Procedure No. I.B.2.PR.002 Issue Date: February 01, 2004
Subject: Coordination of Waiver Enrollment Activities for Effective Date: upon release Individuals Receiving State Funded Services Revised: July 20, 2004
Section: Planning and Resource Allocation,
This procedure outlines the HCBS waiver enrollment process for individuals who are receiving community-based services from DMR.
This procedure applies to individuals who are provided services and supports in any facility or program administered or funded by the Department of Mental Retardation (DMR) including those who have an individual support agreement. Children served by the Birth to Three System are excluded.
Department of Administrative Services (DAS) - The state agency responsible for investigation, determination and collection of charges for support of people served by DMR.
Department of Social Services (DSS) - The designated single state Medicaid agency which administers the State Medicaid Plan.
Facility or Program Administered or Funded by DMR – Includes public or private community living arrangements (CLA), supported living programs (SL), community training homes (CTH), day programs, supported employment services, or individual support agreements (ISA).
HCBS Waiver – The Home and Community-Based Services Waiver administered by DMR which “waives” certain restrictions of Medicaid regulations and allows a flexible approach to providing services within the community. These services assist a person to live in the community who would otherwise be eligible for placement in an ICF/MR.
Individual Support Agreement (ISA) - The term used to describe the method by which individuals direct their own services and supports through a legally-binding agreement between the individual or their guardian and DMR.
Out of Home Placement: Is the term used to describe a community living arrangement ( CLA, group home), ICF/MR, residential school, or other paid 24-hour supervised living arrangement outside of a family home.
Planning and Resource Allocation Team (PRAT) - A regional team chaired by the planning and quality coordinator, and comprised of representatives from resource management, case management supervision, business office, family support, and regional administration. This team manages the process whereby DMR identifies available resources, identifies individual consumer needs, assigns priority; implements waiting list policies and procedures, makes recommendations regarding applicants for the HCBS waiver, and processes allocation of resources and referrals to available out of home residential group living settings and provider agency-based day services.
People residing in the community who currently receive services and supports which are included in the Home and Community-Based Services Waiver from DMR shall be evaluated for enrollment in the HCBS Waiver when waiver slots are available. This enables the state to bill Medicaid and receive federal assistance in funding those waiver services, and thereby assists the state of Connecticut in its goal of supporting all citizens with mental retardation to safely and successfully live in their community.
Waiver “Cap” and State Appropriations
The HCBS waiver includes a limit as to the number of individuals who can be enrolled and served through the waiver. In Connecticut, this cap increases for each of the five years of the current waiver, i.e., there is an established number of “waiver slots” which are available. In addition, the availability of HCBS waiver services depends, in the first instance, on state appropriations for which prospective Medicaid funding under the waiver is available.
The ability to accept and process applications for waiver services and enrollment, therefore, requires an on-going assessment of “waiver slots” available AND the sufficiency of state appropriations to support waiver enrollment and waiver services. The DMR regions will be advised by the DMR central office waiver unit of the status of these two factors on a periodic basis. Applications will not be processed, and will be held for future consideration, whenever (a) “waiver slots” are unavailable, or (b) state legislative appropriations are not sufficient to support the services needed by potential new enrollee/recipients.
1. Initiation of Application: Current Service/Support Recipients – DMR Review and Initiation.
a. Each DMR case manager should regularly review individuals on his/her caseload who are receiving regular and substantive services/support from DMR to determine whether such services/support would be a covered service under the waiver. This review is to allow the case manager to make a preliminary recommendation to the Planning and Resource Allocation Team (PRAT) as to whether the department could initiate the waiver enrollment process for the individual. Consumers/families/guardians/representatives will be provided the current “Fact Sheet” on the Connecticut HCBS Waivers at this time, and at least annually thereafter during the annual planning process. The fact sheet provides a summary of approved waiver services, the application and enrollment process, and hearing rights for decisions related to the waiver.
b. A preliminary recommendation should be made to PRAT by the case manager, with concurrence from the case management supervisor, based upon the following factors:
i) the individual has mental retardation or a related condition; and,
ii) there is a reasonable indication that the person, but for the provision of waiver services, would need services in an ICF/MR or NF, as evidenced by one or more of the following:
(a) the services/support provided (state-funded, generic/community, and natural and family support) is critical to maintaining the individual in his or her current living situation, (b) without such services/support the individual would require the level of care provided in an ICF/MR-institutional setting,
(c) in the absence of such services/support, the individual would present an immediate need for an ICF/MR institutional placement, OR,
(d) there are other compelling indications of an immediate risk of institutional placement, AND,
(e) the present services/support, in combination with other funding, entitlements, community services and natural supports, is/are sufficient to reasonably assure the individual’s basic health and safety.
