DDRS Waiver Manual

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Additionally, participants of the CIH waiver have the right to appeal the assessment used to determine the objective-based allocation amount. On request, the Case Manager may advise the participant on how to prepare the written request for appeal and fair hearing. The Case Manager may advise the participant of the required time frames, the address for submission of the appeal, and provide an opportunity to discuss the issue being appealed, but due to conflict free Case Management requirements, the Case Manager may not file an appeal or appear on behalf of a participant at an appeal hearing unless they are the Medicaid Authorized representative noted on the participant’s record with the Division of Family Resources (DFR), as doing so could result in a conflict of interest. The request for an appeal and a fair hearing is recorded in a case note by the Case Manager as well as recorded at the FSSA’s Hearing and Appeals office. Section 8.2: Group Appeals The following pertain to group appeals: The FSSA’s Office of General Counsel or Office of Hearings and Appeals may respond to a series of requests for hearings by providing group hearings, on similar questions or changes in federal or State law or regulation. Similarly, a group of individuals that wishes to appeal some aspect of policy may request to be heard as a group. If there is disagreement as to whether the issue is one of federal or State law or regulation or the facts of an appellant’s personal situation, Hearings and Appeals makes the decision as to whether the appeal may be included in a group hearing. The administrative law judge may limit the discussion in a group hearing to the sole issue under appeal. When an appellant’s request for a hearing involves additional issues to the issue serving as the basis for the group hearing, the appeal is handled individually. An appellant scheduled for a group hearing may choose to withdraw and be granted an individual hearing, even if the grievance is limited to the sole issue involved in the group hearing. Policies governing the conduct of individual hearings are pertinent to group hearings. Each appellant (or representative) is given full opportunity to present the case (or have a representative present the case). Section 8.3: Time Limits for Requesting Appeals The following are time limits for requesting appeals: Plan of Care/Cost Comparison Budget (POC/CCB): The applicant, participant, or his or her legal guardian/authorized representative has the right to appeal any waiver-related decision of the State. An NOA is issued with the release of each State decision pertaining to a POC/CCB. Each NOA contains the appeal rights of the applicant/participant, as well as instructions for filing an appeal. The appeal must be received by FSSA within 33 calendar days of NOA. 68
Objective-based allocation (OBA): The participant, or his or her legal guardian/authorized representative, has the right to appeal the OBA within 30 calendar days of the NOA. Each NOA contains the appeal rights of the participant, as well as instructions for filing an appeal. Developmentally Disabled (DD) eligibility: The applicant, participant, or his or her legal guardian/authorized representative has the right to appeal DD eligibility within 15 calendar days of the decision. The decision letter will contain the appeal rights of the applicant/participant, as well as instructions for filing an appeal. Individuals with Intellectual Disabilities (IID) level of care (LOC): The applicant, participant, or his or her legal guardian/authorized representative has the right to appeal level of care within 15 calendar days of the decision. The decision letter contains the appeal rights of the applicant/participant, as well as instructions for filing an appeal. Reserved <strong>Waiver</strong> Capacity (priority criteria): The applicant, participant, or his or her legal guardian/authorized representative has the right to appeal a denial for entrance to the waiver via priority criteria within 18 calendar days of the decision. The decision letter will contain the appeal rights of the applicant/participant, as well as instructions for filing an appeal. Section 8.4: The Hearing Notice The FSSA’s Office of General Counsel or Office of Hearings and Appeals sends a notice acknowledging the appeal to the individual filing the appeal. The Notice of Scheduled Hearing is then sent to all parties, which includes the individual (the representative), the service coordinator, and the Case Manager. The <strong>DDRS</strong> Central Office also receives a notice if the central office was involved in the decision. The Notice of Scheduled Hearing The Notice of Scheduled Hearing contains the following: Includes a statement of the date, time, place, and nature of the hearing, which, For budget-related issues, is always conducted in the appellant’s county of residency or by phone; and For DD and/or waiver eligibility-related issues, is conducted by phone. Advises the appellant of the name, address, and telephone number of the person to notify in the event it is not possible for him or her to attend. Specifies that the hearing request will be dismissed if the appellant fails to appear for the hearing without good cause. Specifies that the appellant may request a continuance of the hearing if good cause is shown. Includes the appellant’s rights, information, and procedures to provide the appellant or representative with an understanding of the hearing process. Explains that the appellant may examine the case record prior to the hearing. 69
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2016 DDRS Waiver Manual Our Mission
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Section 1: Roles and Responsibiliti
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Section 7.5: State Authorization of
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Section 10.23: Psychological Therap
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Section 1.1: The Centers for Medica
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ules or standards that may affect t
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Information Sharing The Individual
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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 and 66: (RHS) under the Community Integrati
Page 67: Section 8.1: Appeal Request The fol
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
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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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