Section He-E 801.04 - Initial Clinical Eligibility Determination(a) The department shall make the clinical eligibility determination of the applicant as follows:(1) Skilled professional medical personnel shall:a. Conduct an on-site, face-to-face visit with the applicant;b. Perform a clinical assessment of the applicant; andc. Develop the identified needs list with the applicant;(2) The applicant shall sign the following: a. A consent for participation in the CFI waiver program, including whether or not he or she has a preference of a case management agency;b. An authorization for release of information; andc. An authorization for release of protected health information;(3) Pursuant to RSA 151-E:3, IV, if the department is unable to determine an applicant's clinically eligible based on the assessment in (a) above, the department shall send notice to the applicant and the applicant's licensed practitioner(s), as applicable, requesting additional medical information within 30 calendar days of the notice and stating that the failure to submit the requested information will impede processing of the application and delay service delivery;(4) Within the 30-day period in (3) above, if the requested information is not received within 20 calendar days, the department shall send a second notice to the applicable licensed practitioner(s), with a copy to the applicant, as a reminder to provide the requested information by the original deadline;(5) Upon request from the treating licensed practitioner or applicant within the 30-day period in (3) above, the department shall extend the deadline in (3) above for a maximum of 30 days if the practitioner or applicant states that he or she has documentation that supports eligibility and will provide it within that time period; and(6) If the information required by (3) above is not received by the date specified in the notice, or as extended by the department in accordance with (5) above, the applicant shall be determined to be clinically ineligible.(b) For each applicant who meets the clinical eligibility requirements, a skilled professional medical personnel shall estimate the costs of the provision of home-based services by identifying the LTSS needed, including units, frequencies, and costs, with consideration of the applicant's expressed needs as identified in the assessment in (a)(1).(c) The applicant shall be determined eligible for the CFI waiver program if it is determined that the applicant meets the financial eligibility requirements described in He-W 600 and He-W 800, the clinical eligibility requirements of He-E 801.03(a)(4), and the other eligibility requirements pursuant to He-E 801.03.(d) Upon a determination of eligibility, the applicant or his or her legal representative shall be sent an approval notice, including:(1) The name and contact information of the case management agency chosen by the applicant or assigned to the applicant by the department, if available at the time of the notice; and(2) The eligibility start date.(e) Upon a determination of ineligibility, because the applicant does not meet the eligibility requirements of He-E 801.03 or because required information is not received pursuant to (a)(6) above, the applicant or his or her legal representative shall be sent a notice of denial, including: (1) A statement regarding the reason and legal basis for the denial;(2) Information concerning the applicant's right of appeal pursuant to He-C 200, including the requirement that the applicant has 30 calendar days from the date of the notice of denial to file such an appeal;(3) An explanation that an applicant who is denied services and who chooses to appeal this denial pursuant to He-C 200 shall not be entitled to medicaid payments for CFI waiver services pending the appeal hearing decision; and(4) The medical credentials of the skilled professional medical personnel making the determination of ineligibility.N.H. Code Admin. R. He-E 801.04
(See Revision Note at part heading for He-E 801) #9969, eff 8-8-11
Amended by Volume XXXIX Number 32, Filed August 8, 2019, Proposed by #12830, Effective 8/7/2019, Expires 2/3/2020.Amended by Volume XLII Number 6, Filed February 10, 2022, Proposed by #13340, Effective 1/29/2022, Expires 1/29/2032.