This determination is documented on DMR Form 219, HCBS ICF/MR Level of Need, and submitted to the PRAT via the regional waiver liaison. This preliminary recommendation to the PRAT informs the department if waiver enrollment could be initiated. As always, case managers must continuously monitor individuals on their caseloads and if immediate risk factors are identified which could be addressed through services covered under the waiver, the case manager will initiate DMR Procedure No: I.B.1.PR.001, Administration of Requests for Day and Residential Supports 2. Regional Enrollment Procedure a. Upon notification by the regional Planning and Resource Allocation Team (PRAT) notifying the case manager of an available waiver slot, the case manager shall coordinate the completion of a Medicaid application if necessary, and completion of the DMR HCBS Waiver enrollment forms: i) DMR 222, Service Selection, ii) DMR 223, Notification of Waiver Services, and iii) DSS W1518, HCBS Referral to Regional Office. A completed Waiting List Assessment, the individual’s current Plan of Care (OPS or FAP, or the ISA Plan Summary) and the above-stated DMR and DSS forms constitutes the initial “Waiver Application and Enrollment” packet. The Waiver Application and Enrollment packet is submitted to PRAT via the regional waiver liaison. NOTE: Completion of these forms does not mean an individual is enrolled in the waiver and consumers and their respective representatives should never be lead to believe, or mislead, that the completion of forms equals waiver eligibility and enrollment. b. The PRAT shall review eligibility for HCBS enrollment based upon the following criteria: i) The applicant is eligible for DMR services under state law; ii) The individual has Title 19 (Medicaid), or is considered to be eligible for Medicaid; iii) The applicant has present services/support, in combination with other funding, entitlements, community services and natural supports, which is/are sufficient to reasonably assure the individual’s basic health and safety. iv) If there are additional services/supports needed to reasonably assure the individual’s basic health and safety, there are sufficient new resources available to meet those needs. v) The person’s needs require the level of care provided in an ICF/MR; and vi) That, but for the provision of one or more of the services covered under the waiver, combined with community and natural supports, it is likely that the applicant would need ICF/MR-institutional services within one month. The following factors may be considered in determining the final criteria: (a) the applicant’s current living situation has deteriorated to the point where either the applicant or others face immediate and serious jeopardy to health and safety; (b) the applicant exhibits severe behavioral/mental health or medical issues which can no longer be managed in the current living situation; (c) the applicant is receiving serious consideration for admission to an institutional/ICF/MR residential setting; (d) the department must respond to a lawfully-issued court order requiring residential placement, services, or support; and/or (e) supports and services available in the HCBS waiver are needed to supplement community supports to prevent imminent placement in an ICF/MR, institutional, or similar residential facility for persons with mental retardation. The PRAT will record the review determination on DMR Form 225, PRAT HCBS Waiver Recommendation, and submit the recommended decision, the reasons therefore, and all records considered, to the DMR CO Waiver Unit along with the waiver enrollment packet. “Need” for immediate placement and other emergency protective services will continue to be addressed under the commissioner’s state law authority, CGS Sec. 17a-274(k), without regard to waiver issues. 3. DMR Central Office Waiver Unit Action The DMR central office waiver unit will issue a final decision on all applications for waiver enrollment. Upon approval by DSS of any such application the applicant will be enrolled in the waiver. If additional services/supports have been authorized for the individual by the region, the case manager/broker will coordinate the necessary planning and/or referral activities to initiate the additional services/supports. An applicant who is denied enrollment in the waivers(s) will receive notice of the right to request a hearing convened by the Department of Social Services (DSS). Forms and directions for initiating the DSS hearing process will be included with any Notice of Denial. DSS, as the “single state Medicaid agency,” makes the final administrative Medicaid/waiver eligibility decision. 