reglab/statecodes huggingface dataset:
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-14 - Allowable costs; wages; costs of employment; record keeping; owner or related party compensation

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 14.
(a)
				Reasonable compensation of individuals employed or to be employed by a provider
				is an allowable cost, provided such employees are engaged in, or will be
				engaged in, patient care-related functions and that forecasted compensation
				amounts are reasonable in light of historical data under this section and
				section 15 of this rule.
(b) The
				provider shall report on the financial report form in the manner prescribed,
				using the forms prescribed by the office, all patient related staff costs and
				hours incurred, and forecasted to be incurred, to perform the function for
				which the provider was certified. Both total compensation and total hours
				worked, and forecasted to be worked, shall be reported. If a service is
				performed through a contractual agreement, imputed hours for contracted
				services shall be reported.
(c)
				Payroll records shall be maintained by the provider to substantiate the
				staffing costs reported to the office. Said records shall indicate each
				employee's classification, hours worked, rate of pay, and the department or
				functional area to which the employee was assigned and actually worked. If an
				employee performs duties in more than one (1) department or functional area,
				the payroll records shall indicate the time allocations to the various
				assignments.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-16 - Allocation of costs

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 16.
(a) The
				detailed basis for allocation of expense between different levels of care in a
				facility shall remain a prerogative of the provider as long as the basis is
				reasonable and consistent between accounting periods. (b) However, the
				following relationships shall be followed:
(1)
				Reported expenses and patient census information must be for the same reporting
				period.
(2) Nursing salary
				allocations must be on the basis of nursing hours worked and must be for the
				reporting period except when specific identification is used based on the
				actual salaries paid for the reporting period.
(3) Any change in the allocations must be
				approved by the office prior to the changes being implemented. Proposed changes
				in allocation methods must be submitted to the office for approval at least
				ninety (90) days prior to the provider's reporting year end.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-17 - State-owned facilities per diem rate

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 17.
(a) The per
				diem rate for providers reimbursed under this rule:
(1) is an all-inclusive rate; and
(2) includes all services provided to members
				by the facility. (b) Resources from health insurance plans available to the
				resident shall apply first to defraying the costs of medical services before
				Medicaid. Such resources shall include, but not be limited to, Medicare,
				Civilian Health and Medical Plan for Uniform Services, Veteran's
				Administration, and other health insurances. Services reimbursed through other
				sources shall be segregated and not claimed on the facility's cost report.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 17 - Rate-Setting Criteria for State-Owned Intermediate Care Facilities for the Mentally Retarded › Section 17-18 - Administrative reconsideration; appeal

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 18.
(a) The
				office shall notify each provider of the provider's rate after such rate has
				been computed. If the provider disagrees with the rate determination, the
				provider must request an administrative reconsideration by the office. Such
				reconsideration request shall be in writing and shall contain specific issues
				to be reconsidered and the rationale for the provider's position. The request
				shall be signed by the provider or the authorized representative of the
				provider and must be received by the office within forty-five (45) days after
				release of the rate computed by the office. Upon receipt of the request for
				reconsideration, the office shall evaluate the data. After review, the office
				may amend the rate, amend the challenged procedure or determination, or affirm
				the original decision. The office shall thereafter notify the provider of its
				final decision in writing, within forty-five (45) days of the office's receipt
				of the request for reconsideration. In the event that a timely response is not
				made by the office to the provider's reconsideration request, the request shall
				be deemed denied and the provider may pursue its administrative remedies as set
				out in subsection (c).
(b) If the
				provider disagrees with a rate redetermination resulting from an audit
				adjustment, the provider must request an administrative reconsideration from
				the office. Such reconsideration request shall be in writing and shall contain
				specific issues to be considered and the rationale for the provider's position.
				The request shall be signed by the provider and must be received by the office
				within forty-five (45) days after release of the rate computed by the office.
				Upon receipt of the request for reconsideration, the office shall evaluate the
				data. After review, the office may amend the audit adjustment or affirm the
				original adjustment. The office shall thereafter notify the provider of its
				final decision in writing within forty-five (45) days of the office's receipt
				of the request for reconsideration. In the event that a timely response is not
				made by the office to the provider's reconsideration request, the request shall
				be deemed denied and the provider may pursue its administrative remedies under
				subsection (c).
(c) After
				completion of the reconsideration procedure under subsection (a) or (b), the
				provider may initiate an appeal under
				405 IAC 1-1.4.
(d) The office may take action to
				prospectively implement Medicaid rates without awaiting the outcome of the
				administrative process.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 18 - Reimbursement of Medicare Cross-Over Claims › Section 18-1 - Definitions

