APD Criteria for Tier Selection: Rule and Operational Detail

Memo from Carolyn Smith

727-546-5568

carolynsmithgroup@verizon.net

Of great concern is 65G-4.0021(1)(a) which states level of need, medically, is reflected in the cost plan, i.e., the waiver cost plan, which does not provide any info on “medical spending/costs” which are mostly paid for under Medicaid.

The APD contact person regarding the proposed rule is Mike Dunn, Deputy Dir. of Legislative Affairs, 850-414-5853

Rule General Provisions, Rule Detail and Operational Detail
Tier 1—65G-4.0022 The client has service needs for intense medical or adaptive needs that cannot be met in Tiers Two, Three, and Four and services are essential for avoiding institutionalization. The client possesses behavioral problems that are exceptional in intensity, duration, or frequency with resulting service needs that cannot be met in tiers Two, Three, and Four, and the client presents a substantial risk of harm to themselves or others.
□ Clients living in a licensed residential facility receiving Special Medical Home Care.□ Clients living in a licensed residential facility receiving intensive behavioral residential habilitation services. □ Children and adults receiving behavior focus res hab services at the current “moderate level or above”, (or 7 or more hours a day based on the previous rate table.) □ Clients living in a licensed residential facility receiving Standard residential habilitation at the extensive 1, or higher, level of support (10 or more hours a day based on the previous rate table.)	□ Nursing service needs that can be met through the Tier Two, Tier Three, or Tier Four Waivers are not “services” or “service needs” that support assignment to the Tier One Waiver.□ Anyone 21 or over receiving continuous nursing services and annual cost plan for all services exceeding $55,000. (Intermittent nursing services do not qualify.) Continuous nursing is defined as 4 or more hours of nursing a day. (Note: Skilled nursing is considered intermittent nursing.)	□ Anyone 21 and over receiving personal care assistant services at 180 hours or more a month and total annual cost plan for all services exceeding $55,000. (The person must be approved for intense PCA services only per the statute and the handbook.)□ Adults (18+) with supported living coaching, in-home supports (quarter hour or live-in), approved cost plan over $55,000, and any one of the following therapies: physical therapy, occupational therapy, respiratory therapy, or behavior analysis. □ Anyone 21 or older living in the family home with combined Behavior Analysis Services and Behavior Assistance services of 60 or more hours per month AND total annual cost plan for all services exceeding $55,000.
TIER 2—65G-4.0023 The total budget in a cost plan year for each Tier Two Waiver client shall not exceed $55,000.
The client’s service needs include placement in a licensed residential facility and authorization for Residential Habilitation levels of support as identified in column 2. Individuals living in their family home are excluded from this Tier at this time.	□ Adults or children receiving standard Residential Habilitation at the moderate level of higher who do not meet the criteria for Tier 1, or □ Adults or children receiving Behavior Focus Residential Habilitation services at the minimal level or higher who do not meet the criteria for Tier 1. □ Adults or children receiving Live-in Residential Habilitation services in a home licensed for 3 or less people. (Live-in is 8 or more hrs. a day.)	□ The client is in supported living and is authorized to receive more than six hours a day of in-home support services. This includes all individuals who receive the in-home live in rate and meet the daily limit of 6 or more hours, as well as those who receive the quarter hr. rate that meets the criteria. (In-home live in is 8 or more hours a day.)
TIER 3—65G-4.0024 The total budget in a cost plan year for each Tier Three Waiver client shall not exceed $35,000.
□ The client is receiving residential habilitation services at the daily or monthly rate at the basic level or higher and is not eligible for the Tier One Waiver or the Tier Two Waiver. (Standard Basic or Minimal levels.)□ The client is 22 or older and is authorized to receive services of a behavior analyst and/or a behavior assistant. □ The client is under the age of 22 and authorized to receive the combined services of a behavior analyst and/or a behavior assistant for more than 60 hours per month and is not eligible for the Tier One Waiver or the Tier Two Waiver.	□ The client is 21 or older, resides in their own home and receives In-Home Support Services and is not eligible for the Tier One Waiver or the Tier Two Waiver or the Tier Four Waiver.□ The client is 21 or older and is authorized to receive Skilled or Private Duty Nursing Services and not eligible for the Tier One Waiver or the Tier Two Waiver. (Client receives Skilled (intermittent) nursing services or other Nursing services of less than 4 hours a day.)	□ The client is 21 or older and is authorized to receive Personal Care Assistance services at the moderate level of support as defined in the DD Handbook.□ The client is 21 or older and is authorized to receives Personal Care Assistance services at the Standard level of support and does not meet the criteria for placement in Tier 1, or Tier 2. □ The client is 21 or older and is authorized to receive Occupational Therapy. □ The client is 21 or older and is authorized to receive Physical Therapy. □ The client is 21 or older and is authorized to receive Speech Therapy. □ The client is 21 or older and is authorized to receive Respiratory Therapy.
TIER 4—65G-4.0025 The total budget in a cost plan year for each Tier Four Waiver client shall not exceed $14,792.
□ Clients who are not eligible for assignment to the Tier One Waiver, the Tier Two Waiver, or the Tier Three Waiver shall be assigned to the Tier Four Waiver.	□ Clients who are currently assigned to receive services through the Family and Supported Living Waiver unless there is a significant change in condition or circumstance as described in subsection 65G-4.0021(4), F.A.C.	□ Dependent children in need of in-home support services through APD who live in a DCF licensed group or foster home under Section 409.175 F.S.. □ Clients who are under the age of 22 and residing in their own home or the family home except for those who have moderate or extensive behavior support needs that are more intense than the Tier level can accommodate.

