[31 Pa.B. 4064]
[Continued from previous Web Page] Comment
The proposed HIP regulations should not go into effect until the previously-referenced waiver program is in place.
Response
The Department disagrees. Although the Department and DPW are both confident that the waiver program will go into effect, the Department's ability to administer HIP should not under any circumstances be held hostage to the success of an initiative on the part of another Commonwealth agency.
Comment
A bill, H.B. 1467, which would create a HIP in the Office of Social Programs of DPW, was introduced in the House of Representatives and referred to the House Health and Human Services Committee. This bill, coupled with the previously-mentioned application for waiver by DPW indicate that the Commonwealth is moving in the direction of transferring responsibility for HIP from the Department to DPW. The timing of the final-form regulations is therefore inopportune.
Response
The Department disagrees. The possibility that there will be a change in policy exists in every aspect of government. That a possibility exists does not mean that those who are responsible for administering programs should ''wait and see'' which way the wind will blow. The Department is currently responsible for administering HIP, and will be responsible to do that for the foreseeable future. A need for these regulations was perceived, and the Department responded.
Comment
If HIP is transferred to DPW, the proposed regulations will be obsolete. Promulgation of the final-form regulations should therefore be precluded.
Response
The Department disagrees. It would be inappropriate to delay the implementation of necessary final-form regulations for an indefinite period of time pending the outcome of uncertain events. The Department is responsible for the Program, and must continue to administer it until an actual transfer of authority takes place. The administration of HIP will be simpler, as well as fairer to head-injured individuals who are still waiting to receive rehabilitation services through HIP, if the final-form regulations are implemented.
Comment
One of the factors to be considered by IRRC in approving or disapproving a regulation is whether the regulation ''represents a policy decision of such a substantial nature that it requires legislative review.'' See 71 P. S. § 745.5a(i)(4). Transfer of HIP from the Department to DPW does present a substantial policy decision that deserves legislative review. In fact, that legislative review has begun through the introduction of H.B. 1467 and its referral to the House Health and Human Services Committee. The publication of the final-form regulations at this time ignores that overriding policy issue.
Response
The Department disagrees. The Regulatory Review Act requires IRRC to review regulations and to consider certain factors in determining whether the regulations are in the public interest. Among these factors, as stated by the commentator, is ''[w]hether the final-form or final-omitted regulation represents a policy decision of such a substantial nature that it requires legislative review.'' However, the commentator then goes on to state that it is the transfer of HIP from the Department to DPW that presents the substantial policy decision which deserves legislative review. That transfer is not before the IRRC; these regulations are. The final-form regulations do not have as their subject matter the contemplated transfer of HIP to DPW. Their sole focus is the Department's administration of moneys from the Fund, which responsibility has been placed upon the Department by statute. The final-form regulations provide that the Department will use Fund money to provide rehabilitation and case management services to persons who have incurred a TBI, set parameters for participation in the Program and establish a system of administration for the Program. These are matters that are appropriately addressed through the promulgation of regulations. The final-form regulations do not present a policy decision of a nature that legislative review is required, other than that which is provided through the rulemaking process. IRRC's determination as to these regulations should be made based upon their content, and not upon its consideration of proposed legislation.
Comment
The Department lacks the statutory authority to promulgate the regulations. Section 14(e) of the act gives the Department only the ability to decide which class or type of injury to fund, in order of priority. The Department does not have the authority to develop detailed administrative regulations relating to the operation of HIP.
Response
The Department disagrees that it lacks the statutory authority to promulgate these regulations. The Department has the statutory power and duty to promulgate rules and regulations to facilitate its administration of the Fund under section 2102(g) of The Administrative Code of 1929 (71 P. S. § 532(g)).
Section 14(e) of the act allocates money to the Fund, which is under the authority of the Department. The Fund, under the act, can be used to pay for all traumatic injuries. Clearly, however, there is not enough money to fund every person. Section 14(e) of the act, therefore, allows the Department to decide which traumatic injuries to fund by category, as opposed to on an individual basis. The Department already has the statutory authority, under section 2102(g) of The Administrative Code of 1929, to promulgate rules and regulations for any program administered by it, including HIP. Nothing in the act indicates that the General Assembly intended to remove this general authority when it gave the Department the specific authority to, ''. . . by regulation, prioritize the distribution of funds by classification of traumatic injury.''
Finally, reading the language of the act so as to prevent the Department from making any administrative decisions with regard to the Fund, other than deciding what types of injuries the money may be used for, leads to an absurd result. The reading would effectively tie the Department's hands with regard to proper and effective administration of the Fund. The Generaly Assembly could not logically have intended to give the Department the authority to decide to whom a significant amount of Fund money would be given, without also giving it the authority to ensure that the Fund is utilized properly and efficiently.
Comment
It is a matter for concern that HIP has not accepted any new applicants for services in over 1 year.
