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    v1.0.28
    OpenPayerPolicy UpdatesPost-Acute & Facility CareMontana DPHHS MFP Coverage & Add-on Policy Update …
    Ask Trek AI about this page
    CurrentMontana Department of Public Health & Human ServicesPolicy N/A

    Evolving from Nursing Home to Community Life — Money Follows the Person (MFP) and Complex Care Add-on Coverage Criteria

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    This document describes Montana DPHHS programs and policies to support Medicaid-eligible individuals moving from nursing facilities or other institutional settings back to community-based living, who are eligible for Money Follows the Person (MFP) and related waiver programs. It affects Montana Medicaid recipients, nursing facilities, case managers, and community service providers involved in transitions and post-acute care.

    Policy Summary
    PayerMontana Department of Public Health & Human Services
    PolicyEvolving from Nursing Home to Community Life — Money Follows the Person (MFP) and Complex Care Add-on Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit referrals via the secure DPHHS MFP website form, email, phone, or fax and document coordination with MFP contacts.
    SourceLink
    POLICY UPDATE CHANGES

    No material clinical or coverage changes in this revision.

    285Moved in MT since 2014
    >107kMoved nationally (MFP)
    $350k+Reinvested into HCBS

    OpenPayer is powered by Trek Health's payer performance platform. Trek continuously ingests, validates, and normalizes Transparency in Coverage data alongside payer policies and other commercial payer data to create a structured payer intelligence foundation. OpenPayer uses this foundation to deliver personalized search results, dynamically generated policy pages, and tailored policy monitoring based on each user's payers, specialties, billing codes, and areas of interest. The same intelligence powers broader payer performance workflows, including reimbursement benchmarking, contract evaluation, payer negotiations, and financial decision-making.

    60dMinimum institutional residency
    365dPost-transition waiver coverage

    Coverage Criteria for MFP and Demonstration Services

    MFP and Complex Care Add-on Coverage Criteria

    Covered when ALL of the following are met

    MFP eligibility and support: Individual is a Montana Medicaid recipient who has resided in an institutional setting for 60 or more consecutive days with at least one day paid by Medicaid; meets institutional level of care (per PASRR when applicable); and meets eligibility criteria for one of Montana's waiver programs (Big Sky Waiver, SDMI, or Developmental Disabilities Program).60 days

    From MFP eligibility criteria; institutional settings include inpatient hospital, inpatient rehabilitation, or skilled nursing facility.

    Residential setting choice: Individual is willing to move into a qualified residential setting determined by person-centered planning (home or apartment owned by the individual or family, community-based residential setting with no more than four unrelated residents, or an assisted living facility meeting tenant control requirements).

    Residential setting requirements are part of MFP eligibility.

    Complex Care Add-on justification: When applicable, resident meets medical necessity for a Complex Care Add-on (Level I, II, or III) based on documented needs such as behavioral disruptions, bariatric care, or stage 3–4 wounds requiring enhanced interventions and staff support; assignment to Levels II or III excludes individuals at risk of elopement without aggressive/assaultive behaviors and individuals enrolled in hospice care.

    Complex Care Add-on is intended for extreme cases and may be temporary or extended; specific level descriptions and rates are in the Complex Care Add-on structure.

    MFP Covered Transition and Demonstration Services

    Covered services and supports associated with MFP transitions

    Post-transition coverage: After moving from an institutional setting to community living, MFP covers 365 days of waiver services and associated services based on person-centered planning (examples: Home Health, Hospice, PT/OT/ST, Community First Choice/Personal Assistance Services).365 days

    MFP monitors participants during the 365-day period; continuation of services after 365 days depends on individual needs and program requirements.

    Demonstration services available prior to transition: Demonstration services that may be made available prior to transition include participation of transition coordination team members, environmental and vehicle modifications, deposits for rent/utilities, assistance with past-due credit impacting housing, and limited furnishings.

    These services support successful transition into community living.

    The policy specifies exclusions related to assignment of Complex Care Add-on Levels II and III. Individuals who are at risk of elopement but do not display aggressive or assaultive behaviors are not eligible for assignment to Levels II or III. Additionally, individuals enrolled in hospice care are excluded from assignment to Complex Care Add-on Levels II and III.

    This portion of the document does not list additional explicit exclusions beyond those tied to Complex Care Add-on assignment. It describes demonstration services and benefits of MFP but does not specify further populations or conditions that are excluded from MFP transition supports or waiver benefits.

    Within the pages cited there are no conditions explicitly labeled as not medically necessary. The content focuses on available demonstration services and the 365-day post-transition waiver coverage rather than on statements of non-coverage.

