Neb. Admin. Code tit. 472 — The Disabled Persons and Family Support Program

Chapter 1 Introduction

Neb. Admin. Code tit. 472, ch. 1 Introduction {#sec-472-nac-1 omnilex-key=us-ne-regs-official--title-472--472 NAC 1}

TITLE 472 DISABLED PERSONS AND FAMILY SUPPORT PROGRAM

CHAPTER 1 INTRODUCTION

001 . SCOPE AND AUTHORITY. This title governs the administration of the Disabled Persons and Family Support Program, Nebraska Revised Statutes (Neb. Rev. Stat.) §§ 68-1501 through 1519.

00 2. DEFINITIONS. As used in this title, the following definitions apply:

002.01 ADEQUATE NOTICE. Notice of a case action which includes a statement of what actions are intended, the reasons for the intended actions, and the specific regulation and guidance document reference that supports or a change in state that requires actions.

002.02 ADAPTIVE EQUIPMENT. Devices, controls, or appliances which enable a client to increase his or her abilities, perform activities for daily living, or to perceive, control, or communicate with the environment in which she or he lives or works and necessary to maintain the client in his or her home.

002.03 ADULT. An individual 19 years of age and older or 18 years of age or younger designated by a court as emancipated.

002.04 ADVERSE ACTION. A determination by the Department that services to an individual will be reduced, denied, or terminated.

002.05 APPLICANT. An individual who is seeking an eligibility determination through an application submitted to the program.

002.06. ARCHITECTURAL MODIFICATIONS. Any service leading to the alteration of the structure of a dwelling to meet a specific service need of an eligible individual.

002.07 BURIAL INSURANCE OR TRUST. Insurance or trusts whose terms specifically provide that the proceeds can be used only to pay the burial expenses of the insured.

002.08 CASH SURRENDER VALUE. The amount which the insurer will pay upon cancellation of the policy before the death of the insured person(s) or before the maturity of the policy.

002.09 CHILD. An individual 18 years of age or under, who has not been designated by a court as emancipated.

002.10 DISABILITY. A person who has a medically determinable severe, chronic disability diagnosed by a licensed physician, registered nurse, physician’s assistant, psychiatrist, psychologist, or physical therapist meeting the criteria as outlined below:

(A) Is attributable to mental or physical impairments or combination of mental and physical impairments;

(B) Is likely to continue indefinitely;

(C) Results in substantial functional limitations in two or more of the following areas of major life activity;

(i) Self-care;

(ii) Receptive and expressive language;

(iii) Learning;

(iv) Mobility;

(v) Self-direction;

(vi) Capacity for independent living;

(vii) Work skills or work tolerance; and

(viii) Economic sufficiency; and

(D) Demonstrates a need for long-term, individually planned and coordinated care, treatment, vocational rehabilitation, or other services.

002.11 EARNED INCOME. The net Nebraska taxable income is reportable under Nebraska law. Taxable income is defined as alimony, wages, salary, commissions, tips, and profits from activities in which an individual is engaged as a self-employed person or as an employee or other money received for a good or service.

002.12 INCOME. Earned of unearned gain or recurrent benefit received in money or in-kind from employment, business, property, investments, gifts, benefits, or annuities, at regular or irregular intervals of time.

002.13 INDEPENDENT LIVING. Residing in a living arrangement other than an alternate living facility that is licensed or certified by the Department or entity acting on behalf of the Department.

002.14 PERSONAL CARE NEEDS. The inability to independently perform self-care including bathing, meal preparation, eating, continence-related tasks, dressing, grooming, and taking medication. A verified medical limitation related to one’s ability to provide self-care mentally or cognitively is also considered a personal care need.

002.15 PROVIDER. An individual or entity that provides authorized services to eligible Program recipients.

002.16 RECIPIENT. Any qualified individual with a disability that has been determined eligible to receive support from the program.

002.17 RESOURCES. Available resources including cash, liquid assets, real estate, personal property, and interest in property that the applicant or recipient owns and has the ability to be converted into cash.

