R414-307-3. General Requirements for Home and Community-Based Services Waivers

  (1) The Department shall apply the provisions of Sec. 2404 of Pub. L. No. 111 148, Patient Protection and Affordable Care Act, which refers to applying the provisions of Section 1924 of the Social Security Act to married individuals who are eligible for home and community-based waiver services.

  (2) To qualify for Medicaid coverage of home and community-based waiver services, an individual must meet:

  (a) the medical eligibility criteria defined in the State Waiver Implementation Plan adopted in Rule R414-61, which applies to the specific waiver under which the individual is seeking services, as verified by the operating agency case manager;

  (b) the financial and non-financial eligibility criteria for one of the Medicaid coverage groups selected in the specific waiver implementation plan under which the individual is seeking services; and

  (c) other requirements defined in this rule that apply to all waiver applicants and recipients, or specific to the waiver for which the individual is seeking eligibility.

  (3) The provisions found in Rule R414-304 and Rule R414-305 apply to eligibility determinations under a Home and Community-Based Services (HCBS) waiver, except where otherwise stated in this rule.

  (4) The Department shall limit the number of individuals covered by an HCBS waiver as provided in the adopted waiver implementation plan.

  (5) The Department adopts and incorporates by reference 42 U.S.C. 1396p(f), in effect February 7, 2016. An individual is ineligible for nursing facility and other long-term care services when an individual has home equity that exceeds the limit set forth in Subsection 1396p(f).

  (a) The Department sets that limit at the minimum level allowed under Subsection 1396p(f).

  (b) An individual who has excess home equity and meets eligibility criteria under a community Medicaid eligibility group defined in the Medicaid State Plan may receive Medicaid for services other than long-term care services provided under the plan or the HCBS waiver.

  (c) An individual who has excess home equity and does not qualify for a community Medicaid eligibility group, is ineligible for Medicaid under both the special income group and the medically needy waiver group.

  (6) To determine initial eligibility for a Medicaid coverage group under an HCBS waiver, the eligibility agency must receive a completed waiver referral form from the operating agency or designee. An individual who is not eligible for Medicaid must also complete a Medicaid application.

  (a) The waiver referral form must verify the date the individual meets the level-of-care requirements as defined in the State Waiver Implementation Plan.

  (b) The following provisions apply for Medicaid eligibility under the HCBS waiver:

  (i) The eligibility agency must approve a client's eligibility within 60 days of the level-of-care date stated on the waiver referral form for the waiver referral form to remain valid; otherwise the operating agency or designee must submit a new waiver referral form to the eligibility agency to establish a new level-of-care date;

  (ii) Waiver eligibility cannot begin before the level-of-care date stated on a valid waiver referral form, and;

  (iii) The eligibility start date must begin within 60 days of the level-of-care date stated on the valid waiver referral form.

  (c) The Medicaid agency may not pay for waiver services before the start date of the individual's approved comprehensive care plan, which may not be earlier than the date the individual meets:

  (i) the eligibility criteria for a Medicaid coverage group included in the applicable waiver; and

  (ii) the level-of-care date verified on a valid waiver referral form.

  (7) In the event an individual is not approved for Waiver Medicaid services due to Subsection R414-307-3(6), an individual who otherwise meets Medicaid financial and non-financial eligibility criteria for a Non-Waiver Medicaid coverage group may qualify for Medicaid services other than services under an HCBS waiver.

  (8) If an individual's Medicaid eligibility ends and the individual reapplies for Waiver Medicaid, the Department shall establish a process of obtaining approval from the operating agency or designee in which the individual continues to meet medical criteria for the Waiver. The operating agency or designee approval may establish a new date in which eligibility to receive coverage of waiver services may begin.

  (9) An individual denied Medicaid coverage for an HCBS waiver may request a fair hearing.

  (a) The Department conducts hearings on programmatic eligibility for payment of waiver services.

  (b) The Department of Workforce Services conducts hearings on financial eligibility issues for a Medicaid coverage group.