Current through Register Vol. 47, No. 12, March 26, 2025
(a) This section applies only to preexisting
services.
(b)
Disclosure of
personal and financial information.
(1)
Prior to the notice date (see section
635-12.1 of this Subpart) the
provider shall take such steps to obtain personal and financial information
concerning individuals without full Medicaid coverage as may be reasonably
required to identify liable parties and to ascertain the individual's and any
other liable parties' ability to pay for services or the individual's ability
to obtain and maintain full Medicaid coverage.
(2) However, when individuals or other liable
parties have agreed to pay the full fee for the services, the provider is not
required to obtain the information specified in paragraph (1) of this
subdivision. In these situations, the provider may obtain such information at
its discretion.
(3) The provider
may require that, during the period that an individual receives preexisting
services, the individual or liable party supply personal and financial
information as may be reasonably required to identify liable parties and to
ascertain the individual's and any other liable parties' ability to pay for
services or the individual's ability to obtain and maintain full Medicaid
coverage.
(4) The provider shall
require that, during the period an individual receives preexisting services,
the individual and other liable parties notify the provider about any changes
in liable parties, any changes in the individual's Medicaid coverage and any
changes that may affect the individual's eligibility for full Medicaid coverage
and/or the individual's and other liable parties' ability to pay for
services.
(c)
Notice and schedule of fees.
On or before the notice date, the provider shall give all
individuals receiving preexisting services and any known other liable parties
copies of the fee schedule for preexisting services which the individual is
receiving, together with a notice including a description of the obligations of
the provider, the individual and liable parties under the law and this
regulation in the form and format specified by the commissioner.
(d)
Reduction or waiver of
fees.
(1) The provider may reduce or
waive fees with prior OPWDD approval subject to the following conditions:
(i) OPWDD approval for a reduction or waiver
of fees for an individual will be based on consideration of the individual's or
other liable parties' available income and resources, the individual's living
situation, and the individual's ability to meet Medicaid eligibility
requirements.
(ii) OPWDD approval
for a reduction or waiver of fees is only available when the individual has
taken all necessary steps to obtain and maintain full Medicaid coverage.
However, OPWDD may approve a reduction or waiver of fees for Medicaid service
coordination (MSC) for up to three months if an individual does not have full
Medicaid coverage and MSC is necessary to assist the individual in obtaining
full Medicaid coverage.
(iii) OPWDD
approval for a reduction or waiver of fees is only available when OPWDD was
paying the full fee or part of the fee for the preexisting services on the
preexisting compliance date (see section
635-12.1 of this Subpart), or when
the individual had full Medicaid coverage on the preexisting compliance
date.
(iv) The provider shall give
the individual and all liable parties 30 days' written notice of any changes in
the reduction or waiver of fees granted with prior OPWDD approval and shall
require the individual and/or liable parties to agree to the full fee or new
reduced fee or acknowledge the waiver of the fee.
(2) The provider may also waive or reduce
fees at their discretion without the prior approval of OPWDD. However, OPWDD
payments are not available when such waivers or reduced fees are
granted.
(e)
Application for HCBS waiver services.
If the preexisting services are HCBS waiver services and
the individual is not already enrolled in the HCBS waiver, the provider shall
require that the individual take all necessary steps to enroll in the HCBS
waiver by the payment start date (see section
635-12.1 of this Subpart), and
take all necessary steps to maintain HCBS waiver enrollment.