    Key Coding & Eligibility Values

    Minimum institutional residency for MFP
    Minimum institutional residency60 consecutive days (at least one day paid by Medicaid)
    Eligible institutional settingsInpatient hospital, inpatient rehabilitation, skilled nursing facility (SNF)
    Required program eligibilityMust meet eligibility for a Montana waiver (Big Sky Waiver, SDMI, or Developmental Disabilities Program)
    Residential willingnessIndividual must be willing to move into a qualified residential setting per person-centered planning

    Provider Responsibilities and Operational Notes

    Prior Authorization

    Complex Care Add-on authorization requires medical necessity documentation

    Requests for Complex Care Add-on funding must include documentation that the resident meets medical necessity for a Complex Care Add-on Level (I, II, or III) tied to the resident’s diagnosis and documented plan of care, and justification for temporary or extended additional assistance beyond routine nursing home care.

    • Add-on intended for extreme cases and based on medically necessary complex care levels tied to diagnosis and plan of care.
    • Documentation must show the specific level (I–III) and needs (behavioral interventions, bariatric care, stage 3–4 wounds, medication/treatment tasks, staffing intensity).
    Note

    No prior authorization process specified for demonstration/waiver services in this section

    This section does not specify prior authorization requirements for MFP demonstration or waiver services; demonstration services are described as available prior to transition but no PA process is defined here.

    Program Background and Purpose

    Money Follows the Person (MFP) is a federal demonstration program implemented in Montana to support Medicaid-eligible individuals moving from institutional settings back to community-based living. The program establishes Transition Coordination teams to plan and execute person-centered moves and offers pre-transition demonstration services—such as environmental and vehicle modifications, deposits for rent/utilities, assistance addressing past-due credit that affects housing, and limited furnishings—to remove barriers to successful community placement. After transition, MFP provides a 365-day period of waiver and associated services (including Home Health, Hospice, PT/OT/ST, and Community First Choice/Personal Assistance Services) with monitoring during that year and continuation of services based on individual need and program requirements.

    Definitions and Service Descriptions

    Complex Care Add-on Levels I–III
    DefinitionTiered payments for residents requiring additional assistance beyond routine nursing home care (Levels I–III)
    Level IMinimal assist — infrequent behavioral or ADL assistance; example rate listed in policy (Level I rate documented)
    Level IIStand-by/Moderate intervention — more frequent behavioral interventions, bariatric needs (350–650 lbs), stage 3 wounds; intended for increased staff assistance
    Level IIITotal assist — intense, direct assistance for ADLs, severe behavioral or bariatric (>650 lbs) needs, stage 4 wounds; highest add-on rate
    Institutional settings (for MFP eligibility)
    Included settingsInpatient hospital, inpatient rehabilitation, skilled nursing facility (SNF)

    Admission Criteria for SNF and Institutional Settings

    SNF — Admission criteria top-level node

    Nursing facility admission: Need for nursing facility services must be established by meeting level of care criteria via the Preadmission Screening and Resident Review (PASRR); individuals with serious mental illness or intellectual disability must be evaluated by PASRR to determine appropriateness of NF admission.

    PASRR and level-of-care required for SNF admission per federal law/regulation.

    SNF/Institutional settings to community — Admission criteria for transition

    Referral eligibility: Anyone may make a referral to MFP; individuals residing in institutional settings are encouraged to refer themselves. Referrals may be submitted via the secure form on the DPHHS MFP website, email, phone, or fax.

    Referral submission methods and contact details are provided by MFP.

    Criteria for Continued Stay in Facility and Community Settings

    SNF — Continued stay criteria top-level node

    Complex ongoing needs for add-on funding: Continued eligibility for Complex Care Add-ons requires documentation that the resident continues to meet the medical necessity criteria for their assigned level (I–III), including ongoing needs for behavioral interventions, bariatric or advanced wound care, medication or treatment administration, and increased staffing intensity; the add-on is intended for temporary assistance but may be extended when justified.

    Complex Care Add-on structure and level descriptions define required clinical conditions and interventions.

    Community post-transition — Continued stay criteria for community setting

    Post-transition monitoring and continued services: MFP monitors participants during the 365-day waiver period; continuation of qualified services after 365 days is based on the individual's documented needs and program requirements.365 days

    Service continuation requires meeting program requirements and documented clinical need.

    Discharge and Transition to Community Criteria

    Discharge planning for transitions to the community centers on completion of transition coordination and person-centered planning. The individual must be willing to move into a qualified residential setting and necessary demonstration services should be arranged prior to discharge—examples include environmental or vehicle modifications, deposits for rent or utilities, and limited furnishings—to support a successful move from an institutional setting to community living.