002.18 UNEARNED INCOME. Any cash benefit that is not the direct result of labor or services performed by the individual as an employee or self-employed person.

History

• Effective 2024-11-12

Chapter 2 Application and Eligibility

Neb. Admin. Code tit. 472, ch. 2 Application and Eligibility {#sec-472-nac-2 omnilex-key=us-ne-regs-official--title-472--472 NAC 2}

TITLE 472 DISABLED PERSONS AND FAMILY SUPPORT PROGRAM

CHAPTER 2 APPLICATION AND ELIGIBILITY

001 . INDIVIDUALS SERVED. The Program serves the following populations of Nebraska residents:

(A) Employed persons with a disability or persons with a disability who could be employed and who require some form of support to maintain or obtain employment. The employment or prospective employment must allow for the person to be self-supporting by earning wages equal to or above the substantial gainful activity amount, identified by the Social Security Administration; and

(B) Persons with a medically determinable severe, chronic disability that require some form of support to prevent placement within an institution or facility or to return to independent living.

002. INDIVIDUAL RESPONSIBILITIES. Each applicant or recipient is required to:

(A) Provide complete and accurate information. State law provides penalties of a fine, imprisonment, or both for persons found guilty of obtaining assistance or services for which the individual is not eligible by making false statements or failing to promptly report any changes in their circumstances.

002.01 REPORTING A CHANGE. Change in the following circumstances must be reported no later than ten calendar days following the change of:

(A) Earned and unearned income;

(B) Resources;

(C) Living arrangement;

(D) Address;

(E) Family composition;

(F) Household composition;

(G) Need for services; or

(H) Recipient’s medical condition or health.

002.02 AUDIT. Cooperate with the Department or auditors during an audit.

002.03 VERIFICATION REQUIREMENTS. Each applicant or recipient is required to provide verification of information when requested by the Department. An applicant who fails to provide the requested information by the due date may have the application denied. A recipient receiving services who fail to provide requested information may have payments delayed, services terminated, and the Department may establish an overpayment for services previously provided. In renewal cases, if the completed application, disability report, and requested supporting documentation are not returned for eligibility renewal before the existing eligibility expires, the program case will be closed at the end of the eligibility period.

002.04 WRITTEN NOTICE BY RECIPIENT. The recipient provides written notice to the Department of the preference for receiving notifications through the United States Postal Service or a designated email address. The recipient is responsible to provide the Department with a current and accurate mailing or email address as well as updating the Department with any changes.

002.05 RENTAL PROPERTY MODIFICATION APPROVAL. If the individual is living in a rental property and the individual is requesting the Department to assist with the installation of adaptive equipment, devices, or modification a rental property modification approval must be received before the Department will authorize services.

003. ELIGIBILITY CRITERIA. A Nebraska resident with a disability described in this chapter is eligible for benefits if the following criteria are met:

(A) Has a personal care need as defined in Chapter 1;

(B) Meets the definition of disability as defined in Chapter 1;

(C) Not residing in an institution of, if in an institution, will be returning home with receipt of program assistance;

(D) Submits a completed, dated, and signed application and self-assessment form, as well as the program disability report completed and signed by a licensed health professional electronically, by mail, fax, or in person;

(E) The applicant or recipient shall be a citizen of the United States or a qualified alien under the federal Immigration and Nationality Act and be lawfully present in the United States as required by state law;

(F) The individual has an ongoing disability-related expense, and the program support shall be supplemental to other support programs for which the family or disabled person is eligible and not intended to reduce the responsibility for services and support by other programs;

(G) The applicant or recipient must not have other sources of assistance as defined within this chapter;

(H) The Department determines whether the requested program services, in combination with any other assistance the applicant or recipient receives, will be sufficient to allow for the applicant or recipient to continue to reside with the family, live independently, or return to an independent living setting. If the available program services will be inadequate to allow the applicant or recipient to continue residing with the family, living independently, or return to independent living, the applicant or recipient is not eligible for services; and

(I) Meets the income and resource criteria of this chapter.

