Fla. Admin. Code R. 65G-4.0213

Current through Reg. 50, No. 222; November 13, 2024

Section 65G-4.0213 - Definitions

For the purposes of this chapter, the term:

(1) "Agency" means the Agency for Persons with Disabilities.

(2) "Allocation Algorithm" means the mathematical formula based upon statistically validated relationships between client characteristics (variables) and the client's level of need for services provided through the Waiver as set forth in Rule 65G-4.0214, F.A.C., and as provided in Section 393.0662(1)(a), F.S.

(3) "Allocation Algorithm Amount" means the result of the Allocation Algorithm apportioned according to available funding.

(4) "Amount Implementation Meeting Worksheet" or "AIM Worksheet" means a form used by the Agency for new Waiver enrollees, and upon recalculation of a client's algorithm, to:

(a) Communicate a client's Allocation Algorithm Amount;

(b) Identify proposed services based upon the Allocation Algorithm Amount; and

(c) Identify additional services, if any, should the client or their legal representative feel that any Significant Additional Needs of the client cannot be met within the Allocation Algorithm Amount. The Amount Implementation Meeting Worksheet - APD Form 65G-4.0213 A, effective 7-1-21, is hereby adopted and incorporated by reference, and is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-12459.

(5) "Approved Cost Plan" means the document that lists all Waiver services that have been authorized by the Agency for the client, including the anticipated cost of each approved Waiver service, the provider of the approved service, and information regarding the provision of the approved service.

(6) "Available Service" means a support that is covered, authorized, or provided by a government program not operated by the agency, a community program, a third party such as a private health insurance company, or provided by a natural support.

(7) "Client" has the same meaning as provided in Section 393.063(7), F.S.

(8) "Client Advocate" has the same meaning as provided in Section 393.063(8), F.S, and includes legal counsel if designated by the client or the client's legal representative.

(9) "Client Review" means the Agency's review of information submitted by a WSC to determine if the request meets significant additional needs criteria.

(10) "Community Supports" means resources or services accessible to a client as a member of the community. This includes, but not limited to, resources available through organizations such as faith-based, cultural, geographic, non-profit, for-profit, and community groups.

(11) "Handbook" means the Florida Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook, as adopted by Rule 59G-13.070, F.A.C. (effective October 2020) and available at https://www.flrules.org/Gateway/reference.asp?No=Ref-12102.

(12) "Health and Safety" includes emotional, behavioral, mental, and physical health and safety.

(13) "iBudget" means the Home and Community-Based Services Medicaid Waiver program under Section 409.906, F.S., that consists of the Waiver service delivery system utilizing individual budgets required pursuant to Section 393.0662, F.S., and under which the Agency for Persons with Disabilities operates the Home and Community-Based Services Waiver.

(14) "iBudget Amount" means the total amount of funds that have been approved by the Agency, pursuant to the iBudget Rules, for a client to spend for Waiver services during a fiscal year.

(15) "iBudget Rules" means Rules 65G-4.0213 through 65G-4.0218, F.A.C., and are the rules which implement and interpret iBudget Amounts.

(16) "Legal Representative" means:

(a) For clients under the age of 18 years, the legal representative or health care surrogate appointed by the Florida court to represent the child or anyone designated by the parent(s) of the child to act on the parent(s)' behalf (e.g., due to military absence).

(b) For clients age 18 years or older, the legal representative could be the client, anyone designated by the client through a Power of Attorney or Durable Power of Attorney, a medical proxy under Chapter 765, F.S., or anyone appointed by a Florida court as a guardian or guardian advocate under Chapter 393 or 744, F.S.

(17)

(a) "Medically necessary" or "medical necessity, " as defined in the Handbook, means that the medical or allied care, goods, or services furnished or ordered must meet the following conditions:

1. Be necessary to protect life, to prevent significant illness or significant disability, or to alleviate severe pain,

2. Be individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient's needs,

3. Be consistent with generally accepted professional medical standards as determined by the Medicaid program, and not experimental or investigational,

4. Be reflective of the level of service that can be safely furnished, and for which no equally effective and more conservative or less costly treatment is available statewide; and

5. Be furnished in a manner not primarily intended for the convenience of the recipient, the recipient's caretaker, or the provider.

(b) The fact that a provider has prescribed, recommended, or approved medical or allied care, goods, or services does not, in itself, make such care, goods or services medically necessary or a medical necessity or a covered service.

