Ala. Admin. Code r. 580-5-30-.14

Current through Register Vol. 43, No. 1, October 31, 2024

Section 580-5-30-.14 - Eligibility And Level Of Care Determinations For Medicaid Waiver Programs

The AMA designates the ADMH as the entity authorized to determine individuals' eligibility for participation in the Medicaid HCBS Waivers. Within the ADMH, the oversight and monitoring of day-to-day operations of the Medicaid HCBS programs are conducted by the DDD through its Central and Regional Community Services offices. Information for eligibility determinations and redeterminations of individuals with intellectual disabilities for enrollment and continued participation in these programs is gathered by DDD Support Coordinators or designated 310 Board and submitted to the appropriate ADMH Regional Community Services office as described in the DDD Operational Guidelines. Appropriately qualified Regional Community Services office staff make the eligibility determinations and redeterminations based on information submitted.

(1) Definitions:

(a) ICAP (Inventory for Client and Agency Planning) -

The standard functional assessment instrument used in the process of determining eligibility for the waiver programs.

This commercial product will produce a three-page summary report known as the Compuscore. An eligibility assessment within ADMH's electronic information system summarizes key information from the ICAP Compuscore, from which the Regional Office can determine the individual's level of care.

(b) Level of Care Evaluation (LOC) - The form required by the Waiver Programs to document that the applicant would otherwise be eligible for and require the LOC provided in an Intermediate Care Facility (ICF).

(c) Designated Support Coordination Entity - The entity or Regional Office designated by ADMH in each county or group of counties responsible for coordinating waiver services and supports for individuals waiting for services.

(d) criticality Summary - The assessment tool created by the Department to evaluate the criticality of an individual's need for services.

(e) Intellectual Disability - A disability characterized by a) significant limitations in both intellectual functioning and b) adaptive behavior, which covers many everyday social and practical skills; c) and is a condition that originates before the age of 18.

(f) Qualifying Psychological Evaluation - A psychological evaluation administered and interpreted by a qualified individual.

(2) Eligibility for the Waiver - Medicaid HCBS Waivers are approved only as cost-effective alternatives to institutional care that would otherwise be reimbursed by the Medicaid Chapter 580-5-30 Mental Health Program. The waivers operated by ADMH are alternatives to a Medicaid reimbursed ICF. For eligibility requirements for HCBS waivers operated by ADMH, refer to the Long-Term Care Waiver section of the AMA's website.

(a) In Alabama, eligibility for the waiver is determined in three steps. In the first step, preliminary eligibility is determined so an individual's name can be added to a statewide waiting list. The second step occurs when the individual can be reached on the waiting list and it becomes his or her turn to be enrolled in the waiver. The third step occurs when the individual has been receiving services for a period no longer than one (1) year and his or her eligibility must be re-determined. Re-determination is required annually for as long as the individual receives services under the waiver.

(3) The Waiting List - The ADMH maintains a statewide waiting list of individuals applying for services through the Medicaid waiver programs it administers under delegation of authority from the AMA. Applicants initially placed on the waiting list requires a determination of preliminary clinical eligibility as defined in the HCBS waiver. If an applicant is financially ineligible for Medicaid at the time of Waiver eligibility determination, the applicant may still be placed on the waiting list, so long as the intellectual disabilities and adaptive functioning criteria are met. However, the requirement of financial eligibility for Medicaid must be met in order to enter services from the waiting list.

Ala. Admin. Code r. 580-5-30-.14

Adopted by Alabama Administrative Monthly Volume XXXVII, Issue No. 11, August 30, 2019, eff. 10/10/2019.

Amended by Alabama Administrative Monthly Volume XXXIX, Issue No. 02, November 30, 2020, eff. 1/14/2021.

Amended by Alabama Administrative Monthly Volume XL, Issue No. 06, March 31, 2022, eff. 5/15/2022.

Original Rule .13 was renumbered to .14 due to certification published November 30, 2020; effective January 14, 2021.

Author: Division of Developmental Disabilities

Statutory Authority:Code of Ala. 1975, § 22-50-11.