DDRS Waiver Manual

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equires a higher budget to meet his or her needs. If the IST identifies one or more of the unanticipated events listed below that it believes increases the short-term needs of the individual, it shall contact the individual’s waiver Case Manager to request a BMR. The individual’s Case Manager is responsible for submitting the initial BMR. Upon receipt of a request from the IST, the waiver Case Manager shall complete the BMR and attach all required documentation in the BDDS’ case management system. If approved, the increased budget shall not exceed 180 calendar days. Unanticipated events are defined as: a. Loss of a housemate due to: i. death; ii. extended hospitalization of fourteen (14) or more calendar days; iii. nursing facility respite stay of fourteen (14) or more calendar days; iv. incarceration of fourteen (14) or more calendar days; v. substantiated abuse, neglect, or exploitation; vi. needed intervention for behavioral needs; vii. needed intervention for health or medical needs; or viii. inability to share staffing b. Loss of employment. c. State substantiated abuse, neglect, or exploitation. d. Behavioral needs requiring intervention. e. Extraordinary Health or medical needs requiring intervention. Documentation requirements for Budget Modification Requests include, but are not limited to, the following: For BMRs resulting from needed intervention for behavior needs, documentation shall include: Documentation of behavior data for past 30 to 90 calendar days; Documentation regarding changes to the individual’s behavior plan that have already occurred prior to the submission of the BMR; and If the IST anticipates that the behaviors will last longer than 90 calendar days, the waiver Case Manager should complete a Budget Review Questionnaire (BRQ) instead of the BMR. For BMRs resulting from a loss of a housemate, the IST shall provide documentation that includes: A schedule identifying when each service is being used, including non-Residential Habilitation and Support (RHS) services activities; and A plan with strategies that IST will use to find a new housemate. The documentation must demonstrate the alternative support options the IST considered before making the submission. The following is a non-exhaustive list of potential alternative support options: Shared staffing with housemates; Electronic monitoring services; Medicaid prior authorization services; and Family and community supports The waiver Case Manager may submit an additional BMR with supporting documentation and ongoing status reports on a month-to-month basis not to exceed a period of 180 calendar days from the initial unanticipated event if a short-term budget is required after 90 calendar days. The DDRS/Bureau of Developmental Disabilities Services (BDDS) responds to new BMRs within seven business days of submission. Final decisions on BMRs are not made until Case Managers respond to all inquiries from the DDRS/BDDS. 50
An individual or the individual’s legal representative may appeal the Algo if he or she feels the Algo is inaccurate. The consumer or legal guardian has the right to appeal any waiver-related decision of the State within 33 calendar days of Notice of Action (NOA). A NOA is issued with the release of each State decision pertaining to a Plan of Care/Cost Comparison Budget (POC/CCB). Each NOA contains the consumer’s appeal rights, as well as instructions for filing an appeal. Note: The BRQ and BMR processes are not used with the already capped Family Supports Waiver Section 6.6: Implementation of Objective Based Allocations The Case Manager for each individual participating in the Community Integration and Habilitation (CIH) Waiver program receives the new OBA three months before the participant’s annual renewal date. The Case Manager must review the OBA with the participant and his or her Individual Support Team (IST) prior to the development of a new annual service plan. If there has been a significant change in the life of the participant, with agreement of the IST, the Case Manager is responsible for requesting a Budget Review Questionnaire (BRQ) (see Section 6.5). Note that the OBA is not used with the Family Supports Waiver. Section 6.7: Personal Allocation Review (PAR) and the Appeal Process Applicable only to participants in the Community Integration and Habilitation Waiver program, an IST may request a PAR (personal allocation review) through the Case Manager via a BRQ. The BRQ states the reason for allocation review. The full list of acceptable reasons for allocation review is found in Section 6.5, but examples include: The IST believes the Algo level is incorrect The IST believes the ICAP assessment has significant errors The IST believes the ICAP addenda (behavioral and health factors) are incorrect The BRQ is submitted by the Case Manager to the Bureau of Developmental Disabilities Services (BDDS). The BRQ and supporting documentation and information are reviewed by the Personal Allocation Review (PAR) unit within the DDRS. The PAR unit determines whether an individual’s Algo score is supported based on the provided information. BDDS reviews the BRQ within seven business days of submission. If additional documentation is needed the PAR unit may request that the individual’s Case Manager submit additional information to support the BRQ. If, after 90 calendar days, the Case Manager fails to provide the requested additional information, the PAR unit shall deny the request to modify the individual’s budget allocation. If the documentation provided with the BRQ is complete, the PAR unit shall determine an individual’s budget allocation and the duration of the budget allocation increase, and, if appropriate, determines a new Algo and budget allocation if it finds that the individual’s Algo changed. The PAR unit will notify the waiver Case Manager of any changes in the Algo or allocation. If a change in the Algo 51
Page 1 and 2: 2016 DDRS Waiver Manual Our Mission
Page 3 and 4: Section 1: Roles and Responsibiliti
Page 5 and 6: Section 7.5: State Authorization of
Page 7 and 8: Section 10.23: Psychological Therap
Page 9 and 10: Section 1.1: The Centers for Medica
