Currently procedures relating to the crisis enrollment of eligible person with developmental disabilities in the Medicaid Home and Community-Based Services waiver are included in the Florida Medicaid Developmental Disabilities Waiver Services ...

 

DEPARTMENT OF CHILDREN AND FAMILY SERVICES
Agency for Persons with Disabilities

RULE NO: RULE TITLE
65G-1.010: Definitions
65G-1.046: Crisis Determination Procedure
65G-1.047: Crisis Status Criteria
PURPOSE AND EFFECT: Currently procedures relating to the crisis enrollment of eligible person with developmental disabilities in the Medicaid Home and Community-Based Services waiver are included in the Florida Medicaid Developmental Disabilities Waiver Services Coverage & Limitations Handbook, incorporated by reference in rule 59G-13-080, F.A.C. During the 2006 legislative session (ch. 2006-227, Laws of Florida), section 393.065, Florida Statutes, was amended to authorize the Agency for Persons with Disabilities to promulgate rules relating to crisis enrollment for waiver services. The purpose of the proposed rule is to adopt rule providing a procedure for persons with developmental disabilities to be considered for enrollment on a Medicaid Home and Community-Based Services waiver if the applicant demonstrates an immediate need for services.

SUMMARY: The proposed rule provides procedures and criteria for crisis enrollment on a Medicaid Home and Community-Based Services waiver.

SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COST: No Statement of Estimated Regulatory Cost was prepared.

Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.

SPECIFIC AUTHORITY: 393.501(1), 393.065 FS.
LAW IMPLEMENTED: 20.197(3), 393.065 FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE SCHEDULED AND ANNOUNCED IN FAW.

THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULES IS: Terri McGarrity, Senior Management Analyst Supervisor, Division of Operations, Suite 360, 4030 Esplanade Way, Tallahassee, Florida, 32399-0950; e-mail: [e-mail].

 

THE FULL TEXT OF THE PROPOSED RULES IS:

65G-1.010 Definitions.

In this chapter, terms and phrases shall have the meanings defined in Chapter 393, F.S., or this section.

(1) “Area Office” means the local office responsible for managing one of the Agency’s 14 service areas.

(2) “Central Office” means the Agency’s headquarters located at 4030 Esplanade Way, Suite 380, Tallahassee, FL 32399-0950; main phone number [phone].

(3) “Crisis enrollment” means expedited enrollment on an Agency operated Medicaid waiver regardless of an applicant’s date of application for the waiver or placement on the Agency’s waitlist.

(4) “Handbook” means the Florida Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook, incorporated by reference in Agency for Health Care Administration (AHCA) Rule 59G-13.080, F.A.C. The Handbook can be found at: http://floridamedicaid.acs-inc.com/index.jsp.

(5) “Protective Services” means the program in the Department of Children and Family Services which responds to reports made to the department’s central abuse hotline alleging abuse, abandonment, neglect, or exploitation pursuant to Chapter 39 or 415, F.S.

(6) “Wait list” means a list, maintained by the Central Office, of persons requesting and waiting for waiver services.

(7) “Waiver” means a Home and Community-Based Services (HCBS) waiver, authorized under section 1915(c) of the federal Social Security Act and Section 409.906, F.S., that provides package of Medicaid-funded home and community-based supports and services to eligible persons with developmental disabilities who live at home or in a home-like setting. The Agency currently operates two HCBS waivers:

(a) The Developmental Disabilities Home and Community-Based Services (DD) waiver, which provides home and community-based supports and services to eligible persons with developmental disabilities who are able to live at home or in a home-like setting. The DD waiver offers services without a dollar cap.

(b) The Family and Supported Living (FSL) waiver, which provides home and community-based supports and services to eligible persons with developmental disabilities who are able to live in their own home or family home. The FSL waiver offers limited services with an annual dollar cap.

Specific Authority 393.501(1), 393.065 FS. Law Implemented 20.197(3), 393.065 FS. History–New________.