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-13; IC
				  12-15-14
Sec. 1.
(a) The
				definitions in this section apply throughout this rule.
(b) "Cross-over claim" means a Medicaid claim
				filed on behalf of a Medicare beneficiary who is also eligible for Medicaid.
				The term includes claims filed on behalf of beneficiaries who are eligible for
				Medicaid in any category, including, but not limited to, qualified Medicare
				beneficiaries (QMBs) and beneficiaries who are eligible for full Medicaid
				coverage.
(c) "Medicaid allowable
				amount" means the reimbursement rate for a Medicaid claim as determined under
				state and federal law and policies. This reimbursement rate shall be the most
				recent rate on file with the office of Medicaid policy and planning or its
				contractor at the time a cross-over claim is processed.
(d) "Medicare payment amount" means the
				amount of payment made by Medicare to the provider for a given claim. It does
				not include coinsurance amounts or deductibles.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 18 - Reimbursement of Medicare Cross-Over Claims › Section 18-2 - Reimbursement of cross-over claims

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-1-15; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-15-14
Sec. 2.
(a)
				Cross-over claims filed by providers are reimbursed as set out in this
				section.
(b) If the Medicare
				payment amount for a claim exceeds or equals the Medicaid allowable amount for
				that claim, Medicaid reimbursement will be zero (0).
(c) If the Medicaid allowable amount for a
				claim exceeds the Medicare payment amount for that claim, Medicaid
				reimbursement is the lesser of:
(1) the
				difference between the Medicaid allowable amount minus the Medicare payment
				amount; or
(2) the Medicare
				cost-sharing costs described in
				42 U.S.C.
				1396d(p)(3)(B) through
				42 U.S.C. 1396d(p)(3)(D), if any,
				for the claim.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 19 - Ownership and Control Disclosures › Section 19-1 - Information to be disclosed

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 1.
(a) In
				accordance with and in addition to
				42 CFR
				455, Subpart B, and
				42 CFR
				1002, Subpart A, as amended, the following
				disclosure requirements apply to all providers of Medicaid services and shall
				be disclosed in accordance with this rule:
(1)
				The name and address of each person with an ownership or control interest in
				the disclosing entity or in any subcontractor in which the disclosing entity
				has direct or indirect ownership of five percent (5%) or more.
(2) Whether any of the persons named, in
				compliance with subdivision (1), is related to another as spouse, parent,
				child, or sibling.
(3) The name of
				any other disclosing entity in which a person with an ownership or control
				interest in the disclosing entity also has an ownership or control interest.
				This requirement applies to the extent that the disclosing entity can obtain
				this information by requesting it in writing from the person. The disclosing
				entity must:
(A) keep copies of all these
				requests and the responses to them;
(B) make them available to the office upon
				request; and
(C) advise the office
				when there is no response to a request.
(4) The name, address, and Social Security
				number of any agent or managing employee.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 19 - Ownership and Control Disclosures › Section 19-2 - Time and manner of disclosure

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 2.
(a) Any
				disclosing entity that is a long term care facility must supply the information
				specified in this rule to ISDH at the time it is surveyed.
(b) Any disclosing entity must supply the
				information specified in this rule to the office at any time there is a change
				in ownership or control.
(c) Any
				provider must supply the information specified in this rule at the time of
				filing a complete application.
(d)
				Any provider must supply the information specified in this rule upon executing
				the provider agreement.
(e)
				Providers are required to notify the office upon such time as the information
				specified in this rule changes within thirty-five (35) days of the effective
				date of change in such form as the office shall prescribe. Long term care
				providers involved in a change of ownership shall also provide notification in
				accordance with
				405 IAC 1-20. New nursing
				facility providers are required to notify the office in accordance with this
				rule and 405 IAC 1-14.6-5.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 20 - Change of Ownership for a Long Term Care Facility › Section 20-1 - General

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 1.
(a) As used
				in 405 IAC 1-19 and this rule, "long
				term care facility" means any of the following:
(1) A nursing facility.
(2) A CRF/DD.
(3) An ICF/IID.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 20 - Change of Ownership for a Long Term Care Facility › Section 20-2 - Notification requirements

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-13-7-3; IC 12-15
Sec. 2.
(a) When a
				change of ownership in a long term care facility is contemplated, the
				transferor provider shall notify the office, or its fiscal agent, no less than
				forty-five (45) days prior to the effective date of sale or lease agreement
				that a change of ownership may take place.
(b) Notification shall be in writing and
				include the following:
(1) A copy of the
				agreement of sale or transfer.
(2)
				The expected date of transfer.
(3)
				If applicable, the name of any individual who has an ownership or control
				interest, is a managing employee, or an agent of the transferor, who will also
				hold an ownership or control interest, be a managing employee, or be an agent
				of the transferee.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 20 - Change of Ownership for a Long Term Care Facility › Section 20-3 - Change of ownership types

