65G-4.0215. General Provisions

(1) Medical necessity alone is not sufficient to authorize a service under the Waiver; in addition:

(a) With the assistance of the WSC, the client must utilize all available State Plan Medicaid services, school-based services, private insurance, natural supports, and any other resources that may be available to the client before expending funds from the client’s iBudget Amount for support or services. As an example, State Plan Medicaid services for children under the age of 21 typically include personal care assistance, therapies, consumable medical supplies, medical services, and nursing;

(b) The services must be within Waiver coverages and limitations; and

(c) The cost of the services must be within the Allocation Algorithm Amount unless there is a significant additional need demonstrated.

Failure to meet the above criteria shall result in a denial of a request for additional funding.

(2) WSCs shall coordinate with the clients they serve to ensure that services are selected from all available resources to keep the annual cost of services within the client’s iBudget Amount while maintaining the client’s health and safety.

(3) Prior to authorizing new or increased services or at the time of a medical necessity review, the Agency must certify and document within the client’s cost plan that the client has used all available services authorized under the Medicaid State Plan; school-based services; private insurance; local, state, and federal government and non-government programs or services; natural or community supports; and any other benefit or resource that may be available to the client before using funds from the iBudget to pay for supports and services.

(a) The iBudget Waiver is the payor of last resort.

(b) A valid and accurate Verification of Available Services form is a condition precedent to the authorization of services. To enable the Agency to certify and document that the client has utilized all available services pursuant to Section 393.0662(3), F.S., the WSC must complete and submit the Verification of Available Services to the Agency:

1. At the time of any requests to add or increase services, or

2. Upon request from the Agency when it is making determinations of medical necessity for Waiver services.

(4) Cost Plan Flexibility.

(a) After the client’s proposed cost plan is approved, he or she may change the services in his or her Approved Cost Plan provided that such change does not jeopardize the health and safety of the client and meets medical necessity.

(b) When changing the services within the Approved Cost Plan, the client and his or her WSC shall ensure that sufficient funding remains allocated for unpaid services that were authorized and rendered prior to the effective date of the change.

(c) Clients enrolled in iBudget will have flexibility and choice to budget or adjust funding among the following services without requiring additional authorizations from the Agency, provided the client’s overall iBudget Amount is not exceeded and all health and safety needs are met:

1. Life Skills Development 1,

2. Life Skills Development 2,

3. Life Skills Development 3, within the approved ratio,

4. Life Skills Development 4, within the approved ratio,

5. Durable Medical Equipment,

6. Adult Dental,

7. Personal Emergency Response Systems,

8. Environmental accessibility adaptations,

9. Consumable Medical Supplies,

10 Transportation,

11. Personal Supports up to $16,000,

12. Respite up to $10,000.

(d) Medically necessary services will be authorized by the Agency for covered services not listed above if the cost of such services are within the client’s iBudget Amount and in accordance with subsection 65G-4.0215(1), F.A.C. The Agency shall authorize services in accordance with criteria identified in Section 393.0662(1)(b), F.S., medical necessity requirements of Section 409.906, F.S., subsection 59G-1.010(166), F.A.C., Handbook limitations, and the authority under Title 42 of the Code of Federal Regulations, Part 440, Section 230(d).

(e) Service authorization and any modifications to it must be received by the provider prior to service delivery. This includes changes to the authorization as a result of clients redistributing funds within their existing cost plan.

(5) Consumer Directed Care Plus (CDC+): clients enrolled in the CDC+ program are subject to iBudget Rule 65G-4.0214, subsections 65G-4.0215(1), (2) and (7), and Rules 65G-4.0216, 65G-4.0217, 65G-4.0218, F.A.C.

(6) Approval, Denial, or Closure of Applications.

(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 through the Agency for Health Care Administration. However, providers do not have to provide Medicaid State Plan services in order to provide Waiver services.