003.01 OTHER PROGRAM ELIGIBILITY. Applicants and recipients are not eligible to receive reimbursement for any services or equipment covered by Medicaid, Medicare, or other health insurance.

(A) Applicants or recipients may not use disability-related expenses covered by Medicaid, Medicare, or health insurance as a disability expense deduction for purposes of financial eligibility; and

(B) The program will not pay for any portion of services required to be paid by a Medicaid recipient to meet a share of the cost obligation.

004. WAITING LIST FOR ELIGIBLE INDIVIDUALS. Applications for program assistance will be pre-screened for eligibility and those potentially eligible may be placed on a waiting list should funding limitations restrict the number of individuals and families that may be assisted. The Department shall give priority to those families providing for a severely or multiple disabled family member and to severely or multiple disabled persons in independent living situations. Priority shall be given to those families and disabled persons:

(A) With the greatest need for support to maintain the disabled person in the family home or independent living situation;

(B) Who have the greatest possibility of maintaining the disabled person in the home or independent living situation on a continual basis; and

(C) Who demonstrate that support pursuant to as required by the applicable state statutes will provide the most cost-effective form of care for the disabled person.

Example: The Department may establish 40 slots available for the program year October 1 through September 30. Applications might then be accepted from August 1 through September 15. The 40 applicants with the highest needs, based upon established criteria, would be eligible beginning next October 1. If a person filling a slot moves out of Nebraska, the needs of the first person on the waiting list would then be considered.

004.01 LATE APPLICATIONS. Applications received after the open application period will be returned to the applicants with a notice of the next open application period. The Department shall provide only information and referral services to these applicants in an effort to ensure that their needs are met by other available programs.

005. APPLICATION. Any individual may contact the Department to obtain program information, explore eligibility, or apply for services. Applications may be submitted by a legally responsible individual, representative, agency, or organization on behalf of any individual. An application may be submitted electronically, by mail, by fax, or in person.

006. NEEDS ASSESSMENT. To determine an applicant’s eligibility, the Department evaluates the applicant’s need for program services.

006.01 MEDICAL NEED. An applicant or recipient’s disability must be documented by submitting the required program disability report. The disability report must be completed and signed by a licensed physician, registered nurse, physician's assistant, psychiatrist, psychologist, or physical therapist. This form must be signed by the applicant, the recipient, or the authorized representative. The licensed health professional signing the forms must be a medical services provider for the individual. A disability report is not acceptable if signed by an in-home service provider for the applicant or recipient paid or to be paid with program funds.

006.01(A) DETERMINATION OF ELIGIBILITY. The need for programs and services must be supported by program plans, evaluations, or medical reports provided to the Department.

006.01(B) SUPPORTING MEDICAL INFORMATION. Any medical information provided to support a medical need must be dated within 12 months of the application.

006.02 OTHER PUBLIC BENEFITS AND ASSISTANCE PROGRAMS. The assistance provided by the program must not replace or reduce services and support from other programs for which the applicant or recipient is eligible or may be eligible.

006.02(A) OTHER PROGRAM ELIGIBILITY. The applicant or recipient must not be, nor could not be, eligible for another state or federally funded support program that can provide the requested assistance.

006.02(B) EVIDENCE OF ELIGIBILITY OR DENIAL. The applicant or recipient must apply for and provide evidence of current application and eligibility denial or lack of available funds for all other support programs that fund the same, or similar, services allowable through other programs before eligibility can be determined.

006.02(C) VERIFICATION OF OTHER SUPPORT PROGRAM FUNDS. The applicant or recipient must provide verification from an agency administering other support program funds. The verification must indicate eligibility for other support services and any support services the applicant or recipient does or may receive. This verification must include whether services are funded in part or whole, identify the service provided, and the amount of assistance available.

006.02(D) ACCEPTANCE OF PROGRAM SUPPORT. Applicants and recipients must accept any appropriate support available through another program.

006.02(E) MEDICAID FINANCIAL OBLIGATIONS. Medicaid-eligible individuals with a share of cost budget must meet the financial obligation before program funds can be authorized.