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 3.
A change of ownership in an existing long term care facility
				  occurs under, but is not limited to, any of the following circumstances:
(1) For a sole proprietorship, if a provider
				of services is an entity owned by a single individual, a transfer of title and
				property to the enterprise to another person or firm, whether or not including
				a transfer of title to the real estate or if the former sole proprietor becomes
				one (1) of the members of a business entity succeeding him or her as the new
				owner.
(2) For a partnership, a new
				partnership, or the removal, addition, or substitution of an individual partner
				in an existing partnership, in the absence of an express statement to the
				contrary in the partnership agreement, that dissolves the old partnership and
				creates a new partnership.
(3) For
				a corporation, a new corporation, the merger of the applicant or provider
				corporation into another corporation, or the consolidation of two (2) or more
				corporations, or any other change resulting in the creation of a new
				corporation. In an incorporated provider entity, the corporation is the owner.
				The governing body of the corporation is the group having direct legal
				responsibility under state law for operation of the corporation's entity,
				whether that body is:
(A) a board of
				trustees;
(B) a board of
				directors;
(C) the entire
				membership of the corporation; or
(D) known by some other name.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 20 - Change of Ownership for a Long Term Care Facility › Section 20-4 - Change of ownership effect

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 4.
When there is a change of ownership of a long term care
				  facility, the office will transfer the provider agreement to the transferee
				  subject to the terms and conditions under which it was originally issued and
				  subject to any existing plan of correction and pending audit findings as
				  follows:
(1) The transferor and
				transferee shall reach an agreement between themselves concerning Medicaid
				reimbursements, underpayments, overpayments, and civil monetary
				penalties.
(2) From the effective
				date of change of ownership and if all requirements are met, all reimbursements
				will be made to the transferee, regardless of whether the reimbursement was
				incurred by a current owner or previous owner.
(3) From the effective date of change of
				ownership, the transferee shall assume liability for repayment to the office of
				any amount due the office, regardless of whether liability was incurred by a
				current owner or operator or by a previous owner or operator.
(4) Liability of current and previous
				providers to the office shall be joint and several.
(5) A current or previous owner or lessee may
				request from the office a list of all known outstanding liabilities due the
				office by the facility and of any known pending office actions against a
				facility that may result in further liability.
(6) For purposes of this section, examples of
				reimbursements, overpayments, and penalties shall include, but not be limited
				to, the following:
(A) Outstanding
				claims.
(B) Any retro rate
				adjustment that results in an underpayment or overpayment based upon the
				transferor's cost report.
(C)
				Amounts identified during past, present, or future audits that pertain to an
				audit period prior to a change in ownership.
(D) Pending or completed surveillance
				utilization review (SUR) audit.
(E)
				Imposition of penalties due to failure of the provider to be in substantial
				compliance with applicable federal requirements for nursing facilities
				participation in the Medicare program or Medicaid.
(F) Civil monetary penalties.
(G) Amounts established by final
				administrative decisions.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 20 - Change of Ownership for a Long Term Care Facility › Section 20-5 - Record retention

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC
				  12-13-7-3; IC 12-15
Sec. 5.
The transferee shall take possession of the Medicaid records
				  of the transferor and safeguard them for no less than three (3) years from the
				  date of the last claim reimbursed by the office or until any pending
				  administrative or judicial appeal is closed, whichever is
				  longer.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 21 - Payments for Psychiatric Residential Treatment Facility Services › Section 21-1 - Purpose; scope

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-15
Sec. 1.
The purpose of this section is to establish a prospective,
				  cost-based reimbursement methodology for services provided by psychiatric
				  residential treatment facilities that are covered by Medicaid. Prospective
				  payment shall constitute full reimbursement. There shall be no year-end cost
				  settlement payments.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 21 - Payments for Psychiatric Residential Treatment Facility Services › Section 21-2 - "Psychiatric residential treatment facility" or "PRTF" defined

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15
Sec. 2.
As used in this rule, "psychiatric residential treatment
				  facility" or "PRTF" means a facility that is licensed under
				  465 IAC 2-11 as a private secure
				  child caring institution and meets the requirements set forth in
				  405 IAC
				  5-20-3.1.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 21 - Payments for Psychiatric Residential Treatment Facility Services › Section 21-3 - Reimbursement rates

