| (a) The department must analyze actuarial cost projections
concerning program administrative and client services to estimate
the amount of funds needed in the fiscal year by the program to serve
program clients and shall monitor such program cost projections and
funding analyses at least monthly to determine whether the estimated
amount of funds needed by the program will:
(1) exceed the program's appropriated funds and other
available resources for the fiscal year; or
(2) be less than the program's appropriated funds and
other available resources for the fiscal year.
(b) When the program projects that the estimated amount
of funds needed in the fiscal year by the program to serve program
clients will exceed the program's appropriated funds and other available
resources for the fiscal year, the program shall use the following
methodology to reduce or limit the amount of funds to be expended
by the program:
(1) give clients and providers who will be directly
affected written notice of any reductions or limitations of services,
coverage, or reimbursements;
(2) take the following actions in the order listed
only until the projected amount of funds to be expended by the program
approximately equals, but does not exceed, the program's appropriated
funds and other available resources:
(A) implement administrative efficiencies while avoiding
changes which may jeopardize the quality and integrity of the program
service delivery;
(B) establish and administer a waiting list for health
care benefits according to the procedures in this section;
(C) at the same time the waiting list is established,
the program shall:
(i) provide only limited prior authorization for family
support services for ongoing clients, as determined by the medical
director or other designated medical staff, only in order to continue
services already being provided at the time the waiting list is established,
when the specific services are required to prevent out-of-home placement
of the client (as documented by the program regional case management
staff or contractors), or when the provision of such services is cost
effective for the program;
(ii) disallow prior authorization (coverage) of diagnosis
and evaluation services for applicants who qualify for up to 60 days
of program coverage for diagnosis and evaluation services only and
refer such applicants to case management services; and
(iii) allow limited prior authorization of diagnosis
and evaluation services on a short-term basis only when such information
is needed to assess whether clients on the waiting list have "urgent
need for health care benefits" as described in subsection (e) of this
section and only with prior authorization and approval by the medical
director or other designated medical staff.
(D) place new applicants or re-applicants with lapsed
eligibility who are determined eligible for program health care benefits
(new clients for health care benefits) on the waiting list. These
clients will be ordered on the waiting list according to the date
and time the client is determined eligible for program health care
benefits;
(E) reduce or limit reimbursements for contractual
service providers while avoiding changes which may jeopardize the
integrity of the contractor base and thereby decrease client access
to services;
(F) place clients who are eligible to receive program
health care benefits and who currently are not on the waiting list
(ongoing clients for health care benefits) on the waiting list. These
clients will be ordered on the waiting list according to the original
date and time that starts the client's latest uninterrupted sequence
of eligibility for program health care benefits and in the following
order of movement to the waiting list:
(i) ongoing clients for health care benefits who have
one or more sources of substantial health insurance coverage (such
as Medicaid, CHIP, or other private health insurance similar in scope)
in addition to the CSHCN Services Program (not including those ongoing
clients for whom the program pays the insurance premiums);
(ii) ongoing clients for health care benefits in the
following order by age groups: 21 years of age or older, 20 years
of age, 19 years of age, 18 years of age; and
(iii) all other ongoing clients for health care benefits
who do not have an urgent need for health care benefits;
(G) employ additional measures to reduce or limit the
amount of funds to be expended by the program as directed by rule.
(c) If the procedures described in subsection (b)(2)(A)
- (G) of this section enable the program to project that the estimated
amount of funds to be expended by the program in the fiscal year approximately
equals, but does not exceed, the program's appropriated funds and
other available resources, the program shall take the following additional
steps in order to provide health care benefits to as many clients
with urgent need for health care benefits as possible who are currently
on the waiting list.
(1) generate cost savings by taking the following steps
in the order listed:
(A) give clients and providers who will be directly
affected written notice of any reductions or limitations of services,
coverage, or reimbursements;
(B) reduce or limit reimbursements for contractual
service providers while avoiding changes which may jeopardize the
integrity of the contractor base and thereby decrease client access
to services; and
(C) employ additional measures to generate cost savings
as directed by rule.
(2) utilize cost savings generated to remove as many
clients with urgent need for health care benefits as possible from
the waiting list and provide health care benefits to those clients.
Clients with urgent need for health care benefits will be removed
from the waiting list according to the original date and time that
starts the client's latest uninterrupted sequence of eligibility for
program health care benefits and in the following group order:
(A) clients who are less than 21 years old and who
have an urgent need for health care benefits as described in subsection
(e) of this section;
(B) clients who are 21 years of age or older and who
have an urgent need for health care benefits as described in subsection
(e) of this section;
(3) provide health care benefits (which may or may
not include coverage of outstanding bills for health care benefits)
for clients with urgent need for health care benefits who are removed
from the waiting list;
(A) as long as program cost savings funds are available;
and
(B) if the outstanding bills for health care benefits
are for dates of service that are within the time period that program
cost savings funds are available and provided the client was eligible
for program health care benefits at the time of the dates of service;
(4) provide limited health care benefits or payment
of outstanding bills for health care benefits for clients with urgent
need for health care benefits who are on the waiting list and remain
on the waiting list. The program's coverage of such health care benefits
may be limited in scope, amount, and duration and is not intended
to be sustained over time. If limited health care benefits coverage
includes coverage of family support services, the coverage of family
support services must be limited according to the parameters set forth
in subsection (b)(2)(C)(i) of this section. Clients with urgent need
for health care benefits who are on the waiting list will be served
in the same order used in paragraph (2) of this subsection to remove
clients with urgent need for health care benefits from the waiting
list. This coverage may be provided to clients with urgent need on
the waiting list prior to or at any point during activities described
by paragraphs (2) - (3) of this subsection only:
(A) when projected cost savings funds are projected
to be insufficient to remove clients with urgent need for health
care benefits (or additional clients with urgent need for health care
benefits) from the waiting list and maintain continuous program health
care benefits coverage for those clients or when projected cost savings
funds may lapse if not expended in this manner;
(B) as long as program cost savings funds are available;
and
(C) if the outstanding bills for health care benefits
are for dates of service that are within the time period that program
cost savings funds are available and provided the client was eligible
for program health care benefits at the time of the dates of service.
Cont'd... |