006.02(F) MEDICAID SHARE OF COST. Program funds cannot be used towards Medicaid's share of cost or co-pays.

006.02(G) PROGRAM COOPERATION. Lack of cooperation with other support programs is grounds for denial or termination from the program.

006.03 INELIGIBILITY DUE TO OTHER AVAILABLE ASSISTANCE. The applicant or recipient is ineligible if:

(A) A parent or legally responsible caregiver of a minor child with a disability or spouse of an applicant or recipient with a disability can meet identified needs unless program staff receives documentation showing otherwise;

(B) Other sources such as relatives, friends, or volunteers will provide identified needs at no cost;

(C) There is available insurance, financial means, or other available support programs to cover the cost of requested program services or equipment;

(D) The applicant or recipient failed to apply for, failed to cooperate with the application process, or failed to provide proof of denial from other support programs for which the applicant o recipient is potentially eligible;

(E) The applicant or recipient is denied Medicaid due to deprivation or disposal of resources;

(F) If the applicant or recipient was denied Medicaid due to the applicant’s or recipient’s action or inaction, then program eligibility will only be approved if the request is for a non-covered Medicaid service. If an applicant or recipient has a Medicaid share of cost or spend down obligation, then program funds can only be used if the share of cost will be met with services not paid by the program; or

(G) The applicant or recipient failed to notify the program of services provided by other funding sources and continued to bill for the same service on the same dates.

006.04 ASSESSMENT OF DISABILITY-RELATED NEEDS AND EXPENSES. The following ongoing disability-related needs and expenses are considered when evaluating an applicant’s or recipient’s eligibility if the expenses are not paid or reimbursed by another source:

(A) Ongoing disability-related needs and expenses above and beyond those incurred in a non-disabled household and not paid for or reimbursed by another source within the previous twelve months;

(B) Additional health insurance costs to support identified disabling conditions are documented on the program’s report. A copy of the current health insurance statement is required to support expenses;

(C) Medical transportation needs and expenses including automobile modification or payment for ambulance travel if required by the disability. A copy of invoices or other provider documentation is required;

(D) Medical costs related to a documented disability. A copy of a repayment agreement with the provider must be submitted when payments are being made by the applicant or recipient. A minimum of three months of documented expenses incurred in the most recent twelve-month period must be submitted for ongoing routine supplies or out-of-pocket expenses;

(E) Costs for monthly personal emergency response system;

(F) Employment expenses related to the disabling condition;

(G) Costs to meet personal care needs. A copy of billing documents or provider invoices describing the services provided and costs paid by or on behalf of the applicant or recipient; and

(H) The degree of disability requiring assistance with personal care needs.

007. INCOME AND RESOURCE ELIGIBILITY. To determine financial eligibility, the program considers the applicant or recipient’s family size, income, and resources. The Department shall not provide support to any family or disabled person whose gross income less the cost of medical or other care specifically related to the disability exceeds the median family income for a family, adjusted for the actual size of the family, in Nebraska.

007.01 TOTAL FAMILY INCOME. For persons who have reached the age of 19, only the income of the applicant or recipient and the applicant or recipient’s spouse will be considered, except the amount which the spouse may designate as community spouse monthly income allowance per the Medical Assistance Act. For persons under the age of 19, and not designated as emancipated by the court, the income and resources of the applicant or recipient and the taxable income of the custodial parent(s) are considered.

007.01(A) INCOME VERIFICATION. Applicants or recipients are to report and provide verification of all grossed earned and unearned income. Verification of earned income consists of the following:

(i) The source of the income;

(ii) The date paid or received;

(iii) The period covered by the payment or benefit; and

(iv) The gross amount of payment or benefit.

