480 Neb. Admin. Code, ch. 3, § 003

Current through September 17, 2024

Section 480-3-003 - PARTICIPANT ELIGIBILITY

003.01ELIGIBILITY CRITERIA. Participants eligible for Waiver services must:

(A) Be eligible for Nebraska Medicaid in a category authorized to receive services from the Waiver under which services are being requested;

(B) Have conditions which place the individual in the target populations identified in the Waiver under which services are being requested;

(C) Have participated in an assessment, including any reassessments, with a services coordinator in accordance with this chapter;

(D) Meet the nursing facility level of care criteria outlined in Title 471 Nebraska Administrative Code (NAC);

(E) Be determined that meeting the care needs of the participant would not result in Nebraska violating the cost effectiveness requirements outlined in this chapter;

(F) Receive an explanation of nursing facility services and Waiver services and choose to receive Waiver services; and

(G) Use Waiver services at least every 60 days. Exceptions apply for cases that are Assistive Technology Supports (ATS) or Home and Vehicle Modification (H/VM) requests only, or in the event there is a delay in enrollment of the preferred provider.

003.02ELIGIBILITY DETERMINATION. All participants must have an eligibility determination in order to be able to access Waiver services. Eligibility determinations include:

003.02(A)ASSESSMENT. An in-person assessment will be completed by the services coordinator, participant, and legal guardian when applicable. A child must be reassessed as an adult when they reach age 18. The following steps are included within the intake process:

(i) A referral for services will be accepted from any source;

(ii) Each participant must be determined Medicaid eligible, or under consideration for Medicaid eligibility; and

(iii) The services coordinator will contact the participant and schedule an in-person meeting to evaluate nursing facility level of care, within 14 calendar days of the referral date. Assessments are scheduled at a time and date convenient to the participant and their guardian, when applicable this may result in scheduling outside the 14 calendar day window.

003.02(B)PRIORITY CRITERIA FOR ASSESSMENT. If a statewide waiting list is required due to limited Waiver capacity, the Department may determine that an individual qualifies for a priority placement into an available Waiver opening. The Department retains sole discretion to determine the applicability of criteria and the need for prioritization of an assessment. Criteria to be considered to expedite the assessment include, but are not limited to:

(i) Needs that are so severe the health and welfare of the participant are jeopardized, but the needs could safely be met with immediate Waiver services;

(ii) Family or caregivers are in a crisis situation;

(iii) No informal support network is available to meet identified needs;

(iv) Inappropriate out-of-home placement is being planned;

(v) No other program is available to meet the needs identified in the referral;

(vi) Support services are required to allow the participant to return home such as, a Medicaid-eligible recipient is ready to be discharged from a hospital or nursing facility; and

(vii) A participant with an identified Waiver service need of Assistive Technology Supports or Home and Vehicle Modifications (ATS, H/VM) lacks access to resources to meet these specific needs AND Waiver eligibility is the only method of addressing the identified needs.

003.02(C)ONGOING ASSESSMENTS. An in-person re-evaluation of nursing facility level of care and needs assessment are required at least annually or any time that there is a change in a participant's condition in order to ensure the participant continues to meet criteria identified in 471 NAC 12-000 to be eligible for Waiver services.

003.02(D)DETERMINATION OF NURSING FACILITY LEVEL OF CARE. The Department will determine nursing facility level of care in accordance with Title 471 NAC.

003.02(E)PERSON-CENTERED PLAN (PCP). A Person-Centered Plan (PCP) must be developed for each participant. For children aged 0-3 years old that are also utilizing early intervention services, the Individual Family Service Plan (IFSP) is the person-centered plan (PCP). The service planning process should be directed by the participant and any applicable representative. Steps included in the person-centered planning process are:

(i) PLAN DEVELOPMENT. The participant, together with the services coordinator, develops a person-centered plan (PCP) based upon assessment results of the potential participant's strengths, needs, priorities, preferences and resources.

(ii) PLAN REQUIREMENTS. The person-centered plan (PCP) must meet the following requirements:

(1) Reflect that the setting in which the participant resides is chosen by the individual;

(2) Reflect the participant's strengths and preferences;

(3) Reflect clinical and support needs;

(4) Include individually identified goals and desired outcomes;

(5) Reflect the services and supports (paid and unpaid) that will assist the client to achieve identified goals, and the providers of services and supports, including informal supports;

(6) Reflect risk factors and measures in place to minimize them, including individualized back-up plans and strategies;

(7) Identify the individual and entity responsible for monitoring the plan;

(8) Document that any modification is supported by a specific assessed need and justified. The following requirements must be documented in the person-centered plan (PCP):

(a) Identify a specific and individualized assessed need;

(b) Document the positive interventions and supports used prior to any modifications to the person-centered plan (PCP);

(c) Document less intrusive methods of meeting the need that have been tried but did not work;

(d) Include a clear description of the condition that is directly proportionate to the specific assessed need;

(e) Include a regular collection and review of data to measure the ongoing effectiveness of the modification;

(f) Include established time limits for periodic reviews to determine if the modification is still necessary or can be terminated;

(g) Include informed consent of the participant;

(iii)PLAN IMPLEMENTATION. The person-centered plan (PCP) must be finalized and agreed to, with the informed consent of the participant, and the participant's legal representative when applicable.

480 Neb. Admin. Code, ch. 3, § 003

Adopted effective 11/26/2014.

Amended effective 10/3/2021