Big Sky Waiver Program Policy Manual

Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances. State Website Disclaimer.

If you experience any difficulty opening a policy from this page,
please email HHS Technology Services Center.

*To obtain copies of this document, contact Jean Perrotta (406) 496-4955 or email JPerrotta@mt.gov

Chapter

Subject

Form Number

Date Revised

001
Table of Contents
 
10/01/2019
002
Alpha Subject Index
 
03/01/2012

400

ELIGIBILITY FOR SERVICES

 

 

 
401
Eligibility for Services
BSW-101
04/01/2019
 
401
BSW Program Approval Notice
BSW-102
01/01/2019
 
402
Slot Categories
 
04/01/2016
 
403
Prior Authorizations
Policy
SLTC-148
SLTC-149*
01/01/2019
01/01/2018
07/01/2018
 
405
Referrals for Services
 
01/01/2012
 
406
Wait List Criteria
 
10/01/2019
 
406
Wait List Placement Approval Notice
BSW-103
01/01/2019
 
406
Wait List-Deeming Form
BSW-101-18
07/01/2018
 
406-1
Wait List Tool and Scoring
SLTC-146
10/01/2019
 
407
Medically Needy Billing Procedures
Policy 
SLTC-131
SLTC-132
01/01/2019
01/01/2018
01/01/2018
 
408
Residency Requirements
 
01/01/2012
 
409
Out-of-State Services
 
01/01/2012
 
410
Retainer Payments
 
01/01/2019
 
410-1
Attachment A, Public Institutions
 
01/01/2012
 
411
Individuals with Intellectual Disabilities
 
01/01/2017
 
412
Adverse Action
Policy
SLTC-137
SLTC-144
SLTC-150*
10/01/2019
01/01/2018
01/16/2018
07/01/2018
 
413
Fair Hearings
 
04/01/2017
 
414
Assisted Living At-Risk Slot Process
 
04/01/2019
 
415
Temporary Absences
 
07/01/2018
 
499-1
DPHHS Release of Information HPS 402
 
10/01/2015

500

PREADMISSION SCREENING

 

 

 
501
Screening Requirements Preadmission Screening
 
01/01/2012
 
502
Screening Referral Procedures
 
01/01/2012
 
503
Level of Care Reevaluations
 
03/01/2011
 
504
RESERVED
 
 
 
599-1
Screening Determination Form*
SLTC-61*
01/01/2019

600

ADMINISTRATIVE REQUIREMENTS

 

 

 

601
Provider Eligibility
 
01/01/2012
 
602
Provider Responsibilities
 
01/01/2019
 
602-1
Progress Notes
 
01/01/2017
 
603
Provider Enrollment
 
04/01/2017
 
604
Payment Requirements
 
01/01/2016
 
604-1
Payment of Legally Responsible Individuals
 
01/01/2016
 
605
Payment Processing
 
07/01/2018
 
606
Reimbursement Methodology
 
01/01/2012
 
607
Licensure Requirements
 
07/01/2016
 
608
Quality Assurance Process
 
07/01/2018
 
608-1
Quality Assurance Communication
 
10/01/2019
 
609
Serious Occurrence Report
 
04/01/2017
 
699-1
Provider Requirements
 
01/01/2016
 
699-2
CMS 1500 Claim Form
 
02/01/2012
 
699-3
File Transfer
 
01/01/2012
 
699-4
RESERVED
 
 
 
699-5
HCBS Referral for Services Form
 
04/01/2007

700

SERVICES

 

 

 

701
Covered Services
 
08/01/2011
 
702
Service Limitations and Exclusions
 
01/01/2019
 
703
Adult Day Health
 
08/01/2011
 
704
Case Management
 
08/01/2011
 
705
Community Supports
 
08/01/2011
 
706
Community Transition
 
08/01/2011
 
707
Consultative Clinical and Therapeutic Services
 
08/01/2011
 
708
Consumer Goods and Services
 
08/01/2011
 
709
Day Habilitation
 
08/01/2011
 
710
Dietetic Services
 
08/01/2011
 
711
Environmental Accessibility Adaptations
 
04/01/2018
 
712
Family Training and Support
 
08/01/2011
 
713
Financial Management Services
 
08/01/2011
 
714
Health and Wellness
 
08/01/2011
 
715
Homemaker
 
01/01/2012
 
716
Homemaker Chore
 
01/01/2012
 
717
Independence Advisor
 
07/01/2018
 
718
Non-Medical Transportation
 
01/01/2019
 
719
Nutrition
 
01/01/2012
 
720
Occupational Therapy
 
08/01/2011
 
721
Pain and Symptom Management
 
01/01/2012
 
722
Personal Assistance Services
 
01/01/2019
 
723
Personal Emergency Response System
 
07/01/2016
 
724
Physical Therapy
 
08/01/2011
 
725
Post Acute Rehabilitation Services
 
07/01/2018
 
726
Prevocational Services
 
08/01/2011
 
727
Private Duty Nursing
 
01/01/2019
 
728
Residential Habilitation
 
01/01/2012
 
729
Respiratory Therapy
 
08/01/2011
 
730
Respite Care
 
08/01/2011
 
731
Senior Companion
 
08/01/2011
 
732
Special Child Care for Medically Fragile Children
 
08/01/2011
 
733
DME: Specialized Medical Equipment, Supplies and Technology
 
07/01/2018
 
733-1
DME Specialized Medical Equipment, Supplies and Technology: Consultations
 
02/01/2017
 
733-2
DME Specialized Medical Equipment, Supplies, and Technology: Commonly Covered Items under Big Sky Waiver
 
