Maximum Monthly Amount - Aggregate and Per Service 525-05-35

(Revised 07/01/22 ML #3687)

The maximum amount allowable under the Medicaid Waiver for Home and Community Based Services per Medicaid waiver recipient and per month is an aggregate of the cost and is limited to the highest monthly rate allowed to a nursing facility within the rate setting structure of the Department of Human Services.

See link below:

https://www.nd.gov/dhs/services/medicalserv/medicaid/longtermcare.html

The maximum amount allowable under the SPED and ExSPED Programs per individual and per month is an aggregate of $3800 for all services excluding Case Management.


	Homemaker Service	70 units
	Respite Care	$1145 (Daily amount not to exceed daily swing bed rate). Refer to link: http://www.nd.gov/dhs/services/medicalserv/medicaid/provider-fee-schedules.html
	Respite Care in Homes with Multiple Residents	$1145 split by the total number of public and private pay residents in the home. Plus $202.29 per month for each additional (2nd 3rd or 4th) public pay residents in the home, the total amount will need to be divided between the public pay residents. For Example: An AFC provider has a total of 3 residents, 2 are public pay & 1 is private pay. To calculate respite for the public pay residents you should divide the current respite cap ($1145) by the total number of public & private pay residents living in the home (3) that equals $381.67 for each residents or $763.34 for the 2 public pay residents combined. Now add $202.29 for the 2nd public pay resident that equals $965.63. Now divide that amount between the 2 public pay residents 2/$965.63 = $482.82. The final step is to allocate $482.82 on each of the public pay resident's care plan.
	Adult Foster Care	$96.18 per day for Medicaid Waiver for Aged & Disabled
	Family Home Care	$48.12 per day
	Family Personal Care	$150.38 per day
	Daily Rate for SPED AFFC and Personal Care	$82.72 per day

When authorizing services that will be paid at the rural differential rate service maximums may be exceeded but the number of units cannot exceed the number of units that are available when using the original service maximum. It is allowable for costs to exceed the service maximum if RD is the only factor causing it to exceed the cap and costs are within the service maximum when calculating the base rate. This also applies to the respite care cap.

Example 1 (monthly respite care cap): An individual resides 70 miles from the agency respite care provider and RD applies. The individual is requiring the maximum amount of respite care per month, which is 153 units. It is allowable for respite care to exceed the monthly maximum of $1145 because the only factor that causes it to exceed is the additional cost of the RD rate. When calculating the base rate of respite, 153 units falls within the cap.
Example 2 (daily respite care cap): An individual resides 70 miles from the agency respite care provider and RD applies. The individual requires overnight respite care & the daily respite care cap is limited to the swing bed daily cap. Under these guidelines, the agency would be allowed to bill a maximum of 41 units of respite care per day. Even though the RD rate will add on an additional cost to this service, it is allowable as that is the only factor causing it to exceed the swing bed cap.

Service Maximums Per Individual Per Month for Dates of Service.

Extraordinary Costs/Exceed Monthly Aggregate or Service Maximum

This policy provides for additional dollars that may be needed because of a client’s special or unique circumstances that warrant a temporary exception of Department policy. IT IS TIME LIMITED.

The HCBS case manager must submit in WRITING a request to exceed the monthly service or funding source maximum prior to authorizing the service(s) in excess of the monthly maximum. The request is to be sent to the HCBS Program Administrator to include:

Name and ID number of the individual.

Reason for the request: the individual’s circumstances that necessitate the short duration extraordinary costs AND what options were explored as alternatives to meeting individual’s need.

The additional dollar amount request, for what service(s) and for what period of time.

The program administrator will notify the case manager in writing of the Department’s decision. It will include the conditions under which the approval is granted AND the procedure for the Qualified Service Provider to bill for the additional funds.

Maximum Room and Board Rate effective 7/1/2022

The current maximum monthly room and board rate that providers may charge Adult Foster Care, Adult Residential and Family Home Care recipients is $815.00. The maximum room and board rate is equal to the current Medicaid medically needy income level for a one person household less a $125 personal needs allowance. The rate is reviewed annually.

Providers are not required to charge a room and board rate and may choose to charge less than the maximum rate.