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

(Revised 1/1/20 ML #3570)

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

See link below:

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

The maximum amount allowable under the SPED and ExSPED Programs per client and per month is an aggregate of $3537 for all services excluding Case Management.

When authorizing services that will be paid at the rural differential rate service maximums may be exceeded but the number of units cannot exceed the number of units that are available when using the original service maximum. For example, homemaker units paid at the rural differential rate cannot exceed 51 units using an agency QSP or 70 units using an individual QSP.

Service Maximums Per Client Per Month for Dates of Service


	Homemaker Service	$328
	Respite Care	$1091 (Daily amount not to exceed daily swing bed rate). Refer to link: http://www.nd.gov/dhs/services/medicalserv/medicaid/provider-fee-schedules.html
	Respite Care in Homes with Multiple Clients	$1091 split by the total number of public and private pay clients in the home. Plus $202.29 per month for each additional (2nd 3rd or 4th) public pay client in the home, the total amount will need to be divided between the public pay clients. For Example: An AFC provider has a total of 3 clients, 2 are public pay & 1 is private pay. To calculate respite for the public pay clients you should divide the current respite cap ($1091) by the total number of public & private pay clients living in the home (3) that equals $363.66 for each client or $727.33 for the 2 public pay clients combined. Now add $202.29 for the 2nd public pay client that equals $929.62. Now divide that amount between the 2 public pay clients 2/$929.62 = $464.81. The final step is to allocate $464.81 on each of the public pay client's care plan.
	Adult Foster Care	$91.77 per day for Medicaid Waiver for Aged & Disabled
	Family Home Care	$45.91 per day
	Family Personal Care	$74.80 per day
	Daily Rate for SPED AFFC and Personal Care	$78.92 per day

Extraordinary Costs/Exceed Monthly Aggregate or Service Maximum

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

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

Name and ID number of the client.

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

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

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

Maximum Room and Board Rate effective 5-1-2019

The current maximum monthly room and board rate that providers may charge Adult Foster Care, Adult Residential and Family Home Care recipients is $739.00. The maximum room and board rate is equal to the current Medicaid medically needy income level for a one person household less a $125 personal needs allowance. The rate is reviewed annually.

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