RELATES TO:
KRS
205.520,
205.5605,
205.5606,
205.5607,
42 C.F.R. 431 Subpart E, 441 Subpart G,
42 U.S.C.
1396a,
1396b,
1396d,
1396n
NECESSITY, FUNCTION, AND CONFORMITY: The Cabinet for Health and
Family Services, Department for Medicaid Services, has responsibility to
administer the Medicaid Program.
KRS
205.520(3) authorizes the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed, or opportunity presented, by federal law to qualify for federal
Medicaid funds. This administrative regulation establishes the policies
governing 1915(c) waiver waiting lists, and governs the circumstances under
which an appeal will be granted if emergency status is not granted for a
waiting list for the Supports for Community Living waiver.
Section 1. Definitions.
(1) "1915(c) waiver program" means a Kentucky
Medicaid program established pursuant to, and in accordance with,
42 U.S.C.
1396n(c).
(2) "Department" means the Department for
Medicaid Services.
(3) "Emergency
category of need" means an order of waiting list placement, including the
placement described in
907
KAR 12:010, Section 12(3)(b), for the Supports for
Community Living (SCL) waiver.
(4)
"Good cause" means a circumstance that:
(a) Is
beyond the control of an individual and affects the individual's ability to
access funding or services; and
(b)
Includes:
1. An illness or hospitalization of
the individual that is expected to last sixty (60) days or less;
2. The required paperwork and documentation
for processing in accordance with Section 2 of this administrative regulation
has not been completed, but is expected to be completed in two (2) weeks or
less; or
3. The individual or his
or her guardian has made diligent contact with a potential provider to secure
placement or access services, but has not been accepted within the sixty (60)
day time period.
(6) "Slot" means an allocation of funding
available for placing an individual in a 1915(c) waiver program.
Section 2. Waiting Lists.
(1) Notwithstanding other provisions
established in KAR Title 907, the provisions of this section and Section 3 of
this administrative regulation shall control in relation to the department's
policy relating to 1915(c) waiting lists and appeals relating to waiting list
placement.
(2) As appropriate, each
1915(c) waiver program shall maintain a statewide waiting list.
(3) If an applicant for a 1915(c) waiver
program meets that waiver's criteria for waiting list placement and there are
no available slots at the time, the applicant shall be placed on the waiting
list for that waiver.
(4) The
department shall send a written notification of placement on the waiting list
to the applicant, the applicant's legal guardian, or authorized
representative.
(5) At least
annually, the department shall contact each individual, the individual's legal
guardian, or authorized representative, on any 1915(c) waiver waiting list
program to verify:
(a) The accuracy of the
individual's information; and
(b)
Whether the individual wishes to continue to pursue enrollment in the
applicable waiver program.
(6) The department shall remove an individual
from a waiting list if:
(a) The individual is
deceased;
(b) A review of
documentation reveals that the individual does not have a diagnosis that
qualifies for the applicable 1915(c) waiver;
(c) The individual has relocated to a primary
residence outside of the Commonwealth of Kentucky; or
(d) The department notifies the individual,
the individual's legal guardian, or authorized representative of potential
funding approved to enroll the individual in the applicable waiver program and
the individual, individual's legal guardian, or authorized representative:
1. Within sixty (60) calendar days of the
potential funding notice, declines the potential funding for enrollment in the
program:
a. Expressly;
b. By not completing the enrollment process,
or
c. By not asking for a good
cause extension to complete the enrollment process within sixty (60) calendar
days of the potential funding notice date; and
2. Does not request to remain on the waiting
list.
(7)
After being notified by the department of potential funding approved to enroll
the individual in the waiver program, the individual shall maintain his or her
current position on the waiting list if the individual and, if applicable, the
individual's legal guardian or authorized representative:
(a) Declines the potential funding;
and
(b) Requests to remain on the
waiver waiting list.
(8)
If the department denies a request for emergency category of need, the
department shall send written notice of the denial, including a notice of
appeal rights, in accordance with 42 C.F.R. Part
431 Subpart E and
907
KAR 1:563, to:
(a)
The individual and, if applicable, the individual's legal guardian or
authorized representative; and
(b)
The individual's case manager, waiver case manager, or participant directed
services case manager if the individual has a waiver case manager or
participant directed services case manager.
(9) The removal of an individual from a
1915(c) waiting list shall not preclude the individual from applying for
participation with any 1915(c) waivers in the future.
(10) If the department removes an individual
from a 1915(c) waiver program waiting list, the department shall send written
notice of the removal, including a notice of appeal rights in accordance with
42 C.F.R. Part
431 Subpart E and
907
KAR 1:563, to:
(a)
The individual, and, if applicable, the individual's legal guardian or
authorized representative; and
(b)
The individual's waiver case manager or participant directed services case
manager if the individual has a waiver case manager or participant directed
services case manager.
(11)
(a) If
requested the department shall grant an appeal regarding an application of this
administrative regulation.
(b) All
appeals shall, as appropriate, be in accordance with
907
KAR 1:563.
(12) The hearing shall be conducted in
accordance with
907
KAR 1:563.
Section 3. Waiting List Emergency Category
Within the Supports for Community Living Waiver. An individual shall be placed
on the waiting list for the Supports for Community Living waiver in the order
of receipt of application in the MWMA. An individual on a waiting list shall be
categorized as established in this section.
(1)
(a)
Notwithstanding the emergency criteria established in
907
KAR 12:010, Section 12(3)(b), an individual's category
of need shall be in the emergency category if the supporting documentation
requirements and request for emergency category of need in the 1915(c) waiver
program submitted to the department, indicate that an immediate service is
needed due to any of the following, if all other applicable and appropriate
service options have been exhausted or determined as inappropriate:
1. Abuse, neglect, or exploitation of the
individual as substantiated by the Department of Community Based
Services;
2. The death of the
individual's primary caregiver and lack of an alternative primary
caregiv-er;
3. The lack of
appropriate living arrangement placement due to:
a. Loss of housing;
b. Loss of funding sources including 1915(c)
waiver funding sources; or
c.
Imminent discharge from a temporary placement;
4. Jeopardy to the health and safety of the
individual due to the primary caregiver's inability to provide all care needed
due to the primary caregiver's:
a. Physical
health status; or
b. Mental health
status;
5. Imminent or
threat of imminent institutionalization if 1915(c) home and community based
waiver program services are not provided; or
6. Present institutionalization and the
applicant is not opposed to community placement in the most integrated setting
appropriate to the applicant's needs; and
(b) The individual:
1. Does not have a combination of care needs
beyond the capability of the supports for community living waiver program;
or
2. Does not pose a serious
potential danger to the health, safety, and welfare of the individual, other
participants, or staff.
(2) An individual on the waiting list who
does not meet the requirements for the emergency category of need pursuant to
subsection (1) of this section shall be placed in the future planning or urgent
category of the Supports for Community Living waiting list, in accordance with
907
KAR 12:010.
(3) Priority on a waiting list shall first be
given to those on the emergency category, then to others on the waiting list.
However, within each category, the order shall remain the same, based on when
the recipient applied for Supports for Community Living waiver
services.
Section 4.
Federal Approval and Federal Financial Participation. The department's coverage
of any services established in this administrative regulation shall be
contingent upon:
(1) Receipt of federal
financial participation; and
(2)
Centers for Medicare and Medicaid Services' approval.