Current through November 28, 2024
(a) The department
will pay for additional services under this section that
(1) are provided for a recipient who is
qualified under (b) of this section and is receiving
(A) residential supported-living services
under 7 AAC 130.255 that are assigned the
procedure code described in
7
AAC 145.520(h); or
(B) group-home habilitation services under
7
AAC 130.265(t) that are assigned the
procedure code described in
7
AAC 145.520(h);
(2) are requested in accordance with (c) of
this section;
(3) the department
determines to be necessary, based upon evaluation of the supporting
documentation submitted in accordance with (d) or (e) of this section;
and
(4) receive prior
authorization.
(b) For
purposes of this section, a qualified recipient is one that
(1) needs services that exceed those
authorized in the recipient's current support plan under
7
AAC 130.217 and
7
AAC 130.218; and
(2) because of the recipient's physical
condition or behavior, needs direct one-to one support from direct care workers
whose time is dedicated solely to providing services under (a)(1) of this
section to that one recipient 24 hours per day, seven days per week, in all
environments in which the recipient functions.
(c) To request additional services under this
section, the care coordinator responsible under
7
AAC 130.217 and
7
AAC 130.218 for the recipient's support plan must
submit
(1) written documentation that
(A) describes how the recipient's physical
condition or behavior justifies the support described in (b) of this
section;
(B) lists each
intervention tried or in use to address the recipient's physical condition or
behavior, and whether the intervention was successful or
unsuccessful;
(C) indicates how
additional services under this section would be consistent with services
approved as part of the recipient's support plan under
7
AAC 130.217 and
7
AAC 130.218; and
(D) addresses how the acuity payment under
this section would be used to improve management of the recipient's physical
condition or behavior; and
(2) the supporting evidence required under
(d) or (e) of this section, as appropriate.
(d) If the recipient needs the support
described in (b)(2) of this section because of the recipient's physical
condition, in whole or in part, the request for additional services must
include, in addition to the information required under (c) of this section,
(1) a copy of the recipient's most recent
medical evaluation conducted as part of an assessment under
7
AAC 130.213 specific to the recipient's support plan
under 7 AAC 130.217 and
7
AAC 130.218;
(2) a record of the recipient's dates of
hospital admission and discharge or of other medical interventions during the
30 days immediately preceding the date of the request;
(3) a copy of the recipient's clinical record
under 7 AAC
105.230(d)(6) documenting 24 hours of
activity for each of the 30 days immediately preceding the date of the request;
and
(4) a description of how
administration of medication is managed, and how other recurring medical
treatments are managed.
(e) If the recipient needs the support
described in (b)(2) of this section because of the recipient's behavior, in
whole or in part, the request for prior authorization must include, in addition
to the information required under (c) of this section, a copy of the
recipient's
(1) most recent medical and
psychological evaluations conducted as part of an assessment under
7
AAC 130.213 specific to the recipient's support plan
under 7 AAC 130.217 and
7
AAC 130.218; and
(2) clinical record under
7
AAC 105.230(d)(6) documenting 24
hours of activity for each of the 30 days immediately preceding the date of the
request.
(f) The
department will not approve additional services under this section for more
than 12 consecutive months.
(g) The
department may terminate authorization for services under this section at any
time if the department verifies that the recipient's physical condition or
behavior no longer requires additional services under this section.
(h) A provider who receives an acuity payment
under this section shall
(1) provide workers
to provide the services described in (b)(2) of this section; and
(2) ensure that at least one worker is awake
at all times to provide those services.
Authority:AS
47.05.010
AS 47.07.030
AS
47.07.040