02/01/2017
 
734
Speech Therapy and Audiology
 
08/01/2011
 
735
Supported Employment
 
08/01/2011
 
736
Supported Living
 
10/01/2019
 
737
Vehicle Modification
 
04/01/2018
 
799-1
Administrative Rules of Montana
 
10/01/2015
 
799-2
CFC/PAS Consumer Referral Form
SLTC-154
10/01/2015
 
799-3
Service Animal: Case Management Team Role
 
10/01/2015
 
799-4
Service Animal: Member Responsibilities
 
10/01/2015
 
799-5
Service Animal: Acquisition Procedure
 
10/01/2015
 
799-6
Consumer Recycling Agreement
 
03/01/2005

800

CASE MANAGEMENT SERVICES

 

 

 
801
Case Management Requirements
 
07/01/2018
 
802
Case Management Team Requirements
 
01/01/2012
 
803
Service Areas
 
03/01/2012
 
804
Record Requirements
 
04/01/2019
 
805
Budget Requirements
 
03/01/2005
 
806
Reporting Requirements
 
01/01/2012
 
807
Contract Termination and Transition
 
03/01/2005
 
808
Transfer of Members or Change in Member Classification
 
07/01/2018
 
809-1
Service Plan Development
 
07/01/2016
 
809-2
Service Plan Components
 
01/01/2012
 
809-3
Service Plan Requirements
 
01/01/2012
 
809-4
Service Plan Costs
 
01/01/2012
 
809-5
Service Plan Reevaluations
 
10/01/2019
 
809-6
Service Plan Amendment
SLTC-141
01/01/2018
 
809-7
Service Plan Annual Updates
 
01/01/2012
 
810
Member Input
 
01/01/2012
 
812
Risk Negotiation Process
 
01/01/2012

 

 

FORMS

 

 

 

899-2
Reporting Requirements, Forms & Instructions
 
04/01/2016
 
899-2a
Internal Chart Audit Form
 
01/01/2009
 
899-2b
Utilization Report
 
01/01/2012
 
899-2c
Nursing Facility Transfer Report
 
01/01/2009
 
899-3
CMS QA Performance Measures
 
01/01/2012
 
899-4
HCBS Forms Requisition
 
01/01/2006
 
899-5
Service Plan Cost Limits
 
10/01/2015
 
899-6
Entrance into Medicaid Instructions
SLTC-55
02/01/2007
 
899-7
Request for Level of Care
SLTC-85
01/01/2006
 
899-8
Level of Care Determination
 
01/01/2016
 
899-10
Service Plan & Cost Sheet
SLTC-134
01/01/2012
 
899-11
Service Plan Instructions
 
04/01/2016
 
899-11
HCBS Service Plan Form
SLTC-135
04/01/2016
 
899-11b
Service Plan Short Form (135b) Instructions
 
04/01/2016
 
899-11b
Service Plan Short Form
SLTC 135b
04/01/2016
 
899-12
Intake Sheet Form Instructions
SLTC-136
01/01/2016
 
 
Authorized Services for Spend Down
SLTC-131
01/01/2018
 
899-15
Re-Evaluation Form
SLTC-139
01/01/2012
 
899-17
Psychosocial Summary Form Instructions
SLTC-143
01/01/2016
 
899-19
Level I Screen
SLTC-145
01/01/2006
 
899-23
Service Animals Provider Assurance Form Instructions
SLTC-142
10/01/2015
 
899-24
Service Animal Stewardship Agreement Instructions
SLTC-147
10/01/2015
 
899-25
Waiting List Database
 
03/01/2005
 
899-26
State Supplement Instructions & Forms
 
02/01/2007
 
899-27
Nursing Home Transition Process & Form
 
03/01/2011
 
899-29
Risk Negotiation Form & Instructions
SLTC-157*
04/01/2018

1100

Person Centered Planning

 

 

 

1101
Person-Centered Planning Requirements Overview
 
04/01/2017
 
1102
Plan Facilitator vs. Provider Responsibilities
 
04/01/2017
 
 
1103
Plan Facilitator Certification for CFC/PAS Providers
 
04/01/2017
 
1104
Person Centered Planning Coordinated Visit
 
04/01/2017
 
1105
Mountain Pacific Quality Health Authorization Documents
 
04/01/2017
 
1106
Person Centered Planning Annual Visits
 
04/01/2017
 
1107
Person Centered Planning - Readmission
 
07/01/2017
 
1108
High Risk Admits
 
07/01/2017
 
1109
Change in Plan Facilitator
 
07/01/2017
 
1110
Short Term Admits
 
07/01/2017
 
1111
Personal Emergency Response Systems (PERS)
 
07/01/2017
 
1112
Person Centered Plan Form Instructions (SLTC 200)
SLTC-200*
04/01/2017
 
1113
Level of Care
 
07/01/2017
 
1115
Case Manager Role When Switching Agencies
 
07/01/2017

Appendix

 

 

 

 

 

9901
Definitions
 
03/01/2005
 
9902
Abbreviations/Acronyms/Initials
 
01/01/2017
 
 
*To obtain copies of this document contact Jean Perrotta 1-406-496-4955 or email: jperrotta@mt.gov