Current through Register Vol. 47, No. 12, March 26, 2025
As used in this Subpart:
(a)
Full Medicaid coverage
means the type of coverage under the Medicaid program that pays for the
services requested or received.
(b)
HCBS waiver means the home and community based services waiver
in effect from October 1, 2009 through September 30, 2014 for individuals with
developmental disabilities granted by the United States Department of Health
and Human services to New York State pursuant to section 1915(c) of the Social
Security Act, and any subsequent renewals of such waiver.
(c)
Liable party means any
party other than a governmental entity who is legally liable to pay for
services pursuant to section
43.03 of
the Mental Hygiene Law or any other applicable provision of law.
(d)
Maintain full Medicaid
coverage means taking all steps necessary to continue to receive full
Medicaid coverage, including, but not limited to, spending down income or
resources to meet the Medicaid eligibility level under section
366
(2)(a) of the Social Services Law.
(e)
Notice date means:
(1) March 15, 2009 for ICF/DD services; the
following HCBS waiver residential habilitation services: community (in a
community residence), IRA, and family care; and HCBS waiver day habilitation
services; or
(2) May 15, 2010 for
Medicaid service coordination; day treatment services; the following HCBS
waiver services: at home residential habilitation services, prevocational
services, supported employment services, and respite services; and blended
services and comprehensive services.
(f)
Payment start date
means:
(1) April 15, 2009 for ICF/DD services;
the following HCBS waiver residential habilitation services: community (in a
community residence), IRA, and family care; and HCBS waiver day habilitation
services; or
(2) June 15, 2010 for
Medicaid service coordination; day treatment services; the following HCBS
waiver services: at home residential habilitation services, prevocational
services, supported employment services, and respite services; and blended
services and comprehensive services.
(g)
Preexisting compliance
date means:
(1) February 15, 2009 for
ICF/DD services; the following HCBS waiver residential habilitation services:
community (in a community residence), IRA, and family care; and HCBS waiver day
habilitation services; or
(2) March
15, 2010 for Medicaid service coordination; day treatment services; the
following HCBS waiver services: at home residential habilitation services,
prevocational services, support employment services, and respite services; and
blended services and comprehensive services.
(h)
Preexisting services.
(1) For ICD/DD services; the following HCBS
waiver residential habilitation services: community (in a community residence),
IRA, and family care; and HCBS waiver day habilitation services,
preexisting services means:
(i) services which an individual was
receiving from a provider on a regular basis as of February 15, 2009 and
receives from the same provider after February 15, 2009; and
(ii) residential habilitation services in an
individualized residential alternative (IRA) which converted from a community
residence after February 15, 2009, if the individual resided in the community
residence on February 15, 2009; and
(iii) services which an individual was
receiving on a regular basis as of February 15, 2009, and receives from a
different provider after February 15, 2009 where the individual's receipt of
the services from the different provider is the result of one provider assuming
operation or control of the other provider's operations and programs, or is the
result of a merger or consolidation of providers;
(iv) residential habilitation and/or group
day habilitation which is received by an individual who formerly received
community habilitation phase II in the following circumstances:
(a) the individual received residential
habilitation and/or group day habilitation prior to the receipt of community
habilitation phase II and the services were preexisting services; and
(b) after the individual stopped receiving
community habilitation phase II, he or she resumed receipt of the residential
habilitation and/or day habilitation services which were formerly provided;
and
(c) the residential
habilitation and/or day habilitation services would have been preexisting
services except for the intervening receipt of community habilitation phase
II.
(2) For
Medicaid service coordination; day treatment services; the following HCBS
waiver services: at home residential habilitation services, hourly community
habilitation services, prevocational services, supported employment services,
respite services; and blended services and comprehensive services,
preexisting services means:
(i) services which an individual was
receiving from a provider on a regular basis as of March 15, 2010 and receives
from the same provider after March 15, 2010; and
(ii) services which an individual was
receiving on a regular basis as of March 15, 2010, and receives from a
different provider after March 15, 2010, where the individual's receipt of the
services from the different provider is the result of one provider assuming
operation or control of the other provider's operations and programs, or is the
result of a merger or consolidation of providers; and
(iii) HCBS waiver respite services which
converted after March 15, 2010 from respite services funded as a type of family
support services if:
(a) the individual
received the respite services funded as a type of family support services on a
regular basis as of March 15, 2010 and continued to receive the services on a
regular basis from the same provider until the conversion date; and
(b) the HCBS waiver respite services are
delivered by the same provider; and
(iv) hourly community habilitation services
which converted on November 1, 2010 from at home residential habilitation
services if:
(a) the individual received the
at home residential habilitation services on a regular basis as of March 15,
2010 and continued to receive the services on a regular basis from the same
provider through November 1, 2010; and
(b) the hourly community habilitation
services are delivered by the same provider.
(i)
Provider
means an individual, corporation, partnership or other organization to which
OPWDD has issued an operating certificate, authorization or funding to provide
services. Provider shall not mean OPWDD or any developmental disabilities
services office.
(j)
Services means ICF/DD services (Intermediate Care Facilities
for Persons with Developmental Disabilities, see Part 681 of this Title),
Medicaid service coordination, day treatment services, and the following HCBS
waiver services: residential habilitation services (community [in a community
residence], IRA, family care, and at home), hourly community habilitation
services, day habilitation services, prevocational services, supported
employment services, respite services, and community habilitation phase II
services. Blended services, which are a combination of day habilitation,
prevocational services and/or supported employment services, and comprehensive
services, which are a combination of IRA residential habilitation services and
day habilitation, are also considered services. A limited exception to the
applicability of certain sections of this Subpart has been made in the case of
some individuals who are applying for or receiving supported employment
services or respite services (see section
635-12.12 of this
Subpart).