007.01(B) INCOME EXCLUSIONS. The following income sources to be excluded in determining gross monthly income:

(i) Amount designated, per Medicaid eligibility, by a spouse living at home to a spouse in an alternate living situation, as defined by the Medical Assistance Act;

(ii) Any grant or loan to any undergraduate student for educational purposes made or insured under any program administered by the Commissioner of Education under the Higher Education Opportunity Act, Public Law 110-315;

(iii) Earnings of a child age 13 or younger;

(iv) Loans and grants (such as scholarships) obtained and used under conditions that prohibit their use for current living costs;

(v) Payments received through the Workforce Innovation and Opportunities Act for classroom training costs. Payments to meet living expenses while attending school are considered income;

(vi) Payments to an individual participating in training or school attendance subsidized by the Division of Vocational Rehabilitation;

(vii) Reimbursement of expenses or payments for services from the Senior Companion Program, AmeriCorps, Senior Corps, Foster Grandparents, Service Corps of Retired Executives, Experience Works, and any other programs under Title II and II of Public Law 93-113;

(viii) Value of United States Department of Agriculture donated foods;

(ix) Value of Supplemental Nutrition Assistance Program and the special food service program for children under the National School Lunch Program Child Nutrition Act of 1966, as amended;

(x) Assigned child or spousal support;

(xi) Subsidized adoption or subsidized guardianship payments from Title IV-E or child welfare funds; and

(xii) Work study for a graduate student or a student working for a second degree.

007.01(C) RESOURCE EXCLUSIONS. The following resources are not considered in determining program eligibility:

(i) Household goods and personal effects of a moderate value used in the home;

(ii) Cash surrender value of life insurance policies with combined face values of $1,500 or less per individual;

(iii) Unspent portion of any lump sum payment or retroactive payment for retirement, survivors, and Disabled Insurance and Supplemental Security Income;

(iv) United States savings bonds;

(v) Value of unavailable resources;

(vi) One motor vehicle;

(vii) Essential property used for an individual’s trade or business;

(viii) Non-business property up to program specified maximum;

(ix) Equity value of the nonbusiness property (real or personal) used to produce goods or services essential to daily activities up to the program specified maximum;

(x) Irrevocable burial trust funds or burial insurance up to program specified maximum;

(xi) Value of purchased burial space up to program specified maximum;

(xii) Qualified Long-Term Care policy;

(xiii) Testamentary trusts and guardianships depending on the availability of the funds as specified in the terms of the trust;

(xiv) Qualified annuities meeting program requirements;

(xv) Special needs or pooled Trusts not considered available if established for a disabled client age 64 or younger or eligible to receive Supplemental Security Income, retirement, survivors, and Disabled Insurance, or Aid to Aged Blind and Disabled;

(xvi) Victims' compensation payments received from a state or local government to aid victims of crime;

(xvii) Payments received from a state or local government to assist in relocation;

(xviii) An unavailable job-related retirement account held by the employer;

(xix) An Individual Development Account;

(xx) A Nebraska Enable Savings Plan pursuant to the Achieving a Better Life Experience Act of 2014 and Section 529A of the U.S. Internal Revenue Code; and

(xxi) Medicare set-aside accounts are used for the payment of medical bills of Medicare beneficiaries.

008. SERVICES FUNDED. The following are services allowed, based on the identified disability-related needs of the applicant, once determined eligible for the program.

008.01 PERSONAL CARE ASSISTANCE. The assistance must enable an individual to function more independently and continue living in their home.

008.02 PURCHASE OR LEASE OF ADAPTIVE EQUIPMENT OR ARCHITECTURAL MODIFICATION OF A HOME. The equipment or modification must improve or facilitate the care, treatment, therapy, general living conditions, or access of the individual with a disability. Adaptive equipment or medical equipment are allowable if the request is not an allowable expense under medical insurance or Medicaid, this includes if insurance or Medicaid is denied due to lack of need.

