Definitions, Allocation Algorithm, General Provisions, Establishment of the iBudget Amount, iBudget Cost Plan, Significant Additional Needs Funding
DEPARTMENT OF CHILDREN AND FAMILIES
Agency for Persons with Disabilities
RULE NOS.:RULE TITLES:
65G-4.0213Definitions
65G-4.0214Allocation Algorithm
65G-4.0215General Provisions
65G-4.0216Establishment of the iBudget Amount
65G-4.0217iBudget Cost Plan
65G-4.0218Significant Additional Needs Funding
NOTICE OF CHANGE
Notice is hereby given that the following changes have been made to the proposed rule in accordance with subparagraph 120.54(3)(d)1., F.S., published in Vol. 40 No. 235, December 5, 2014 issue of the Florida Administrative Register and as amended by the Notice of Change published in Vol. 41 No. 84, April 30, 2015 issue of the Florida Administrative Register, and as further amended by the Notice of Change published in Vol. 41 No. 98, May 20, 2015 issue of the Florida Administrative Register.
65G-4.0213 Definitions.
For the purposes of this chapter, the term:
(1) through (4) No change.
(5) Client Advocate: has the same meaning as provided in s. 393.063(6), F.S., and includes legal counsel if designated by the individual or the individual’s representative.
(6) No change.
(7) Handbook: Means the Florida Medicaid Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook, which is hereby incorporated by reference, and is available at:
http ://portal.flmmis.com/flPublic/, as adopted by Rule 59G-13.070 (effective 9-3-2015).
(7) through (15) renumbered (8) through (16) No change.
(17) (16) Person-centered planning - A planning approach directed by an individual with long term care needs, intended to identify the strengths, capacities, preferences, needs and desired outcomes of the individual. The individual or family determines the other participants in this process for the purposes of assisting the individual to identify and access a personalized mix of paid and non-paid services and supports that will assist him/her to achieve personally-defined outcomes in the most inclusive community setting and to facilitate health, safety, and well-being. based on the recipient’s perspective rather than that of a program or resource used to identify the services and supports necessary to meet the recipient’s needs involving the recipient and significant people in the recipient's life. The most important goals and outcomes are identified as well as the supports needed to achieve them.
(17) through (21) renumbered (18) through (22) No change.
(23)(22) Significant Additional Needs (SANs): Need for additional funding that if not provided would place the health and safety of the individual, the individual’s caregiver, or public in serious jeopardy which are authorized under Section 393.0662(1)(b), F.S., and categorized as extraordinary need, significant need for one time or temporary support or services, or significant increase in the need for services after the beginning of the service plan year. In addition, the term includes a significant need for transportation services as provided in Rule 65G-4.2018(1)(d). Examples of SANs SAN that may require long-term support include, but are not limited to, any of the following:
a. through c. No change.
d. A need for total physical assistance with activities of daily living such as eating, bathing, toileting, grooming, dressing, and personal hygiene, lifting, transferring or ambulation;
e. through j. No change.
k. Need for transportation to and from a waiver-funded adult day training program site or a waiver-funded supported employment site that cannot be accommodated with the funding authorized by the client’s support plan without affecting the health and safety of the client, public transportation is not an option due to the unique needs of the client, and no other transportation resources are reasonably available.
(23) through (26) renumbered (24) through (27) No change.
Rulemaking Authority 393.501(1), 393.0662 FS. Law Implemented 393.0662, 409.906 FS. History–New October 20, 2015 July 1, 2015.
65G-4.0214 Allocation Algorithm.
(1) No change.
(a) The QSI assessor shall arrange for a face to face meeting with the individual or the individual’s representative. The WSC shall attend the face to face meeting with consent upon request of the individual or the individual’s representative. If the individual or the individual’s representative is not capable of fully responding to all of the assessment questions, at least one participant with day-to-day knowledge of the individual’s care should participate.
(b) No change.