(18) "Natural Support" means unpaid supports that are or may be provided voluntarily to the client in lieu of Waiver services and supports. Any determination of the availability of natural supports includes, but is not limited to consideration of the client's caregiver(s) age, physical and mental health, travel and work or school schedule, responsibility for other dependents, sleep, and ancillary tasks necessary to the health and well-being of the client.

(19) "Person-centered planning" - means a planning approach directed by a client with long term care needs, intended to identify the strengths, capacities, preferences, needs, and desired outcomes of the client. The client or legal representative determines the other participants in this process for the purposes of assisting the client to identify and access a personalized mix of paid and non-paid services and supports that will assist him/her to achieve personally-defined outcomes in the most inclusive community setting and to facilitate health, safety, and well-being.

(20) "Qualified Organization" means an organization which employs support coordinators who serve clients that receive Agency services and is determined by the Agency to have met all of the requirements of Section 393.0663(2), F.S., the Developmental Disabilities Individual Budgeting Waiver Services Coverage and Limitations Handbook, and Chapter 65G-14, F.A.C.

(21) "Questionnaire for Situational Information" or "QSI" effective 5-21-15 means an assessment instrument used by the Agency to determine a client's needs in the areas of functional, behavioral, and physical status. The QSI is adopted by the Agency as the current valid and reliable assessment instrument and is hereby incorporated by reference. The QSI is available at: http://www.flrules.org/Gateway/reference.asp?No=Ref-07075.

(22) "QSI Assessor" - means an Agency employee who has been certified by the Agency in the administration of the QSI.

(23) "Service Authorization" - means an Agency notification that authorizes the provision of specific Waiver services to a client and includes, at a minimum, the provider's name and the specific amount, duration, scope, frequency, and intensity of the approved service.

(24) "Service Families" means eight categories that group services related to: Life Skills Development, Supplies and Equipment, Personal Supports, Residential Services, Support Coordination, Therapeutic Supports and Wellness, Transportation and Dental Services. The Service Families include the following services:

(a) Life Skills Development, which includes:

1. Life Skills Development Level 1 (companion services),

2. Life Skills Development Level 2 (supported employment); and

3. Life Skills Development Level 3 (adult day training).

4. Life Skills Development Level 4 (prevocational services).

(b) Supplies and Equipment which includes:

1. Consumable Medical Supplies,

2. Durable Medical Equipment and Supplies,

3. Environmental Accessibility Adaptations; and

4. Personal Emergency Response Systems (unit and services).

(c) Personal Supports, which includes:

1. Services formerly known as in-home supports, respite, personal care and companion for clients age 21 or older, living in their own home or family home and also for those at least 18 but under 21 living in their own home; and

2. Respite Care (for clients under 21 living in their family home).

(d) Residential Services, which includes:

1. Standard Residential Habilitation,

2. Behavior- Focused Residential Habilitation,

3. Intensive- Behavior Residential Habilitation,

4. Enhanced Intensive Behavior Residential Habilitation,

5. Medical Enhanced Intensive Behavior Residential Habilitation,

6. Live-In Residential Habilitation,

7. Special Medical Home Care; and

8. Supported Living Coaching.

(e) Waiver Support Coordination.

(f) Therapeutic Supports and Wellness, which includes:

1. Private Duty Nursing,

2. Residential Nursing,

3. Skilled Nursing,

4. Dietician Services,

5. Respiratory Therapy,

6. Speech Therapy,

7. Occupational Therapy,

8. Physical Therapy,

9. Specialized Mental Health Counseling,

10. Behavior Analysis Services; and

11. Behavior Assistant Services.

(g) Transportation; and

(h) Dental Services, which consists of Adult Dental Services.

(25) "Significant" means of considerable magnitude or considerable effect.