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-21-2; IC 12-15-21-3
Affected: IC 12-15
Sec. 3.
Covered inpatient psychiatric facility services for
				  individuals under twenty-one (21) years of age provided in PRTFs shall be
				  reimbursed in accordance with the following:
(1) The PRTFs shall be reimbursed for
				services provided to Medicaid members based upon the lower of:
(A) the statewide PRTF prospective per diem
				rate calculated by the office; or
(B) the usual and customary daily charges
				billed for the psychiatric treatment of eligible members.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1 - MEDICAID PROVIDERS AND SERVICES › Rule 21 - Payments for Psychiatric Residential Treatment Facility Services › Section 21-4 - Cost reports and audits

Current through July 10, 2024
Authority: IC
				  12-15-1-10; IC
				  12-15-21-2; IC
				  12-15-21-3
Affected: IC 12-15
Sec. 4.
PRTFs shall file a cost report annually using a uniform cost
				  report form prescribed by the office. The office may audit or review the cost
				  reports as it deems necessary.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1.1 - APPEAL PROCEDURES FOR APPLICANTS AND RECIPIENTS OF MEDICAID › Rule 1 - Administrative Law Judge Hearings › Section 1-1 - Purpose

Current through July 10, 2024
Authority: IC
				  12-15-1-10
Affected: IC 12-15-28
Sec. 1.
(a) It is
				the purpose of this article to establish a uniform method of administrative
				adjudication for appeals concerning applicants and recipients of Medicaid, in
				order to determine whether or not any action complained of was done in
				accordance with federal and state statutes, regulations, rules, and policies.
				As used in this article, "policies" includes program manuals, administrative
				directives, transmittals, and other official written pronouncements of state or
				federal policy.
(b) This article
				shall be construed in such a manner as to provide all parties with an adequate
				opportunity to be heard in accordance with due process of law. As used in this
				article, "party" means:
(1) a person to whom
				the agency action is specifically directed;
(2) the office of Medicaid policy and
				planning; or
(3) the county office
				of the division of family resources.
A contractor of the office of Medicaid policy and planning
				  may act on behalf of the office for purposes of this article.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1.1 - APPEAL PROCEDURES FOR APPLICANTS AND RECIPIENTS OF MEDICAID › Rule 1 - Administrative Law Judge Hearings › Section 1-2 - Standing

Current through July 10, 2024
Authority: IC
				  12-15-1-10
Affected: IC 12-15-28
Sec. 2.
(a) In the
				event that the rights, duties, obligations, privileges, or other legal
				relations of any person or entity are required or authorized by law to be
				determined by the office of Medicaid policy and planning or any county office
				of family and children, then such person or entity may request, as provided for
				in section 3 of this rule, an administrative hearing under this article. The
				person requesting the hearing shall be known as the appellant.
(b) Unless otherwise provided for by law,
				only those persons or entities, or their respective attorneys at law, whose
				rights, duties, obligations, privileges, or other legal relations are alleged
				to have been adversely affected by any action or determination by the office of
				Medicaid policy and planning or county office of family and children, may
				request an administrative hearing under this article. Any alleged harm to an
				appellant must be direct and immediate to the appealing parties and not
				indirect and general in character.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1.1 - APPEAL PROCEDURES FOR APPLICANTS AND RECIPIENTS OF MEDICAID › Rule 1 - Administrative Law Judge Hearings › Section 1-3 - Filing an appeal; scheduling appeals

Current through July 10, 2024
Authority: IC 12-15-1-10
Affected: IC 12-15-28
Sec. 3.
(a) Any
				party complaining of an action by the office of Medicaid policy and planning or
				by the division of family resources action in accordance with section 2 of this
				rule may file a request for an administrative hearing as provided in this
				section.
(b) Unless otherwise
				provided for by statute, regulation, or rule, appeal requests by recipients or
				applicants shall be filed in writing with the division of family resources or
				the office of hearings and appeals of the family and social services
				administration as provided in the notice of agency action. The appeal request
				must be received by close of business not later than:
(1) thirty-three (33) calendar days following
				the effective date of the action being appealed; or
(2) thirty-three (33) calendar days from the
				date of the notice of agency action;
whichever is later. Applicant and recipient appeal hearings
				  shall be conducted at a reasonable time, place, and date.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1.1 - APPEAL PROCEDURES FOR APPLICANTS AND RECIPIENTS OF MEDICAID › Rule 1 - Administrative Law Judge Hearings › Section 1-4 - Conduct and authority of administrative law judge