(c) Upon receiving QSI results if the individual or their representative identifies an error in the QSI results the WSC shall notify the Agency in writing setting forth the details of the error. At any time, the individual or WSC can prepare a statement to be maintained in individual’s Central File identifying any concerns with the QSI assessment score or responses. If any error is identified in the QSI assessment of the challenged responses are considered as variables in determining the individual’s algorithm, the agency shall review the error to determine if any adjustments are needed. a new assessment may be requested from the agency. The agency shall reevaluate the QSI outcome and inform the WSC of the result of the review and provide a revised algorithm amount, if appropriate, within 15 days of notification of the error. The WSC shall reevaluation who must in turn notify the individual or the individual’s representative.
(d) The individual or WSC may request a reassessment any time there has been a significant change in circumstance or condition that would impact any of the questions used as variables in the algorithm determination. The Agency shall arrange for a reassessment at the earliest possible time in accordance with the circumstances, complete the reassessment, and notify the individual and WSC of the results within 45 60 days of the request for reassessment. and notify the individual and WSC of the results within 30 days from the administration of the QSI. This section shall not be construed to require the Agency to wait for the completion of a QSI in order to address an emergency situation of the individual.
(2) To calculate the Allocation Algorithm Amount for each individual, the following weighted values, as applicable, shall be summed, and the resulting total then squared:
(a) through (c) No change.
(d) If the individual resides in supported or independent living, or the individual resides in a licensed facility and does not receive residential habilitation services, 35.8220
(e) through (v) No change.
(3) (2) The squared result of the sum of the applicable values of paragraphs (2)(a) through (v) above, then apportioned according to available funding, is the individual’s Allocation Algorithm Amount.
Rulemaking Authority 393.501(1), 393.0662 FS. Law Implemented 393.0662 FS. History–New October 20, 2015 July 1, 2015.
65G-4.0215 General Provisions.
(1) through (2) No change.
(3) No change.
(a) through (b) No change.
(c) No change.
1. through 10. No change.
11. Respite up to $10,000 $5,000.
Medically necessary services will be authorized by the Agency for covered services not listed above if the cost of such services are within the individual’s iBudget Amount and in accordance with Rule 65G-4.0215(1). The Agency shall will authorize services in accordance with criteria identified in sSection 393.0662(1)(b), F.S., medical necessity requirements of section 409.906, F.S., Rule subsection 59G-1.010(166), F.A.C., and hHandbook limitations, adopted in the iBudget Rules and the Florida Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook, (effective November 2010), which is hereby incorporated by reference, and is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-01050, as adopted by Rule 59G-13.083, F.A.C. (5-133-2012) and the authority under Rule 42 CFR 440.230(d).
(d) through (e) No change.
(4) No change.
(5)(a) iBudget Waiver providers must have applied through the Agency for Persons with Disabilities to ensure that they meet the minimum qualifications to provide iBudget Waiver services. iBudget Waiver providers must also be enrolled as a Medicaid provider though the Agency or Healthcare Administration. However providers do not have to provide Medicaid State Plan services in order to provide waiver services. To enroll as a provider for iBudget Waiver Services, the provider must first submit an application to the Agency or Persons with Disabilities using the Regional iBudget Provider Enrollment Application – Waiver Support Coordinator (WSC) – APD 2015-02, effective date 7-1-2015, for waiver support coordinator applications, or the Regional iBudget Provider Enrollment Application – Non-WSC – APD 2015-03, effective date 7-1-2015, for all other provider applications. These forms are hereby incorporated by reference and are available at http://apdcares.org/providers/enrollment/. On the application providers must identify the counties where they intend to provide services. The Agency for Persons with Disabilities will review the application, request missing documentation, and issue a decision about whether the provider meets the qualifications to provide services. The qualifications to provide services are identified in the hHandbook adopted in Rule 59G-13.083, F.A.C.
(b) No change.
1. through 2. No change.
