Iowa Admin. Code r. 441-83.125 - Redetermination
Current through Register Vol. 44, No. 12, December 15, 2021
The department shall redetermine a consumer's eligibility for the children's mental health waiver at least once every 12 months or when there is significant change in the consumer's situation or condition.
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441—83.125(249A) Redetermination. The department shall redetermine a consumer’s eligibility for the children’s mental health waiver at least once every 12 months or when there is significant change in the consumer’s situation or condition.
83.125(1) Eligibility review.
a. Every 12 months, the department shall review a consumer’s eligibility in accordance with procedures in rule 441—76.7(249A). The review shall verify continuing eligibility factors as specified in rule 441—83.122(249A).
b. The IME medical services unit or a managed care organization shall review the member’s need for continued care annually and recertify the member’s need for long-term care services, pursuant to rule 441—83.122(249A) and the appeal process at rule 441—83.129(249A), based on the completed information submission tool designated in 83.122(3) and other supporting documentation as relevant.
c. The IME medical services unit or the member’s managed care organization shall be responsible for annual redetermination of the level of care.
d. The managed care organization must submit documentation to the IME medical services unit for all reassessments, performed at least annually, which indicate a change in the member’s level of care. The IME medical services unit shall make a final determination for any reassessments which indicate a change in the level of care. If the level of care reassessment indicates no change in level of care, the member is approved to continue at the already established level of care.
83.125(2) Continuation of eligibility. A consumer’s waiver eligibility shall continue until one of the following conditions occurs.
a. The consumer fails to meet eligibility criteria listed in rule 441—83.122(249A).
b. The consumer is an inpatient of a medical institution for 120 or more consecutive days.
(1)After the consumer has spent 120 consecutive days in a medical institution, the local office shall terminate the consumer’s waiver eligibility and review the consumer for eligibility under other Medicaid coverage groups. The local office shall notify the consumer and the consumer’s parents or legal guardian through Form 470-0602, Notice of Decision.
(2)If the consumer returns home after 120 consecutive days, the consumer must reapply for children’s mental health waiver services, and the IME medical services unit must redetermine the consumer’s level of care.
c. The consumer does not reside at the consumer’s natural home for a period of 60 consecutive days. After the consumer has resided outside the home for 60 consecutive days, the local office shall terminate the consumer’s waiver eligibility and review the consumer for eligibility under other Medicaid coverage groups. The local office shall notify the consumer and the consumer’s parents or legal guardian through Form 470-0602, Notice of Decision.
83.125(3) Payment slot. When a consumer loses waiver eligibility, the consumer’s assigned payment slot shall revert for use to the next consumer on the waiting list.
[ARC 2361C, IAB 1/6/16, effective 1/1/16; ARC 3184C, IAB 7/5/17, effective 8/9/17; ARC 3234C, IAB 8/2/17, effective 9/6/17]