Current through July 10, 2024
Authority: IC
				  12-15-1-10
Affected: IC 12-15-28
Sec. 4.
(a) An
				administrative law judge's (ALJ) conduct shall be in a manner that promotes
				public confidence in the integrity and impartiality of the administrative
				hearing process. The ALJ who conducts a hearing is prohibited from:
(1) consulting any party or party's agent on
				any fact in issue unless upon notice and opportunity for all parties to
				participate;
(2) performing any of
				the investigative or prosecutorial functions of the agency in the
				administrative action heard or to be heard by him or her or in a factually
				related administrative or judicial action;
(3) being influenced by partisan interests,
				public clamor, or fear of criticism;
(4) conveying or permitting others to convey
				the impression that they are in a special position to influence the
				ALJ;
(5) commenting publicly,
				except as to hearing schedules or procedures, about pending or impending
				proceedings; or
(6) engaging in
				financial or business dealings that tend to:
(A) reflect adversely on his or her
				impartiality;
(B) interfere with
				the proper performance of his or her duties;
(C) exploit the ALJ's position; or
(D) involve the ALJ in frequent financial
				business dealings with attorneys or other persons who are likely to come before
				the ALJ.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1.1 - APPEAL PROCEDURES FOR APPLICANTS AND RECIPIENTS OF MEDICAID › Rule 1 - Administrative Law Judge Hearings › Section 1-5 - Conduct of hearing

Current through July 10, 2024
Authority: IC
				  12-15-1-10
Affected: IC 12-15-28
Sec. 5.
(a) The
				administrative law judge (ALJ) shall conduct the hearing in an informal manner
				and without recourse to the technical common law rules of evidence.
(b) The ALJ shall exclude from consideration
				irrelevant, immaterial, or unduly repetitious evidence.
(c) Every party shall have the right to
				submit evidence. In the event that an objection to evidence is sustained, the
				party proffering the evidence may make an offer of proof. Each party shall have
				the right to cross-examine the witnesses and offer rebutting evidence.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1.1 - APPEAL PROCEDURES FOR APPLICANTS AND RECIPIENTS OF MEDICAID › Rule 1 - Administrative Law Judge Hearings › Section 1-6 - Hearing decision

Current through July 10, 2024
Authority: IC 12-15-1-10
Affected: IC 12-15-28
Sec. 6.
(a)
				Following the completion of the hearing, or after the submission of briefs by
				the parties (if briefing is permitted by the ALJ), the administrative law judge
				shall issue his or her decision in the matter concurrently to the parties. The
				decision shall be final unless a party requests agency review of the decision
				in accordance with 405 IAC 1.1-2.
(b) The ALJ's decision shall:
(1) include findings of fact;
(2) specify the reasons for the decision;
				and
(3) identify the evidence and
				statutes, regulations, rules, and policies supporting the decision.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1.1 - APPEAL PROCEDURES FOR APPLICANTS AND RECIPIENTS OF MEDICAID › Rule 2 - Agency Review › Section 2-1 - Conduct of agency review

Current through July 10, 2024
Authority: IC
				  12-15-1-10
Affected: IC
				  4-21.5-3-33; IC
				  12-15-28
Sec. 1.
(a) Any
				party who is not satisfied with the decision of the administrative law judge
				may request agency review of the decision within ten (10) days of receipt
				thereof in accordance with instructions issued with the decision.
(b) After receiving a request for agency
				review of a hearing decision, the hearings and appeals section of the family
				and social services administration shall notify all parties when the decision
				will be reviewed. The agency review shall be completed by the secretary of the
				family and social services administration or the secretary's designee. All such
				reviews shall be conducted upon the record as defined in IC
				4-21.5-3-33, except that
				a transcript of the oral testimony shall not be necessary for review unless a
				party requests that one be transcribed at the party's expense.
(c) No new evidence will be considered during
				the agency review; however, any party wishing to submit a memorandum of law,
				citing evidence in the record, may do so pursuant to instructions issued by the
				hearings and appeals section of the family and social services administration.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1.1 - APPEAL PROCEDURES FOR APPLICANTS AND RECIPIENTS OF MEDICAID › Rule 2 - Agency Review › Section 2-2 - Decision on agency review

