Getting iBudget Services
iBudget provides a wide assortment of services tailored to the needs of individuals with differing developmental disabilities. In addition to direct care staffing (personal supports and private duty nursing), iBudget also offers support for employment, day programs, residential options, and an array of therapies and treatments, including behavioral services.
STEPS TO GETTING SERVICES
STEP 1: SELECT A WAIVER SUPPORT COORDINATOR (WSC)
APD will provide you with a list of WSCs in your area who are taking new clients. WSCs are not employed by APD but are independent providers. You can interview WSC candidates before selecting and ask to change to another WSC if you are not satisfied.
WSCs are your liaison with APD. They act as case managers to assist you in selecting and requesting services and finding providers, monitor delivery of services, help you maintain Medicaid eligibility, and keep track of your budget and all the forms and data that are part of your case file. They are required to have face-to-face visits regularly.
Having an experienced, well-trained WSC who will advocate on your behalf is critical to the functioning of the whole system.
STEP 2: HAVE A QSI ASSESSMENT FOR BASELINE FUNDING
APD must complete a face-to-face assessment prior to beginning the process of setting a budget. The assessment tool currently being used is the QSI, a long list of questions primarily related to functional, behavior, and physical needs. When this assessment is done, it is important that someone who understands your history and care needs be present.
Certain questions on the QSI act as variables for calculating a baseline budget, known as an Allocation Algorithm Amount. Do not worry if this baseline amount is too low to meet your needs. Most enrollees are funded above the baseline.
APD services are described in detail in the Medicaid Developmental Disabilities Individual Budgeting Waiver Handbook. To receive approval for any service, it must be determined to be “medically necessary.”
STEP 3: REQUEST FOR SIGNIFICANT ADDITIONAL NEEDS (SAN)
If you haven’t worked with your WSC to develop a Support Plan or it has not been updated recently, you will need to do this before asking for more funding/services. The Support Plan is developed with your input. It is a narrative of your goals and daily needs with a plan of services designed to help you live as independently as possible.
To request more funding, the WSC will need to work with you to make sure that you are using other resources available to you (e.g., private insurance, basic Medicaid, school services) because a HCBS Waiver is the “payer of last resort.” The WSC can then submit a request explaining why the additional funding is needed and provide any documentation. All of this and more must be input correctly into APD’s data system or it will be considered “incomplete.” You should be advised of any delays by your WSC.
STEP 4: ASK FOR A FAIR HEARING IF SERVICES ARE DENIED
APD should send you written notice of its decision on the SAN request. READ YOUR NOTICE! It may look complicated, but you should be able to get an idea of why the SAN was denied in whole or part, how to ask for a fair hearing, and what information to provide in the hearing request.
Fair hearings are heard by hearing officers from DCF Office of Appeal Hearings. The hearings are usually by phone or video conference but may be requested in person. You are not required to have an attorney but can chose to represent yourself or have someone else speak on your behalf. Both you and APD will have the opportunity to put on testimony and evidence to support your position. The hearing results in a Final Order.
STEP 5: ASK FOR A FAIR HEARING IF SERVICES ARE REDUCED OR TERMINATED
APD occasionally does internal reviews and decides that a service that is currently authorized is no longer medically necessary. When that happens, you not only have the right to ask for a fair hearing, you also have the right to ask that the currently authorized services continue pending the outcome of the hearing. In addition, APD has the burden of proving why its decision was justified.
Once again, READ YOUR NOTICE. It is important for you to understand the basis for APD’s decision so that you can plan your response.
STEP 6: THE CDC+ OPTION
Consumer Directed Care Plus is an option available to iBudget enrollees that allows greater flexibility in use of services and employment of paid providers, including family members. Service authorizations are still through iBudget, but the iBudget funds can be reallocated (with some restrictions) through a CDC+ purchasing plan.
CDC+ requires that you or someone on your behalf must be trained in the program and act as your unpaid representative in developing purchasing plans and finding staff. In addition, iBudget funds are reduced to cover the administrative expenses for CDC+ and employee payroll taxes.