Current through Reg. 50, No. 187; September 24, 2024
(1) Medical
necessity alone is not sufficient to authorize a service under the Waiver; in
addition:
(a) With the assistance of the WSC,
the client must utilize all available State Plan Medicaid services,
school-based services, private insurance, natural supports, and any other
resources that may be available to the client before expending funds from the
client's iBudget Amount for support or services. As an example, State Plan
Medicaid services for children under the age of 21 typically include personal
care assistance, therapies, consumable medical supplies, medical services, and
nursing;
(b) The services must be
within Waiver coverages and limitations; and
(c) The cost of the services must be within
the Allocation Algorithm Amount unless there is a significant additional need
demonstrated.
Failure to meet the above criteria shall result in a denial
of a request for additional funding.
(2) WSCs shall coordinate with the clients
they serve to ensure that services are selected from all available resources to
keep the annual cost of services within the client's iBudget Amount while
maintaining the client's health and safety.
(3) Prior to authorizing new or increased
services or at the time of a medical necessity review, the Agency must certify
and document within the client's cost plan that the client has used all
available services authorized under the Medicaid State Plan; school-based
services; private insurance; local, state, and federal government and
non-government programs or services; natural or community supports; and any
other benefit or resource that may be available to the client before using
funds from the iBudget to pay for supports and services.
(a) The iBudget Waiver is the payor of last
resort.
(b) A valid and accurate
Verification of Available Services form is a condition precedent to the
authorization of services. To enable the Agency to certify and document that
the client has utilized all available services pursuant to Section
393.0662(3),
F.S., the WSC must complete and submit the Verification of Available Services
to the Agency:
1. At the time of any requests
to add or increase services, or
2.
Upon request from the Agency when it is making determinations of medical
necessity for Waiver services.
(4) Cost Plan Flexibility.
(a) After the client's proposed cost plan is
approved, he or she may change the services in his or her Approved Cost Plan
provided that such change does not jeopardize the health and safety of the
client and meets medical necessity.
(b) When changing the services within the
Approved Cost Plan, the client and his or her WSC shall ensure that sufficient
funding remains allocated for unpaid services that were authorized and rendered
prior to the effective date of the change.
(c) Clients enrolled in iBudget will have
flexibility and choice to budget or adjust funding among the following services
without requiring additional authorizations from the Agency, provided the
client's overall iBudget Amount is not exceeded and all health and safety needs
are met:
1. Life Skills Development 1,
2. Life Skills Development 2,
3. Life Skills Development 3,
within the approved ratio,
4. Life
Skills Development 4, within the approved ratio,
5. Durable Medical Equipment,
6. Adult Dental,
7. Personal Emergency Response Systems,
8. Environmental accessibility
adaptations,
9. Consumable Medical
Supplies,
10 Transportation,
11. Personal Supports up to $16,
000,
12. Respite up to $10,
000.
(d) Medically
necessary services will be authorized by the Agency for covered services not
listed above if the cost of such services are within the client's iBudget
Amount and in accordance with subsection
65G-4.0215(1),
F.A.C. The Agency shall authorize services in accordance with criteria
identified in Section
393.0662(1)(b),
F.S., medical necessity requirements of Section
409.906, F.S., subsection
59G-1.010 (166), F.A.C.,
Handbook limitations, and the authority under Title 42 of the Code of Federal
Regulations, Part 440, Section 230(d).
(e) Service authorization and any
modifications to it must be received by the provider prior to service delivery.
This includes changes to the authorization as a result of clients
redistributing funds within their existing cost plan.
(5) Consumer Directed Care Plus (CDC+):
clients enrolled in the CDC+ program are subject to iBudget Rule
65G-4.0214, subsections
65G-4.0215(1), (2) and
(7), and Rules
65G-4.0216,
65G-4.0217,
65G-4.0218, F.A.C.
(6) Approval, Denial, or Closure of
Applications.
(a) iBudget Waiver providers
must have applied through the Agency for Persons with Disabilities to ensure
that they meet the minimum qualifications to provide iBudget Waiver services.
iBudget Waiver providers must also be enrolled as a Medicaid provider through
the Agency for Health Care Administration. However, providers do not have to
provide Medicaid State Plan services in order to provide Waiver
services.