3. No unresolved outstanding billing discrepancies or plan of remediation;
4. No adverse performance history relating to the health and safety of individuals served in their home region; and
5. No open investigations or referrals to the Agency for Health Care Administration (AHCA) AHCA and the Department of Children and Families (DCF) DCF.
Agency staff shall check with the provider's home regional office to determine whether there is a history of complaints filed and logged on the remediation tracker, any open investigations or referrals to AHCA's Medicaid Program Integrity (MPI) or the Attorney General's Medicaid Fraud Control Unit (MFCU), or DCF the Department of Children and Families DCF. The Agency shall make the determination required under this paragraph in not more than 90 days.
(6) (a) When an a individual is enrolled in the iBudget, that individual remains enrolled in the waiver position allocated unless the individual becomes disenrolled due to one of the following conditions:
1. through 7. No change.
8. The individual becomes enrolled in another home and community-based services (HCBS) Waiver.
If an individual is disenrolled from the waiver and becomes eligible for reenrollment within 365 days that individual can return to the waiver and resume receiving waiver services. If waiver eligibility cannot be re-established or if the individual who has chosen to disenroll has exceeded this time period, the individual cannot return to the waiver until a new waiver vacancy occurs and funding is available. In this instance, the individual is added to the waitlist of individuals requesting waiver participation. The new effective date is the date eligibility is re-established or the individual requests re-enrollment for waiver participation.
(b) Providers are responsible for notifying the individual’s WSC and the Agency if the provider becomes aware that any one of the these conditions of paragraph (a) or (c) exists.
(c) If an individual, family member, or individual representative refuses to cooperate with the provision of waiver services in any of the following ways: (such as refusing to develop a cost plan or support plan, participate participation in a required QSI assessment or other approved agency needs assessment tool, or refuse refuses to annually sign the waiver eligibility worksheet that, required to establishes establish a level of care,) then the Agency will review the circumstances to determine if the individual should be removed from the waiver for failing to comply with specific eligibility requirements. Any such decision by the Agency shall provide written notice to the individual, the individual’s representative and the WSC, at least 30 days before terminating services. Individuals denied services shall have the right to a fair hearing. Individuals are exempted from this provision if they do not have the ability to give informed consent and do not have a guardian or individual representative. The Agency shall not remove an individual from the waiver due to non-compliance if it directly impacts the individual’s health, safety, and welfare.
Rulemaking Authority 393.501(1), 393.0662 FS. Law Implemented 393.0662, 409.906 FS. History–New October 20, 2015 July 1, 2015.
65G-4.0216 Establishment of iBudget Amount.
(1) No change.
(2) The Agency will determine the iBudget Amount consistent with the criteria and limitations contained in the following provisions: Sections 409.906 and 393.0662, F.S.; and Rules 59G-13.080, 59G-13.081, and 59G-13.070, F.A.C. 59G-13.083, F.A.C.
(3) Significant Additional Needs Review: Each time an Allocation Algorithm amount is calculated the WSC will discuss the Allocation Algorithm amount with the individual, or individual’s representative and, if applicable, the client advocate, in order to determine if the individual has any Significant Additional Needs. The Agency will conduct an Individual Review to determine whether services requested meet health and safety needs and waiver coverage and limitations. The AIM Worksheet form APD 2015-01 must be completed as part of the Individual Review and submitted to the Agency within 30 days of receipt of the new Algorithm Amount. The Agency will issue a decision of the iBudget Amount within 30 days of receipt of the AIM Worksheet form. The individual or their representative will be advised of the Agency’s decision for the amount of the individual’s final iBudget Amount within 30 days. If additional documentation is requested, the deadline for the Agency’s response shall be extended to 60 days following the receipt of the original request. In the event a WSC does not submit a request for SANs and the individual, the individual’s representative or the client advocate disagrees with the WSC’s failure to submit a SAN funding request, or if the individual or the individual’s representative or client advocate are unsatisfied with the request submitted, the individual or the individual’s representative may submit the their own SANsS request by email to the applicable Agency regional office. The Agency shall approve an increase to the iBudget Amount if additional funding is required to meet the Significant Additional Needs subject to the provisions of the iBudget rules. The AIM Worksheet form APD 2015-01 will be completed as part of the Individual Review. The Agency, upon completion of its review shall notify in writing the individual, the WSC and the client advocate, if any, of its decision.