Response
The final-form regulations restrict the type of services a client will receive through HIP, the cost of services per enrollment period for which HIP will pay and the length of time that each enrollment period may last. These provisions are designed to open HIP up to a greater number of qualified people. A main purpose of the final-form regulations is to make HIP resources available to a greater number of persons across this Commonwealth who have suffered TBIs. The HIP waiting list demonstrates that there are many individuals who would like to participate in HIP. The Department believes that a number of these people have not been able to secure rehabilitation services, and will not be able to do so except through HIP. The limitations on client participation in the final-form regulations are aimed at ensuring that individuals with TBIs have an opportunity to receive rehabilitation services for at least 1 year. If 1 year of services does not enable a client to function as fully as before the TBI was sustained, it is likely to at least prepare that individual to be able to utilize other services and programs appropriately.
Fiscal Impact
Implementation of the final-form regulations will entail administrative costs associated with contract development, data analysis, fiscal monitoring and other program activities. HIP currently has similar administrative costs from current program operations. Additional costs may be incurred due to the review and administrative appeal process, depending upon the frequency of appeals. The final-form regulations are intended to channel the bulk of funding into rehabilitation services for clients who are able to progress as a result of those services.
Paperwork Requirements
The Department will experience some increase in paperwork related to Program review of rehabilitation service plans and plan modifications, as well as the quarterly patient reports required from providers. Providers will have to provide quarterly patient status reports. Rehabilitation service plans and modifications are a part of rehabilitation treatment; the necessity for them does not arise from the final-form regulations. Persons applying to HIP must complete an application and provide verifying documentation.
Effective Date/Sunset Date
The final-form regulations will become effective August 27, 2001. A sunset date has not been established. The Department will continue to monitor these regulations on an ongoing basis, and they will be subject to revision as it becomes necessary.
Statutory Authority
Section 14(e) of the act authorizes the Department to promulgate regulations prioritizing distribution of moneys in the Fund by classification of traumatic injury. The Department has the statutory power and duty to promulgate its rules and regulations under section 2102(g) of The Administrative Code of 1929.
Regulatory Review
Under section 5(a) of the Regulatory Review Act (71 P. S. § 745.5(a)), on May 22, 1999, the Department submitted a copy of the notice of proposed rulemaking, published at 29 Pa.B. 2671, to IRRC and the Chairpersons of the House Health and Human Service Committee and the Senate Public Health and Welfare Committee for review and comment.
Under section 5(c) of the Regulatory Review Act, the Department also provided IRRC and the Committees with copies of all comments received, as well as other documentation. In preparing these final-form regulations, the Department has considered all comments received from IRRC, the Committees and the public.
In compliance with section 5.1(a) of the Regulatory Review Act (71 P. S. § 745.5a(a)), the Department submitted a copy of the final-form regulations to IRRC and the Committees on May 3, 2001. In addition, the Department provided IRRC and the Committees with information pertaining to commentators and a copy of a detailed Regulatory Analysis Form prepared by the Department in compliance with Executive Order 1996-1, ''Regulatory Review and Promulgation.'' A copy of this material is available to the public upon request.
On May 22, 2001, the Department requested that the regulations be tolled in accordance with section 5.1(g)(1) of the Regulatory Review Act to consider revisions recommended by IRRC. IRRC did not object to tolling. The Department submitted the revised regulations to the Committees and to IRRC for their review on May 24, 2001.
Under authority of section 5.1(d) of the Regulatory Review Act (71 P. S. § 745.5a(d)), on June 4, 2001, these final-form regulations were deemed approved by the House and Senate Committees. Under section 5.1(e) of the Regulatory Review Act, IRRC met on June 7, 2001, and approved the final-form regulations. The Attorney General approved the regulations on July 10, 2001.
Contact Person
Questions regarding the final-form regulations may be submitted to Elaine Terrell, Head Injury Program, Department of Health, P. O. Box 90, Harrisburg, PA 17108-0090, (717) 783-5436. Persons with disabilities may submit questions in alternative formats (such as audio tape or Braille) by using V/TT: (717) 783-6514 or the Pennsylvania AT&T Relay Service at (800) 654-5984 (TT).
Persons with disabilities who would like to obtain this document in an alternative format (that is, large print, audiotape or Braille) should contact Elaine Terrell to make the necessary arrangements.
Findings
The Department finds that:
(1) Public notice of intention to adopt the final-form regulations adopted by this order has been given under sections 201 and 202 of the act of July 31, 1968 (P. L. 769, No. 240) (45 P. S. §§ 1201 and 1202), and the regulations thereunder, 1 Pa. Code §§ 7.1 and 7.2.
(2) A public comment period was provided as required by law and all comments were considered.
(3) The adoption of final-form regulations in the manner provided by this order is necessary and appropriate for the administration of the authorizing statute.
Order
The Department, acting under the authorizing statutes, orders that:
(a) The regulations of the Department, 28 Pa. Code, are amended by adding §§ 4.1--4.15 and Appendix A to read as set forth in Annex A.
