Alaska Administrative Code
Title 7 - Health and Social Services
Part 8 - Medicaid Coverage and Payment
Chapter 130 - Medicaid Coverage; Home and Community-Based Waiver Services
Article 2 - Home and Community-Based Waiver Services; Nursing Facility and ICF/MR Level of Care
7 AAC 130.219 - Enrollment in home and community-based waiver services; disenrollment
Universal Citation: 7 AK Admin Code 130.219
Current through November 28, 2024
(a) The department will enroll an applicant, determined eligible under 7 AAC 130.205, in the recipient category for which the recipient is qualified if the department determines that enrolling the applicant will not bring the department out of compliance with the terms of the waiver approved under 42 U.S.C. 1396 n(c) by exceeding the
(1) number of recipients approved for
participation in the waiver program for the applicable recipient category;
or
(2) average per capita
expenditure limit on home and community-based waiver services for the
applicable recipient category.
(b) The department will notify
(1) an applicant, determined eligible under
7
AAC 130.205, that the applicant may choose between
home and community-based waiver services and institutional care in a nursing
facility or ICF/IID; the applicant's choice of service must be documented in a
format provided by the department; and
(2) a recipient, determined eligible and
enrolled in a recipient category for home and community-based waiver services
under 7 AAC 130.205, that the recipient
may choose to receive home and community-based waiver services from any
provider that
(A) is certified under
7
AAC 130.220; and
(B) provides the home and community-based
waiver service for which the recipient is eligible.
(c) The department will consider the recipient to be enrolled under this section after the recipient has
(1) submitted an application under
7
AAC 130.207;
(2) been approved for assessment under
7
AAC 130.211;
(3) been assessed or has received an interim
level-of-care review under
7
AAC 130.213;
(4) met the level-of-care requirement under
7
AAC 130.215; and
(5) received an approved support plan under
7
AAC 130.217 and
7
AAC 130.218.
(d) The earliest date that an individual is eligible to receive home and community-based waiver services is the date when all of the requirements in (c) of this section have been met.
(e) The department will disenroll a recipient for any of the following reasons:
(1) the
department terminates its participation in the waiver program under
42 U.S.C.
1396 n(c);
(2) the department is unable to determine
eligibility for home and community-based waiver services because the
documentation required under
7
AAC 130.217 and
7
AAC 130.218 to determine the recipient's continuing
eligibility for services was not submitted by the recipient, the recipient's
representative, or the recipient's care coordinator at least 30 days before
expiration of the current plan year;
(3) the recipient is no longer eligible for
Medicaid coverage under
AS
47.07.020 or
7
AAC 100.002;
(4) the recipient is no longer eligible for
services because the recipient's assessment or interim level-of-care review,
conducted in accordance with
7
AAC 130.213(c) - (f), indicates the
condition that made the recipient eligible for services has materially improved
since the previous assessment, and
(A) the
annual assessment and determination or the interim level-of- care review and
determination, have been reviewed in accordance with
AS
47.07.045(b)(2) using the
department's
(i)
Material Improvement
Reporting for CCMC Waivers, adopted by reference in
7
AAC 160.900, if the recipient is in the recipient
category of children with complex medical conditions;
(ii)
Material Improvement Reporting
for IDD Participants Under The Age of Three, adopted by reference in
7
AAC 160.900, if the recipient is younger than three
years of age and in the recipient category of individuals with intellectual and
developmental disabilities;
(iii)
Material Improvement Reporting for IDD Participants Age Three or
Over, adopted by reference in
7
AAC 160.900, if the recipient is three years of age or
older and in the recipient category of individuals with intellectual and
developmental disabilities; or
(iv)
Material Improvement Reporting for ALI/APDD Waivers, adopted
by reference in
7
AAC 160.900, if the recipient is in the recipient
category of older adults or adults with physical disabilities or in the
recipient category of adults with physical and developmental disabilities; and
(B) the reviewer
confirms to the department that the condition that made the recipient eligible
for services has materially improved;
(5) the recipient or the recipient's
representative chooses to end the recipient's participation in the home and
community-based waiver services program;
(6) the recipient or the recipient's
representative misrepresents the recipient's physical, intellectual,
developmental, or medical condition in an effort to obtain services that are
not medically necessary or for which the recipient does not qualify;
(7) the recipient has a documented history of
failing to cooperate with the delivery of services identified in the support
plan prepared under
7
AAC 130.217 and
7
AAC 130.218, or of placing caregivers or other
recipients at risk of physical injury, and no other providers are willing to
provide services to the recipient; for the purposes of this paragraph, a
documented history exists if a provider
(8) the recipient or the recipient's
representative fails to take an action or to submit documentation required
under 7 AAC 130.209 -
7
AAC 130.218.
(A)
reports that the provider has been unable obtain cooperation with service
delivery or to mitigate the risk of physical injury to a caregiver or other
recipients through reasonable accommodation of the recipient's disability;
and
(B) maintains records to
support that report, and makes those records available to the department for
inspection; the department will review those records before making a decision
on disenrollment under this paragraph
(f) An applicant or recipient that is denied enrollment for home and community-based waiver services, or a recipient that is disenrolled for reasons described in (e) of this section, may appeal that decision under 7 AAC 49.
Authority:AS 47.05.010
AS 47.07.030
AS 47.07.040
AS 47.07.045
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