(b) To enroll as a
provider for iBudget Waiver services, the provider must first submit an
application to the Agency or Persons with Disabilities using the Regional
iBudget Provider Enrollment Application - WSC - APD Form
65G-4.0215 A, effective date
01-2023, for Waiver Support Coordinator applications, which is available at
http://www.flrules.org/Gateway/reference.asp?No=Ref-12444,
or the Regional iBudget Provider Enrollment Application - Non-WSC - APD Form
65G-4.0215 B, effective date
7-1-2021, for all other provider applications, which is available at
https://www.flrules.org/Gateway/reference.asp?No=Ref-14984.
These forms are hereby incorporated by reference. The qualifications to provide
services are identified in the Handbook.
(c) The Agency will review the application
and approve or deny complete applications within 90 days of receipt; the Agency
will close incomplete applications.
1. The
Agency will only consider complete applications that include all required
information and meet the requirements delineated in this chapter, the iBudget
Handbook, and Section
393.0663, F.S. An application is
complete upon the Agency's receipt of all requested information and correction
of any error or omission for which the applicant was notified.
2. If the Agency receives an incomplete
application, the Agency will notify the applicant. The applicant will have 45
calendar days from the date of the notice to submit the documentation,
information, or make any corrections designated in the notice. If the applicant
does not complete the application within 45 days of the notice, the application
must be closed by the Agency. After an application is closed, all documentation
and information submitted will no longer be considered, and a new complete
application must be submitted for consideration by the Agency. The closure of
an application is not Agency action and will not be considered substantively by
the Agency in any subsequent application.
(d) If a Waiver provider wishes to, expand by
providing additional services, expand services geographically, or expand from
solo to agency, the provider must notify the Agency regional office by
submitting a Provider Expansion Request form - APD Form
65G-4.0215 C, effective date
01-2023, which is hereby incorporated by reference and is available at
http://www.flrules.org/Gateway/reference.asp?No=Ref-14985.
The Agency regional office must approve any expansion prior to the provision of
expanded services. The qualifications to provide or expand services are
identified in the Handbook.
(7)
(a)
When a client is enrolled in the iBudget, that client remains enrolled in the
Waiver position allocated unless the client becomes disenrolled due to one of
the following conditions:
1. The client or
client's legal representative chooses to terminate participation in the
Waiver.
2. The client moves
out-of-state.
3. The client loses
eligibility for Medicaid benefits and this loss is expected to extend for a
lengthy period.
4. The client no
longer needs Waiver services.
5.
The client no longer meets level of care for admission to an ICF/IID.
6. The client no longer resides in a
community-based setting but moves to a correctional facility, detention
facility, defendant program, or nursing home or resides in a setting not
otherwise permissible under Waiver requirements.
7. The client is no longer able to be
maintained safely in the community.
If a client is disenrolled from the Waiver and becomes
eligible for reenrollment within 365 days that client can return to the Waiver
and resume receiving Waiver services. If Waiver eligibility cannot be
re-established or if the client who has chosen to disenroll has exceeded this
time period, the client cannot return to the Waiver until a new Waiver vacancy
occurs and funding is available. In this instance, the client is added to the
preenrollment category of clients requesting Waiver participation. The new
effective date is the date eligibility is re-established or the client requests
re-enrollment for Waiver participation.
(b) Providers are responsible for notifying
the client's WSC and the Agency if the provider becomes aware that any of the
conditions of paragraph (a) or (c), exists.
(c) If a client or legal representative
refuses to cooperate with the provision of Waiver services in any of the
following ways: develop a cost plan or support plan, participate in a required
QSI assessment or other approved Agency needs assessment tool, or refuse to
annually sign the Waiver eligibility worksheet that establishes a level of
care, then the Agency will review the circumstances to determine if the client
should be removed from the Waiver for failing to comply with specific
eligibility requirements. Any such decision by the Agency shall provide written
notice to the client, the client's legal representative and the WSC, at least
30 days before terminating services.
(d) Clients denied services shall have the
right to a fair hearing. Clients are exempted from this provision if they do
not have the ability to give informed consent and do not have a legal
representative. The Agency shall not remove a client from the Waiver due to
non-compliance if it directly impacts the client's health, safety, and
welfare.
(8) This rule
shall be reviewed, and if necessary, renewed through the rulemaking process
five years from the effective date.
Rulemaking Authority
393.501(1),
393.0662 FS. Law Implemented
393.063,
393.0662,
409.906
FS.
New 7-7-16, Amended 9-12-18, 7-1-21,
1-3-23.