4. Waiver Recipient Request for Additional Waiver Services Any “waiver recipient” may request additional services under the waiver at any time. The case manager must complete the DMR Waiting List Assessment Tool if one is not already on file and current for the waiver recipient. All such requests, the completed WL Assessment Tool, and an explanation as to why the recipient “needs” such services, will be documented by the case manager, reviewed by the case management supervisor, and transmitted to the PRAT for consideration. The PRAT will review the request based upon the recipient’s “need,” that is, in the absence of such additional service(s), the recipient is likely to require – and be eligible for – placement in an ICF/MR/institutional setting within one month. If a request for additional waiver services is approved by the PRAT, based upon DMR Needs Assessment criteria, the region will coordinate the provision of such services as soon as possible. PRAT will record the decision on DMR Form 225, PRAT HCBS Waiver Recommendation and return the form to the case manager supervisor if approved. Approval of additional waiver services does not require DMR central office review, but the DMR region will provide immediate notice to the DMR central office waiver unit of any changes in waiver services using DMR Form 223, Notification of Waiver Services. Any denial of a request for additional waiver services will be issued by the DMR central office waiver unit, upon recommendation of the PRAT via submission of DMR Form 225, and include notice to the recipient of applicable hearing rights as set forth above for eligibility determinations. 5. Hearing Process All determinations by the DMR central office waiver unit to deny waiver eligibility or additional requested waiver services are subject to a request for hearing before DSS in accordance with the Uniform Administrative Procedures Act. The DMR division of legal and government affairs will coordinate the hearing process and present the department’s position at such hearings. If an applicant/waiver recipient prevails at the DSS hearing, the DMR regional office will be notified and DMR shall implement the hearing decision as soon as possible thereafter. 6. Ineligible Applicants due to Excess Income or Assets (or Refusal to Participate in the Waiver Enrollment Process) For individuals who are being funded in DMR-administered programs and who are not having costs reimbursed through the Medicaid program (i.e. ICF/MR or HCBS Waiver) due to ineligibility based on excess income and/or assets, or a refusal to participate in the waiver application and enrollment process, DMR Form 224, Reasons for Declining to Submit Medicaid and/or DMR HCBS Waiver Applications must be completed by the case manager and submitted to the central office waiver unit. The CO waiver unit will make a formal written request to the individual, guardian, and legal/personal representative to explain the basis for refusal to engage in the waiver application and enrollment process and to provide appropriate documentation in support of such refusal. The request will also advise that the failure to submit the requested explanation and supporting documentation may result in the termination of DMR funding for supports and services. The CO waiver unit will evaluate the explanation and supporting documentation which is submitted and determine a course of action, including, but not limited to, advice regarding asset and income management, response to the explanation for refusal, or termination of DMR funding for supports and services. E. References 1. CT General Statute 4a-12, 2. CT General Statute 17b-222 3. Rules, Regulations and Policy – 42CFR 441.301 – 42CFR 441.303 4. Rules, Regulations and Policy or Instructions – DMR Procedure II.B.2.32, II.B.2.34, PAR procedure DMR Procedure No: I.B.1.PR.001, Administration of Requests for Day and Residential Supports, PRAT procedures F. Attachments 1. DMR Forms 219, 222, 223, 224, 225, 2. DSS Form W-1518 3. Notification of Enrollment in the DMR HCBS Waiver 4. Notification of Denial of HCBS Application or Services 5. Connecticut HCBS Waiver Fact Sheet WAIVER ENROLLMENT FOR INDIVIDUALS IN SERVICE q Level of Need for ICF/MR established by CM, DMR Form 219, submits to PRAT q PRAT notifies CM of available waiver slot q CM Completes waiver application and enrollment packet and submits to Regional Waiver Liaison: Ø Medicaid (Title 19) Application if needed Ø DMR 222, Service Selection Ø DMR 223, Notification of Waiver Services Ø DSS W-1518, HCBS Referral to Regional DSS Office Ø OPS, FAP or ISA Plan Summary q PRAT reviews eligibility and recommends approval/denial Ø Submits DMR 225, PRAT HCBS Waiver Recommendation and all documents to CO Waiver Unit q CO Waiver Unit issues final decision on enrollment and sends approval/denial and due process notice to the individual/legal representative and copies CM. q Additional Service/Support(s) requested: CM submits PRAT Request for Service/Support q PRAT reviews request and recommends approval/denial: Ø Approval: DMR 225 to CM Ø CM completes DMR 223, Notification of Services, submits to Regional Waiver Liaison Ø Regional Waiver Liaison submits to CO Waiver Unit Ø Denial: DMR 225 to CO Waiver Unit Ø CO Waiver Unit issues final decision on request and sends approval/denial to the individual/legal representative and copies CM. If approved, copies PRAT to initiate service/support planning for individual q Individual/legal representative declines or has asset/income concerns: Ø CM completes DMR 224, Reasons for Declining to Submit Medicaid and/or HCBS Waiver Application, submits to Regional Waiver Liaison Ø Regional Waiver Liaison submits to CO Waiver Unit