provider with specialized training and experience working with caregivers and youth in their homes, with temporary services available when a youth is homeless for fewer than 90 days.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, MCA
37.87.1407 HOME SUPPORT SERVICES (HSS) AND THERAPEUTIC FOSTER CARE (TFC), PROVISIONS OF SERVICE (1) The main focus of the service is to address the mental health needs and strengthen the structure and support for youth and the caregivers. HSS and TFC serves the youth and the caregivers in their home and community environment through understanding the needs of the youth and the dynamics of the caregivers. HSS and TFC requires a structured, consistent, strength based therapeutic relationship between the provider and the youth and the caregiver for the purpose of treating the behavioral health needs of the youth, including improving the caregiver's ability to provide effective support for the youth and to promote healthy functioning.
(2) through (4) remain the same.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, MCA
37.87.1408 HOME SUPPORT SERVICES (HSS) AND THERAPEUTIC FOSTER CARE (TFC), DISCHARGE PLANNING AND DOCUMENTATION (1) and (2) remain the same.
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, MCA
37.87.1410 HOME SUPPORT SERVICES (HSS) AND THERAPEUTIC FOSTER CARE (TFC), PROVIDER REQUIREMENTS (1) Effective January 31, 2014, HSS and The TFC providers must be a mental health center as described in ARM Title 37, chapter 106, subchapter 19.
(2) Providers of therapeutic foster care The provider must also be a child-placing agency.
(3) A full-time clinical lead is responsible for not more than five full-time home family support services specialists (HSS-S) (FSS).
(4) The clinical lead must:
(a) provide direction and consultation to the HSS-S FSS to address the clinical needs of the youth and the caregiver as identified in the individualized treatment plan (ITP);
(b) respond to the youth and the caregiver's needs when the HSS-S FSS is not available;
(c) orient, train, and coach the HSS-S FSS; and
(d) provide one-on-one supervision at least monthly to the HSS-S FSS.
(5) A full-time HSS-S FSS is responsible for not more than ten youths at a time.
(6) The following requirements must be met by either the clinical lead, the HSS-S FSS, or both:
(a) through (7) remain the same.
(8) The providers of HSS and TFC must use a research-based practice curriculum specific to provide family-based services. Staff training in the research-based practice must be documented in the provider personnel records
AUTH: 53-2-201, 53-6-113, MCA
IMP: 53-2-201, 53-6-101, MCA
5. STATEMENT OF REASONABLE NECESSITY
The Department of Public Health and Human Services (department) is proposing to amend ARM 37.87.903, 37.87.1401, 37.87.1402, 37.87.1407, 37.87.1408, and 37.87.1410.
In addition, the department proposes adding New Rule I and New Rule II.
The following summaries explain programmatic changes and the reasonable necessity for the proposed rule amendments.
Home Support Services for Youth with Serious Emotional Disturbances
The department's Children's Mental Health Bureau (CMHB) worked in collaboration with a taskforce of children's mental health stakeholders to review the home support services (HSS) for youth with serious emotional disturbance program and make program changes to enhance the quality of services provided to youth and caregivers while ensuring a fiscally sound program. The redesigned program has the following components:
(a) Providers will determine medical necessity criteria using an evidence-based standardized assessment tool, Child and Adolescent Service Intensity Instrument (CASII). Also, providers must make clinical outcome recommendations that can be achieved through the services provided to youth. Caregivers must be willing to participate in treatment. This provision is found in the Children's Mental Health Bureau, Medicaid Services Provider Manual, dated January 1, 2021 (manual), which is adopted and incorporated by reference through the administrative rules.
(b) Providers are required to provide a variety of interventions including family meetings, psychoeducation, skill building for the youth and caregivers, cognitive behavioral interventions for the youth, and family and systemic interventions. This provision is found in the manual.
(c) Providers must incorporate the strengths of the youth and caregivers in treatment planning with focus on all key life domains including school, family, social, community, and vocational functioning based on results of the CASII.
(d) Caregiver engagement standards and requirements will be incorporated into the treatment planning process to ensure caregivers understand the treatment and participate in the HSS process. In addition, the proposed rule changes require providers to establish clear treatment goals with monthly summaries and updates of the treatment goals.
(e) Requirements for safety and crisis response planning have been added to ensure plans are current and promptly accessible when needed.
(f) The proposed fee structure for home support services is part of MAR Notice No. 37-933, which was filed on October 27, 2020. The fiscal impact of the redesigned HSS program may be found in that rulemaking notice.
(g) HSS will use a team structure consisting of a family support specialist (FSS) and clinical lead. The clinical lead will provide regular skills-based coaching and feedback to the FSS and meet with the FSS regularly. The department proposes to define HSS caseload as being sufficiently small to permit providers to respond flexibly to varying service needs of youth and their families. FSS may carry a caseload of 4 to 14 families, with size based on complexity of cases, skills, and competencies.
The reasonable necessity for proposing the amendment and adoption of the following rules is to enact the redesigned HSS program, described above, which will provide eligible youth and families greater access to enhanced services: ARM 37.87.903, 37.87.1401, 37.87.1402, 37.87.1407, 37.87.1408, 37.87.1410, New Rule I, and New Rule II.
The department proposes to update language in ARM 37.87.903 to accurately reflect current practices.
The rule changes proposed in this rule notice will not result in a fiscal impact to the department's budget. The rate change for Home Support Services is proposed in MAR Notice No. 37-933, and the fiscal impact relating to the rate change is included in that notice.
The department intends for the adoption and amendment of these rules to be effective January 1, 2021.
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: Heidi Clark, Department of Public Health and Human Services, Office of Legal Affairs, P.O. Box 4210, Helena, Montana, 59604-4210; fax (406) 444-9744; or e-mail dphhslegal@mt.gov, and must be received no later than 5:00 p.m., December 4, 2020.
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. The bill sponsor contact requirements of 2-4-302, MCA, do not apply.
10. With regard to the requirements of 2-4-111, MCA, the department has determined that the adoption and amendment of the above-referenced rules will not significantly and directly impact small businesses.
11. Section 53-6-196, MCA, requires that the department, when adopting by rule proposed changes in the delivery of services funded with Medicaid monies, make a determination of whether the principal reasons and rationale for the rule can be assessed by performance-based measures and, if the requirement is applicable, the method of such measurement. The statute provides that the requirement is not applicable if the rule is for the implementation of rate increases or of federal law.
The department has determined that the proposed program changes presented in this notice are not appropriate for performance-based measurement and therefore are not subject to the performance-based measures requirement of 53-6-196, MCA.
/s/ Brenda K. Elias                                       /s/ Sheila Hogan
Brenda K. Elias                                            Sheila Hogan, Director
Rule Reviewer                                              Public Health and Human Services
Certified to the Secretary of State October 27, 2020.
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