S.D. Admin. R. 67:44:03:16

Current through Register Vol. 51, page 67, December 16, 2024

Section 67:44:03:16 - Exceptions process

The total amount the department will authorize for all HOPE waiver services for a participant is based on assessed need as identified in the individual support plan, with a maximum threshold equal to the average cost of nursing facility care. Services over this threshold are subject to an exceptions review process initiated and conducted by the department.

To qualify for an exception, a participant must meet all of the following criteria:

(1) The participant is not severely impaired based on the most recent assessment conducted by the department;

(2) The participant has an assessed need for extensive or total assistance, in at least two of the following activities of daily living:

(a) Locomotion;

(b) Toilet transfer;

(c) Toilet use;

(d) Bed mobility; or

(e) Eating;

(3) Without additional waiver services, nursing facility care is required to assure the participant's health, safety, and welfare;

(4) The participant's needs cannot be met without exceeding one hundred percent of the cost of nursing facility care;

(5) The participant has demonstrated compliance with the individual support plan;

(6) The participant has demonstrated compliance with medical advice from the participant's physician, if applicable;

(7) The participant has demonstrated that support offered through the HOPE waiver program provides opportunities for increased community integration that would not otherwise be available if residing in a nursing facility; and

(8) The participant does not experience seclusion from the greater community and the living arrangement does not promote isolation.

A participant who does not meet all exceptions criteria is limited to services that do not exceed the average cost of nursing facility care.

The exceptions request may not exceed one hundred and fifty percent of the average cost of nursing facility care. A participant approved for services above the one hundred and fifty percent limit prior to the effective date of this rule is not subject to this limit unless there is a significant change in health status or case closure.

S.D. Admin. R. 67:44:03:16

51 SDR 036, effective 9/30/2024

General Authority: SDCL 1-36A-26.

Law Implemented: SDCL 1-36A-25, 1-36A-26.