Current through Reg. 50, No. 187; September 24, 2024
(1)
Supplemental funding for Significant Additional Needs (SANs) may be of a
one-time, temporary, or long-term in nature.
(2) The presence of a significant additional
need or significant change in condition or circumstance alone does not warrant
an increase in the amount of funds allocated to a client's iBudget as
determined by the algorithm.
(3) A
client's annual expenditures for home and community-based services Medicaid
Waiver services may not exceed the limits of his or her iBudget. The total of
all clients' projected annual iBudget expenditures may not exceed the Agency's
appropriation for Waiver services.
(4) SANs can only be approved after the
determination of a client's initial allocation amount and after the WSC has
documented the availability of non-Waiver resources on the Verification of
Available Services form. Nothing in this section prohibits the authorization of
emergency services on a temporary basis through the Agency. Requests for SANs
require:
(a) The client to have a significant
additional need as defined in this chapter; and
(b) A significant additional need cannot be
created by failing to maintain sufficient funds to cover services previously
authorized in accordance with subsections
65G-4.0215(2) and
(5), F.A.C.
(5) The WSC shall submit a SANs request that
reflects the specific Waiver services and supports that will assist the client
to meet identified needs, with all required supporting documentation as
specified in the WSC Job Aid for Cost Plans and Significant Additional Needs
Documentation. The documentation identified in the WSC Job Aid is material to
the SANs requests. The Agency must close or deny the SANs request without such
documentation.
(a) The SANs request shall be
submitted indicating how the current budget allocation and requested SANs funds
would be used. The request should also include an explanation of why additional
funding is needed, and any additional documentation appropriate to support the
request.
(b) The SANs request shall
be submitted with an updated support plan, which must include an explanation of
why additional funding is needed and indicate how the current budget allocation
and requested SANs funds would be used. The request must include documentation
appropriate to support the request in accordance with the WSC Job Aid for Cost
Plans and Significant Additional Needs Documentation form.
(c) Documentation of attempts within the last
30 days prior to submitting the SANs request to locate natural or community
supports, third-party payers, or other sources of support to meet the client's
health and safety needs must also be documented and verified by the WSC on the
Verification of Available Services form.
(d) If there are any concerns about the
accuracy of the QSI results, the WSC shall submit this as
well.
(6) If a client's
iBudget Amount includes Significant Additional Needs beyond what was determined
by the Allocation Algorithm, and the Agency determines that the intensity,
frequency or duration of the service(s) is no longer medically necessary, the
Agency will adjust the client's services to match the current need.
(7)
(a) The
Agency will not consider incomplete SANs requests due to lacking material
information to determine whether SANs criteria are met. A SANs request is
incomplete if it does not:
1. Provide detail
the client's current approved services, including the number and type of units
and dollar amount for each service. The client to staff ratio, if applicable,
must also be included;
2. Clearly
indicate whether the current approved services are requested to continue on an
annualized basis;
3. Clearly
identify any new or increased services being requested in the current fiscal
year and on an annualized basis, if applicable to that service type;
4. Include a complete Verification of
Available Services form;
5. Include
documentation to support the information provided in the Verification of
Available Services Form, or identify the location of the currently valid
documentation in the designated data management system;
6. Place the request in the proper status for
submission in the designated data management system; or
7. Include certification that the request
meets the criteria for SANs.
(b) The Agency shall close incomplete SANs
requests upon receipt.
(8) The Agency will request the documentation
and information necessary to evaluate a client's increased funding requests
based on the client's needs and circumstances. The documentation will vary
according to the funding request and may include the following as applicable:
support plans, results from the Questionnaire for Situational Information, cost
plans, expenditure history, current living situation, interviews with the
client and his or her providers and caregivers, prescriptions, data regarding
the results of previous therapies and interventions, assessments, and provider
documentation.
(9) Within 30 days
of receipt of a request for SANs funding, and adjustments in the client's
service array, the Agency shall approve, deny (in whole or in part), or request
additional documentation concerning the request.
(a) If the request does not include all
necessary documentation, the Agency shall provide the client and WSC with a
written notice of what additional documentation is required. The client or WSC
shall provide the documentation within 10 days, or notify the Agency in writing
that the client wishes the Agency to render its decision based upon the
documentation provided.
(b) If
additional documentation is requested, the deadline for the Agency's response
shall be extended to 60 days following the receipt of the original request. If
the client has not received a notice from the Agency approving, denying or
requesting additional information within 60 days, the client or WSC may notify
the Agency in writing of such failure to issue a timely notice and the Agency
shall have 20 days from receipt of the Notice to approve or deny the
request.
(c) Failure of the Agency
to issue this Notice within 20 days shall mean the requested funding for
services are authorized as of the 21st day, and the client and service
providers may treat the authorization as an approval.
(10) Individual and Family Supports (IFS)
funding may cover temporary emergency services pursuant to Chapter 65G-13,
F.A.C., while requests for Significant Additional Needs are being
processed.
(11) 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
7-1-21.
