H. Review and Determination Process for the ISP

Upon receipt of the Application Packet, and ISP, the RRDS has fourteen (14) calendar days to review the information and make a final determination.

The RRDS completes the RRDS Initial Service Plan Review form (refer to Appendix B - form B.10) while reviewing the ISP to determine that:

  1. the individual is in need of waiver services;
  2. Medicaid eligibility has been verified;
  3. the individual meets the appropriate age requirement;
  4. the individual has a disability determination, if under age 65;
  5. the PRI/SCREEN is current, and identifies the applicant as needing a nursing home level of care;
  6. the ISP is reasonable given the context of the participant's stated goals and needs;
  7. all available informal supports and non-waiver services are utilized wherever appropriate;
  8. waiver services will be used appropriately, and in a reasonable and effective manner;
  9. the services described in the ISP will maintain the individual's health and welfare;
  10. the overall plan and goals for each waiver service describes the activities that each service will provide towards the accomplishment of the participant's goals;
  11. the PPO is completed, signed and reasonable;
  12. the Insurance, Resource and Funding Information Sheet is completed and signed;
  13. all other forms included in the Application Packet are completed and signed by the applicant;
  14. the waiver applicant has signed the Initial Service Plan; and
  15. projected costs for Medicaid services fit within the regional aggregate Medicaid cap established by DOH.

The RRDS will request review of an Application Packet, included in the ISP by the Nurse Evaluator if the needs of that applicant appear to be medically complex.

The RRDS must send all Service Plans over a projected $300 per day to the QMS, with a copy of the RRDS Service Plan Review form attached for further review and recommendations. The QMS must return the Service Plan with recommendations to the RRDS within three (3) business days.

If there are any discrepancies/concerns regarding the Service Plan, the RRDS must return it to the SC for correction or additional information. This is documented on the RRDS Initial Service Plan Review form.

The SC has fourteen (14) calendar days to respond to the RRDS's request for additional information or corrections and resubmit the Service Plan to the RRDS for final review and determination. Prior to resubmission of the ISP, the SC must present the revised plan to the applicant for review and signature.

Total turn around time for waiver eligibility determination is expected to be less than ninety (90) days from the time of Service Coordination selection to final determination by the RRDS.

Upon final determination, the RRDS signs the RRDS Service Plan Review form, ISP and PPO.

If approved, the applicant is acknowledged as a 'participant'. The RRDS must complete the Notice of Decision (NOD) - Authorization and distributes it to the participant and all others listed on the NOD (refer to Section II - Becoming a Waiver Participant). The RRDS will return the Application Packet to the SC who must provide a copy of the ISP and PPO to the participant. The SC communicates the authorization and the effective date to the facility (e.g. nursing home, hospital, etc., if applicable) and all non-waiver providers involved in the ISP. The SC also sends a copy of the approved ISP and PPO to all NHTD waiver service providers responsible for delivery of the services and items identified in the ISP.

If the RRDS believes that the applicant will be denied for the NHTD waiver program, he/she must contact DOH Waiver Management Staff (WMS) to discuss the reasons for this decision. Following this discussion, if the applicant is denied, the RRDS completes and sends a NOD- Denial of Waiver Program to the applicant and SC. The SC in consultation with the RRDS will provide alternative referral options (e.g. names and phone numbers of other LTC programs, etc) to the denied applicant The SC will notify the nursing home, if applicable, and all waiver and non-waiver providers involved in the development of the ISP of the denial decision.