9 CSR 45-2.015 - Prioritizing Access to Funded Services

9 CSR 45-2.015. Prioritizing Access to Funded Services

PURPOSE: This rule establishes how individuals otherwise eligible for services will be selected for funded services and programs administered by the Department of Mental Health, Division of Developmental Disabilities, when services cannot be provided to all eligible individuals with developmental disabilities in the state of Missouri through the funding that is appropriated.

(1) Definitions.

(A) Autism waiver-A set of services, not including residential services, for children eligible for Medicaid, who have been diagnosed by a licensed physician, psychologist, or mental health professional to have autism or autism spectrum disorder and who have been determined to otherwise require the level of care provided in an intermediate care facility for developmental disabilities (ICF/DD).

(B) Community services-Supports funded and purchased through the Department of Mental Health Purchase of Service (POS) system with general revenue appropriations to assist individuals who have an intellectual disability (also called mental retardation) and/or developmental disabilities to live in the community. Eligibility for MO HealthNet is not required. Community services includes services for people with autism spectrum disorders funded with general revenue appropriations and administered through the Autism Projects defined at 9 CSR 45-3.060.

(C) Community Support waiver-A set of services, not including residential services, for Medicaid eligible individuals who have an intellectual disability (also called mental retardation) and/or a developmental disability who have been determined to otherwise require the level of care provided in an ICF/DD.

(D) Comprehensive waiver-A set of services, including residential services, for Medicaid-eligible individuals who have an intellectual disability (also called mental retardation) and/or a developmental disability who have been determined to otherwise require the level of care provided in an ICF/DD.

(E) Division-Division of Developmental Disabilities.

(F) Intermediate care facility for mental retardation-Any facility certified under 42 CFR 440.150. These facilities are referred to as intermediate care facilities for developmental disabilities (ICF/DD) throughout this rule.

(G) Missouri children with developmental disabilities waiver (also called Sarah Jian Lopez waiver)-A set of services, not including residential services, for children under the age of eighteen (18) living with their parents, who will qualify for Medicaid by qualifying for the waiver, who have intellectual disability (also called mental retardation) and/or a developmental disability who have been determined to otherwise require the level of care provided in an ICF/DD.

(H) Partnership for Hope waiver-A set of services, not including residential services, for Medicaid-eligible individuals who have an intellectual disability (also called mental retardation) and/or a developmental disability who have been determined to otherwise require the level of care provided in an ICF/DD. The Partnership for Hope is a county-based waiver operational in any Missouri county with a levy authorized under section 205.968, RSMo, whose board of directors has authorized funds to support the Partnership for Hope waiver or in any Missouri county approved by the Centers for Medicare and Medicaid Services for inclusion in this waiver.

(I) Prioritization of Need (PON) scoring- A process that assigns a score to the level of need for an individual, as set forth in 9 CSR 45-2.017. PON scoring is used to determine access to services when funding is limited and shall be applied to all individuals prior to participation in any of the following programs:

1. Comprehensive waiver;

2. Community Support waiver;

3. Missouri children with developmental disabilities waiver (also called Sarah Jian Lopez waiver);

4. Autism waiver; or

5. Community services funded with general revenue appropriations and purchased through the Department of Mental Health Purchase of Service (POS) system.

(J) Waiting list-A list of all people who have requested but are not currently receiving services from the division. The waiting list shall be subdivided into the following categories:

1. Children under the age of eighteen (18) with autism spectrum disorder who are not eligible for MO HealthNet;

2. Youth who have reached their seventeenth birthday;

3. Children and adults who are eligible for MO HealthNet who have needs that require the level of care in an ICF/DD and have an immediate need (within ninety (90) days) for residential services;

4. Children and adults who are eligible for MO HealthNet who have needs requiring the level of care in an ICF/DD, who do not have an immediate need for residential services but have service needs beyond the scope of the Partnership for Hope waiver;

5. Children and adults who are eligible for MO HealthNet, who have needs requiring the level of care in an ICF/DD, whose needs can be met safely with services in the Partnership for Hope waiver;

6. Children age three through eighteen (3-18) with autism spectrum disorder who have needs requiring the level of care in an ICF/DD and who are eligible for MO Health-Net; and

7. Children who have needs requiring the level of care in an ICF/DD and who are not eligible for MO HealthNet.

(2) Prioritizing Access to State General Revenue-Funded Services. People who are on the waiting list shall be prioritized for access to general revenue funded services based on PON score. When two (2) or more individuals have the same PON score, the individu-al(s) who has been on the waiting list the longest time shall be given priority.

(3) People with autism spectrum disorders may access services administered through the Autism Projects defined at 9 CSR 45-3.060.

(4) The following sections describe how the waiting list for home and community-based waivers will be established and managed when funding is limited and establishes the methods used to determine which waiver is most appropriate to meet the needs of individuals when funding becomes available.

(A) Individuals who reside in a participating Partnership for Hope waiver county who would otherwise require care in a ICF/DD may be considered for enrollment in the waiver if the individual is experiencing crisis or meets other priority criteria as outlined below in this rule. When participation in the Partnership for Hope waiver is limited by available funds, individuals experiencing a crisis will be served first. If more than one (1) individual is experiencing a crisis, the individual who has been waiting the longest will be served first. If no one is experiencing a crisis, then individuals meeting other priority criteria will be served. If more than one (1) individual meets priority criteria, the individual who has been waiting the longest will be served first.