Page 11 and 12: ules or standards that may affect t
Page 13 and 14: Information Sharing The Individual
Page 15 and 16: Here are some tips on what to discu
Page 17 and 18: 6. Does each person have his or her
Page 19 and 20: Section 3: Additional Medicaid Prog
Page 21 and 22: HCBS waiver services. HCBS waiver p
Page 23 and 24: Section 4.1: Medicaid Waiver Overvi
Page 25 and 26: Section 4.4: Coordination with Medi
Page 27 and 28: personal beliefs and customs, ensur
Page 29 and 30: Section 5.1: Request for Applicatio
Page 31 and 32: Internet access, call toll free 1-8
Page 33 and 34: understanding and use of language,
Page 35 and 36: If an individual declines the offer
Page 37 and 38: waiver slot when it appears that th
Page 39 and 40: Five calendar days to interview and
Page 41 and 42: The individual or guardian has sign
Page 43 and 44: Section 6: Objective Based Allocati
Page 45 and 46: adjustments to the allocation amoun
Page 47 and 48: BMAN Reserve $0 $0 $2,620.80 $5,241
Page 49: An individual’s behavioral condit
Page 53 and 54: Your Appeal Right as an Applicant f
Page 55 and 56: Section 7.1: Level of Care Re-Evalu
Page 57 and 58: RN/LPN, who must be actively involv
Page 59 and 60: o Children receiving adoption assis
Page 61 and 62: including the DDRS Case Management
Page 63 and 64: When the individual “Re-Enters”
Page 65 and 66: (RHS) under the Community Integrati
Page 67 and 68: Section 8.1: Appeal Request The fol
Page 69 and 70: Objective-based allocation (OBA): T
Page 71 and 72: administrative hearing must still b
Page 73 and 74: The person testifying should be the
Page 75 and 76: In all cases, the decision of the A
Page 77 and 78: Section 9.1: Overview The Family an
Page 79 and 80: Structural or environmental issues
Page 81 and 82: implemented in order to ensure that
Page 83 and 84: conducted by the ombudsman must als
Page 85 and 86: Section 10.24: Recreational Therapy
Page 87 and 88: Medicaid Waiver Services, Codes, an
Page 89 and 90: FSW CIH MFP- CIH INsite Code Servic
Page 91 and 92: The Case Manager should give the co
Page 93 and 94: Aversive techniques - any technique
Page 95 and 96: Services delivered to persons who d
Page 97 and 98: where services are not rendered wit
Page 99 and 100: Section 10.7: Community Based Habil
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Activities that do not foster the a
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The system to be installed must be
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The monitoring base staff must have
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Electronic Monitoring may not be us
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Adaptations to service provider-own
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independence and are consistent wit
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Group supports delivered to individ
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o Small (4:1 or smaller) o Medium (
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The data may reside in multiple loc
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Providers must be able to indicate,
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programmed, constructive interactio
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The IBI Director will provide a nar
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As applicable, monthly/quarterly re
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participate in their communities, a
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Homeschooling, special education, a
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or before the fifteenth day of the
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o Medium (5:1 to 10:1) o Larger (la
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Services must address needs identif
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The following activities are not al
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maintaining natural supports, physi
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tool for individual assessment. The
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o o o o o Individuals receiving RHS
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(C) requires minimal residential ha
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as well the development, oversight,
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Available only under the Community
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Services furnished to a minor by a
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Section 10.30: Speech/Language Ther
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to be utilized in service plan deve
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Transportation services through the
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Bus passes or alternate methods of
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The participant requires assistance
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Service Standards The following ser
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Section 11: Request for Approval (R
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Choice of Provider The individual c
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Reimbursement Reimbursement is avai
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Modifications/Items - Non-Covered E
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Authority: 42 CFR §441.302 Section
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Total Cost $$$$$ 175
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Items - Covered Justification and d
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These requests should be extremely
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Choice of Provider The individual c
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Completed by an approved Medicaid W
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The case management entity, working
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DDRS Waiver Manual

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