(b) The Secretary of Health shall submit this order and Annex A to the Office of General Counsel and the Office of Attorney General for approval as required by law.
(c) The Secretary of Health shall submit this order, Annex A and a Regulatory Analysis Form to IRRC, the House Committee on Health and Human Services and the Senate Committee on Public Health and Welfare for their review and action as required by law.
(d) The Secretary of Health shall certify this order and Annex A and deposit them with the Legislative Reference Bureau as required by law.
(e) This order shall take effect August 27, 2001.
ROBERT S. ZIMMERMAN, Jr.,
Secretary(Editor's Note: For the text of the order of the Independent Regulatory Review Commission relating to this document, see 31 Pa.B. 3370 (June 23, 2000).)
Fiscal Note: 10-129. No fiscal impact; (8) recommends adoption.
Annex A
TITLE 28. HEALTH AND SAFETY
PART I. GENERAL HEALTH
CHAPTER 4. HEAD INJURY PROGRAM Sec.
4.1. Scope and purpose. 4.2. Definitions. 4.3. Services eligible for payment. 4.4. Requirements for provider participation. 4.5. Application for enrollment as a HIP client. 4.6. Assessment. 4.7. Enrollment. 4.8. Rehabilitation service plan. 4.9. Rehabilitation period. 4.10. Transition period. 4.11. Case management services. 4.12. Funding limits. 4.13. Payment for HIP services. 4.14. Peer review. 4.15. Administrative review. § 4.1. Scope and purpose.
(a) This chapter establishes standards for the Department to administer the Fund.
(b) The Department will use the Fund to administer a head injury program, as set forth in this chapter, to pay for medical, rehabilitation and attendant care services for persons with traumatic brain injury.
§ 4.2. Definitions.
The following words and terms, when used in this chapter, have the following meanings, unless the context clearly indicates otherwise:
Agency head--The Secretary or a deputy secretary designated by the Secretary.
Alternative financial resources--
(i) All income subject to tax under section 61 of the Internal Revenue Code (26 U.S.C.A. § 61).
(ii) Funds which are available to the applicant or client by virtue of experiencing a TBI. These include, but are not limited to, court awards, insurance settlements and other financial settlements made as a result of the TBI and received by any person on behalf of or for the use of the applicant or client.
(iii) Funds which are available to the applicant or client through other State or Federal programs including, but not limited to, Medicaid, Medicare, Social Security Disability Insurance (Title II), Supplemental Security Income (Title XVI), veterans' benefits, workers' compensation insurance and unemployment compensation insurance.
Applicant--An individual for whom a completed application for enrollment in HIP has been submitted to the Department.
Authorized representative--An individual who is authorized by law to make a decision for, or enter into an agreement on behalf of, an applicant or client. The term does not include an employee of the provider unless the employee is appointed by a court to serve as the legal guardian of the applicant or client.
Case management services--Services to be offered by the provider to a client during the enrollment period.
Case manager--An individual who delivers case management services to a client through a provider.
Client--An individual enrolled in HIP.
Day services--Nonresidential services intended to improve the physical, cognitive, behavioral or functional abilities of the client through therapeutic intervention and supervised activities which are provided on an outpatient basis at a facility belonging to a provider.
Department--The Department of Health of the Commonwealth.
Division--The Division of Child and Adult Health Services.
Enrollment period--The period of time, comprised of the rehabilitation period and the transition period, during which a client is enrolled in HIP.
Fund--The Catastrophic Medical and Rehabilitation Fund.
HIP--Head Injury Program--The traumatic brain injury program of the Department.
HIP Peer Review Committee--A committee, composed of professionals and representatives of organizations offering rehabilitation services in this Commonwealth to persons with traumatic brain injury, whose members are appointed by the Department to review rehabilitation plans and services offered to clients and to recommend actions to improve services.
HIP services--Rehabilitation and case management services for which the Department authorizes payment through HIP.
Home facilitation--A formal rehabilitation program which provides a community reentry specialist in the client's home to continue therapy learned by the client and to assist the client in the practice of techniques and strategies for living independently.
Immediate family--A parent, spouse, child, brother, sister, grandparent or grandchild and, when living in the family household (or under a common roof), all other individuals related by blood or marriage.
Peer review--A review of services and rehabilitation service plans for clients conducted by the HIP Peer Review Committee for the purpose of advising the Department on best practices to be followed in offering services to clients.
Provider--An individual, organization or facility that delivers rehabilitation and case management services to clients under a contractual agreement with the Department.
Rehabilitation period--The period of time that a client receives rehabilitation services through HIP.
Rehabilitation service plan--The written plan developed by the provider, which states specific goals to be achieved and expected time frames for achievement of each goal.
Rehabilitation services--Services provided to assist the client to recover from TBI, improve the client's health and welfare, and realize the client's maximum physical, social, cognitive, psychological and vocational potential for useful and productive activity. These services include neuropsychological evaluation, physical therapy, occupational therapy, speech or language therapy, behavior management, home facilitation, therapeutic recreation, prevocational services, case management services and psychological services which may include cognitive remediation.
