Current through September 21, 2024
(a)
Eligibility shall be determined pursuant to Section 6 of this Chapter before an
individualized budget amount is determined.
(b) Determination of the targeted
individualized budget amount.
(i) The
Division's methodology to determine the amount of Medicaid waiver funds that
shall be available to a participant to meet his or her needs shall include the
following factors:
(A) The services the
participant has received in the past or that are determined by projected
services.
(B) Participant
characteristics, including the participant's needs, as measured on the
Inventory for Client and Agency Planning, and
(C) Economic factors, such as the cost of
receiving services in different geographical areas or where the participant
resides.
(ii) Using
specific participant factors, the methodology shall correlate a participant's
characteristics with the participant's individualized budget amount, so that
the participants with higher needs are assigned a higher individualized budget
amount, and vice versa.
(iii) The
Division shall not approve an individualized budget amount that is above the
average cost of the ICF/MR.
(c) Redetermination of the individualized
budget amount.
(i) The Division or the
individual plan of care team may request a new Inventory for Client and Agency
Planning or neuropsychological assessments to determine if the characteristics
or needs of the participant have changed and if a new individualized budget
amount may be assigned.
(A) The Division may
request a new Inventory for Client and Agency Planning or neuropsychological
assessment at any time.
(B) If the
individual plan of care team requests a new Inventory for Client and Agency
Planning or neuropsychological assessment, the Division shall review the
request and decide whether a new Inventory for Client and Agency Planning or
neuropsychological assessment will be approved.
(C) If the new Inventory for Client and
Agency Planning or neuropsychological assessment results in a change in the
individualized budget amount determination, a change in the individualized
budget amount shall be approved or denied in accordance with the procedure
described in paragraph (b) of this section.
(ii) If the individualized budget amount does
not meet the characteristics and needs of an individual, the Extraordinary Care
Committee may approve a new individualized budget amount as a long-term
increase, pursuant to Section 12. This will be re-evaluated at least every five
years.
(iii) At least once every
two years the Division shall update the targeted individualized budget amount
model using the most current Inventory for Client and Agency Planning data,
current services, and current funding information.
(d) If funds for covered services become or
are projected to become limited or unavailable, the Division may modify
participants' individualized budget amounts as necessary to bring projected
expenditures in line with projected funding, recognizing that services shall be
altered accordingly.
(e) If funding
for covered services is or is projected to be reduced below the level required
to pay for all approved individualized budget amounts, or is eliminated, the
Division shall have the discretion to modify participants' individualized
budget amounts in order to bring projected expenditures for covered services
within the projected available funding.
(f) If the waiver is modified or eliminated,
the Division shall have the discretion to modify the individualized budget
amounts in order to bring projected expenditures for covered services within
projected available funding.
(g)
Reinstatement of services. If additional funding becomes available, services
that were reduced or eliminated shall be reinstated based on individual needs
to the extent of the available funds. There shall be no requirement for the
Division to disperse all available funds without a demonstrated need as
described in these rules.
