N.H. Code Admin. R. He-E 801.04 - Eligibility Determination
Current through Register Vol. 41, No. 39, September 30, 2021
(See Revision Note at part heading for He-E 801) #9969, eff 8-8-11
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He-E 801.04 Eligibility Determination.
(a) The department shall make the clinical eligibility determination of the applicant as follows:
(1) A registered nurse employed or designated by the department shall:
a. Conduct an on-site, face-to-face visit with the applicant;
b. Perform a clinical assessment of the applicant; and
c. Develop a list of identified needs with the applicant;
(2) The applicant shall sign the following:
a. The identified needs section of the assessment, indicating his or her agreement or disagreement with the identified needs;
b. A consent for participation in the CFI program, including whether or not he or she has a preference of a case management agency;
c. An authorization for release of information; and
d. An authorization for release of protected health information;
(3) Pursuant to RSA 151-E:3, IV, if the department is unable to determine an applicant clinically eligible based on the assessment in (a) above, the department shall send notice to the applicant and the applicant’s licensed practitioner(s), as applicable, requesting additional medical information within 30 calendar days of the notice and stating that the failure to submit the requested information will impede processing of the application and delay service delivery;
(4) Within the 30 day period in (3) above, if the requested information is not received, the department shall send a second notice to the applicable licensed practitioner(s), with a copy to the applicant, as a reminder to provide the requested information by the original deadline;
(5) Upon request from the treating licensed practitioner within the 30 day period in (3) above, the department shall extend the deadline in (3) above for a maximum of 30 days if the practitioner states that he or she has documentation that supports eligibility and will provide it within that time period; and
(6) If the information required by (3) above is not received by the date specified in the notice, or as extended by the department in accordance with (5) above, the applicant shall be determined to be clinically ineligible.
(b) For each applicant who meets the clinical eligibility requirements, a registered nurse employed or designated by the department shall estimate the costs of the provision of home-based services by identifying medical and other services, including units, frequencies, and costs, that would meet the needs identified in the assessment in (a)(1) above in order to determine if services that meet the applicant’s needs can be provided at a cost that is the same as, or lower than, the Medicaid cost of nursing facility services, pursuant to He-E 801.03(a)(6), and does not exceed the cost limits described in He-E 801.09.
(c) The applicant shall be determined eligible for the CFI program if it is determined that the applicant meets the financial eligibility requirements described in He-W 600, the clinical eligibility requirements of He-E 801.03(a)(4), and the other eligibility requirements in He-E 801.03.
(d) Upon a determination of eligibility, the applicant or his or her legal representative shall be sent an approval notice, including:
(1) The name and contact information of the case management agency and case manager chosen by the applicant or assigned to the applicant by the department, if available at the time of the notice; and
(2) The eligibility start date.
(e) Upon a determination of ineligibility, because the applicant does not meet the eligibility requirements of He-E 801.03 or because required information is not received pursuant to (a)(6) above, the applicant or his or her legal representative shall be sent a notice of denial, including:
(1) A statement regarding the reason and legal basis for the denial;
(2) Information concerning the applicant’s right of appeal pursuant to He-C 200, including the requirement that the applicant has 30 calendar days from the date of the notice of denial to file such an appeal; and
(3) An explanation that an applicant who is denied services and who chooses to appeal this denial pursuant to He-C 200 shall not be entitled to Medicaid payments for CFI services pending the appeal hearing decision.
Source. (See Revision Note at part heading for He-E 801) #9969, eff 8-8-11; ss by #12830, INTERIM, eff 8-7-19, EXPIRED: 2-3-20