Current through Register 1531, September 27, 2024
(A)
Service Plan .
(1) The MassHealth agency or its designee
assigns a case manager to each participant under an HCBS waiver.
(2) The participant will lead the service
plan process where possible. The participant's representative should have a
participatory role, as needed and as defined by the participant, unless the
legal representative has decision-making authority.
(3) The service planning process must comply
with requirements in the federally approved HCBS waiver application and HCBS
waiver policies for service planning established by DDS or MRC, and must
include identification of the strengths, preferences, and cultural
considerations of the participant, goals, desired outcomes, clinical and
support needs, HCBS services and supports to be furnished, strategies for
solving disagreement within the process, and modifications that are supported
by a specific assessed need and justified in the service plan.
(4) The service plan must also comply with
all requirements in the federally approved HCBS waiver application and HCBS
waiver policies for service plans established by DDS or MRC including, but not
limited to, containing the HCBS services and supports to be furnished, the
amount, frequency, and duration of each service, and the type of provider to
furnish each service; reflecting that the setting in which the participant
resides was chosen by the participant; reflecting clinical and support needs as
identified through an assessment of functional needs; reflecting risk factors
and measures in place to minimize them; and documenting that any additional
conditions are supported by a specific assessed need and justified in the
service plan.
(5) The service plan
may not be backdated.
(B)
Notice of
Approval . For all HCBS waiver services authorized and included in
a service plan, the MassHealth agency or its designee will provide a copy of
the service plan to the participant. The service plan must contain, at a
minimum, the types of HCBS waiver services to be furnished, the amount,
frequency, and duration of each service, and the effective date of the
authorization.
(C)
Notice of Denial or Modification and Right of Appeal .
(1) A participant and the participant's
authorized representative, as applicable, will receive a written notification
from the MassHealth agency or its designee whenever a service plan contains a
denial or modification of a requested HCBS waiver service requested by a
participant or the participant's authorized representative. The notification
will describe the reason for the denial or modification and provide information
about the participant's right to appeal and the appeal procedure.
(2) A participant may request a fair hearing
whenever the MassHealth agency or its designee denies or modifies the
participant's request for an HCBS waiver service. As described in 130 CMR
630.409, a denial or modification includes the MassHealth agency's denial,
suspension, reduction, or termination of a requested HCBS waiver service as
well as the agency's failure to act on the participant's request for an HCBS
waiver service within 30 days of receiving such request. The participant must
request a fair hearing in writing within the time limits set forth in
130 CMR 610.015(B)(1) or
(2), as applicable. The Office of Medicaid
Board of Hearings conducts the hearing in accordance with 130 CMR 610.000:
MassHealth: Fair Hearing Rules.
(D)
Information for HCBS Waiver
Providers . The MassHealth agency or its designee will furnish
applicable information from each service plan to an HCBS waiver provider that
provides an HCBS waiver service to a participant. Applicable information will
include the amount, frequency, duration, and effective date of the HCBS waiver
service that is authorized in the service plan. The information will be
provided in a manner and format specified by the MassHealth agency or its
designee.
(E)
Information for Fiscal Intermediary (FI) . Waiver
participants will be given the option to self-direct certain waiver services as
specified in the particular HCBS waiver in which they are enrolled.
Participants who choose to self-direct will have those self-directed waiver
services listed in their service plan. Information regarding the frequency and
duration of the self-directed services in the service plan must be forwarded to
the FI. The information will be provided in a manner and format specified by
the MassHealth agency or its designee.