Current through July 10, 2024
Authority: IC
				  12-15-1-10
Affected: IC 12-15-28
Sec. 2.
(a) The
				secretary of family and social services administration or the secretary's
				designee shall review the administrative law judge's (ALJ) decision to
				determine if the decision is supported by the evidence in the record and is in
				accordance with the statutes, regulations, rules, and policies applicable to
				the issue under appeal.
(b)
				Following the review of the secretary or designee, the secretary or designee
				shall issue a written decision:
(1) affirming
				the decision of the ALJ;
(2)
				amending or modifying the decision of the ALJ;
(3) reversing the decision of the
				ALJ;
(4) remanding the matter to
				the ALJ for further specified action; or
(5) make such other order or determination as
				is proper on the record.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 1.1 - APPEAL PROCEDURES FOR APPLICANTS AND RECIPIENTS OF MEDICAID › Rule 3 - Judicial Review › Section 3-1 - Judicial review

Current through July 10, 2024
Authority: IC
				  12-15-1-10
Affected: IC
				  4-21.5-3-33; IC 4-21.5-5;
				  IC 12-15-28
Sec. 1.
(a) If the
				Medicaid applicant or recipient is not satisfied with the final action after
				agency review, he or she may file a petition for judicial review in accordance
				with IC 4-21.5-5.
(b) The Medicaid
				applicant or recipient is required to seek agency review prior to filing a
				petition for judicial review.
(c)
				The record of the administrative proceedings shall be that as defined in IC
				4-21.5-3-33.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1 - General Requirements; Medicaid Member Eligibility › Section 1-1 - Definitions

Current through July 10, 2024
Authority: IC 12-13-5-3; IC 12-13-7-3; IC 12-15-1-10
Affected: IC 12-15-4; IC 12-15-5
Sec. 1.
The following definitions in this section apply throughout
				  this article:
(1) "Applicant" means
				the person for whom Medicaid is requested.
(2) "Dependent child" means a nonmember
				child:
(A) under eighteen (18) years of age;
				or
(B) between eighteen (18) and
				twenty-one (21) years of age and a student regularly attending a school,
				college, or university, or a course of vocational or technical training
				designed to prepare him or her for gainful employment.
A dependent child must be the biological or adoptive child of
				  the applicant or member or the biological or adoptive child of the applicant's
				  or member's parent.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1 - General Requirements; Medicaid Member Eligibility › Section 1-2 - Interview of applicants and members

Current through July 10, 2024
Authority: IC 12-13-5-3; IC 12-13-7-3; IC 12-15-1-10
Affected: IC 12-15-4; IC 12-15-5
Sec. 2.
(a) In
				addition to the requirements of
				470
				IAC 2.1-1-2, each applicant and member, or the
				individual authorized to act in the individual's behalf must be interviewed by
				the office at the time of the initial investigation and at each annual
				reinvestigation of eligibility.
(b)
				The initial investigation interview required under subsection (a) may be
				conducted:
(1) in a division or county
				office;
(2) at a home
				visit;
(3) by telephone;
				or
(4) at a community location
				designated by the division or designee.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1 - General Requirements; Medicaid Member Eligibility › Section 1-3 - Date of application for assistance

Current through July 10, 2024
Authority: IC 12-13-5-3; IC 12-13-7-3; IC 12-15-1-10
Affected: IC 12-15-4; IC 12-15-5
Sec. 3.
For the purpose of determining when notice of the decision
				  to approve or deny assistance must be mailed to an applicant for Medicaid under
				  42 CFR
				  435.911, the date of application is the date
				  on which the application for assistance, Part I, is received by the county
				  office.
Transferred from the Division of Family and Children ( 470
					 IAC 9.1-1-3 ) to the Office of the Secretary of Family and Social Services (
					 405 IAC 2-1-3 ) by P.L. 9-1991,
					 SECTION
					 131, effective January 1,
					 1992.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1.1 - Methodology for Conducting Eligibility Determinations › Section 1.1-1 - Definitions

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-15-2; IC 12-15-3
Sec. 1.
(a) The
				definitions in this section apply throughout this rule.
(b) "Applicant" means an individual applying
				for Medicaid eligibility on the basis of blindness or disability.
(c) "Change in circumstances" means any of
				the following:
(1) A disabling condition
				different from, or in addition to, that considered by SSA in making a previous
				SSA determination.
(2) That more
				than twelve (12) months after the most recent SSA determination denying
				disability, an individual's condition has changed or deteriorated resulting in
				a new period of disability, and such individual has not applied to SSA for a
				determination with respect to these new allegations.
(3) That less than twelve (12) months after
				the most recent SSA determination denying disability, an individual's condition
				has changed or deteriorated, alleging a new period of disability and either the
				individual:
(A) has applied to SSA for
				reconsideration or reopening of its disability decision and SSA refused to
				consider the new allegations; or
(B) no longer meets the nondisability
				requirements for SSI but may meet the state's nondisability requirements for
				Medicaid eligibility.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1.1 - Methodology for Conducting Eligibility Determinations › Section 1.1-2 - Application

