Section 480-2-005 - NOTIFICATION OF ADVERSE DECISIONSRefer to 465 NAC 2-000 and 6-000, and title 477 NAC 3-000, 9-000, and 10-000. Persons who request, apply for, or receive services may appeal any adverse action or inaction. These may include, but are not limited to, a potential Waiver participant being denied services, a Waiver participant's services being reduced, or a Waiver participant determined ineligible for Waiver services.
005.01MEDICAID ELIGIBILITY. If the termination of Waiver services is because of loss of Medicaid eligibility, the effective date of the termination must match the effective date of the termination of Medicaid eligibility.005.02DENIAL OR TERMINATION OF ELIGIBILITY. Eligibility for Medicaid Waiver services may be denied or terminated for any of the following reasons: (A) The unavailability of Waiver capacity;(B) The participant has no Waiver service need;(C) The participant has not used Waiver services in the most recent 60 calendar days;(D) The participant's needs are being met by another source;(E) The participant does not meet priority assessment criteria;(F) The participant or their guardian has not supplied needed information to complete the eligibility or person-centered plan (PCP) review process;(G) The participant fails to meet the specified eligibility criteria at the initial determination or a later re-determination;(H) A person-centered plan (PCP) cannot be developed and maintained which protects the participant's health and welfare;(I) The participant or their guardian has not signed necessary forms consenting to Waiver services;(J) The participant or their guardian voluntarily withdraws;(K) The participant moves out of Nebraska;(L) The death of the participant;(M) The agency loses contact with the participant and the participant's whereabouts are unknown;(N) The need for Assistive Technology Supports (ATS), Home and Vehicle Modifications (H/VM) has been addressed and no other Waiver services are needed;(O) The participant or their guardian is not able to meet in-person with their Services Coordinator at least every three months; or(P) The participant has become a resident of a nursing facility, intermediate care facility for the developmentally disabled (ICF/DD), or an institute for mental disease and is expected to remain there for more than 60 days.005.03PROVIDER NOTICE. Refer to 471 NAC 2-000 for specific information regarding notice of action information sent to providers. When a Waiver participant's services are being changed or terminated, the services coordinator will provide written notice to the provider of the change in service provision or termination of payment for Waiver services.480 Neb. Admin. Code, ch. 2, § 005
Adopted effective 10/3/2021