(b) 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 – WSC – APD Form 65G-4.0215 A, effective date 01-2023, for Waiver Support Coordinator applications, which is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-12444, or the Regional iBudget Provider Enrollment Application – Non-WSC – APD Form 65G-4.0215 B, effective date 7-1-2021, for all other provider applications, which is available at https://www.flrules.org/Gateway/reference.asp?No=Ref-14984. These forms are hereby incorporated by reference. The qualifications to provide services are identified in the Handbook.

(c) The Agency will review the application and approve or deny complete applications within 90 days of receipt; the Agency will close incomplete applications.

1. The Agency will only consider complete applications that include all required information and meet the requirements delineated in this chapter, the iBudget Handbook, and Section 393.0663, F.S. An application is complete upon the Agency’s receipt of all requested information and correction of any error or omission for which the applicant was notified.

2. If the Agency receives an incomplete application, the Agency will notify the applicant. The applicant will have 45 calendar days from the date of the notice to submit the documentation, information, or make any corrections designated in the notice. If the applicant does not complete the application within 45 days of the notice, the application must be closed by the Agency. After an application is closed, all documentation and information submitted will no longer be considered, and a new complete application must be submitted for consideration by the Agency. The closure of an application is not Agency action and will not be considered substantively by the Agency in any subsequent application.

(d) If a Waiver provider wishes to, expand by providing additional services, expand services geographically, or expand from solo to agency, the provider must notify the Agency regional office by submitting a Provider Expansion Request form – APD Form 65G-4.0215 C, effective date 01-2023, which is hereby incorporated by reference and is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-14985. The Agency regional office must approve any expansion prior to the provision of expanded services. The qualifications to provide or expand services are identified in the Handbook.

(7)(a) When a client is enrolled in the iBudget, that client remains enrolled in the Waiver position allocated unless the client becomes disenrolled due to one of the following conditions:

1. The client or client’s legal representative chooses to terminate participation in the Waiver.

2. The client moves out-of-state.

3. The client loses eligibility for Medicaid benefits and this loss is expected to extend for a lengthy period.

4. The client no longer needs Waiver services.

5. The client no longer meets level of care for admission to an ICF/IID.

6. The client no longer resides in a community-based setting but moves to a correctional facility, detention facility, defendant program, or nursing home or resides in a setting not otherwise permissible under Waiver requirements.

7. The client is no longer able to be maintained safely in the community.

If an client is disenrolled from the Waiver and becomes eligible for reenrollment within 365 days that client can return to the Waiver and resume receiving Waiver services. If Waiver eligibility cannot be re-established or if the client who has chosen to disenroll has exceeded this time period, the client cannot return to the Waiver until a new Waiver vacancy occurs and funding is available. In this instance, the client is added to the Waiting List of clients requesting Waiver participation. The new effective date is the date eligibility is re-established or the client requests re-enrollment for Waiver participation.

(b) Providers are responsible for notifying the client’s WSC and the Agency if the provider becomes aware that any of the conditions of paragraph (a) or (c), exists.

(c) If a client or legal representative refuses to cooperate with the provision of Waiver services in any of the following ways: develop a cost plan or support plan, participate in a required QSI assessment or other approved Agency needs assessment tool, or refuse to annually sign the Waiver eligibility worksheet that establishes a level of care, then the Agency will review the circumstances to determine if the client 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 client, the client’s legal representative and the WSC, at least 30 days before terminating services.

(d) Clients denied services shall have the right to a fair hearing. Clients are exempted from this provision if they do not have the ability to give informed consent and do not have a legal representative. The Agency shall not remove a client from the Waiver due to non-compliance if it directly impacts the client’s health, safety, and welfare.

(8) This rule shall be reviewed, and if necessary, renewed through the rulemaking process five years from the effective date.

Rulemaking Authority 393.501(1), 393.0662 FS. Law Implemented 393.063, 393.0662, 409.906 FS. History–New 7-7-16, Amended 9-12-18, 7-1-21, 1-3-23.