Current through July 10, 2024
Authority: IC 12-13-7-3; IC 12-15
Affected: IC 12-15-2; IC 12-15-3
Sec. 2.
This rule applies to individuals seeking or receiving
				  benefits on the basis of age, blindness, or disability. This rule specifically
				  does not include eligibility criteria for individuals receiving benefits on the
				  basis of income as determined using MAGI under 42 CFR 435.603, which is hereby
				  incorporated by reference.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1.1 - Methodology for Conducting Eligibility Determinations › Section 1.1-3 - Applying for benefits

Current through July 10, 2024
Authority: IC 12-13-7-3; IC 12-15
Affected: IC 12-15-2; IC 12-15-3
Sec. 3.
(a) For
				purposes of this rule, any determination of eligibility on the basis of
				blindness or disability made by SSA is binding upon the state. A determination
				of eligibility by SSA for SSI automatically confers Medicaid eligibility upon
				that individual. This subsection governs when:
(1) an eligibility determination is to be
				made by SSA; and
(2) a
				determination is to be made by the state.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1.1 - Methodology for Conducting Eligibility Determinations › Section 1.1-4 - Criteria for determining disability

Current through July 10, 2024
Authority: IC 12-13-7-3; IC 12-15
Affected: IC 12-15-2; IC 12-15-3
Sec. 4.
When the state makes disability determinations, it shall do
				  so in accordance with 42 CFR 435.541(d) through 42 CFR 435.541(f).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1.1 - Methodology for Conducting Eligibility Determinations › Section 1.1-5 - Income

Current through July 10, 2024
Authority: IC 12-13-7-3; IC 12-15
Affected: IC 12-15-2; IC 12-15-3
Sec. 5.
(a)
				Individuals declared eligible for benefits by reason of age, disability, or
				blindness are subject to the income definition and exclusions set forth in
				42
				U.S.C. 1382a and 20 CFR Part 416, Subpart K
				Income.
(b) The income standard to
				be used is one hundred percent (100%) of FPL.
(c) The following apply in determining the
				household size of an applicant or member for purposes of determining income:
(1) An unmarried applicant or member will be
				considered a household of one (1).
(2) A married applicant or member will be
				considered a household of two (2).
(3) A child applicant or member under
				eighteen (18) years of age living with only one (1) biological or adopted
				parent will be considered a household of one (1).
(4) A child applicant or member under
				eighteen (18) years of age living with:
(A)
				two (2) biological parents;
(B) two
				(2) adopted parents; or
(C) one (1)
				biological and one (1) adopted parent; will be considered a household of two
				(2).
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1.1 - Methodology for Conducting Eligibility Determinations › Section 1.1-6 - Individuals receiving behavioral and primary health care coordination services

Current through July 10, 2024
Authority: IC 12-13-7-3; IC 12-15
Affected: IC 12-15-2; IC 12-15-3
Sec. 6.
(a) Except
				as provided under subsection (b), individuals may be eligible for Medicaid
				services if they meet the following criteria:
(1) They qualify to receive behavioral and
				primary health care coordination services based on the criteria set forth in
				405 IAC
				5-21.8-4.
(2) They have met the income threshold set
				forth in section 5(b) of this rule.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1.1 - Methodology for Conducting Eligibility Determinations › Section 1.1-7 - Posteligibility treatment of income

Current through July 10, 2024
Authority: IC 12-13-7-3; IC 12-15
Affected: IC 12-15-7-2
Sec. 7.
(a) This
				section applies to individuals who are determined eligible under section 5(g)
				of this rule who are either residing in an institution or are receiving home
				and community based waiver services.
(b) Except as provided in
				405
				IAC 2-3-17, the following procedure shall be used to
				determine the amount of income to be paid to an institution for an applicant or
				member who has been determined eligible under section 5(g) of this rule and who
				is residing in an institution as defined in
				405 IAC 2-1-1(4)
				 or receiving home and community based waiver
				services:
(1) Determine the applicant's or
				member's total income that is not excluded by federal statute, which includes
				amounts deducted in the eligibility determination under section 5(g)(3) of this
				rule.
(2) Subtract the minimum
				personal needs allowance equal to either of the following amounts:
(A) Specified in IC
				12-15-7-2
				for an individual residing in an institution.
(B) The special income level for an
				individual receiving home and community based waiver services.
(3) Subtract an amount for
				increased personal needs as allowed under Indiana's approved Medicaid state
				plan. The increased personal needs allowance includes, but is not limited to,
				court ordered guardianship fees paid to an institutionalized applicant or
				member's legal guardian, not to exceed thirty-five dollars ($35) per month.
				Guardianship fees include all services and expenses required to perform the
				duties of a guardian, as well as any attorney's fees for which the guardian is
				liable.
(4) Subtract the amount of
				any health insurance premiums.
(5)
				Subtract an amount for expenses incurred for necessary or remedial care
				recognized by state law but not covered under the state plan, subject to any
				reasonable limits set forth in Indiana's approved Medicaid state
				plan.
(6) Subtract an amount for
				federal, state, and local taxes owed and paid by the applicant or member. This
				deduction is limited to one (1) calendar month per year.
The resulting amount is the amount by which the Medicaid
				  payment to the institution where the individual resides, or to other Medicaid
				  approved providers, when the individual is receiving home and community based
				  waiver services, shall be reduced.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1.1 - Methodology for Conducting Eligibility Determinations › Section 1.1-8 - Resource definitions and exclusions