1. To be considered for access based on a crisis, an individual must be experiencing one (1) of the following:

A. Health and safety conditions pose a serious risk of immediate harm or death to the individual or others;

B. Loss of primary caregiver support or change in caregiver's status to the extent the caregiver cannot meet needs of the individual; or

C. Abuse, neglect, or exploitation of the individual.

2. To be considered for access to the Partnership for Hope waiver when no one in that county who is on the waiting list is experiencing a crisis, individuals meeting the following criteria will be served on the basis of length of time on the waiting list:

A. The individual's circumstances or conditions necessitate substantial accommodation that cannot be reasonably provided by the individual's primary caregiver;

B. The individual has exhausted both their educational and Vocational Rehabilitation (VR) benefits or they are not eligible for VR benefits and they have a need for pre-employment or employment services;

C. Individual has been receiving supports (other than case management) from local funding for three (3) months or more and the services are still needed and the service can be covered by the waiver; and

D. Individual living in a non-Medi-caid funded residential care facility chooses to transition to the community and has been determined to be capable of residing in a less restrictive environment with access to Partnership for Hope waiver services.

(B) Individuals who are determined to meet emergency criteria as described in 9 CSR 45-2.017(1)(E) and who require out-of-home residential services or for whom out-of-home residential care is imminent, and whose needs cannot be met with services and supports other than residential services or whose needs for services is anticipated to be in excess of the cost limitations of other waivers shall receive priority consideration to participate in the Comprehensive waiver.

1. Individuals on the waiting list shall be enrolled in the Comprehensive waiver according to the PON score, as set forth in 9 CSR 45-2.017 as funding becomes available.

2. When two (2) or more individuals have the same PON score, the individual(s) who has been on the waiting list the longest time shall be given priority access to the Comprehensive waiver.

3. When individuals on the waiting list are offered and refuse waiver services a new PON assessment shall be completed.

(C) Individuals on the waiting list whose needs can be met without residential services, whose needs can be met safely in the community, and whose annual service costs is anticipated to be less than the cost limits of those waivers, shall be prioritized for access in waivers other than the Comprehensive waiver.

(D) Children under the age of eighteen (18) who would otherwise require care in an ICF/DD, but who are not otherwise eligible for MO HealthNet because of parental income and/or assets, may be considered for participation in the Sarah Jian Lopez waiver, and shall be served from the waiting list as turnover occurs based on prioritized need. When two (2) or more individuals have the same PON score, the individual(s) who has been on the waiting list the longest time shall be given priority. When individuals on the waiting list are offered and refuse the service or services for which they were placed on the waiting list a new PON assessment shall be completed. Determining prioritized need shall include reviewing the following:

1. PON score(s);

2. Frequency of need for waiver services;

3. Family ability to otherwise meet needs;

4. Any emergency need (9 CSR 45-2.017); and

5. Access to other resources to meet needs.

(E) Children with autism spectrum disorder who have attained the age of three (3) but who have not yet reached their eighteenth birthday and who would otherwise require care in an ICF/DD may be considered for participation in the Autism waiver, and shall be served from the waiting list as turnover occurs based on PON. When two (2) or more individuals have the same PON score, the individual(s) who has been on the waiting list the longest time shall be given priority. When individuals on the waiting list are offered and refuse the service or services for which they were placed on the waiting list, a new PON assessment shall be completed. Determining prioritized need shall include reviewing the following:

1. Have a diagnosis of autism spectrum disorder (ASD) as defined in the most recent edition of the Diagnostic and Statistics Manual of Mental Disorders, American Psychiatric Association. (Includes autistic disorder, Asperger's syndrome, pervasive developmental disorder-not otherwise specified, childhood disintegrative disorder, and Rett's syndrome);

2. Lives with their family in the community;

3. Must have behavioral and/or social or communication deficits that require supervision, that impact the ability of the child's family providing care in the home, and that interferes with the child participating in activities in the community;

4. PON score;

5. Any emergency need (9 CSR 45-2.017); and

6. Access to other resources to meet needs.

(5) Program Turnover.

(A) Funds becoming available due to participants leaving (turnover) any programs listed under subsection (1)(I) shall first be used for individuals served in that program who have increased needs. When these needs are met, funds that become available from turnover may be used to enroll new individuals in the program.

(B) When turnover occurs in an existing living arrangement, the regional office shall determine if an individual in the region, district, or state meeting emergency criteria or with the highest PON score would be appropriately served in the arrangement and chooses this living arrangement (including location), and if the agency providing supports is able to provide the supports to the individual.

1. If the arrangement is not appropriate or acceptable to an individual meeting emergency criteria or with the highest PON score, the regional office shall determine if the living arrangement is acceptable and appropriate for an individual with the next highest PON score on the waiting list. If it is not, the regional office may request approval for another individual on the waiting list to participate in the waiver according to prioritized need, who is agreeable to the living arrangement and is a compatible household member for current residents.

(6) No individual shall receive services under more than one (1) home and community-based waiver at the same time, including home and community-based waivers operated by any other Missouri state agency. Any individual who is eligible for services under more than one (1) waiver and has priority access to services based on their score as set forth in 9 CSR 45-2.017, when funding is available under both programs, shall be offered a choice of the waiver that best meets their needs, including home and community-based waivers operated by any other Missouri state agency.

(7) An individual may receive services under a waiver and may also receive community services funded with general revenue appropriations and purchased through the Department of Mental Health Purchase of Service (POS) system with approval from the division director when there is a need that cannot be met with waiver services.

(AUTHORITY: sections 630.050 and 633.110.2., RSMo Supp. 2011.* Emergency rule filed Oct. 1, 2004, effective Oct. 15, 2004, expired April 15, 2005. Original rule filed March 31, 2006, effective Nov. 30, 2006. Amended: Filed Feb. 1, 2012, effective Sept. 30, 2012.)

*Original authority: 630.050, RSMo 1980, amended 1993, 1995, 2008 and 633.110, RSMo 1980, amended 2011 .

The following state regulations pages link to this page.