65G-4.0021: Tier Waivers
65G-4.0022: Tier One Waiver
65G-4.0024: Tier Three Waiver
65G-4.0025: Tier Four Waiver
PURPOSE AND EFFECT: The purpose of the proposed rulemaking is to clarify existing language and includes incorporation of information collected in the “Operational Detail.”
SUMMARY: The purpose of the proposed rulemaking is to clarify certain provisions regarding the description of services provided under Rule 65G-4.0021, 65G-4.0022, 65G-4.0024 and 65G-4.0025.
SUMMARY OF STATEMENT OF ESTIMATED REGULATORY COSTS: The Agency for Persons with Disabilities provides a summary of the Statement of Estimated Regulatory Costs (SERC). Rule 65G-4.022, F.A.C., is being amended for clarification of the description of services provided under Tier One pursuant to Section 120.541, Florida Statutes. There is no economic impact to the clients being served by the Developmental Disability Home and Community-based Waiver or its service providers due to the amendment to Rule 65G-4.0022, F.A.C.
Any person who wishes to provide information regarding a statement of estimated regulatory costs, or provide a proposal for a lower cost regulatory alternative must do so in writing within 21 days of this notice.
SPECIFIC AUTHORITY: 393.0661(3) FS.
LAW IMPLEMENTED: 393.0661(3) FS.
IF REQUESTED WITHIN 21 DAYS OF THE DATE OF THIS NOTICE, A HEARING WILL BE SCHEDULED AND ANNOUNCED IN FAW.
THE PERSON TO BE CONTACTED REGARDING THE PROPOSED RULE IS: Mike Dunn, Deputy Director of Legislative Affairs, Office of the Chief of Staff, (850)414-5853
THE FULL TEXT OF THE PROPOSED RULE IS:
65G-4.0021 Tier Waivers.
(1) The Agency for Persons with Disabilities will assign clients of home and community-based waiver services for persons with developmental disabilities to one of the four Tier Waivers created by Section 393.0661, F.S. (20078). The Agency will determine the Tier Waiver for which the client is eligible and assign the client to that waiver based on the developmental disabilities waiver criteria and limitations contained in the following provisions: Sections 409.906(13) and 393.0661, F.S.; and Rule 59G-13.0803, F.A.C.:
(a) The client’s level of need in functional, medical, and behavioral areas, as reflected in the client’s approved cost plan. determined through Agency evaluation of client characteristics, the Agency approved assessment process, and support planning information;
(b) The client’s cost plan is developed through Agency evaluation of client characteristics, the Agency approved assessment process, support planning information, and the Agency’s prior service authorization process as determined through the Agency’s prior service authorization process to be medically necessary;
(c) The client needs considered in tier assignments are only those services approved through the prior service authorization process;
(d)(c) The client’s age and the current living setting; and
(e)(d) The availability of supports and services from other sources, including natural and community supports.
(2) The services described by the Developmental Disabilities Waiver Services Coverage and Limitations Handbook, July 2007 (hereinafter referred to as the “DD Handbook”), adopted by Rule 59G-13.0803, F.A.C. and incorporated herein by reference, are available to clients of the Developmental Disabilities Waiver (hereinafter called “the Tier One Waiver”), the Developmental Disabilities Tier Two Waiver (hereinafter called “the Tier Two Waiver”), and Developmental Disabilities Tier Three Waiver (hereinafter called “the Tier Three Waiver”). The following services described in the DD Handbook are available to clients assigned to the Tier Four Waiver (presently known as The Family and Supported Living Waiver):
(a) Adult Day Training;
(b) Behavior Analysis;
(c) Behavior Assistance;
(d) Consumable Medical Supplies;
(e) Durable Medical Equipment;
(f) Environmental Accessibility Adaptations;
(g) In-Home Support Service;
(h) Personal Emergency Response System;
(i) Respite Care;
(j) Support Coordination;
(k) Supported Employment;
(l) Supported Living Coaching; and
(m) Transportation.
(3) For all Tiers the client must utilize all available State Plan Medicaid services including, but not limited to, personal care assistance, therapies, and medical services, and nursing services, that duplicate the waiver services proposed for the client. A client shall not be provided waiver services that duplicate available State Plan Medicaid Services including, but not limited to, personal care assistance, therapies, and medical services.
(4) The Agency will review a client’s tier eligibility when a client has a significant change in circumstance or condition that impacts on the client’s health, and safety, or welfare or when a change in the client’s plan of care is required to avoid institutionalization. The information identifying and documenting a significant change in circumstance or condition that necessitates additional or different services must be submitted by the client’s Waiver Support Coordinator to the appropriate Agency Area office for determination.
(5) Only the following services, if approved through the Agency’s prior authorization process, will be used as the basis for making a tier assignment or determining whether a tier change is required:
(a) Personal Care Assistance;
(b) Behavior Analysis;
(c) Behavior Assistance;
(d) Supported Living Coaching;
(e) In-home Supports;
(f) Skilled, Residential or Private Duty Nursing Services;
(g) Intensive Behavioral Residential Habilitation Services;
(h) Behavior Focus Residential Habilitation Services at the moderate or above level of support;
(i) Standard Residential Habilitation at the extensive 1, or higher, level of support;
(j) Special Medical Home Care;
(k) Occupational Therapy;
(l) Physical Therapy;
(m) Speech Therapy;
(n) Respiratory Therapy; or
(o) Specialized Mental Health Services.