Rule General Provisions, Rule Detail and Operational Detail

Tier 1—65G-4.0022 The client has service needs for intense medical or adaptive needs that cannot be met in Tiers Two, Three, and Four and services are essential for avoiding institutionalization. The client possesses behavioral problems that are exceptional in intensity, duration, or frequency with resulting service needs that cannot be met in tiers Two, Three, and Four, and the client presents a substantial risk of harm to themselves or others.

□ Clients living in a licensed residential facility receiving Special Medical Home Care.□ Clients living in a licensed residential facility receiving intensive behavioral residential habilitation services.

□ Children and adults receiving behavior focus res hab services at the current “moderate level or above”, (or 7 or more hours a day based on the previous rate table.)

□ Clients living in a licensed residential facility receiving Standard residential habilitation at the extensive 1, or higher, level of support (10 or more hours a day based on the previous rate table.)

□ Nursing service needs that can be met through the Tier Two, Tier Three, or Tier Four Waivers are not “services” or “service needs” that support assignment to the Tier One Waiver.□ Anyone 21 or over receiving continuous nursing services and annual cost plan for all services exceeding $55,000. (Intermittent nursing services do not qualify.) Continuous nursing is defined as 4 or more hours of nursing a day. (Note: Skilled nursing is considered intermittent nursing.)

□ Anyone 21 and over receiving personal care assistant services at 180 hours or more a month and total annual cost plan for all services exceeding $55,000. (The person must be approved for intense PCA services only per the statute and the handbook.)□ Adults (18+) with supported living coaching, in-home supports (quarter hour or live-in), approved cost plan over $55,000, and any one of the following therapies: physical therapy, occupational therapy, respiratory therapy, or behavior analysis.

□ Anyone 21 or older living in the family home with combined Behavior Analysis Services and Behavior Assistance services of 60 or more hours per month AND total annual cost plan for all services exceeding $55,000.

TIER 2—65G-4.0023 The total budget in a cost plan year for each Tier Two Waiver client shall not exceed $55,000.

The client’s service needs include placement in a licensed residential facility and authorization for Residential Habilitation levels of support as identified in column 2.

Individuals living in their family home are excluded from this Tier at this time.

□ Adults or children receiving standard Residential Habilitation at the moderate level of higher who do not meet the criteria for Tier 1, or

□ Adults or children receiving Behavior Focus Residential Habilitation services at the minimal level or higher who do not meet the criteria for Tier 1.

□ Adults or children receiving Live-in Residential Habilitation services in a home licensed for 3 or less people. (Live-in is 8 or more hrs. a day.)

□ The client is in supported living and is authorized to receive more than six hours a day of in-home support services.

This includes all individuals who receive the in-home live in rate and meet the daily limit of 6 or more hours, as well as those who receive the quarter hr. rate that meets the criteria. (In-home live in is 8 or more hours a day.)

TIER 3—65G-4.0024 The total budget in a cost plan year for each Tier Three Waiver client shall not exceed $35,000.

□ The client is receiving residential habilitation services at the daily or monthly rate at the basic level or higher and is not eligible for the Tier One Waiver or the Tier Two Waiver. (Standard Basic or Minimal levels.)□ The client is 22 or older and is authorized to receive services of a behavior analyst and/or a behavior assistant.

□ The client is under the age of 22 and authorized to receive the combined services of a behavior analyst and/or a behavior assistant for more than 60 hours per month and is not eligible for the Tier One Waiver or the Tier Two Waiver.

□ The client is 21 or older, resides in their own home and receives In-Home Support Services and is not eligible for the Tier One Waiver or the Tier Two Waiver or the Tier Four Waiver.□ The client is 21 or older and is authorized to receive Skilled or Private Duty Nursing Services and not eligible for the Tier One Waiver or the Tier Two Waiver. (Client receives Skilled (intermittent) nursing services or other Nursing services of less than 4 hours a day.)

□ The client is 21 or older and is authorized to receive Personal Care Assistance services at the moderate level of support as defined in the DD Handbook.□ The client is 21 or older and is authorized to receives Personal Care Assistance services at the Standard level of support and does not meet the criteria for placement in Tier 1, or Tier 2.

□ The client is 21 or older and is authorized to receive Occupational Therapy.

□ The client is 21 or older and is authorized to receive Physical Therapy.

□ The client is 21 or older and is authorized to receive Speech Therapy.

□ The client is 21 or older and is authorized to receive Respiratory Therapy.

TIER 4—65G-4.0025 The total budget in a cost plan year for each Tier Four Waiver client shall not exceed $14,792.

□ Clients who are not eligible for assignment to the Tier One Waiver, the Tier Two Waiver, or the Tier Three Waiver shall be assigned to the Tier Four Waiver.

□ Clients who are currently assigned to receive services through the Family and Supported Living Waiver unless there is a significant change in condition or circumstance as described in subsection 65G-4.0021(4), F.A.C.

□ Dependent children in need of in-home support services through APD who live in a DCF licensed group or foster home under Section 409.175 F.S.. □ Clients who are under the age of 22 and residing in their own home or the family home except for those who have moderate or extensive behavior support needs that are more intense than the Tier level can accommodate.

Specialgathering's Weblog