Secretary--The Secretary of the Department.
TBI--traumatic brain injury--An insult to the brain, not of a degenerative or congenital nature, caused by an external physical force that may produce a diminished or altered state of consciousness, which results in impairment of cognitive abilities or physical functioning or in the disturbance of behavioral or emotional functioning. These impairments may be either temporary or permanent and cause partial or total functional disability or psychosocial maladjustment.
Transition period--The period of time following the rehabilitation period during which a client receives case management services through HIP to guide and assist the client to make the transition out of HIP.
§ 4.3. Services eligible for payment.
HIP will pay for the following:
(1) Assessments of applicants by providers.
(2) Development of rehabilitation service plans by providers.
(3) Rehabilitation services.
(4) Case management services.
§ 4.4. Requirements for provider participation.
(a) Providers of residential, outpatient, day and home-based rehabilitation services shall be accredited by a National accrediting body as approved by the Department. From time to time, the Department will publish a list of approved National accrediting bodies in the Pennsylvania Bulletin.
(b) Providers shall provide rehabilitation services in accordance with their contractual agreements with the Department.
(c) Providers shall use forms and procedures as prescribed by the Division in the provision of rehabilitation services.
§ 4.5. Application for enrollment as a HIP client.
(a) Initial contact. An individual who is interested in enrolling in HIP or in arranging for another individual to be enrolled in HIP shall contact the Eligibility Specialist of the Division by writing to: Eligibility Specialist, Department of Health, Division of Child and Adult Health Services, Post Office Box 90, Room 724, Health And Welfare Building, Harrisburg, Pennsylvania 17108. Contact may also be made by facsimile or electronic mail.
(b) Funding. The Division will accept an application for enrollment in HIP only if the funds designated to HIP from the Catastrophic Medical and Rehabilitation Appropriation exceed projected expenditures in providing HIP services to current clients.
(c) Waiting list. If the funds designated to HIP from the Catastrophic Medical and Rehabilitation Appropriation are not adequate to enable the Division to accept an application for an individual for whom enrollment in HIP is sought, the Division will place the individual on a waiting list if the individual so elects. The individual on the waiting list or the authorized representative shall immediately notify the Division of any change in mailing address. The Division will request an individual on the waiting list, or the authorized representative, to submit an application for enrollment as funding becomes available. Except as otherwise provided in this chapter, the Division will request individuals on the waiting list, or their authorized representatives, to submit applications in the order that the requests to be placed on the waiting list were received by the Division. Individuals who are receiving case management services through HIP as of August 27, 2001, but who have never received rehabilitation services through HIP, will be given first priority on the waiting list.
(d) Application. When an individual qualifies to receive an application for enrollment in HIP, the Division will send to that individual or the person who sought to enroll that individual in HIP, at the mailing address provided to the Division, information on HIP and application materials. If the individual is on a waiting list, the Division will also request that the individual notify the Division in writing whether the individual is still seeking enrollment in HIP. The notification shall be timely only if it is postmarked within 21 days after the date the materials were sent by the Division. If the Division receives a timely notification that enrollment in HIP is desired, the Division will proceed with the application process. If the Division is apprised that enrollment in HIP is no longer desired, or if the Division does not receive timely notification of continued interest in enrollment, the Division will remove the individual from the waiting list, contact the next person on the waiting list and repeat the process.
(e) Request and application for reenrollment. A request for reenrollment may be filed for an individual who was previously enrolled in HIP. If there is a waiting list, the Division will not accept an application for reenrollment. Instead, it will place the individual on the waiting list. The Division will give priority to individuals on the waiting list who have not previously received rehabilitation services from HIP. The Division will request individuals who have previously received rehabilitation services from HIP who are on the waiting list, or their authorized representatives, to submit applications for reenrollment. The Division's requests for these applications will be made in the order that the requests for reenrollment were received. Except as provided in subsection (c), the Division will only accept a request or application for reenrollment for an individual who is not a client at the time the request or application is made.
(f) Acceptance of application. The Division will accept an application for enrollment only from the individual for whom enrollment is sought or from an authorized representative.
§ 4.6. Assessment.
(a) Eligibility for assessment. The Division will review an application for enrollment in HIP to determine whether the applicant is eligible for an assessment, as follows:
(1) General criteria. An applicant shall be eligible for an assessment only if all of the following requirements are met:
(i) The applicant sustained a TBI after July 2, 1985.
(ii) The applicant is a citizen of the United States and was domiciled in this Commonwealth at the time of the injury and at the time of application for enrollment in HIP.
(iii) The applicant is 21 years of age or older.
(iv) The application is completed and is accompanied by the documentation that is requested to verify the applicant's satisfaction of the eligibility criteria in this subsection.
(v) The applicant's alternative financial resources are at or below 300% of the Federal Poverty Income Guidelines.