008.03 DISABILITY-RELATED COUNSELING OR TRAINING. Counseling or training includes programs or services which assist the family in providing proper care for the family member with a disability or assist the individual in an independent living situation to pursue or maintain competitive, integrated employment; training to determine or use appropriate technology to help become successful to accomplish activities of daily living, gain equal access to school, campus, or work environment. Furthermore, to maximize the ability to perform essential skills; consultation to identify appropriate architectural modifications or assistive technology and use of equipment for continued independence. For training or counseling to be covered the following verification is needed:

(A) Written acknowledgment from a licensed professional providing counseling or training, instructor or other staff, or enrollment and participation in Department approved online distance learning class, training, or related program activity with dates included;

(B) Schedules or logs demonstrating participation in an internship, job shadowing, on-the-job training, or volunteer projects, which are signed or acknowledged by an instructor or staff; or

(C) Other documentation as agreed by the Department and the recipient at the time-of-service authorization.

008.04 MEDICAL, SURGICAL, THERAPEUTIC, DIAGNOSTIC, AND OTHER PHYSICAL OR MENTAL HEALTH SERVICES RELATED TO THE DISABILITY OR DISABILITIES. Expenses incurred during evaluation or treatment not covered by insurance, Medicaid, or Medicare to treat the reported disability may be reimbursed with Department's prior approval. Costs for general healthcare not related to the identified disability are excluded. Insurance premiums and deductibles are excluded, and no assistance with Medicaid spend downs or copayments will be approved.

008.05 HOUSEKEEPING SERVICES. Housekeeping services may be approved for adults with disabilities living alone and unable to perform these activities. For a married couple to receive housekeeping, both parties must be determined disabled at the time of application or renewal. Allowable services include general household cleaning tasks necessary to maintain the recipient in a healthy and safe environment because of a disability; changing and laundering bed linens and personal clothing, ironing, folding, and storing laundry in the recipient’s home or utilizing laundry services on behalf of the recipient, in-home light cleaning in essential areas of the home used by the recipient; cleaning and care of household equipment, appliances, or furnishings; cleaning recipient’s dishes; and purchasing food and essential personal items.

008.06 MEDICATION MANAGEMENT. Medication management is the education, evaluation, monitoring, administration, and documentation of the recipient’s use of medication. The provider must be currently licensed or certified in medication management by the Department’s regulation and licensure program. The provider must coordinate care with the recipient’s primary medical provider.

008.07 MEDICATIONS AND SUPPLIES. Medications and supplies must be specific to treat the reported disability. To be reimbursed, disability-related nonprescription drugs, prescribed medications, and medical supplies must be approved by the Department.

008.08 MEDICAL MILEAGE. The program may pay for non-emergency medical transportation for eligible recipients when help is needed getting to or from medical appointments related to the identified disability need. Mileage for the recipient’s or provider’s vehicle, room, and board costs incurred by the provider or disabled person during medical evaluation or treatment may be reimbursed under the following circumstances:

(A) The Department gave prior approval;

(B) Program-approved medical mileage form must be submitted by following instructions on the form and attached to the Department billing document for reimbursement;

(C) Reimbursable mileage is to be reimbursed at the current Internal Revenue Service rate allowed for medical purposes but is subject to Department directed changes to the amount requested based on the availability of program funding;

(D) The provider must provide proof of current vehicle insurance, driver’s license, and current vehicle registration annually; and

(E) Mileage will only be for the distance to the nearest provider. The recipient may select a provider of their choice but if the provider is in a town further away than a closer provider, mileage will be reimbursed based on the distance to the closest provider.

008.09 VEHICLE MODIFICATIONS OR EQUIPMENT REPAIR. Physical adaptations to a vehicle enable a recipient to function with greater independence in the community and include but are not limited to a van lift purchase and installation or lift repairs. The following procedures must be followed:

(A) A mechanic must certify the working condition of the vehicle. Documentation from a certified mechanic shop must be submitted to the Department to determine service eligibility;

(B) The cost of vehicle repair or modification must not exceed the fair market value of the vehicle as verified by the Department using the Department’s approved industry standards;

(C) Applicant or recipient must submit two written cost estimates from vendors for the requested device, labor, and installation costs;

(D) The applicant or recipient must verify acceptable completion or installation of equipment or repair;

(E) The disability report must support the need for vehicle modification; and

(F) If approved, the program will pay one time up to $150 for expenses related to obtaining a certified mechanic’s statement of the vehicle’s working condition.

