Section 197-11-06 - POLICIES AND PROCEDURES(A) Eligibility DeterminationAn eligibility assessment, using the Department's approved Medical Eligibility Determination (MED) form, shall be conducted by the Department or the ASA. All Home Based Care services require an eligibility determination and prior authorization by the Authorized Agent to determine eligibility pursuant to Section 11.02.
(1) The ASA will accept verbal or written referral information on each prospective new consumer, to determine appropriateness for an assessment. When funds are available to conduct assessments, prospective consumer's will receive a face to face medical eligibility determination assessment at their current residence within fifteen (15) business days of the date of referral to the Authorized Agent. All requests for assessments shall be documented indicating the date and time the assessment was requested and all required information provided to complete the request. The individual conducting the assessment shall be a Registered Nurse (RN), occupational therapist (OT) or a certified occupational therapy assistant (COTA), whose work will be reviewed and signed off by an OT, and will be trained in conducting assessments and developing an authorized plan of service with the Department's approved MED tool. The assessor's findings and scores recorded in the MED form shall be the basis in establishing eligibility for services and the authorized plan of service. The anticipated costs of covered services to be provided under the authorized plan of service must conform to the limits set forth in Section 11.03(A).(2) The ASA shall inform the consumer of available community resources and authorize a plan of service that reflects the identified needs documented by scores and timeframes on the MED form, giving consideration to the consumer's living arrangement, informal supports, and services provided by other public and private funding sources. CDHBC services provided to two or more consumer's sharing living arrangements shall be authorized by the Authorized Agent with consideration to the economies of scale provided by the group living situation, according to limits in Section 11.03.T he Authorized Agent shall authorize a plan of service based upon the scores and findings recorded in the MED assessment. The covered services to be provided in accordance with the authorized plan of service shall: 1) not exceed the lesser of the monthly plan of service authorized by the Authorized Agent or the Maximum Authorized Service established by Department of Health and Human Services; and 2) be prior authorized by the Department or its Authorized Agent. The assessor shall approve an eligibility period for the consumer, based upon the scores and needs identified in the MED assessment and the assessor's clinical judgment. (3) The assessor will provide a copy of the authorized service plan, in a format understandable by the average reader and approved by the Department, a copy of the eligibility notice, release of information and the appeal hearing rights notice, to the consumer at the completion of the assessment. The assessor will inform the consumer of the estimated co-payment and the cost of services authorized.(4) The assessor shall forward the fully completed assessment packet to the Department within five (5) business days of the medical eligibility determination and authorization of the plan of service. The Department will not approve eligibility or payment without a fully completed assessment.(5) The Authorized Agent will complete initial skills training within thirty (30) days of the date of the completion of the medical eligibility determination form. Payment of Consumer Directed services can begin only after the Department is notified that the consumer has successfully completed this training and the complete medical eligibility packet has been received.(B)Waiting List(1) consumer's will be assessed on a first come, first served basis.(2) For consumer's found ineligible for CDHBC services the Authorized Agent will inform each consumer of alternative services or resources, and offer to refer the person to those other services.(3) When funds are not available to serve new consumer's, or to increase needed services to current consumer's, a waiting list will be established by the Department in consultation with the Authorized Agent. Individuals on the waiting list will be interviewed by the Authorized Agent by phone for a pre-admission screening to determine their potential eligibility. As funds become available consumer's will be taken off the list, fully assessed, and served on a first come, first served basis.(4) When there is a waiting list, the Authorized Agent will inform each consumer who is placed on the waiting list of alternative services or resources, and offer to refer the person to those other services.(5) The Authorized Agent will maintain one statewide waiting list.(6) The Authorized Agent must suspend services if the consumer is hospitalized or using institutional care. If such circumstances extend beyond thirty (30) days, the consumer participation in the program will be suspended, and the consumer will be reassessed to determine medical eligibility for these services. consumer's will continue to receive their prior level of service until a reassessment is completed. The reassessment will be conducted within two weeks following the consumer's discharge from the hospital or institutional care facility.(C)Reassessment and Continued Services(1) For all consumer's under this section, in order for the reimbursement of services to continue uninterrupted beyond the approved classification period, a reassessment and prior authorization of services is required and must be conducted within the timeframe of 15 days prior to and no later than the reassessment due date. CDHBC payment ends with the reassessment date, also known as the end date.(2) The Authorized Agent shall review, face-to-face, with the consumer, at the consumer's residence, the medical eligibility for services at least twice during the first six months the consumer received services under this section and at least annually thereafter, or when there is a significant change as defined in 11.01(FF). The agent shall provide consumer instruction services as needed by the individual consumer to demonstrate competency in the direction and management of the PA for initially instructing the consumer in the management of Personal Assistants and additional instruction as needed.(3) Significant change reassessments will be requested by the consumer. According to the definition in Section 11.01(DD) the Authorized Agent will review the request and the most recent assessment to determine whether a reassessment is warranted and has the potential to change the level of service or alter the authorized plan of service.(4) For consumer's currently under the appeal process, reassessments will not be conducted unless the consumer experiences a significant change as defined in Section 11.01(GG) or no longer has the ability to self direct as defined in Section 11.01(EE).14- 197 C.M.R. ch. 11, § 06