65G-1.046. Crisis Determination Procedure

(1) Subject to funding availability, the Agency will accept oral or written requests for crisis enrollment in a HCBS waiver by the applicant or the applicant’s family, guardian, guardian advocate, or support coordinator.

(2) The applicant or applicant’s representative shall request crisis enrollment through the Area Office in the service area where the applicant resides. The Agency may not enroll an applicant on the waiver unless the Agency has determined that the applicant has a developmental disability, as defined in Section 393.063(9), F.S., and also meets the following waiver eligibility requirements listed in the Handbook, Chapter 2 “Requirements to Receive Services”:

(a) The recipient’s intelligence quotient (IQ) is 59 or less, or

(b) The recipient’s IQ is 60-69 inclusive and the recipient has a secondary handicapping condition that includes:

1. Cerebral palsy, spina bifida, Prader-Willi syndrome, epilepsy, autism, or

2. Ambulation, sensory, chronic health, and behavioral problems;

(c) The recipient’s IQ is 60-69 inclusive and the recipient has severe functional limitations in at least three of the following major life activities:

1. Self-care,

2. Learning,

3. Mobility,

4. Self-direction,

5. Understanding and use of language,

6. Capacity for independent living, or

(d) The recipient is eligible under a primary disability of autism, cerebral palsy, spina bifida, or Prader-Willi syndrome and the condition results in substantial functional limitations in three or more major life activities listed in paragraph (c), above.

(3) The Area Office will collect pertinent information and supporting documentation relevant to a crisis determination and conduct a preliminary assessment based on the crisis status criteria specified in Rule 65G-1.047, F.A.C.

(a) If the Area Office concludes that the applicant does not meet crisis status or that the services needed are available from other agencies or programs or covered by other third-party payors, the Area Office will deny the crisis enrollment request and provide written notification of the denial to the applicant or applicant’s representative.

(b) If the Area Office concludes that the applicant may meet crisis status and does not have access to insurance, other agencies or programs for needed services, or concludes that programs in which the applicant is participating cannot meet the applicant’s service needs, the Area Office will submit its initial assessment and supporting documentation to the Central Office for review and final determination of whether the applicant meets crisis status. The applicant or the applicant’s representative may, upon request, review the initial assessment and supporting documentation to ensure that all necessary information is included.

(4) The Central Office will notify the Area Offices of deadlines for submission of crisis enrollment requests to the Central Office for periodic review. Following review of the submissions, the Central Office will notify the Area Office whether it has approved or denied each submission. The Area Office is responsible for notifying the applicant or applicant’s representative of the Central Office’s final crisis determination.

(a) APPROVAL.

1. If funding is available and the applicant is approved for crisis enrollment, the applicant will be offered placement on the FSL waiver, unless that waiver cannot reasonably meet the applicant’s specific service needs for addressing the crisis. In such instances, the person will be offered placement on the DD waiver. In determining the appropriate waiver placement, the Central Office will consider the availability of services necessary to resolve the crisis situation that are not provided under the FSL waiver, including the need for residential habilitation services, nursing services beyond the coverage provided through the Medicaid State Plan, or placement in a residential facility.

2. After the Central Office determines the appropriate waiver placement, the Area Office will provide written notice of placement to the applicant or applicant’s representative. If the applicant is not already a client of the Agency or is not already on the waitlist, the Agency will provide a full determination of the applicant’s eligibility for services within 45 days of the crisis eligibility determination, as provided in Section 393.065(2), F.S. Eligibility for Medicaid waiver services is contingent upon eligibility for the state Medicaid services, such as Supplemental Security Income (SSI), MEDS-AD, or TANF provided by the Department of Children and Families, as required by the Handbook, Chapter 2, “Requirements to Receive Services.” If the applicant is not enrolled in a state Medicaid program, the Area Office will refer the applicant to the local Department of Children and Families for submission of a Request for Assistance (RFA). If the applicant is deemed eligible for state Medicaid, the Area Office will complete the waiver enrollment. If the applicant is not Medicaid-eligible, the Area office will rescind the approval for crisis enrollment on the Medicaid waiver.

(b) DENIAL. The Area Office will notify the applicant or applicant’s representative in writing of a denial of crisis enrollment. If the Agency denied the application based on lack of documentation and additional documentation becomes available, or a change in the applicant’s situation may affect the applicant’s status for crisis determination, the applicant may reapply to the Area Office for crisis consideration.

Rulemaking Authority 393.501(1), 393.065 FS. Law Implemented 393.065. History–New 9-19-07.