(4) No change.
(5) The individual or their representative will be advised of the Agency’s decision for the amount of the individual’s final iBudget Amount.
(6) renumbered (5) No change.
Rulemaking Authority 393.501(1), 393.0662 FS. Law Implemented 393.0662, 409.906 FS. History–New October 20, 2015 July 1, 2015.
65G-4.0217 iBudget Cost Plan.
(1) No change.
(2) Each individual’s proposed iBudget cost plan shall be reviewed and approved by the Agency in conformance with the iBudget Rules and the Florida Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook, (effective November 2010), which is hereby incorporated by reference, and is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-01050, as adopted by Rule 59G-13.083, F.A.C. (5-3-2012),. Any conflict between the Hhandbook and these iBudget Rules shall be resolved in favor of these Rules.
(3) through (4) No change.
Rulemaking Authority 393.501(1), 393.0662 FS. Law Implemented 393.0662, 409.906 FS. History–New October 20, 2015 July 1, 2015.
65G-4.0218 Significant Additional Need Funding.
(1) Supplemental funding for Significant Additional Needs (SANs) (SAN) may be of a one-time, temporary, or long-term in nature including the loss of Medicaid State Plan or school system services due to a change in age. SANs SAN funding requests must be based on at least one of the four three categories, as follows:
(a) through (c) No change.
(d) A significant need for transportation services to a waiver-funded adult day training program or to a waiver
funded supported employment where such need cannot be accommodated within the funding authorized by the client's iBudget amount without affecting the health and safety of the client, where public transportation is not an option due to the unique needs of the client, and where no other transportation resources are reasonably available. However, such increases may not result in the total of all clients' projected annual iBudget expenditures exceeding the agency's appropriation for waiver services.
(2) A client’s iBudget shall be the total of the amount determined by the algorithm and any additional funding provided pursuant to subsection (1). A client’s annual expenditures for home and community-based services Medicaid waiver services may not exceed the limits of his or her iBudget. The total of all clients’ projected annual iBudget expenditures may not exceed the agency’s appropriation for waiver services.
(4) renumbered (3) No change.
(3) through (4) renumbered (4) through (5) No change.
(6)(5) Response to funding requests: Within 30 thirty (30) days of receipt of a request for SANs SAN funding, and adjustments in the individual’s service array, the Agency shall approve, deny (in whole or in part), or request additional documentation concerning the request. If the request does not include all necessary documentation, the Agency shall provide the client and WSC with a written notice of what additional documentation is required. The client or WSC shall provide the documentation within 10 calendar days, or notify the Agency in writing that the client wishes the Agency to render its decision based upon the documentation provided. If additional documentation is requested, the deadline for the Agency’s response shall be extended to 60 sixty (60) days following the receipt of the original request. Nothing in this section prohibits the authorization of emergency services on a temporary basis through the Agency’s Regional offices. If the client has not received a notice from the Agency approving, denying or requesting additional information within 60 days, the client or WSC may notify the Agency in writing of such failure to issue a timely notice and the Agency shall have 20 days from receipt of the Notice to approve or deny the request. Failure of the Agency to issue this Notice within 20 days shall mean the requested funding for services are authorized as of the 21st day, and the client and service providers may treat the authorization as an approval.
(6) through (7) renumbered (7) through (8). No change.
Rulemaking Authority 393.501(1), 393.0662 FS. Law Implemented 393.0662, 409.906 FS. History–New October 20, 2015 July 1, 2015.