 

65G-1.046 Crisis Determination Procedure.

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

(2) The request shall be made to the Area Office in the service area where the applicant resides. If the applicant is not already a client of the Agency, or is not already on the waitlist, the applicant must apply and be determined eligible for Agency services as provided in Section 393.065, F.S. No person may be enrolled on the waiver unless the person has been determined by the Agency to have a qualifying diagnosis of a developmental disability and meet waiver criteria as provided in the Handbook.

(3) The Area Office shall collect any pertinent information and supporting documentation relevant to a crisis determination, and conduct an initial 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 needed services are currently available from other agencies or programs or covered by other third party payors, the Area Office shall deny crisis enrollment and provide notification to the applicant or other authorized representative of the denial in writing.

(b) If the Area Office concludes that the applicant may meet crisis status and does not have access to insurance, or other agencies or programs for needed services, or that programs in which the applicant is currently participating are unable to meet the applicant’s service needs, the initial assessment and supporting documentation shall be submitted to the Agency’s Central Office for review and final determination as to whether the applicant meets crisis status. Upon request, the applicant, or the person requesting enrollment on behalf of the applicant, may review the information to be sent to the Central Office to determine whether all necessary information is included.

(4) The Central Office shall notify the area offices of the date all crisis enrollment requests that have not been denied must be submitted to the Central Office for consideration of crisis enrollment. Once all crisis applications are received and reviewed by the Central Office, the Central Office will notify the Area Office whether each request is approved or denied. The Area Office shall be responsible for notifying the applicant, or the person requesting enrollment on behalf of the applicant, of the Central Office’s decision.

(a) APPROVAL.

1. If funding is available and the applicant is approved for crisis enrollment, the applicant shall be offered placement on the FSL waiver unless the specific identified service needs of the applicant that qualify the applicant as in crisis cannot reasonably be met by the FSL waiver. In such instances the person may be offered placement on the DD waiver. Factors to be considered are the availability of services that cannot be provided under the FSL waiver that are needed to resolve the crisis situation including the need for residential habilitation services, the need for nursing services beyond the coverage provided through the Medicaid State Plan, or placement in a residential facility.

2. The Area Office shall notify the applicant in writing. If the applicant is not enrolled in Medicaid, the Area Office shall make appropriate referrals for the determination of Medicaid eligibility. Once the applicant is determined eligible for Medicaid, the Area Office shall complete waiver enrollment. If the Area Office subsequently determines that the applicant cannot be enrolled due to Medicaid or waiver ineligibility, the approval will be rescinded.

(b) DENIAL. The Area Office shall notify the applicant in writing of denial of crisis enrollment. If the application was denied due to the lack of documentation and the additional documentation becomes available, or there is a change in the applicant’s situation that may affect the applicant’s status for crisis determination, the applicant may reapply when funding is available and the Agency is accepting requests.

Specific Authority 393.501(1), 393.065 FS. Law Implemented 20.197(3), 393.065 FS. History–New________.

 

65G-1.047 Crisis Status Criteria.

The presence of the following factors are indicators of crisis status. Additional factors to be considered include the severity and immediacy of the need for services.

(1) The applicant does not have a place to live and is homeless, or is living in a temporary or unsafe environment that poses an immediate threat to the health and safety of the applicant or others with whom the applicant is living. The presence of the following factors are indicators of crisis status:

(a) The applicant is currently homeless or living in a homeless shelter.

(b) The applicant is currently staying with friends or relatives, but the situation is temporary and not expected to last beyond the month and no other alternatives are readily available.

(c) The commitment of the applicant’s caregiver to shelter the applicant is low.

(d) The applicant’s living situation is not providing sufficient supervision and support to prevent the applicant’s exposure to perilous situations.

(e) The applicant’s living situation is not providing sufficient supervision and support to prevent the applicant’s behavior from threatening other vulnerable persons living with the applicant.

