13 CSR 70-3.280 - Home and Community-Based Services Waiver Definitions
(1)
"Enroll/Enrollment" is the process that Missouri Medicaid Audit and Compliance
(MMAC) uses to establish eligibility to receive a Medicaid billing number
and/or Medicaid billing privileges. The process includes-
(A) Identification of a provider;
(B) Validation of the provider's eligibility
to provide items or services to Medicaid beneficiaries;
(C) Identification and confirmation of the
provider's practice location(s) and owner(s); and
(D) Granting the provider Medicaid billing
privileges and/or a Medicaid billing number.
(2) "Heightened Scrutiny" is a process
whereby a provider submits information to Department of Social Services (DSS),
or its designee, to overcome the presumption that the setting has the qualities
of an institution. If DSS or its designee, based on the information presented
by the provider, determines that the setting does have the qualities of a home
and community-based setting, the evidence will be sent to the Centers for
Medicare and Medicaid Services. The Centers for Medicare and Medicaid Services
will review evidence submitted by the state and make a final determination as
to whether the evidence is sufficient to overcome the presumption that the
setting has the qualities of an institution. These settings include those in a
publicly or privately-owned facility that provide inpatient treatment; are on
the grounds of, or are immediately adjacent to, a public institution; or that
have the effect of isolating individuals receiving Medicaid-funded Home and
Community-Based Services (HCBS) from the broader community of individuals not
receiving Medicaid-funded HCBS.
(3)
"Home and Community-Based Services" are MO HealthNet Division covered services
provided to individuals in their own home or community rather than in a
hospital, nursing home, or intermediate care facility for individuals with
intellectual disabilities.
(4)
"Home and Community-Based Services Waiver" is a program approved by the Centers
for Medicare and Medicaid Services under the authority of Section 1915(c) of
the Social Security Act that provides home and community based
services.
(5) "Hospital" is a
facility licensed by the Missouri Department of Health and Senior Services, or
by the appropriate state agency for facilities located in another state, as an
acute care, psychiatric or rehabilitation hospital.
(6) "Institution for Mental Diseases (IMD)"
is a hospital, nursing facility, or other institution of seventeen (17) beds or
more that is primarily engaged in providing diagnosis, treatment, or care of
people with mental diseases.
(7)
"Intermediate Care Facilities for individuals with Intellectual disability
(ICF/IID)" is a facility as defined at
19 CSR
30-83.010(24).
(8) "Missouri Medicaid Audit and Compliance
Unit (MMAC)" is the unit within the Department of Social Services that is
responsible for the oversight and auditing of compliance for the Medicaid Title
XIX, CHIP Title XXI, and Waiver Program in Missouri, which includes the
oversight and auditing of compliance of MO HealthNet providers and Medicaid
participants through the lock-in program. MMAC is charged with the
responsibility of detecting, investigating, and preventing fraud, waste, and
abuse of the Missouri Medicaid Title XIX, CHIP Title XXI, and Waiver
Programs.
(9) "MO HealthNet" is the
division within the Department of Social Services, pursuant to sections
208.001 and
208.201, RSMo, that administers
the Medicaid Title XIX, CHIP Title XXI, and waiver programs, approves claims
from MO HealthNet providers for services or merchandise provided to eligible
Medicaid participants, and authorizes and disburses payment for those services
or merchandise accordingly.
(10)
"MO HealthNet Program" is a program operated pursuant to Title XIX of the
Social Security Act, Title XXI of the Social Security Act and/or waiver
programs authorized by the United States Department of Health and Human
Services.
(11) "Licensed Nursing
Home" is a skilled nursing facility as defined at
19 CSR
30-83.010(49).
(12) "Person-Centered Service Plan" is a
document that is the result of a planning process which identifies the
strengths, capacities, preferences, needs, goals, and desired personal outcomes
of the individual.
(13) "Provider"
is a person or entity who enters into a contract or provider agreement with
MMAC for the purpose of providing items or services to Missouri Medicaid
participants. Provider includes ordering and referring physicians, dentists,
and nonphysician practitioners.
(14) "Provider Owned or Controlled
Residential Setting" is a physical place where an individual resides and is
owned, co-owned, and/or operated by a provider of HCBS. A setting is considered
provider owned or controlled if the HCBS provider leases from a third party or
owns the property. If the HCBS provider does not lease or own the property but
has a direct or indirect financial relationship with the property owner, the
setting is considered provider controlled unless the property owner or provider
establishes that the nature of the relationship did not affect either the care
provided or the financial conditions applicable to tenants.
(15) "Residential Setting" is a physical
place to live where an individual has services and supports, ranging from
twenty-four- (24-) hour supervision to on-call assistance, to live as
independently as possible.
(16)
"Revalidation" is a requirement that all existing MO HealthNet Program
providers must go through in accordance with 13 CSR 65-2 to continue to be a MO
HealthNet Program provider.
(17)
"Setting" is the place where a home and community-based service or support is
provided.
Notes
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