(A) The applicant's income will be assessed using the applicant's most recent Federal Income Tax form, which the applicant shall provide. If that form is unavailable, the Division may request other documentation of income. If the most recent Federal Income Tax form is not representative of the applicant's income at the time of application, the applicant may submit documents to that effect in support of the application.
(B) The applicant shall provide, on forms provided by the Division, information about any court award or financial settlement made or pending as a result of the TBI, and any other funds which are available to the applicant. If all or part of the award, settlement or other funds is unavailable to the applicant to use for HIP services, the applicant may submit documents to that effect in support of the application.
(2) Condition criteria. An applicant shall be eligible for an assessment only if the applicant's impairment is not the result of one or more of the following conditions:
(i) Cognitive or motor dysfunction related to congenital or hereditary birth defects.
(ii) Putative birth trauma or asphyxia neonatorum (hypoxic-ischemic-encephalopathy).
(iii) Hypoxic encephalopathy unrelated to TBI.
(iv) Significant preexisting psychiatric, organic or degenerative brain disorder.
(v) Stroke.
(vi) Spinal cord injury in the absence of TBI.
(3) Symptom criteria. An applicant shall be eligible for an assessment only if the applicant does not manifest any symptom, such as a comatose condition, which would prevent the applicant from participating in the assessment in a meaningful way or prevent the provider from doing a full and complete assessment.
(4) Assignment agreement. An applicant shall be eligible for an assessment only if the applicant or authorized representative completes an assignment agreement which, conditioned upon the applicant's receipt of HIP services, would assign to the Department rights in future court awards, insurance settlements or any other proceeds which have accrued or will accrue to the applicant as a result or by virtue of the applicant's TBI, up to the amount expended for HIP services on behalf of that individual.
(b) Assessment process. The Division will refer an applicant who is eligible for an assessment to a provider. The provider shall assess the applicant for the following:
(1) To corroborate the Division's determination that the applicant satisfies the condition and symptom criteria in subsection (a)(2) and (3).
(2) To determine that the applicant has the physical, social, cognitive, psychological and vocational potential for useful and productive activity which can be nurtured by rehabilitation services available through HIP so as to enable the applicant to progress toward a higher level of functioning and transition to a less restrictive environment.
(3) To determine that the applicant has needs that can be addressed by HIP services, that will not be addressed by any other services to which the applicant is entitled.
(4) To determine that the applicant does not manifest suicidal or homicidal ideation, or potentially harmful aggressive behavior, to such a degree that HIP cannot provide the appropriate services through its providers to sufficiently address these ideations or behaviors.
(c) Forms and procedure. The provider shall complete the assessment on forms provided by the Division. A provider conducting an assessment shall:
(1) Review the applicant's medical records.
(2) Review all pertinent documentation submitted by physicians on behalf of the applicant.
(3) Evaluate the applicant's ability to benefit from rehabilitation services, performed in accordance with standards prevailing in the field.
(d) Development of rehabilitation service plan. If the provider corroborates the Division's initial determination under subsection (a)(2) and (3), and determines that the applicant meets the criteria in subsection (b)(2)--(4), the provider shall develop a rehabilitation service plan for the applicant as specified in § 4.8 (relating to rehabilitation service plan).
(e) Assessment period. The provider shall complete its assessment and give written notification of its determination to the Division and the applicant or authorized representative within 14 days after the provider begins to conduct an assessment of the applicant. If the provider determines that the applicant is eligible for enrollment in HIP, the provider shall also complete a rehabilitation service plan for the applicant within that 14-day period.
(f) Reapplication. If the Division determines that an individual is not eligible for an assessment or that an applicant is not eligible for enrollment in HIP after an assessment has been completed, the individual may repeat the process for seeking enrollment in HIP when the individual or authorized representative believes that the factors which rendered the individual ineligible for enrollment in HIP have been eliminated.
§ 4.7. Enrollment.
(a) Notification of decision. The Division will notify an applicant or authorized representative in writing of its decision regarding an application for enrollment within 16 days after receiving from the provider the completed assessment and, if applicable, its decision regarding the rehabilitation service plan. If the Division determines that the applicant is ineligible, the notice will include the reason for that determination and will advise of appeal rights.
(b) Provider determination that applicant is not eligible for enrollment. If, after assessing the applicant the provider determines that the applicant does not satisfy the condition and symptom criteria in § 4.6(a)(2) and (3) (relating to assessment), lacks the potential to benefit or the need described in § 4.6(b)(2) and (3) or manifests ideation or behavior which would render the applicant unfit to participate in HIP under § 4.6(b)(4), the provider shall share its findings with the Division and the applicant or authorized representative. The Division will provide the applicant or authorized representative the opportunity to rebut the provider's findings, and then will make a determination as to whether the applicant is eligible for enrollment in HIP.
(c) Overturning provider determinations. If the Division determines that an applicant is eligible for enrollment in HIP despite the provider's determination to the contrary, or that a rehabilitation service plan is unacceptable, the Division will direct the provider, or another provider at the Division's discretion, to develop a rehabilitation service plan for the applicant within 14 days of receiving the Division's decision. The Division will act on the revised rehabilitation service plan within 16 days after receipt.
