As used in this part, unless the context otherwise requires:
(1)"Budget allowance" means the amount of money that can be directed, utilizing the services of a fiscal intermediary, by a medicaid-eligible long-term care member participating in this consumer-directed care option, to pay for home and community-based long-term care services defined under the medicaid state plan or any federal waivers or amendments thereto that are necessary to meet the member's long-term care needs and to delay or prevent institutionalization. The budget allowance shall be based on the results of a functional assessment performed by a qualified entity and the availability of family and other caregivers who can help provide needed support, and when combined with the cost of home health services and private duty
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As used in this part, unless the context otherwise requires: (1) "Budget allowance" means the amount of money that can be directed, utilizing the services of a fiscal intermediary, by a medicaid-eligible long-term care member participating in this consumer-directed care option, to pay for home and community-based long-term care services defined under the medicaid state plan or any federal waivers or amendments thereto that are necessary to meet the member's long-term care needs and to delay or prevent institutionalization. The budget allowance shall be based on the results of a functional assessment performed by a qualified entity and the availability of family and other caregivers who can help provide needed support, and when combined with the cost of home health services and private duty nursing in the home or other community-based setting, cannot exceed the cost of institutional care; (2) "Commissioner" means the commissioner of finance and administration or the commissioner's designee; (3) "Cost-effective" means that the total cost of services provided to an eligible elderly or physically disabled adult in the home or other community-based setting does not exceed the cost of reimbursement for institutional care in a nursing facility. The total cost of services shall include the cost of home health services and private duty nursing, as well as home and community-based long-term care services provided pursuant to the medicaid state plan or any federal waiver or amendments thereto; (4) "Fiscal intermediary" means an entity with whom the commissioner or a contractor responsible for the coordination of medicaid primary, acute and long-term care services has contracted to help a member participating in this consumer-directed care option manage the member's budget allowance. The fiscal intermediary will manage all payments to providers and paid caregivers for specified home and community-based services on behalf of the member, process employment and tax information as applicable, review records to ensure accuracy and provide full accountability for all expenditures made on behalf of each participating member; (5) "Qualified entity" means an entity with which the commissioner has contracted to assess the needs of persons determined medically eligible for long-term care services and to develop care plans to address their identified needs. Such entity shall have the expertise and capacity to timely perform these services and shall not provide any direct long-term care service which may create a conflict of interest. A managed-care organization performing care coordination services under this part shall be a qualified entity only to the extent that appropriate regulatory and contractual safeguards are in place to help ensure that such assessment and care plan development processes are fair, objective and consistent with the needs of the individual and the individual's family caregivers, as applicable; and (6) "Rebalance" means reaching a more equitable balance between the proportion of medicaid long-term care expenditures used for institutional, i.e., nursing facility, services and those used for home and community-based services and supports under the medicaid state plan or federal waivers or amendments to the medicaid state plan or federal waivers.