7 AAC 130.219 - Enrollment in home and community-based waiver services; disenrollment

(a) The department will enroll an applicant, determined eligible under 7 AAC 130.205, in the recipient category for which the recipient is qualified if the department determines that enrolling the applicant will not bring the department out of compliance with the terms of the waiver approved under 42 U.S.C. 1396 n(c) by exceeding the

(1) number of recipients approved for participation in the waiver program for the applicable recipient category; or

(2) average per capita expenditure limit on home and community-based waiver services for the applicable recipient category.

(b) The department will notify

(1) an applicant, determined eligible under 7 AAC 130.205, that the applicant may choose between home and community-based waiver services and institutional care in a nursing facility or ICF/IID; the applicant's choice of service must be documented in a format provided by the department; and

(2) a recipient, determined eligible and enrolled in a recipient category for home and community-based waiver services under 7 AAC 130.205, that the recipient may choose to receive home and community-based waiver services from any provider that

(A) is certified under 7 AAC 130.220; and

(B) provides the home and community-based waiver service for which the recipient is eligible.

(c) The department will consider the recipient to be enrolled under this section after the recipient has

(1) submitted an application under 7 AAC 130.207;

(2) been approved for assessment under 7 AAC 130.211;

(3) been assessed or has received an interim level-of-care review under 7 AAC 130.213;

(4) met the level-of-care requirement under 7 AAC 130.215; and

(5) received an approved support plan under 7 AAC 130.217 and 7 AAC 130.218.

(d) The earliest date that an individual is eligible to receive home and community-based waiver services is the date when all of the requirements in (c) of this section have been met.

(e) The department will disenroll a recipient for any of the following reasons:

(1) the department terminates its participation in the waiver program under 42 U.S.C. 1396 n(c);

(2) the department is unable to determine eligibility for home and communitybased waiver services because the documentation required under 7 AAC 130.217 and 7 AAC 130.218 to determine the recipient's continuing eligibility for services was not submitted by the recipient, the recipient's representative, or the recipient's care coordinator at least 30 days before expiration of the current plan year;

(3) the recipient is no longer eligible for Medicaid coverage under AS 47.07.020 or 7 AAC 100.002;

(4) the recipient is no longer eligible for services because the recipient's assessment interim level-of-care review, or reassessment, conducted in accordance with 7 AAC 130.213(c) - (f), indicates the condition that made the recipient eligible for services has materially improved since the previous assessment, and

(A) the annual assessment and determination or the interim level-of- care review and determination, have been reviewed in accordance with AS 47.07.045(b)(2) using the department's

(i) Material Improvement Reporting for CCMC Waivers, adopted by reference in 7 AAC 160.900, if the recipient is in the recipient category of children with complex medical conditions;

(ii) Material Improvement Reporting for IDD Participants Under The Age of Three, adopted by reference in 7 AAC 160.900, if the recipient is younger than three years of age and in the recipient category of individuals with intellectual and developmental disabilities;

(iii) Material Improvement Reporting for IDD Participants Age Three or Over, adopted by reference in 7 AAC 160.900, if the recipient is three years of age or older and in the recipient category of individuals with intellectual and developmental disabilities; or

(iv) Material Improvement Reporting for ALI/APDD Waivers, adopted by reference in 7 AAC 160.900, if the recipient is in the recipient category of older adults or adults with physical disabilities or in the recipient category of adults with physical and developmental disabilities; and

(B) the reviewer confirms to the department that the condition that made the recipient eligible for services has materially improved;

(5) the recipient or the recipient's representative chooses to end the recipient's participation in the home and community-based waiver services program;

(6) the recipient or the recipient's representative misrepresents the recipient's physical, intellectual, developmental, or medical condition in an effort to obtain services that are not medically necessary or for which the recipient does not qualify;

(7) the recipient has a documented history of failing to cooperate with the delivery of services identified in the support plan prepared under 7 AAC 130.217 and 7 AAC 130.218, or of placing caregivers or other recipients at risk of physical injury, and no other providers are willing to provide services to the recipient; for the purposes of this paragraph, a documented history exists if a provider

(8) the recipient or the recipient's representative fails to take an action or to submit documentation required under 7 AAC 130.209 - 7 AAC 130.218.

(A) reports that the provider has been unable obtain cooperation with service delivery or to mitigate the risk of physical injury to a caregiver or other recipients through reasonable accommodation of the recipient's disability; and

(B) maintains records to support that report, and makes those records available to the department for inspection; the department will review those records before making a decision on disenrollment under this paragraph

(f) An applicant or recipient that is denied enrollment for home and community-based waiver services, or a recipient that is disenrolled for reasons described in (e) of this section, may appeal that decision under 7 AAC 49.

Notes

7 AAC 130.219

Eff. 7/1/2013, Register 206; am 7/1/2015, Register 214, July 2015; am 11/5/2017, Register 224, January 2018; am 3/3/2021, Register 238, July 2021

Authority: AS 47.05.010

AS 47.07.030

AS 47.07.040

AS 47.07.045