Home and Community Based Services

In January 2014, the Centers for Medicare and Medicaid Services (CMS) announced a requirement for states to review and evaluate current Home and Community-Based Services (HCBS), including residential and non-residential settings. These federal guidelines were developed to ensure that members receiving long-term services and supports through HCBS programs under Medicaid waiver authorities have full access to benefits of community living and the opportunity to receive services in the most integrated setting appropriate. This includes opportunities to engage in community life, control personal resources, receive services in the community, control personal resources, receive services in the community, and seek employment and work in competitive and integrated settings to the same degree as individuals who do not receive HCBS.

The regulations also aim to ensure that individuals have a free choice of where they live and who provides services to them, as well as ensuring that individual rights are not restricted. While Medicaid HCBS has never been allowed in institutional settings, these new regulations clarify that HCBS will not be allowed in settings that have the qualities of an institution or the effect of isolating. Settings defined as institutions are: a nursing facility; institution for mental diseases; an intermediate care facility for individuals with intellectual disabilities; a hospital; or any location that have qualities of institutional setting.

In the Summer of 2024, the Department of Public Health and Human Services (DPHHS) is implementing a new technology system for HCBS providers. The new system is a HCBS settings portal and will be used by DPHHS and HCBS providers to ensure ongoing compliance with the HCBS Settings Rule. The HCBS settings portal will improve the efficiency of HCBS compliance activities by giving providers one portal in which they will complete their self-assessments and communicate with DPHHS on all related settings activities. Guidance and training will be forthcoming.

Current Montana HCBS Settings Information:

Key Facts:  HCBS settings will now be defined based on the nature and quality of the member’s experiences in residential and non-residential settings where HCBS is delivered.

General Requirements

  1. Is integrated in and supports access to the greater community
  2. Provides opportunities to seek employment and work in competitive, integrated settings, engage in community life, and control personal resources
  3. Is selected by the individual from among setting options, including non-disability specific settings and an option for a private unit in a residential setting with the options documented in the person-centered plan of care based on the individual’s needs and preferences
  4. Ensures the individual receives services in the community to the same degree of access as individuals not receiving Medicaid HCBS
  5. Ensures an individual’s rights of privacy, dignity, respect, and freedom from coercion and restraint
  6. Optimizes individual initiative autonomy, and independence in making life choices
  7. Facilitates individual choice regarding services and supports, and who provides them

Additional Requirements for Provider-Owned or Controlled Settings

  1. Has a lease or other legally enforceable agreement providing similar protections
  2. Has privacy in their unit, including lockable entrance, bedroom and bathroom doors, choice of roommates, and freedom to furnish or decorate the unit
  3. Control their own schedule, including access to food at any time
  4. May have visitors at any time
  5. The setting is physically accessible

Rights Restrictions/Health and Safety Modifications
Any modification of the settings rule requirements must be supported by a specific assessed need and justified in the person-centered plan of care with the following items documented in the plan:

  1. Identifies a specific and individualized assessed need
  2. Documents the positive interventions and supports used prior to any modifications to the person-centered plan of care
  3. Documents less intrusive methods of meeting the need that have been tried but did not work
  4. Includes a clear description of the condition that is directly proportionate to the specific assessed need
  5. Includes regular collection and review of data to measure the ongoing effectiveness of the modification
  6. Includes established time limits for periodic reviews to determine if the modification is still necessary or can be terminated
  7. Includes the informed consent of the individual
  8. Includes an assurance that interventions and supports will cause no harm to the individual