    For individuals already living in the community post-transition, the policy emphasizes that MFP provides 365 days of waiver services and associated supports following relocation. During this 365-day monitoring period, the program tracks participant status; continuation of qualified services after 365 days depends on the participant’s documented needs and applicable program requirements.

    Time Limits and Eligibility Timing

    MFP transition
    Eligibility precondition60 or more consecutive days residing in an institutional setting required prior to MFP transition eligibility
    Medicaid payment requirementAt least one of the institutional days must have been paid by Medicaid
    Applies toResidents of inpatient hospital, inpatient rehabilitation, or SNF settings
    Community — Post-transition coverage
    Waiver services coverage duration365 days of Waiver services covered following transition to community living
    Examples of covered servicesHome Health, Hospice, Physical/Occupational/Speech Therapy, Community First Choice/Personal Assistance Services
    Policy Summary
    PayerMontana Department of Public Health & Human Services
    PolicyEvolving from Nursing Home to Community Life — Money Follows the Person (MFP) and Complex Care Add-on Coverage Criteria
    Policy CodePolicy N/A
    Change TypeNo material clinical or coverage changes
    Effective DateN/A
    Next Review DateN/A
    Key ActionSubmit referrals via the secure DPHHS MFP website form, email, phone, or fax and document coordination with MFP contacts.
    SourceLink
    On This Page
    Coverage Criteria for MFP and Demonstration ServicesKey Coding & Eligibility ValuesProvider Responsibilities and Operational NotesProgram Background and PurposeDefinitions and Service DescriptionsAdmission Criteria for SNF and Institutional SettingsCriteria for Continued Stay in Facility and Community SettingsDischarge and Transition to Community CriteriaTime Limits and Eligibility Timing
  1. Demonstration services (transition coordination team participation, environmental/vehicle modifications, deposits, past-due credit assistance, limited furnishings) are listed as may be made available prior to transition.
  2. Waiver and associated services are covered for 365 days after transition; no PA instructions are provided in these pages.
    3. Step Therapy

    Step therapy not specified

    Step therapy requirements are not described in this portion of the document; no step therapy sequencing or required trials are stated.

    Step Therapy

    No step therapy requirements in this section

    This portion of the document contains no step therapy-related requirements or sequencing rules for services described here.

    Documentation Required

    Document contacts and coordination with MFP and nursing facility staff

    When coordinating transitions, providers must use the listed MFP and nursing facility program contacts and document coordination with MFP project staff or the named nursing facility contacts.

    • Document contact with MFP Project staff or listed nursing facility contacts (names, emails, and phone numbers are provided).
    • Use provided DPHHS contact methods when coordinating transition planning and Complex Care Add-on discussions.
    Billing Rule

    Referral submission and contact methods — use secure form, email, phone, or fax

    Submit referrals and inquiries using the secure referral form on the DPHHS MFP website, or by email, phone, or fax using the provided contact details.

    • Website secure form: DPHHS.MT.GOV/SLTC/MFP → Make a Referral tab.
    • Email: MoneyFollowsThePerson@mt.gov; Phone: 406.439.6870; Fax: 406.655.7646.
    Denial Risk

    PASRR and level-of-care must be met for admission and service authorization

    Nursing facility admission and any authorization of services require that the resident meets level of care criteria established through the Preadmission Screening and Resident Review (PASRR); failure to meet PASRR/level-of-care criteria may result in services not being authorized.

    • Individuals with serious mental illness or intellectual disability must be evaluated by the state's PASRR program to determine if nursing facility admission is needed and appropriate.
    Denial Risk

    No explicit denial triggers stated in this section

    This portion of the document does not list explicit denial triggers for services or authorizations.

    Residency requirement60 consecutive days of residence (one day paid by Medicaid) required for MFP eligibility
    Waiver eligibilityMust meet institutional level of care and eligibility for a Montana waiver program (BSW, SDMI, DDP)
    Demonstration Services
    Transition coordination team participationTeams consist of the individual, existing case managers, social workers, nursing staff and others involved in facilitating transitions
    Environmental and vehicle modificationsModifications may be provided prior to transition to support community living
    Financial supportsDeposits for rent/utilities and assistance with past-due credit impacting housing eligibility
    FurnishingsLimited furnishings may be provided to support move-in
    Post-transition Waiver Coverage
    Post-transition waiver window365 days of Waiver services covered after moving to community living
    Covered associated servicesHome Health, Hospice, Physical/Occupational/Speech Therapy, Community First Choice/Personal Assistance Services
    Monitoring during coverageMFP monitors participant status during the 365-day period; continuation after requires demonstration of ongoing need and program requirements
    Post-365-day processAfter 365 days, continuation of qualified services depends on individual needs and program requirements