(d) Commencement of enrollment. A client's enrollment begins on the first day that a client receives rehabilitation services from a provider after the Division issues its written notification granting enrollment in HIP.
(e) Duration of enrollment. The enrollment period of a client shall be specified in the client's rehabilitation service plan. It may not exceed 18 consecutive months, comprised of a maximum rehabilitation period of 12 consecutive months followed by a maximum transition period of 6 consecutive months. A client's enrollment shall end prior to the time designated in the client's rehabilitation service plan when one of the following occurs:
(1) The Division determines that the continuation of HIP services will not enable the client to progress to a higher level of functioning and transition to a less restrictive environment.
(2) The client fails to cooperate or exhibits unmanageable behavior so that HIP cannot provide the appropriate services to meet the client's needs under § 4.6(b)(4).
(3) The maximum funds available for allocation to the client under § 4.12 (relating to funding limits) are exhausted.
(4) The client becomes eligible for other services offered as a result of the TBI, which services will meet the client's needs or duplicate HIP services so that HIP services are rendered unnecessary.
(f) Notification of discharge from HIP. The Division will notify a client or authorized representative in writing of its decision to terminate the client's participation in HIP. The notice will include the reason for the decision and will advise of appeal rights.
(g) Grandfather clause. Clients who are receiving rehabilitation services as of August 27, 2001 are eligible for the maximum enrollment period, beginning on August 27, 2001. Clients who are receiving only case management services as of August 27, 2001 are eligible for the maximum transition period.
§ 4.8. Rehabilitation service plan.
(a) Development of rehabilitation service plan. The provider shall collaborate with the applicant or authorized representative, and may collaborate with other individuals identified by the applicant, to develop a rehabilitation service plan for the applicant.
(b) Goal. The primary goal of the rehabilitation service plan shall be to enable the client to progress to a higher level of functioning, which will, in turn, enable the client to transition to a less restrictive environment.
(c) Requirements. The initial rehabilitation service plan shall contain the following:
(1) A description of desirable goals and the anticipated outcomes in objective and measurable terms, including the expected time frames for the achievement of each goal and outcome, for the entire enrollment period.
(2) A specification of the HIP services necessary to attain the agreed-upon goals.
(3) A specification of any other services to which the applicant is entitled and a description of the impact of those services upon the attainment of the agreed-upon goals.
(4) Beginning and ending dates of each HIP service.
(5) The terms and conditions for HIP service delivery.
(6) The specific responsibilities of the applicant and service provider relative to implementation of each HIP service.
(7) The extent of financial responsibility of the applicant, HIP and any third party.
(d) Quarterly review. The rehabilitation service plan shall include a procedure and schedule for quarterly review and evaluation of progress towards the specified goals. These written reviews shall be submitted to the Division.
(e) Modifications. The provider shall make modifications to the rehabilitation service plan as often as necessary, and in accordance with subsections (a)--(d). Modifications shall indicate whether previously set goals were met. When goals were not met, modifications shall address the reasons why, and modify or change goals appropriately.
§ 4.9. Rehabilitation period.
(a) Provision of rehabilitation services. During the rehabilitation period a provider shall coordinate the provision of rehabilitation services to a client to ensure achievement of goals consistent with the rehabilitation service plan, and as appropriate to the needs of the client to improve the client's health, welfare and the realization of the client's maximum physical, social, cognitive, psychological and vocational potential for useful and productive activity.
(b) Supervision. Rehabilitation services shall be provided or their provision shall be supervised by a physician or other appropriate health professional qualified by training or experience to provide or supervise these services.
(c) Purpose. If authorized under the rehabilitation service plan, rehabilitation services may be provided for the following purposes:
(1) Helping a client develop behaviors that enable the client to take responsibility for the client's own actions.
(2) Facilitating a client's successful community integration.
(3) Assisting a client to accomplish functional outcomes at home and in the community.
(4) Teaching a client skills to live independently.
(5) Supervising a client living in a home setting through the following:
(i) Home facilitation.
(ii) Physical rehabilitation.
(iii) Cognitive remediation.
(iv) Life-skills coaching.
(v) Assisting the client in maintaining independence.
(6) Providing transitional living services to assist a client with community reentry skills.
(7) Maximizing a client's physical potential.
§ 4.10. Transition period.
(a) Provision of case management services. Following the rehabilitation period, HIP will provide case management services to assist the client in making the transition out of HIP.
(b) Commencement of transition period. The transition period will commence immediately following the end of the rehabilitation period.
(c) Duration of transition period. The transition period may not exceed 6 consecutive months, and shall end when the maximum funds available for allocation to the client are exhausted under § 4.12 (relating to funding limits).
§ 4.11. Case management services.
