N.H. Admin. Code § He-M 524.26

Current through Register No. 45, November 7, 2024

Section He-M 524.26 - Funding and Payment

(a) Area agencies shall submit to the bureau a proposed individualized budget for each individual requesting services under He-M 524. The proposed budget shall contain detailed line item information regarding all services to be requested.

(b) The bureau shall review the proposed budget and issue a response within 10 business days from the date of request.

(c) For each request an area agency makes for funding individual services under He-M 524, the bureau shall make the final determination on the cost effectiveness of requested services.

(d) Based on an individualized budget approved by the bureau and service agreement approved by the individual or representative, the area agency shall request a prior authorization from the bureau.

(e) Requests for prior authorization shall include the documentation in (d) above and be submitted to:

Bureau of Developmental Services

Hugh J. Gallen State Office Park

105 Pleasant Street

Concord, NH 03301

(f) If information submitted pursuant to (e) above, or similar information obtained at any other time by the bureau, indicates that an individual might no longer meet the criteria for home and community-based care specified in He-M 524.03 the bureau shall re-determine the individual's eligibility pursuant to He-M 524.03 above.

(g) Once an area agency obtains a prior authorization from the bureau, it shall submit claims for in-home supports electronically to the Medicaid Management Information System.

(h) Payment for in-home supports shall only be made if prior authorization has been obtained from the bureau.

(i) The bureau shall approve requests for prior authorization that meet the criteria in (j)-(k) below.

(j) Payment for in-home supports shall not be available to any service provider who:

(1) Is a person under age 18, except as specified in He-M 524.22(b)(2); or

(2) Is the spouse of an individual receiving services.

(k) Payment for provision of in-home residential habilitation shall be available to the parent of an individual receiving in-home supports when the following apply:

(1) The individual has at least one of the following factors:

a. The individual's level of dependency in performing activities of daily living, including the need for assistance with toileting, eating, or mobility, exceeds that of his or her developmentally disabled peers as determined by a nationally recognized standardized functional assessment tool;

b. The individual requires support for a complex medical condition, including airway management, enteral feeding, catheterization, or other similar procedures; or

c. The individual's need for behavioral management exceeds that of his or her developmentally disabled peers, as determined by a nationally recognized standardized behavioral assessment tool, and the child's destructive or injurious behavior represents a risk for serious injury or death;

(2) The parent has at least one of the following factors:

a. The parent has exhausted all options for obtaining in-home support assistance due to the lack of availability of qualified providers, as exemplified in (l) below; or

b. The child's need for care has an imminent, negative effect on a parent's ability to maintain paid employment; and

(3) The parent meets all applicable provider qualifications pursuant to He-M 524.22 and all documentation requirements of He-M 524.24.

(l) Examples of lack of availability of qualified providers shall include the following:

(1) A family lives in a rural or remote area and cannot secure providers;

(2) The extensive medical or behavioral needs of the child prevent the recruiting and maintaining of providers;

(3) A family whose cultural background is different from the culture of the overall pool of providers cannot secure providers who demonstrate cultural competence;

(4) A family's work schedule requires that providers be available during evening, overnight, weekend, and holiday hours, thus making it difficult to retain providers;

(5) A family's needs are such that no provider agency can be identified or is available to provide the required service; and

(6) Any other circumstance or condition of a parent or child or of local provider agencies that results in a family being unable to obtain in-home support assistance.

(m) The area agency shall administer payments to parents for in home residential habilitation and submit requests for parent payment to BDS for prior authorization.

(n) Payments to parents under (k) above shall apply solely to the provision of in home residential habilitation services.

(o) When a parent is paid to provide in-home residential habilitation, the number of hours for which a parent will receive payment shall be specified in the service agreement.

N.H. Admin. Code § He-M 524.26

Derived from Volume XLII Number 28, Filed July 14, 2022, Proposed by #13397, Effective 6/18/2022, Expires 6/18/2032 (formerly He-M 524.14)