Big Sky Waiver policy manual revisions and constituent meeting outcomes
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Summarizes the October 29, 2020 constituent meeting about proposed changes to the Big Sky Waiver policy manual, covering eligibility, slot categories, and prior authorization topics; affects DPHHS waiver staff, providers, and stakeholders involved in Big Sky Waiver implementation.
Policy manual language will shift to person-first and strengths-based language, eliminate duplication, and emphasize a functional versus medical-only model.
Slot categories will be retained in the policy manual (not placed into rule) and updated to reflect current practice, including removing obsolete slots and adding new residential services.
Prior authorization philosophy and criteria from the approved waiver application will be included in rule as agreed-upon guidelines, with DPHHS documenting processes for authorization level changes.
DPHHS will analyze documentation overlap between waiver teams and the Office of Public Assistance to reduce burdens on members.
DPHHS will add and define the term 'legally responsible third-party resources' in prior authorization policy content.
Prior Authorization Inclusion Criteria
Prior Authorization Inclusion Criteria (to be included in rule)
Covered when ALL of the following inclusion criteria are satisfied, and the request also meets every required condition.
ALL of the following
One of
- Decrease the need for other Medicaid services
- Promote inclusion in the community
- Promote the independence of the member
- Fulfill a medical, social, or functional need based on unique cultural approaches
- Increase the person's safety in the home environment
And must meet all of these
- Meet member's identified needs and outcomes in their service plan
- Goods and services collectively must provide an alternative to institutional placement
- Be a cost-effective means of addressing an identified need in the service plan
- Be of sole benefit to the member
Prior Authorization Process and Provider Responsibilities
Prior Authorization Criteria and Philosophy — Include waiver criteria in rule and document PA change process
DPHHS will include the waiver application's detailed prior-authorization criteria in rule and will document a prior authorization philosophy and a transparent process for changing authorization levels. The rule will list the five inclusion criteria (decrease the need for other Medicaid services; promote inclusion in the community; promote the member's independence; fulfill a medical, social, or functional need based on unique cultural approaches; increase the person's safety in the home) and the four required conditions that must all be met (meet member's identified needs and outcomes in their service plan; goods and services collectively must provide an alternative to institutional placement; be a cost-effective means of addressing an identified need in the service plan; be of sole benefit to the member). DPHHS will document and publicly explain the evaluation and rationale whenever prior authorization levels are changed.
- Include waiver application's detailed criteria in rule as agreed-upon guideline
- List five inclusion criteria and four required conditions (all must be met)
- Document prior authorization philosophy and process for changing authorization levels
- Ensure evaluation and rationale for authorization-level changes are recorded and publicly transparent
Define 'Legally Responsible Third‑Party Resources' in PA policy
DPHHS will add the term 'legally responsible' before 'third-party resources' in prior authorization policy content and will provide a formal definition of 'legally responsible third-party resources' in the policy.
- Amend prior-authorization policy language to read 'legally responsible third-party resources'
- Add and publish a definition for 'legally responsible third-party resources' in prior authorization content
Key Definitions and Terms
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