Case management services shall be provided by a case manager who has a minimum of 1 year of experience in TBI case management, and shall include the following activities by the case manager:
(1) Monitoring the client's progress with respect to the rehabilitation service plan and collaborating with the client or authorized representative, the client's significant others and the rest of the treatment team in the development and modification of the rehabilitation service plan.
(2) Assisting the client in gaining access to services from which the client may benefit and for which the client may be eligible.
(3) Monitoring and evaluating the client's progress in transitioning to living in a home or community setting and ensuring that any necessary supports are in place, or facilitating placement of the client in a long-term care facility.
(4) Determining that the client has fully transitioned to the home or community or has been referred to the appropriate long-term care facility.
§ 4.12. Funding limits.
(a) HIP will provide no more than $100,000 for case management and rehabilitation services for a client during a rehabilitation period. This amount will be reduced by any client share of costs under § 4.13(b) (relating to payment for HIP services).
(b) HIP will provide no more than $1,000 for case management services for a client during a transition period. This amount will be reduced by any client share of costs under § 4.13(b).
(c) The Division will notify an applicant of these maximum funding limits when it accepts the applicant as a client.
§ 4.13. Payment for HIP services.
(a) Written authorization. The Division will provide written authorization, to the client and to the provider, as to HIP services for which the client is eligible and the maximum available funding and time limits for those services.
(b) Client responsibility for payment. If the Division determines that a client is responsible to pay for any part of HIP services, the client will be informed of that fact, and of the amount for which the client is responsible, as follows:
(1) The client shall be assessed a share of the cost of HIP based upon alternative financial resources between 185% and 300% of the Federal Poverty Income Guidelines. The patient's share of the cost shall be determined using the Patient Share of Cost Table in Appendix A, as periodically updated and published in the Pennsylvania Bulletin.
(2) The client will be responsible to pay for HIP services up to the amount of alternative financial resources which exceed 300% of the Federal Poverty Income Guidelines.
(c) Notification of discontinuance of HIP funding. The Division will notify a client in writing of any discontinuance of funding. The notice will include the reason for the discontinuance and advise of appeal rights.
(d) Duty to update financial information. A client shall immediately report to the Division all changes in availability of alternative financial resources.
(e) Preexisting conditions. HIP will not pay for services to address conditions existing prior to the TBI.
(f) Services funded through other benefit programs. HIP will not pay for services available through other publicly funded programs. The provider will coordinate HIP with other public and private programs to assist clients to access benefits for which they may be eligible.
(g) Reimbursement. The Department may seek reimbursement for payments made with HIP funds on behalf of a client from an insurer that provides coverage to the client or from the proceeds of any litigation arising out of the injury which led to eligibility for enrollment in HIP.
§ 4.14. Peer review.
(a) Purpose. The Department will appoint a peer review committee to conduct a review of services and rehabilitation service plans for clients. The HIP Peer Review Committee (Committee) shall advise the Department on best practices to be followed in offering services to clients.
(b) Procedures.
(1) The Committee shall meet quarterly and review selected client charts, including charts for at least one client from each provider providing services at the time of the quarterly meeting, to evaluate the appropriateness of provision of services and client progress.
(2) Within 30 days after it completes its review, the Committee shall provide to the Department, in writing, recommendations regarding the provision of services by each provider.
(3) A member of the Committee may not participate in a review conducted by the Committee that presents a conflict of interest for that member. Examples of conflicts include, but are not limited to, participating in a review conducted by the Committee for one of the following:
(i) A service provided to a client of that member, that member's employer or that member's immediate family.
(ii) A service provided by a person who is in the immediate family of the member.
(4) The Division will notify the Committee of any actions taken on the recommendations of the Committee.
§ 4.15. Administrative review.
(a) Reconsideration by Division.
(1) An applicant, client or authorized representative may file with the Division a request for it to reconsider any of the following decisions made by the Division:
(i) An applicant is not eligible for an assessment.
(ii) An assessed applicant is not eligible for enrollment.
(iii) A disapproval or revision of a rehabilitation service plan.
(iv) A client is to be discharged from HIP prior to the date specified in the client's rehabilitation service plan.
(v) Alternative financial resources are available so that the client must pay for HIP services.
(2) At the time a decision is made, the Division will notify the applicant, client or authorized representative in writing of the right to seek administrative review. The letter will advise the recipient to seek assistance from legal counsel, family and others who may serve in an advisory role, and include contact information for a HIP representative to answer questions.
(3) An applicant, client or authorized representative shall file a request for reconsideration within 15 calendar days after the mailing date of the Division's determination. The request shall meet the following standards:
(i) State the specific legal and factual reasons for disagreement with the decision.
(ii) Identify the relief that is being sought for the applicant or client.
(iii) Include supporting documentation, if any, to support the factual averments made.
(4) The Division will notify the applicant, client or authorized representative in writing of its decision within 30 days after receiving the request for reconsideration.
(b) Administrative appeal.
