He-E 801.03 - Eligibility

He-E 801.03. Eligibility

(a) An individual shall be eligible to receive CFI services if he or she meets all of the following requirements:

(1) Submits a signed and dated application, as defined in He-W 601.17, to the department;

(2) Is at least 18 years of age;

(3) Has been determined financially eligible as either categorically needy or medically needy;

(4) Meets the clinical eligibility requirements for nursing facility care in RSA 151-E:3, I(a), namely, the person requires 24-hour care for one or more of the following purposes, as determined by registered nurses appropriately trained to use an assessment instrument and employed by the department, or a designee acting on behalf of the department:

a. Medical monitoring and nursing care when the skills of a licensed medical professional are needed to provide safe and effective services;

b. Restorative nursing or rehabilitative care with patient-specific goals;

c. Medication administration by oral, topical, intravenous, intramuscular, or subcutaneous injection, or intravenous feeding for treatment of recent or unstable conditions requiring medical or nursing intervention; or

d. Assistance with 2 or more activities of daily living involving eating, toileting, transferring, bathing, dressing, and continence;

(5) Requires the provision of at least one CFI waiver service, as documented in the identified needs list, and receives at least one CFI waiver service at least monthly;

(6) Is determined by a registered nurse employed or designated by the department to require CFI waiver services that can be provided at a cost that is the same as, or lower than, the Medicaid cost of nursing facility services; and

(7) Has chosen, or whose legal representative has chosen, by signing the application in (1) above, CFI services as an alternative to institutional care.

(b) Pursuant to 42 CFR 441.301(b)(1)(iii) and (b)(6), eligibility shall be restricted to individuals who meet the target population criteria approved by CMS for this program and who, without the services provided by the program, would otherwise require institutional placement in a long term care nursing facility as described in He-E 802, and not services provided in a hospital, an institution for mental diseases (IMD) as defined in 42 CFR 435.1010, or an intermediate care facility for the mentally retarded (ICF/MR) as defined in 42 CFR 440.150.

(c) While receiving care as a resident in a nursing facility, an individual shall not be eligible for coverage of CFI services listed in He-E 801.12(b).

(d) An individual shall not be considered to be a resident of a nursing facility in (c) above if he or she is a CFI participant who is admitted to a nursing facility on a temporary basis for treatment or care for an acute episode.

(e) For those CFI participants who are receiving short-term inpatient care in a hospital or nursing facility, the following shall apply:

(1) Services described in He-E 801.12(b) shall not be provided while the participant is in the facility, except for services that have been prior authorized for the purpose of enabling the participant to transition back to his or her community; and

(2) The participant's clinical eligibility shall be maintained until such time that an eligibility redetermination is conducted in accordance with He-E 801.07 and the participant is determined ineligible.

(Amended by Volume XXXIX Number 32, Filed August 8, 2019, Proposed by #12830, Effective 8/7/2019, Expires 2/3/2020.)

(See Revision Note at part heading for He-E 801) #9969, eff 8-8-11

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