009. MAXIMUM SUPPORT. The amount of support is based on the applicant’s or recipient’s documented needs and the program funds available. The amount of support provided through this program must not exceed the maximum as outlined within Nebraska Revised Statute (Neb. Rev. Stat.) § 68-1512 per family or disabled person per month, averaged over the number of months in the eligibility period. The maximum support allowed per month per family averaged over any one year shall be no more than the amount outlined in the applicable state statutes for the first disabled family member plus the amount outlined in Neb. Rev. Stat. § 68-1512 for each additional disabled family member per month averaged over any one year.

010. ELIGIBILITY PERIODS. The Department establishes eligibility periods for recipients with ongoing needs. Eligibility must be renewed based on reported information at least every 12 months. A renewal will be completed more frequently if the recipient’s circumstances change.

010.01 ELIGIBILITY REVIEWS. Upon receipt of a renewal request from the Department, the recipient has 45 calendar days from the date of the renewal notifications to provide the same documentation that is required for initial eligibility.

010.02 ACCEPTABLE VERIFICATION FOR ANNUAL ELIGIBILITY REVIEWS. The recipient must provide the same documentation required for initial eligibility.

010.03 VERIFICATION REQUESTS. The applicant or recipient has ten calendar days to respond to written requests from the Department for supportive documentation or the application will be denied, or the case closed.

History

• Effective 2024-11-12

Chapter 3 Dpf Support Providers

Neb. Admin. Code tit. 472, ch. 3 Dpf Support Providers {#sec-472-nac-3 omnilex-key=us-ne-regs-official--title-472--472 NAC 3}

TITLE 472 DISABLED PERSONS AND FAMILY SUPPORT PROGRAM

CHAPTER 3 AUTHORIZING SUPPORT AND PAYMENT

001. NOTICES. Applicants and recipients are sent adequate notice of eligibility decisions within 30 calendar days of the Department’s receipt of the application. Recipients are also sent notices when services are to be reduced, added, or terminated.

001.01 TIMELY NOTICE. A notice of case action must be dated and mailed at least ten calendar days before the date the action becomes effective. Timely notice must be issued unless only adequate notice is required if services are to be reduced or terminated before the current authorization period ends.

001.02 SITUATIONS REQUIRING ADEQUATE NOTICE. In some instances, timely notice is not needed, but adequate notice is still required. A notice is sent to the recipient no later than the action’s effective date.

001.03 NOTICE NOT REQUIRED. The recipient will not receive a notice of action when:

(A) The Department learns of a recipient’s death;

(B) The applicant or recipient is committed to an institution or admitted to a nursing home on a long-term basis;

(C) The applicant or recipient’s whereabouts are unknown; or

(D) The authorization period is ending and the recipient has not acted upon a request for renewal information.

002. FUNDING COORDINATION. The program may share costs of services not fully covered by non-Medicaid covered programs. The recipient is responsible for any costs over the amount authorized by the program.

003. APPEALS. Every applicant, recipient, or authorized representative has the right to appeal.

003.01 APPEAL RIGHTS. An applicant, recipient, or their authorized representative may appeal based upon the following:

(A) Denial of program application;

(B) Suspension of program services;

(C) Reduction of program services;

(D) Termination of program services;

(E) Inaction or belief that the Department’s action was erroneous; or

(F) If the Department determines an overpayment has occurred.

003.02 APPEAL TIME LIMITS. The applicant, recipient, or authorized representative must request a fair hearing in writing within 90 calendar days of the date of the notice or alleged inaction. This appeal request must include:

(A) Include a short, timely, and accurate summary of the Department's action being appealed;

(B) Describe the reason for the appeal; and

(C) Be sent to the Nebraska Department of Health and Human Services Hearing Office.

003.03 CONTINUED SERVICE DURING APPEAL. If an appeal is requested in writing within 10 calendar days following the date the notice of action was mailed, the Department will not carry out the adverse action until a fair hearing decision is made, except when the adverse action is a denial of eligibility.