(f) Given the presence of others in the home and the size and configuration of the home, there is insufficient room to provide adequate shelter to the applicant or the applicant is sharing a room with another in a situation inappropriate based on the age, sex and condition of the persons sharing the room.

(g) The applicant’s present living environment is substandard and the applicant’s safety is in peril.

(h) The applicant’s health status has been or is in jeopardy because of his or her current living situation.

(i) There has been law enforcement involvement.

(j) Protective Services has been involved.

(2) The applicant is either in danger of abuse or neglect, or poses an immediate threat to the health and safety of others. The presence of the following factors are indicators of crisis status:

(a) There have been confirmed instances of abuse towards the applicant, or others in the home.

(b) The level of care, supervision or services that the applicant is currently receiving are not sufficient to maintain the health and safety of the applicant.

(c) The applicant is exhibiting behaviors that may result in a life-threatening situation for the applicant or others, or result in bodily harm to the applicant or others that will require emergency medical care from a physician.

(d) The frequency and intensity of the applicant’s behavior is likely to result in serious injury or permanent damage to the applicant or others.

(e) There is a reasonable possibility for a fatal or life-threatening injury, or there has been documented injury to the applicant or others requiring medical treatment.

(f) Other reasonable behavioral assessments and interventions have been attempted but have proven ineffective.

(g) The relative age, sex, and size of the aggressor and other persons subject to his or her aggression places the others at great risk.

(h) The caregiver has insufficient ability or capabilities to handle the applicant’s behavior.

(i) The age or disability of the applicant or caregiver exacerbates the problem.

(j) There has been law enforcement involvement.

(k) Protective Services has been involved.

(3) The applicant’s current caregiver is in extreme duress and is no longer able to provide for the applicant’s health and safety. The presence of the following factors are indicators of crisis status:

(a) The age, illness or injury of the caregiver prevents rendering necessary care to the applicant.

(b) Due to the caregiver’s physical or mental condition, the applicant’s health and safety are at imminent risk.

(c) Other caregivers, such as another parent, stepparent, brother, sister or other relative or person willing and able to assume care are not available.

(d) The caregiver’s age has resulted in significant impairment of his or her physical or mental ability to provide care and supervision to the applicant.

(e) The caregiver is unable to provide sufficient care due to the age, size or physical, functional, or behavioral demands of the applicant.

(f) The intensity and scope of services that the caregiver can provide results in the applicant’s remaining semi-independent or totally dependent.

(g) The caregiver has an unstable economic situation in part because of the care giving demands required by the applicant and the situation is unlikely to change.

(h) The caregiver serves others who also require care, and due to these other demands the caregiver is unable to provide adequate care to the applicant or the demands of providing care to the applicant places the others at risk of insufficient care.

(i) The disability of the caregiver is permanent, or the caregiver is deceased or about to expire.

(j) There has been law enforcement involvement.

(k) Protective Services has been involved.

Specific Authority 393.501(1), 393.065 FS. Law Implemented 20.197(3), 393.065 FS. History–New________.

 

NAME OF PERSON ORIGINATING PROPOSED RULE: Terri McGarrity, Senior Management Analyst Supervisor, Division of Operations, Suite 360, 4030 Esplanade Way, Tallahassee, Florida 32399-0950; e-mail: [e-mail].

NAME OF SUPERVISOR OR PERSON WHO APPROVED THE PROPOSED RULE: Mac McCoy, Interim Deputy Director of Operations

DATE PROPOSED RULE APPROVED BY AGENCY HEAD:  January 10, 2007

DATE NOTICE OF PROPOSED RULE DEVELOPMENT PUBLISHED IN FAW: Two workshops where noticed. The first was noticed September 29, 2006, Vol. 32, No. 39, p. 4543, and held in Tallahassee on October 17, 2007. The second was noticed October 6, 2006, Vol. 32, No. 40, p. 4701, and held in Orlando on October 24, 2006