DDRS Waiver Manual

Recommendations

Info

Section 8: Appeal Process Sections 8.1 – 8.18 Section 8.1: Appeal Request Section 8.2: Group Appeals Section 8.3: Time Limits for Requesting Appeals Section 8.4: The Hearing Notice Section 8.5: Request for Continuance from the Appellant Section 8.6: Review of Action Section 8.7: Disposal of Appeal without a Fair Hearing Section 8.8: The Fair Hearing Section 8.9: Preparation for Hearing by Appellant Section 8.10: Preparation for Hearing by the BDDS Service Coordinator or District representative, BDDS Waiver Unit, or DDRS Central Office Section 8.11: Conduct of the Hearing Section 8.12: Continuance of Hearing Section 8.13: The Hearing Record Section 8.14: The Fair Hearing Decision Section 8.15: Actions of the Administrative Law Judge’s Decision Section 8.16: Agency Review Section 8.17: Judicial Review Section 8.18: Lawsuit Return to Table of Contents 66
Section 8.1: Appeal Request The following pertain to requests for appeal: An appeal is a request for a hearing before an administrative law judge with the Family and Social Services Administration (FSSA)/Office of General Counsel or Office of Hearings and Appeals. The purpose of an appeal is to determine whether a decision made by a service coordinator, Case Manager, waiver specialist, or the Division of Disability and Rehabilitative Services (DDRS) Central Office affecting the waiver applicant or waiver participant, was correct. An appeal request must be in writing and forwarded to the hearing authority. State Form 46015 Form HCBS 5 is used to notify each Medicaid Home and Community-Based Services (HCBS) waiver applicant or participant of any action that affects the applicant’s, participant’s, or prospective participant's: o Choice of home and community-based services as an alternative to institutional care o Medicaid benefits related to HCBS waivers, including determinations regarding level of care o HCBS waiver service actions, including reduction, termination, or denial of a service o Authorized services and service providers Providers can find an explanation regarding a waiver service applicant/participant or prospective participant’s appeal rights and the opportunity for a fair hearing on the back of the Notice of Action (NOA). Part 2 – "Your Right to Appeal and Have a Fair Hearing" advises the applicant/participant or prospective participant of his/her right to appeal and the timeliness requirements association with the right to appeal. Part 3 – “How to Request an Appeal” provides instructions regarding the procedures that are necessary in the appeal process, including the right of the appellant to authorize representation by an attorney, relative, or other spokesperson on behalf of the appellant. HCBS waiver participants are advised of the right to appeal and request a fair hearing by the Case Manager. The Case Manager provides each participant and eligible prospective participant (as well as his or her guardian or advocate, as appropriate) with a copy of the NOA. For HCBS waiver participants, an NOA is generated and sent to a participant when the Case Manager generates the Plan of Care/Cost Comparison Budget (POC/CCB) and the POC/CCB is authorized by the Division of Disability and Rehabilitative Services (DDRS)/Bureau of Developmental Disabilities Services (BDDS). The NOA specifies any adverse determination (when he or she is denied the services or the providers of his or her choice, or when actions are taken to deny, suspend, reduce, or terminate services). The NOA informs the participant (and the participant’s guardian or advocate, as appropriate) of his or her right to appeal the determination and also advises the participant that services will be continued if he or she files the appeal in a timely manner. Appeals must be received by the FSSA within 33 calendar days of the decision date noted on the NOA. When a request for entrance to the Community Integration and Habilitation (CIH) waiver program is denied, the denial letter advises the applicant of his or her right to file an appeal with the Office of General Counsel. 67
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 and 50: An individual’s behavioral condit
Page 51 and 52: An individual or the individual’s
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: (RHS) under the Community Integrati
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
Page 101 and 102: Activities that do not foster the a
Page 103 and 104: The system to be installed must be
Page 105 and 106: The monitoring base staff must have
Page 107 and 108: Electronic Monitoring may not be us
Page 109 and 110: Adaptations to service provider-own
Page 111 and 112: independence and are consistent wit
Page 113 and 114: Group supports delivered to individ
Page 115 and 116: o Small (4:1 or smaller) o Medium (
Page 117 and 118:
The data may reside in multiple loc
Page 119 and 120:
Providers must be able to indicate,
Page 121 and 122:
programmed, constructive interactio
Page 123 and 124:
The IBI Director will provide a nar
Page 125 and 126:
As applicable, monthly/quarterly re
Page 127 and 128:
participate in their communities, a
Page 129 and 130:
Homeschooling, special education, a
Page 131 and 132:
or before the fifteenth day of the
Page 133 and 134:
o Medium (5:1 to 10:1) o Larger (la
Page 135 and 136:
Services must address needs identif
Page 137 and 138:
The following activities are not al
Page 139 and 140:
maintaining natural supports, physi
Page 141 and 142:
tool for individual assessment. The
Page 143 and 144:
o o o o o Individuals receiving RHS
Page 145 and 146:
(C) requires minimal residential ha
Page 147 and 148:
as well the development, oversight,
Page 149 and 150:
Available only under the Community
Page 151 and 152:
Services furnished to a minor by a
Page 153 and 154:
Section 10.30: Speech/Language Ther
Page 155 and 156:
to be utilized in service plan deve
Page 157 and 158:
Transportation services through the
Page 159 and 160:
Bus passes or alternate methods of
Page 161 and 162:
The participant requires assistance
Page 163 and 164:
Service Standards The following ser
Page 165 and 166:
Section 11: Request for Approval (R
Page 167 and 168:
Choice of Provider The individual c
Page 169 and 170:
Reimbursement Reimbursement is avai
Page 171 and 172:
Modifications/Items - Non-Covered E
Page 173 and 174:
Authority: 42 CFR §441.302 Section
Page 175 and 176:
Total Cost $$$$$ 175
Page 177 and 178:
Items - Covered Justification and d
Page 179 and 180:
These requests should be extremely
Page 181 and 182:
Choice of Provider The individual c
Page 183 and 184:
Completed by an approved Medicaid W
Page 185 and 186:
The case management entity, working
show all

DDRS Waiver Manual

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?