00 4. LOCATING PROVIDERS. Recipients are expected to self-direct their care. This includes locating providers, interviewing, hiring, and directing the quality service provision. Providers are not employees of the State of Nebraska when providing services for eligible program clients.

004.01 PROVIDER SCREENING. The Department will complete annual background checks for providers that are billing for authorized services of personal care assistance, housekeeping, and medical mileage. If the person billing for medical mileage is the client’s authorized representative, power of attorney, or guardian; background checks will not be required.

005. ELIGIBILITY PERIODS AND PAYMENTS. Eligibility begins the first day of the month the recipient is determined eligible and may continue until the last day of the 12th month.

005.01 ELIGIBILITY AND SERVICE PLAN. The eligibility period and service plan must be in place before services are authorized.

005.02 SUPPORT PAYMENTS. The Department and the recipient must agree whether support payments are to be provided directly to the recipient, the authorized representative, or as vendor payments to providers of authorized program services.

005.03 REFUNDS. In the event of an identified payment mistake or overpayment, the Department may pursue a refund. The party receiving the incorrect payment will cooperate with the Department to refund the amount paid by mistake.

005.04 CLAIMS. Claims shall be paid in accordance with the Prompt Payment Act.

005.05 AUTHORIZED AMOUNT OF SERVICE. Regardless of the total service amount submitted, the Department will not pay more than authorized to the recipient.

005.06 NOTIFICATION OF PAYMENT ERROR. Providers and recipients must notify the Department of any payment received in error and refund the payment.

006. BILLING INSTRUCTIONS. The Department supplies recipients and providers with billing forms. The approved form must be completed, signed, and dated according to instructions found on the billing document. The recipient and provider are responsible for complying with the following:

(A) Recipients must review and approve billing document accuracy before submitting the billing to the Department for payment;

(B) Billing documents not supported by proper documentation, signature, or other required itemized detail may be rejected. The provider, recipient or authorized representative will receive notification from the Department that the claim cannot be paid as submitted;

(C) Recipients or providers must submit billing documents, and receipts if required, within 60 calendar days of the last day of the month service was provided or the billing document will not be paid;

(D) The date a Department approved billing document is signed by the recipient or authorized representative must be on or after the last date of service. The provider must sign and date the Department approved billing document on or before the date of the recipient’s signature after services are provided;

(E) Submit to the Department charges that do not exceed the recipient’s service authorization;

(F) Submit claims that are true, accurate, and complete;

(G) Each provider must submit a separate billing document;

(H) Recipients or providers must submit billings no more than once a month after all program services have been provided for the month;

(I) Billing document may be submitted on any day of the month after the last day eligible service for the month has been provided; and

(J) Submit claims electronically when possible.

007. PAYMENT REFUNDS. The Department may request a refund when there is a Department mistake in a payment made or when there is verified fraud by the recipient, the recipient’s authorized representative, or a provider.

007.01 REFUND REQUEST. When the Department provides a written notification for a refund request of all or part of a paid claim, whomever was paid or reimbursed by the Department must respond within 30 calendar days of the dated written notification to make arrangements to repay the amount owed or dispute the requested refund amount.

007.02 FAILURE TO RESPOND. The notified party’s failure to respond within 30 calendar days is cause for the Department to recoup from future payments until the situation is resolved or to sanction the party that did not comply with the refund. The refund request notification constitutes notice of the sanction to recoup from future payments if the notified party does not respond within 30 calendar days of the notification.

007.03 PAYMENT OF REFUND. The provider or recipient, whomever was paid or reimbursed by the Department, is allowed 90 calendar days from the date of the notification to refund the amount requested, to show that the refund has already been made, or to document why the refund request is in error or to appeal.

007.04 OVERPAYMENT AS A RESULT OF FRAUD. When the overpayment appears to be the result of fraud, the case will be referred to the Special Investigation Unit within the Department.

History

• Effective 2024-11-12