Title 7 . Health and Social Services

Chapter 43 . Hearings

Section 1010. Recipient enrollment and eligibility

7 AAC 43.1010. Recipient enrollment and eligibility

(a) For the department to make payment under Medicaid for home and community-based waiver services provided to an individual, the

(1) individual must be

(A) eligible for coverage under 7 AAC 43.020 and (d) of this section; and

(B) enrolled in accordance with (e) of this section; and

(2) services must be provided in accordance with the applicable requirements of 7 AAC 43.1000 - 7 AAC 43.1110.

(b) Home and community-based waiver services are not available to an individual

(1) while the individual is an inpatient of a nursing facility, acute care hospital, or intermediate care facility for the mentally retarded or individuals with related conditions (ICF/MR); or

(2) if the individual's need for home and community-based services, supports, devices, or supplies may be provided for entirely under 7 AAC 43.100 - 7 AAC 43.942.

(c) A recipient enrolled in the home and community-based waiver services program is eligible to receive other Medicaid services for which the recipient is otherwise eligible.

(d) For the department to determine an applicant eligible to receive home and community-based waiver services, the applicant must

(1) fall into one of the following recipient categories:

(A) children with complex medical conditions; the department will determine an applicant to be a child with a complex medical condition if the applicant

(i) is under 22 years of age;

(ii) would receive long-term care in a facility for more than 30 days per year if the applicant did not receive home and community-based waiver services;

(iii) has a severe chronic physical condition that results in a prolonged dependency on medical care or technology to maintain health and well-being;

(iv) experiences periods of acute exacerbation or life-threatening conditions;

(v) needs extraordinary supervision and observation; and

(vi) either needs frequent or life-saving administration of specialized treatment or is dependent on mechanical support devices;

(B) adults with physical disabilities; in this subparagraph, "adult" means an individual at least 21 years of age and less than 65 years of age;

(C) individuals with mental retardation and developmental disabilities;

(D) older adults; in this subparagraph, "older adult" means an individual 65 years of age or older; and

(2) require a level of care provided in a nursing facility or ICF/MR; the department will base a determination of eligibility under this paragraph on the level-of-care assessment under 7 AAC 43.1030(b), and will determine eligibility under

(A) 7 AAC 43.180 - 7 AAC 43.190, if the applicant falls within the recipient category of

(i) children with complex medical conditions;

(ii) adults with physical disabilities; or

(iii) older adults; or

(B) 7 AAC 43.300, if the applicant falls within the recipient category of individuals with mental retardation and developmental disabilities;

(e) An applicant determined eligible under (a)(1)(A) of this section will be enrolled for home and community-based waiver services if the department determines that enrolling the applicant will not bring the department out of compliance with the terms of the waiver approved under 42 U.S.C. 1396n(c) by exceeding the

(1) number of recipients approved for participation in the waiver program for the applicable recipient category; or

(2) average per capita expenditure limit on home and community-based waiver services for the applicable recipient category.

(f) Except as provided in 7 AAC 43.1041, home and community-based waiver services to be provided to a recipient are reimbursable under 7 AAC 43.1000 - 7 AAC 43.1110 only after the department

(1) approves, under 7 AAC 43.1030, the plan of care for the recipient; and

(2) determines that a home and community-based services provider is available that

(A) is enrolled with the department in accordance with 7 AAC 43.1090; and

(B) has the capacity to meet the service levels approved under (1) of this subsection as part of the plan of care.

(g) The earliest date that an individual may receive home and community-based waiver services is the first date when all of the requirements in (d) of this section have been met. Except as provided in 7 AAC 43.1041, the department will not make payment for services that are reimbursable under (f) of this section unless the recipient is enrolled under (e) of this section.

(h) An applicant or recipient who is denied enrollment for home and community-based waiver services may appeal that decision under 7 AAC 49.

History: Eff. 12/19/93, Register 128; am 5/15/2004, Register 170

Authority: AS 47.05.010

AS 47.07.030