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9510.1040 APPLICATION TO BE COMPLETED BY PROVIDER.

Subpart 1.

Application.

The provider shall apply to the county for a special needs rate exception to cover the cost of a staff intervention or piece of equipment necessary to serve clients eligible under part 9510.1050, subpart 2. A separate application must be completed for each client unless the staff intervention or equipment is shared by the clients identified. If more than one client is included in the application, client information must be submitted for each client. The application must include the information in subparts 2 to 4.

Subp. 2.

Information about client's needs and methods used to address needs.

The provider shall:

A.

identify the client including:

(1)

name;

(2)

name and address of the client's legal representative;

(3)

medical assistance identification number;

(4)

date of admission or anticipated admission to the provider's program;

(5)

diagnosis;

(6)

age;

(7)

current residence; and

(8)

current day program;

B.

describe the client's special need or needs which put the client at risk of regional treatment center placement or continued regional treatment center placement;

C.

describe the proposed staff intervention including:

(1)

the amount of staff or consultant time required;

(2)

qualifications of the program staff or outside consultants providing the intervention;

(3)

type of intervention;

(4)

frequency of intervention;

(5)

intensity of intervention; and

(6)

duration of intervention;

D.

describe the equipment needed and the plan for use of the equipment by the client;

E.

identify the total cost and the unit cost of the equipment or the staff intervention;

F.

describe the modifications needed to integrate the equipment and staff intervention into the client's individual program plan;

G.

describe the projected behavioral outcomes of the staff intervention or the use of the equipment and when the outcomes will be achieved;

H.

describe how the client's progress toward the behavioral outcomes in item G will be measured and monitored by the provider; and

I.

describe the degree of family involvement with the client.

Subp. 3.

Information about provider.

The provider shall submit:

A.

information identifying the provider including:

(1)

name and address of the provider;

(2)

name and address of the place where the staff intervention and equipment will be delivered, if different from subitem (1);

(3)

name and telephone number of the person authorized to answer questions about the application; and

(4)

medical assistance provider number; and

B.

an explanation of the efforts used to meet the client's needs within the provider's current per diem rate, including:

(1)

modifications made to the individual program plan;

(2)

reallocation of current program personnel;

(3)

training and in-service provided to program personnel for the year immediately preceding the date of the provider's application to the county; and

(4)

other available resources used.

Subp. 4.

Supporting documentation.

The provider shall submit with the application the following:

A.

A copy of the individual program plan including the measurable behavioral outcomes which are anticipated to be achieved by the client as a result of the proposed staff intervention or the equipment.

B.

Documentation of the provider's historical costs on which the current per diem rate is based. An ICF/DD provider shall submit a copy of the most recent rate determination letter. A training and habilitation service program shall submit a copy of its current budget, year-to-date expenses, and current assets.

C.

Work papers showing the method used to determine the cost of the staff intervention and equipment identified in subpart 2, item E, including the hourly wage of staff who will implement the intervention, the unit cost of consultation or training services, and the unit cost of equipment requested.

D.

Documentation that any equipment requested in the application is not available from the Department of Vocational Rehabilitation or covered under parts 9505.0170 to 9505.0475.

E.

Documentation that any consultant services requested in the application are not services covered under parts 9505.0170 to 9505.0475.

F.

The name and address of any vendor or contractor to be reimbursed by the special needs rate exception and the name of the person or persons who will actually provide the equipment or services if known.

G.

A plan to decrease the client's reliance on the proposed staff intervention.

Statutory Authority:

MS s 252.46; 256B.501

History:

10 SR 922; 14 SR 2354; L 2005 c 56 s 2

Published Electronically:

October 8, 2007