Section 16.03.18.400 - PARTICIPATION IN THE COST OF HOME AND COMMUNITY-BASED WAIVER SERVICES (HCBS)Participants required to participate in the cost of HCBS services as described in IDAPA 16.03.10, "Medicaid Enhanced Plan Benefits," must have their share of cost determined under this rule.
01.Excluded Income. Income excluded under IDAPA 16.03.05, "Eligibility for Aid to the Aged, Blind, and Disabled (AABD)," is excluded in determining participation.02.Base Participation Amount. The base participation amount is income available to the participant after subtracting all allowable deductions, except for the incurred medical expense in IDAPA 16.03.05, "Eligibility for Aid to the Aged, Blind, and Disabled (AABD)."03.Personal Needs Allowance (PNA). The participant's PNA depends on the participant's legal obligation to pay rent or mortgage and is deducted from countable income after income exclusions and any incurred medical expenses allowances. a. PNA for participants not responsible for rent or mortgage equals one hundred percent (100%) of the federal SSI benefit.b. PNA for participants responsible for rent or mortgage equals one hundred eighty percent (180%) of the federal SSI benefit.04.Participants with Developmental Disabilities. These allowances are specified in IDAPA 16.03.05, "Eligibility for Aid to the Aged, Blind, and Disabled (AABD)." PNA for adult participants receiving services under the Developmentally Disabled Waiver is three (3) times the federal SSI benefit amount to an individual in their own home.05.Incurred Medical Expenses. Amounts for certain limited medical or remedial services not covered by the participant's Idaho Medicaid Plan and not paid by a third party may be deducted from the base participation amount. The Department must determine whether incurred expenses for such limited services meet the criteria for deduction. The participant must verify such expenses for any to be considered for deduction. Costs for over-the-counter medications are included in the PNA and are not considered a medical expense. Department-approved deductions for necessary medical or remedial expenses are subtracted upon application, and updated when a participant reports changes to the Department.06.Remainder After Calculation. Any remainder after the calculation is the maximum participation amount to be deducted from the participant's provider payments to offset the cost of services. The participation amount is collected from the participant by the provider. The Department notifies the provider and the participant of the amount to be collected.07.Recalculation of Participation. The participant's participation amount is recalculated annually at eligibility redetermination or upon verified changes.08.Adjustment of Participation Overpayment or Underpayment Amounts. The participant's participation amount is reduced or increased the month following the month of overpayment or underpayment.Idaho Admin. Code r. 16.03.18.400