Fla. Admin. Code Ann. R. 65G-4.0218 - Significant Additional Need Funding

(1) Supplemental funding for Significant Additional Needs (SANs) may be of a one-time, temporary, or long-term in nature.

(2) The presence of a significant additional need or significant change in condition or circumstance alone does not warrant an increase in the amount of funds allocated to a client's iBudget as determined by the algorithm.

(3) A client's annual expenditures for home and community-based services Medicaid Waiver services may not exceed the limits of his or her iBudget. The total of all clients' projected annual iBudget expenditures may not exceed the Agency's appropriation for Waiver services.

(4) SANs can only be approved after the determination of a client's initial allocation amount and after the WSC has documented the availability of non-Waiver resources on the Verification of Available Services form. Nothing in this section prohibits the authorization of emergency services on a temporary basis through the Agency. Requests for SANs require:

(a) The client to have a significant additional need as defined in this chapter; and

(b) A significant additional need cannot be created by failing to maintain sufficient funds to cover services previously authorized in accordance with subsections 65G-4.0215(2) and (5), F.A.C.

(5) The WSC shall submit a SANs request that reflects the specific Waiver services and supports that will assist the client to meet identified needs, with all required supporting documentation as specified in the WSC Job Aid for Cost Plans and Significant Additional Needs Documentation. The documentation identified in the WSC Job Aid is material to the SANs requests. The Agency must close or deny the SANs request without such documentation.

(a) The SANs request shall be submitted indicating how the current budget allocation and requested SANs funds would be used. The request should also include an explanation of why additional funding is needed, and any additional documentation appropriate to support the request.

(b) The SANs request shall be submitted with an updated support plan, which must include an explanation of why additional funding is needed and indicate how the current budget allocation and requested SANs funds would be used. The request must include documentation appropriate to support the request in accordance with the WSC Job Aid for Cost Plans and Significant Additional Needs Documentation form.

(c) Documentation of attempts within the last 30 days prior to submitting the SANs request to locate natural or community supports, third-party payers, or other sources of support to meet the client's health and safety needs must also be documented and verified by the WSC on the Verification of Available Services form.

(d) If there are any concerns about the accuracy of the QSI results, the WSC shall submit this as well.

(6) If a client's iBudget Amount includes Significant Additional Needs beyond what was determined by the Allocation Algorithm, and the Agency determines that the intensity, frequency or duration of the service(s) is no longer medically necessary, the Agency will adjust the client's services to match the current need.

(7)

(a) The Agency will not consider incomplete SANs requests due to lacking material information to determine whether SANs criteria are met. A SANs request is incomplete if it does not:

1. Provide detail the client's current approved services, including the number and type of units and dollar amount for each service. The client to staff ratio, if applicable, must also be included;

2. Clearly indicate whether the current approved services are requested to continue on an annualized basis;

3. Clearly identify any new or increased services being requested in the current fiscal year and on an annualized basis, if applicable to that service type;

4. Include a complete Verification of Available Services form;

5. Include documentation to support the information provided in the Verification of Available Services Form, or identify the location of the currently valid documentation in the designated data management system;

6. Place the request in the proper status for submission in the designated data management system; or

7. Include certification that the request meets the criteria for SANs.

(b) The Agency shall close incomplete SANs requests upon receipt.

(8) The Agency will request the documentation and information necessary to evaluate a client's increased funding requests based on the client's needs and circumstances. The documentation will vary according to the funding request and may include the following as applicable: support plans, results from the Questionnaire for Situational Information, cost plans, expenditure history, current living situation, interviews with the client and his or her providers and caregivers, prescriptions, data regarding the results of previous therapies and interventions, assessments, and provider documentation.

(9) Within 30 days of receipt of a request for SANs funding, and adjustments in the client's service array, the Agency shall approve, deny (in whole or in part), or request additional documentation concerning the request.

(a) If the request does not include all necessary documentation, the Agency shall provide the client and WSC with a written notice of what additional documentation is required. The client or WSC shall provide the documentation within 10 days, or notify the Agency in writing that the client wishes the Agency to render its decision based upon the documentation provided.

(b) If additional documentation is requested, the deadline for the Agency's response shall be extended to 60 days following the receipt of the original request. If the client has not received a notice from the Agency approving, denying or requesting additional information within 60 days, the client or WSC may notify the Agency in writing of such failure to issue a timely notice and the Agency shall have 20 days from receipt of the Notice to approve or deny the request.

(c) Failure of the Agency to issue this Notice within 20 days shall mean the requested funding for services are authorized as of the 21st day, and the client and service providers may treat the authorization as an approval.

(10) Individual and Family Supports (IFS) funding may cover temporary emergency services pursuant to Chapter 65G-13, F.A.C., while requests for Significant Additional Needs are being processed.

(11) This rule shall be reviewed, and if necessary, renewed through the rulemaking process five years from the effective date.

Notes

Fla. Admin. Code Ann. R. 65G-4.0218

Rulemaking Authority 393.501(1), 393.0662 FS. Law Implemented 393.063, 393.0662, 409.906 FS.

Adopted by Florida Register Volume 42, Number 120, June 21, 2016 effective 7/7/2016, Amended by Florida Register Volume 47, Number 012, January 20, 2021 effective 7/1/2021.

New 7-7-16, Amended 7-1-21.