Current through July 10, 2024
Authority: IC
				  12-13-7-3;
				  IC 12-15
Affected: IC 12-15-2; IC 12-15-3
Sec. 8.
Individuals declared eligible for benefits by reason of age,
				  disability, or blindness are subject to resource definitions and exclusions set
				  forth in
				  42
				  U.S.C. 1382b and 20 CFR Part 416, Subpart L,
				  Resources.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1.1 - Methodology for Conducting Eligibility Determinations › Section 1.1-9 - Appeals

Current through July 10, 2024
Authority: IC
				  12-13-7-3;
				  IC 12-15
Affected: IC 12-15
Sec. 9.
When any appeal of a determination is filed with FSSA, such
				  appeal will be conducted in accordance with the procedures set forth in 405 IAC
				  1.1.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 1.1 - Methodology for Conducting Eligibility Determinations › Section 1.1-10 - Individuals receiving end stage renal disease services

Current through July 10, 2024
Authority: IC
				  12-15-1-10;
				  IC
				  12-15-1-15;
				  IC
				  12-15-21-2;
				  IC
				  12-15-21-3
Affected: IC
				  12-13-7-3;
				  IC 12-15
Sec. 10.
In order to be eligible for end stage renal disease (ESRD)
				  services under this rule, an individual must meet the following
				  conditions:
(1) Has been diagnosed
				with ESRD.
(2) Is currently
				enrolled in Medicare.
(3) Has
				income between one hundred fifty percent (150%) and three hundred percent
				(300%) of the FPL.
(4) Has
				resources below one thousand five hundred dollars ($1,500) for an individual or
				two thousand two hundred fifty dollars ($2,250) for a couple.
(5) Is not institutionalized.
(6) Meet all other Medicaid nonfinancial
				eligibility criteria.
(7) Is not
				Medicaid eligible on any other basis, or is eligible under ESRD waiver
				Population 1, effective May 31, 2014.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 2 - Eligibility Requirements Other than Need › Section 2-1 - Age requirement; Medicaid for the aged

Current through July 10, 2024
Authority: IC 12-15-1-10; IC 12-15-1-15; IC 12-15-21-2
Affected: IC 12-13-7-3; IC 12-15
Sec. 1.
In order to be eligible for assistance under the Medicaid
				  for the aged program as an aged person, the applicant must be at least
				  sixty-five (65) years of age.
Transferred from the Division of Family and Children ( 470
					 IAC 9.1-2-1 ) to the Office of the Secretary of Family and Social Services (
					 405 IAC 2-2-1 ) by P.L. 9-1991,
					 SECTION
					 131, effective January 1,
					 1992.
Indiana Administrative Code › Title 405 - OFFICE OF THE SECRETARY OF FAMILY AND SOCIAL SERVICES › Article 2 - MEDICAID MEMBERS; ELIGIBILITY › Rule 2 - Eligibility Requirements Other than Need › Section 2-2 - Visual eligibility; Medicaid for the blind

Current through July 10, 2024
Authority: IC 12-15
Affected: IC 12-13-7-3
Sec. 2.
(a) To be
				considered blind for eligibility purposes, a person must meet the criteria set
				forth in
				42
				U.S.C.
				1382c(a)(2).
(b) There is no minimum age requirement for a
				person who is blind.
(c) A person
				must have a medical determination of blindness before the office can determine
				eligibility.
Transferred from the Division of Family and Children ( 470
					 IAC 9.1-2-2 ) to the Office of the Secretary of Family and Social Services (
					 405 IAC 2-2-2 ) by P.L. 9-1991,
					 SECTION
					 131, effective January 1,
					 1992.