(6) The following services will not be used as the basis for making a tier assignment or determining whether a tier change is required:
(a) Meaningful Day Activities (Supported Employment, Adult Day Training, Companion);
(b) Respite;
(c) Support Coordination;
(d) Transportation;
(e) Durable Medical Equipment;
(f) Consumable Medical Supplies;
(g) Dental Services;
(h) Dietician;
(i) Environmental Accessibility;
(j) Medication Review;
(k) Personal Emergency Response;
Rulemaking Specific Authority 393.0661(3) FS. Law Implemented 393.0661(3) FS. History–New 10-20-08, Amended________.
65G-4.0022 Tier One Waiver.
(1) The Tier One Waiver is limited to clients that the Agency has determined meet at least one of the following criteria:
(a) The client’s needs for medical or adaptive services are intense and cannot be met in Tiers Two, Three, and Four and are essential for avoiding institutionalization, or
(b) The client possesses behavioral problems that are exceptional in intensity, duration, or frequency with resulting service needs that cannot be met in Tiers Two, Three, and Four, and the client presents a substantial risk of harm to themselves or others.
(2) Clients receiving any of the following services shall be deemed to have intense medical or adaptive needs and shall be assigned to the Tier One Waiver if their need for these services cannot be met in any other Tier:
(a) 180 hours or more of intensive Personal Care Assistance, if age 21 or older;
(b) Supported Living Coaching and In-home Supports, in combination with any of the following additional services: Physical Therapy, Occupational Therapy, Respiratory Therapy or Behavior Analysis, if age 18 or older;
(c) Behavior analysis and Behavior Assistance services of sixty or more hours per month, if age 22 or older and living in the family home; or
(d) More than four or more hours of continuous Nursing Services, if age 21 or older.
(3)(2) Clients living in a licensed residential facility receiving any of the following services shall be assigned to the Tier One Waiver:
(a) Intensive behavioral residential habilitation Services;
(b) Behavior focus residential habilitation Services at the moderate or above level of support; or
(c) Standard residential habilitation at the extensive 1, or higher, level of support; or
(d) Special medical home care.
(4)(3) Nursing service needs that can be met through the Tier Two, Tier Three, or Tier Four Waivers are not “services” or “service needs” that support assignment to the Tier One Waiver.
Rulemaking Specific Authority 393.0661(3) FS. Law Implemented 393.0661(3) FS. History–New 10-20-08, Amended________.
65G-4.0024 Tier Three Waiver.
The total budget in a cost plan year for each Tier Three Waiver client shall not exceed $35,000. A client must meet at least one of the following criteria for assignment to the Tier Three Waiver:
(1) The client resides in a licensed residential facility and is not eligible for the Tier One Waiver or the Tier Two Waiver; or
(2) The client is 21 or older, resides in their own home and receives In-Home Support Services, and is not eligible for the Tier One Waiver or the Tier Two Waiver or the client’s needs cannot be met in Tier Four; or
(3) The client is 21 or older and is authorized to receive Personal Care Assistance services at the standard or moderate level of support as defined in the DD Handbook.
(4) The client is 21 or older and is authorized to receive Skilled or Private Duty Nursing Services and is not eligible for the Tier One Waiver or the Tier Two Waiver; or
(5) The client is 22 or older and is authorized to receive services of a behavior analyst and/or a behavior assistant.
(6) The client is under the age of 22 and authorized to receive the combined services of a behavior analyst and/or a behavior assistant for more than 60 hours per month and is not eligible for the Tier One Waiver or the Tier Two Waiver.
(7) The client is 21 or older and is authorized to receive at least one of the following services:
(a) Occupational Therapy;
(b) Physical Therapy;
(c) Speech Therapy;
(d) Respiratory Therapy;
(e) Specialized Mental Health Services.
Rulemaking Specific Authority 393.0661(3) FS. Law Implemented 393.0661(3) FS. History–New 10-20-08, Amended________.
65G-4.0025 Tier Four Waiver.
(1) The total budget in a cost plan year for each Tier Four Waiver client shall not exceed $14,792 per year.
(2) Clients who are not eligible for assignment to the Tier One Waiver, the Tier Two Waiver, or the Tier Three Waiver, and who meet the following criteria, shall be assigned to the Tier Four Waiver:
(a) Clients who are currently assigned to receive services through the Family and Supported Living Waiver unless there is a significant change in condition or circumstance as described in subsection 65G-4.0021(4), F.A.C.; or
(b) Clients who are under the age of 22 and residing in their own home or the family home, or
(c) Clients who are dependent children who reside in residential facilities licensed by the Department of Children and Families under Section 409.175, F.S.;
Rulemaking Specific Authority 393.0661(3) FS. Law Implemented 393.0661(3) FS. History–New 10-20-08, Repromulgated ________.