Current through Register No. 40, October 3, 2024
(a) When the department's monthly monitoring
of cost effectiveness results in an estimated, projected annual home care cost
for a recipient which is higher than the appropriate type of institutional care
cost, the department shall notify the recipient in writing.
(b) The notification in (a) above shall
include:
(1) A reminder of the requirement to
maintain annual home care costs at or below the cost of care for the
appropriate type of institution pursuant to state and federal law in order to
maintain HC-CSD eligibility;
(2)
Medicaid payment data showing the recipient's monitored home care costs and
estimated, projected annual home care costs, including a copy of the report
used;
(3) The calculated cost of
care in an appropriate type of institution for the same time period as in (2)
above and the projected annual institutional costs, including identification of
the appropriate type of institution; and
(4) Contact information for the department's
care coordination services unit.
(c) Upon receipt of the notification in (a)
above, the recipient's family or guardian may contact the department:
(1) For an explanation of the information
included in the notification pursuant to (b) above;
(2) To report costs they believe the
department should not include in the home care costs; and
(3) To request assistance with reducing the
costs of home care or achieving cost effectiveness pursuant to
He-W
508.06(a) .
(d) For each state fiscal year ending June
30, the department shall complete an annual determination of cost effectiveness
for each recipient pursuant to
He-W
508.06(b) .
(e) If the department's annual determination
of cost effectiveness indicates that home care costs are higher than the costs
of the appropriate type of institutional care, the department shall provide
written notice to the recipient within 30 days of the determination.
(f) The written notice pursuant to (e) above
shall include:
(1) A statement that annual
cost effectiveness has not been demonstrated;
(2) A statement that the recipient is
required to reduce and maintain annual home care costs at or below the cost of
care for the appropriate type of institution pursuant to state and federal law
in order to maintain HC-CSD eligibility;
(3) Medicaid payment data showing the
recipient's annual home care costs and a copy of the report used;
(4) The calculated annual cost of care in an
appropriate type of institution, including identification of the appropriate
type of institution;
(5) A
statement that the recipient's family or guardian shall submit and implement a
written plan for reducing costs in accordance with (f) (2) within 3 months of
the date of the notice in (e) above;
(6) Contact information for the department's
care coordination services unit which the recipient's family or guardian may
use for assistance in identifying any billing errors and in developing the cost
reduction plan in (5) above; and
(7) Information that a fair hearing on the
requirement to reduce costs may be requested within 30 calendar days of the
date on the cost effectiveness annual determination notice, in accordance with
He-C 200.
(g) If the
recipient's family or guardian requests assistance in accordance with (f) (6)
above, the department shall assign a care coordination manager to assist the
recipient's family or guardian.
#9291, eff
7-1-09