(1) An applicant, client or authorized representative may file an administrative appeal to the Agency Head within 30 days after the mailing date of the Division's decision on the request for reconsideration. An applicant, client, or authorized representative may not file an administrative appeal unless reconsideration has been sought and the requested relief has been denied.
(2) A hearing will be held only if a material issue of fact is in dispute.
(c) General rules. The General Rules of Administrative Practice and Procedure, 1 Pa. Code Part II, apply except when inconsistent with this section.
(d) Status of clients and applicants. A client shall continue to receive HIP services until the client's right to administrative review has been exhausted, and until the maximum funds available to a client under § 4.12 (relating to funding limits) are exhausted, or the maximum duration for enrollment under § 4.7(e) (relating to enrollment) has expired. An applicant, including one who has completed the assessment period, will not receive HIP services pending the disposition of the administrative review.
Appendix A
BUREAU OF FAMILY HEALTH
DIVISION CHILD AND ADULT HEALTH SERVICES
PATIENT SHARE of COST (PSC) TABLE
PSC
$0
$0
$50
$250
$400
$550
$700
$850
$1000
$1150 % of Poverty 0 to 100% >100 to 185% >185 to 225% >225 to 250% >250 to 275% >275 to 300% >300 to 325% >325 to 350% >350 to 375% >375 to 400% Size of
Family
Unit
Income Ranges
Use these columns only for clients
who were in DCAHS programs prior
to 1/1/97 and have continuous
participation without a lapse in eligibility.1 0 8,591 15,893 19,329 21,476 23,624 25,771 27,919 30,066 32,214 8,590 15,892 19,328 21,475 23,623 25,770 27,918 30,065 32,213 34,360 2 0 11,611 21,480 26,124 29,026 31,929 34,831 37,734 40,636 43,539 11,610 21,479 26,123 29,025 31,928 34,830 37,733 40,635 43,538 46,440 3 0 14,631 27,067 32,919 36,576 40,234 43,891 47,549 51,206 54,864 14,630 27,066 32,918 36,575 40,233 43,890 47,548 51,205 54,863 58,520 4 0 17,651 32,654 39,714 44,126 48,539 52,951 57,364 61,776 66,189 17,650 32,653 39,713 44,125 48,538 52,950 57,363 61,775 66,188 70,600 5 0 20,671 38,241 46,509 51,676 56,844 62,011 67,179 72,346 77,514 20,670 38,240 46,508 51,675 56,843 62,010 67,178 72,345 77,513 82,680 6 0 23,691 43,828 53,304 59,226 65,149 71,071 76,994 82,916 88,839 23,690 43,827 53,303 59,225 65,148 71,070 76,993 82,915 88,838 94,760 7 0 26,711 49,415 60,099 66,776 73,454 80,131 86,809 93,486 100,164 26,710 49,414 60,098 66,775 73,453 80,130 86,808 93,485 100,163 106,840 8 0 29,731 55,002 66,894 74,326 81,759 89,191 96,624 104,056 111,489 29,730 55,001 66,893 74,325 81,758 89,190 96,623 104,055 111,488 118,920 9 0 32,751 60,589 73,689 81,876 90,064 98,251 106,439 114,626 122,814 32,750 60,588 73,688 81,875 90,063 98,250 106,438 114,625 122,813 131,000 10 0 35,771 66,176 80,484 89,426 98,369 107,311 116,254 125,196 134,139 35,770 66,175 80,483 89,425 98,368 107,310 116,253 125,195 134,138 143,080 11 0 38,791 71,763 87,279 96,976 106,674 116,371 126,069 135,766 145,464 38,790 71,762 87,278 96,975 106,673 116,370 126,068 135,765 145,463 155,160 12 0 41,811 77,350 94,074 104,526 114,979 125,431 135,884 146,336 156,789 41,810 77,349 94,073 104,525 114,978 125,430 135,883 146,335 156,788 167,240 13 0 44,831 82,937 100,869 112,076 123,284 134,491 145,699 156,906 168,114 44,830 82,936 100,868 112,075 123,283 134,490 145,698 156,905 168,113 179,320 14 0 47,851 88,524 107,664 119,626 131,589 143,551 155,514 167,476 179,439 47,850 88,523 107,663 119,625 131,588 143,550 155,513 167,475 179,438 191,400 15 0 50,871 94,111 114,459 127,176 139,894 152,611 165,329 178,046 190,764 50,870 94,110 114,458 127,175 139,893 152,610 165,328 178,045 190,763 203,480 16 0 53,891 99,698 121,254 134,726 148,199 161,671 175,144 188,616 202,089 53,890 99,697 121,253 134,725 148,198 161,670 175,143 188,615 202,088 215,560 Note: This table is revised each year based on the release of HHS Federal Poverty Income Guidelines by the United States Department of Health and Human Services. The figures above were published in the Federal Register: February 16, 2001 (Volume 66, Number 33) Notices: (pages 10695--10697).
[Pa.B. Doc. No. 01-1379. Filed for public inspection July 27, 2001, 9:00 a.m.]
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