Tracking# 2012-01006
FA/E 1/4/13, eff. 3/2/13

(former #2012-00989
emergency 11/9/12, eff. 11/9/12 )

I:/12101901.rtf
[I:/12101901.doc] 

(9 CCR 2503-1)

[Note: Statement of Basis and Purpose has been incorporated with Tracking# 2012-01005 (#12-10-17-1).] 

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(9 CCR 2503-7)

Instructions:  Replace line 2326393.] 
3.744  Functional Assessment, Care Plan, and Provider Agreement [Em. eff. 11/9/12; Permanent rev. eff. 3/2/13] 
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Instructions:  Replace lines 2345158 through 2345162.] 
F.  The SEP shall monitor the provision of services by the care provider to ensure that the care plan is implemented, the care provider is providing services as agreed, the client’s services are appropriate, and to identify any changes in functional need. 
1.  A review of the client’s current assessment shall be conducted every six (6) months in conjunction with the HCBS required visit. The review shall be conducted by telephone or home visit. 
2.  A review via telephone or home visit earlier than six (6) months shall be conducted when the SEP, in its professional opinion, believes the client’s needs may have changed, and/or the client is not receiving or paying for appropriate care as established in the care plan agreement, and/or the client reports concerns regarding the provision of services. 
3.  A client or authorized representative’s refusal to allow a review via telephone or home visit is grounds for discontinuation from the SP-HCA grant program, as outlined in Section 3.746, D.
G.  The SEP shall perform all other duties for the SP-HCA program as is required for the HCA program, outlined in Section 3.720. 

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Instructions:  Replace lines 2326476 through 2326519.] 
3.746  Denials and Discontinuations [Em. eff. 11/9/12; Permanent rev. eff. 3/2/13] 
A.  A client shall meet all eligibility requirements outlined in Section 3.743, D, 1-4, each month to continue to be eligible for the SP-HCA program. 
B.  Clients shall be denied or discontinued from the SP-HCA program if he/she is determined ineligible. The client shall be informed of the adverse action and appeal rights in accordance with rules under Section 3.745. 
C.  Clients that are denied and/or are discontinued from the SP-HCA program are permanently disqualified from the program and shall not be eligible to apply for or be approved for benefits in subsequent months or years. 
1.  To ease the eligibility process for the SP-HCA program, the following provisions shall apply: 
a.  Clients originally approved for the SP-HCA program and then subsequently discontinued from SP-HCA on or before June 30, 2013, pursuant to Section 3.746, D, may reapply for reinstatement of benefits.
b.  Application must be received no later than July 12, 2013, for reinstatement of benefits.
c.  The application shall be reviewed to determine if between January 1, 2012 and June 30, 2013, the client again met SP-HCA eligibility criteria following the most recent discontinuation.
d.  If the client is determined to meet SP-HCA eligibility criteria again following the most recent discontinuation but still on or before June 30, 2013, benefits shall be retroactive to the new eligibility date.
2.  Clients originally approved for the SP-HCA program and then subsequently discontinued from SP-HCA pursuant to Section 3.746, D, on or after July 1, 2013, will be permanently discontinued from receiving SP-HCA benefits.
D.  The SEP and/or CCB shall notify the State Department when the agency has knowledge that any of the following occurs. The State Department shall notify the client of discontinuation from SP-HCA when it has information from the SEP, CCB, program data systems, or any other source that any of the following has occurred: 
1.  The client no longer receives services under the HCBS-SLS or HCBS-CES waiver. 
2.  The client’s needs change and his/her level of service need is no longer within $1,000 of the SPAL or Spending Limitation for HCBS-SLS or HCBS-CES. 
3.  The client no longer meets financial eligibility criteria, as outlined in Section 3.743, D, 2.
4.  The client no longer meets the functional capacity and need for paid care scores necessary to be approved for SP-HCA. 
5.  The client has not received services for thirty (30) or more consecutive days. 
6.  The client or authorized representative has refused to schedule an appointment with the SEP, CCB, or State Department or refuses to allow for a home visit, an initial assessment, six-month review, reassessment, or other review. 
7.  The client or authorized representative has failed to keep two (2) scheduled appointments. 
8.  The client or authorized representative refuses to sign the application, the care plan, or other documents and forms required to receive services or in any other way refuses to cooperate with the requirements of the SP-HCA program. 
9.  The client or authorized representative refuses to use the SP-HCA grant to pay for services, uses the grant for services not identified in the care plan and provider agreement, or uses the grant to purchase household expenses including, but not limited to, shelter costs, utilities, food, toiletries, clothing, home furnishings or other items not authorized by the SP-HCA care plan. 
10.  The client is a resident of a nursing facility, hospital, alternative care facility, group home, licensed or unlicensed long-term care facility, or other institution. 
11.  The client enters a hospital or other long-term care facility for treatment or rehabilitation that continues for thirty (30) or more consecutive days. 
a.  SP-HCA benefits shall be temporarily discontinued while the client remains in the hospital or long-term care facility for treatment or rehabilitation. 
b.  SP-HCA benefits shall be permanently discontinued if the client remains in the hospital or long-term care facility for treatment or rehabilitation for one hundred eighty (180) or more consecutive days. 
12.  The client cannot be safely served given the type and/or amount of services available. To support a denial or discontinuation for safety reasons related to service limitations, the SEP shall document the limitations and evidence of safety concerns, when available, including, but not limited to: 
a.  The results of an adult protective services assessment; 
b.  A statement from the client's physician attesting to diminished mental capacity or increased medical or physical care needs; 
c.  Lack of available services and/or providers; 
d.  An assessment score indicating a level of need for services in excess of those available under the SP-HCA program; and/or, 
e.  Other available information or evidence that will support the determination that the client’s safety is at risk. 
13.  The level of service need is not cost effective under the SP-HCA program. To support a denial or discontinuation due to cost effectiveness the SEP shall document the level of service need and more cost effective alternatives. 
14.  The client has moved out of the state or country or has or been out of the state or country for more than thirty (30) consecutive days. Discontinuation shall be effective the day after the date of the move or on day thirty one (31) of the absence from the state or country. 
15.  The client or authorized representative requests withdrawal from the program. 
16.  The client or authorized representative has failed to report a change in circumstances that potentially affects eligibility for SP-HCA, as outlined in Section 3.743, G. 
17.  The client has died. Discontinuation shall be effective the day after the client’s death. No notice of discontinuation shall be sent. 
E.  The notice of adverse action shall include the reason for denial or discontinuation, the appropriate rule cite, and appeal rights. 
F.  In the event of denial or discontinuation, the SEP shall: 
1.  Provide appropriate referrals to other community resources, as needed, within one (1) working day of discontinuation. 
2.  Notify all providers on the care plan within one (1) working day of discontinuation. 
3.  Notify the State Department within one (1) working day of discontinuation. 
4.  Attend the appeal hearing to defend the denial or discontinuation. 

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