C. Referral, Intake, Application and Determination Processes
The following describes the processes for becoming a waiver participant:
A potential participant or an individual acting on his/her behalf contacts the RRDC in the region where he/she chooses to reside or where they are currently living. The RRDS completes the Referral form (refer to Appendix B) and makes a determination whether to proceed to the Intake process. If the individual is considered not to meet the basic criteria for the waiver or indicates his/her preference not to pursue admission into the NHTD waiver, the RRDS will provide available options for referrals to other programs/services.
Note: It is expected that within two (2) weeks of receiving the referral the RRDS will make contact with the individual and schedule an Intake. If it is immediately apparent that the Referral will not proceed to Intake (e.g. the individual is under age 18), the RRDS has two (2) business days to contact the individual and give them information for other community resources.
If the potential participant has a Legal Guardian the RRDS will request a copy of the Guardianship document be provided at the time of Intake. The RRDS meets with the potential participant, his/her Legal Guardian, if applicable and anyone the potential participant chooses to be present and describes the waiver philosophy and available services.
The RRDS reviews the Initial Applicant Interview Acknowledgment form (refer to Appendix B – form B.3) with the potential participant and has him/her sign it. The RRDS makes a preliminary determination of probable eligibility for the waiver. If the potential participant is considered ineligible for the waiver or indicates his/her preference not to pursue admission into the NHTD waiver, the RRDS will provide available options for referrals to other programs/services. The RRDS closes the Intake process.
If the RRDS determines probable eligibility for the waiver and the potential participant indicates his/her interest in pursuing admission into the NHTD waiver, the RRDS reviews the Freedom of Choice form with the potential participant and has him/her sign it.
The individual completes and signs the Application for Participation form.
The RRDS provides the potential participant with a list of approved Service Coordination providers and encourages him/her to interview potential Service Coordinators.
The potential participant selects a Service Coordination Agency from the list of approved providers, completes the Service Coordinator Selection form (refer to Appendix B – form B.5) and returns it to the RRDS. The RRDS forwards the Service Coordinator Selection form to the selected Service Coordinator provider for their signature along with a copy of the Intake form. The Service Coordination Agency will return the completed Service Coordination Selection form to the RRDS, indicating that they are willing and able to accept the applicant. The RRDS completes the Intake form (refer to Appendix B – form B.2). The RRDS will then forward a copy of the Freedom of Choice form, and the Service Coordination Selection form to the Service Coordination Agency. If the potential participant has a Legal Guardian, the RRDS will assure that a copy of the Guardianship documentation is given to the selected Service Coordinator prior to the development of the Service Plan.
If the Service Coordination Agency is unable to provide this service then the potential participant is notified by the RRDS. The potential participant must select another Service Coordination Agency.
Note: The RRDS and Service Coordination agency must follow their Health Insurance Portability and Accountability Act (HIPAA) compliance policies. If the intake meeting does not occur within sixty (60) calendar days after the scheduled date for the Intake meeting, the Intake is cancelled for it did not proceed to the application process. If after this time period the individual decides to proceed with the Intake process, the RRDS must start a new Referral process.
It is at this point the individual becomes a formal applicant. The applicant and anyone he/she may choose, works with their chosen Service Coordinator to develop an ISP (refer to Appendix C – form C.1) and PPO. This process includes the applicant and Service Coordinator working together to develop the ISP and PPO.
Note: It is expected that once the Service Coordinator agency has accepted the applicant the Service Coordinator has sixty (60) calendar days to complete the Application Packet and submit it to the RRDS (refer to Section V - The Service Plan).
The ISP is signed by the applicant indicating they had choice of waiver services and providers of these services. If the waiver service provider agency is unable to provide the service(s) requested, then the applicant is notified by the Service Coordinator. The applicant must then select another waiver provider agency.
Note: All NHTD Waiver Provider agencies must follow their HIPAA compliance policies.
The Service Coordinator assembles the Application Packet, which includes the following forms:
- Application for Participation - completed with the RRDS
- Participant Rights and Responsibilities
- H/C PRI and SCREEN
- Initial Service Plan (ISP) - including Medicaid coverage Verification (Medicaid Eligibility Verification System)
- Provider Selection form(s)
- Insurance, Resource and Funding Information Sheet;
- Plan of Protective Oversight (PPO)
- Proof of physical disability determination (if under age 65)
- Freedom of Choice - completed with the RRDS
- Service Coordination Selection - completed with the RRDS
The Service Coordinator sends his/her part of the completed Application Packet to the RRDS which includes Participant Rights and Responsibilities, H/C PRI and SCREEN , PPO, Initial Service Plan, Provider Selection forms, Insurance, Resource and Funding Information Sheet, Proof of disability determination (if under age 65) (refer to Section V - The Service Plan).
The RRDS reviews the entire Application Packet, which includes the ISP, and either approves the Packet or sends the RRDS ISP Review form (refer to Appendix B – form B.10) to the Service Coordinator and requests in writing, revisions and/or additional information needed for approval. All Service Plans over $300 per day must be reviewed by the RRDS and forwarded to the QMS for recommendations. The QMS will review, make recommendations and return the Service Plan to the RRDS within three (3) business days of receipt. The RRDS is responsible for the final decision.
Note: The RRDS has fourteen (14) calendar days from receipt of the Application Packet to review and make a determination.
A Notice of Decision (NOD) - Authorization is issued to the applicant by the RRDS for the approved Application Packet indicating the applicant's transition to participant status. This Notice of Decision indicates the start date for the initial six (6) month approval period of the waiver program for the participant. Subsequent six (6) month approvals are based on the participant's choice to remain in the waiver, continued eligibility, and an approved Service Plan. The RRDS also forwards a copy of the NOD to the Local Department of Social Services (LDSS) and to the Service Coordinator. Upon receipt of the NOD, the LDSS inputs program code 60 (NHTD) into the Welfare Management System (WMS).
A Notice of Decision (NOD) - Denial is issued to the applicant when the RRDS determines that the individual is not eligible for the waiver or the Service Plan does not describe a sufficient level of supports and/or services to maintain the individual's health and welfare in the community.
Note: During the referral and intake process when an individual chooses to relocate to a region covered by another RRDS, the current RRDS is responsible for making the initial contact with the RRDS in the relocation region. The RRDS from the new region will contact the individual to provide the list of approved Service Coordination providers in that region.