(26) "Significant Additional Needs" or "SANs" means, as provided in Section 393.063(39), F.S., an additional need for medically necessary services which would place the health and safety of the client, the client's caregiver, or the public in serious jeopardy if it is not met. The term also includes services to meet an additional need that the client requires in order to remain in the least restrictive setting, including, but not limited to, employment services and transportation services. The Agency may provide additional funding only after the determination of a client's initial allocation amount and after the WSC has documented the availability of non-Waiver resources on the Verification of Available Services form. Examples of SANs that may require long-term support include, but are not limited to, any of the following:

(a) A documented history of significant, potentially life-threatening behaviors, such as recent attempts at suicide, arson, nonconsensual sexual behavior, self-injurious behavior requiring medical attention, dementia, or age-related behaviors that present significant health and safety risks,

(b) A complex medical condition that requires active intervention by a licensed nurse on an ongoing basis that cannot be taught or delegated to a non-licensed person,

(c) A need for total physical assistance with activities of daily living such as eating, bathing, toileting, grooming, dressing, personal hygiene, lifting, transferring or ambulation;

(d) Permanent or long-term loss or incapacity of a caregiver;

(e) Loss of services authorized under the state Medicaid plan or through the school system due to a change in age;

(f) Significant decline in medical, behavioral or functional status;

(g) Lack of a meaningful day activity needed to foster mental health, prevent regression or engage in meaningful community life and activities;

(h) One or more of the situations described in Rule 65G-1.047, F.A.C., Crisis Status Criteria; and

(i) Risk of abuse, neglect, exploitation, or abandonment that can be mitigated with Waiver services.

(27) "Significant change in condition or circumstance" means a significant change or deterioration in a client's health status, an actual or anticipated change in the client's living situation, a change in the caregiver relationship or the caregiver's ability to provide supports, loss of or deterioration of his or her home environment, or loss of the client's spouse or caregiver. Examples of a significant change include:

(a) A deterioration in health status that requires that the client receive services at a greater intensity or in a different setting to ensure that client's health or safety;

(b) Onset of a health, environmental, behavioral, or medical condition that requires that the client receive services at a greater intensity or in a different setting to ensure the client's health or safety; or

(c) A change in age or living setting resulting in a loss of services funded or otherwise provided from sources other than the Waiver. This may include a change in living setting which requires a different service array or a change in the availability or health status of a primary caregiver that prevents that caregiver from continuing to provide support.

(28) "Support plan" means an individualized and person-centered plan of supports and services designed to meet the needs of a client enrolled in the iBudget. The plan is based on the preferences, interests, talents, attributes and needs of a client, including the availability of natural supports.

(29) "Temporary basis" means a time period of less than 12 months.

(30) "Verification of Available Services" means a form completed by the WSC to enable the Agency to certify and document that the client has utilized all available services through the Medicaid State Plan, school-based services, private insurance, other benefits, and any other resources, such as local, state, and federal government and non-government programs or services and natural or community supports, that might be available prior to requesting Waiver funds. The Verification of Available Services documents and verifies that the iBudget Waiver is the payer of last resort. A valid and accurate Verification of Available Services is a condition precedent to the authorization of services. The Verification of Available Services - APD Form 65G-4.0213 B, effective 7-1-21, is hereby adopted and incorporated by reference and is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-12445.

(31) "Waiver" means the iBudget operated by the Agency.

(32) "Waiver Support Coordinator" or "WSC" means an employee of a qualified organization as defined in Section 393.0663, F.S., who is selected by the client or the client's legal representative to assist the client and family in identifying their capacities, needs, and resources; finding and gaining access to necessary supports and services; coordinating the delivery of supports and services; advocating on behalf of the client and family; maintaining relevant records; and monitoring and evaluating the delivery of supports and services to determine the extent to which they meet the needs and expectations identified by the client, family, and others who participated in the development of the support plan with person-centered planning.

(33) "WSC Job Aid for Cost Plans and Significant Additional Needs Documentation" means a form that identifies the documentation required for each service requested in the cost plan. The documentation identified by this form is a material part of each request. The WSC Job Aid for Cost Plans and Significant Additional Needs Documentation - APD Form 65G-4.0213 D, effective 7-1-21, is hereby adopted and incorporated by reference and is available at http://www.flrules.org/Gateway/reference.asp?No=Ref-12447.

(34) This rule shall be reviewed, and if necessary, renewed through the rulemaking process five years from the effective date.

Fla. Admin. Code Ann. R. 65G-4.0213

Rulemaking Authority 393.501(1), 393.0662 FS. Law Implemented 393.063, 393.0662, 409.906 FS.

Adopted by Florida Register Volume 42, Number 120, June 21, 2016 effective 7/7/2016, Amended by Florida Register Volume 47, Number 012, January 20, 2021 effective 7/1/2021, Amended by Florida Register Volume 48, Number 245, December 20, 2022 effective 1/3/2023.

New 7-7-16, Amended 7-1-21, 1-3-23.