Sec. 10.09.46.04. Program Model

A. The program services and supports shall:

(1) Maximize the level of functioning of an individual with BI through assistance and support with independent living, self care skills, and social skills in an environment which encourages the participant's ability to make decisions about the individual's life and create opportunities for choice regarding home, school or work, and community activities;

(2) Promote the use of community resources to integrate the individual into the community;

(3) Provide services that are:

(a) Appropriate to the age of the populations being served;

(b) Offered at times and places suitable to the individuals served; and

(c) Coordinated by BHA’s administrative case manager with other medical rehabilitation, mental health, and primary care services that the individual is receiving; and

(4) Assure that staff are available, on call, 24 hours per day, 7 days per week.

B. Development of the Initial Waiver Plan of Care. Before the start of waiver services:

(1) A case manager shall meet with the participant or the participant's legal representative to develop the initial waiver plan of care;

(2) The case manager, the participant, or the participant's legal representative shall sign the waiver plan of care to indicate approval of its recommendations; and

(3) The BHA’s authorized representative shall review the initial waiver plan of care and sign to indicate approval if the plan of care is determined to be:

(a) Sufficient to assure the participant's health and safety and meet the participant's needs in a community-based setting;

(b) Feasible according to the specifications in the waiver plan of care; and

(c) Individually cost-neutral by costing the Program no more for the participant's waiver and other Program services than the participant would have cost the Program in the alternative nursing facility or special hospital setting.

C. Waiver Plan of Care.

(1) The participant's waiver plan of care:

(a) Preauthorizes the specific waiver services to be provided to the participant, as covered under Regulations .07-.09 of this chapter;

(b) Is documented on the waiver plan of care form included in the approved waiver proposal;

(c) Specifies for each preauthorized waiver service the following information, as appropriate:

(i) Description of the specific service to be provided;

(ii) Level of service;

(iii) Service start date;

(iv) Estimated duration;

(v) Approved frequency and units of service to be delivered;

(vi) The provider for that service, if known; and

(vii) Estimated unit costs and monthly costs;

(d) Describes other Program services recommended for the participant;

(e) Evaluates the participant's total costs to the Program, to ensure the participant's cost-neutrality as compared to the cost to the Program for the individual in the alternative nursing facility or special hospital setting; and

(f) Is subject to the BHA’s approval.

(2) A participant shall be given freedom of choice among all qualified and available providers for each service included in the participant's waiver plan of care.

D. Periodic Review of the Waiver Plan of Care.

(1) At least every 12 months or more frequently if determined necessary by the BHA:

(a) A case manager and the participant or the participant's legal representative shall review the waiver plan of care and revise it as necessary;

(b) The case manager and the participant or the participant's legal representative shall sign the waiver plan of care, as revised, to indicate approval of its recommendations; and

(c) The BHA or its authorized representative shall review the revised waiver plan of care, and if the plan of care is determined to meet all of the criteria specified in §C(3) of this regulation, sign to indicate approval.

(2) Periodic reviews and updates shall take place to:

(a) Determine the appropriateness and adequacy of the participant's services; and

(b) Ensure that the furnished services are consistent with the services needed for the participant's disability.