1. (a) Provider agencies shall submit claims for covered HCBS waiver services pursuant to He-M 504.05:
2. (b) Payment for HCBS waiver services shall only be made if prior service authorization has been obtained from the bureau pursuant to He-M 517.11.
3. (c) For those individuals whose net income exceeds the appropriate standard of need, medicaid claims payment shall reflect a reduction in reimbursement equal to the cost of care amount.

4. (d) Payment for environmental or vehicle modification services shall not be made until the bureau receives the following, as applicable to the modification:

   1. (1) A copy of any required building permit and written confirmation from the building inspector that the work was completed as allowed by the permit;
   2. (2) A signed statement from the individual or guardian, if applicable, stating that the work has been completed according to the approved bid and plans and to the satisfaction of the individual; and
   3. (3) A signed confirmation from the service coordinator stating that the work was completed.

5. (e) Payment for HCBS waiver services shall not be available to any provider who:

   1. (1) Is the parent of an individual under age 18;
   2. (2) Is a person under age 18, except as permitted in He-M 525; or
   3. (3) Is the spouse of an individual receiving services, except as provided in (g) below.

6. (f) Payment for provision of residential habilitation services to a person who is receiving services for an acquired brain disorder shall be available to a spouse when:

   1. (1) The individual, or guardian, if applicable, choses the individual's spouse to provide the service;
   2. (2) It is determined that this is in the best interest of the individual;

   3. (3) At least one of the following applies:

      1. 1. The individual’s level of dependency in performing activities of daily living, including the need for assistance with toileting, eating, or mobility, exceeds that of the individual’s peers with an acquired brain disorder;
      2. 2. The individual requires support for a complex medical condition, including airway management, enteral feeding, catheterization, or other similar procedures; or
      3. 3. The individual’s need for behavioral management or cognitive supports exceeds that of the individual’s peers with an acquired brain disorder;
   4. (4) The spouse meets all applicable provider qualifications in accordance with He-M 504.03, He-M 504.04, and He-M 504.11;
   5. (5) The spouse does not provide more than 40 hours per week of residential habilitation services; and
   6. (6) The service coordinator conducts service monitoring in accordance with He-M 522.09.

Source. #4315, eff 9-25-87; EXPIRED: 9-25-93 New. #6360, eff 10-23-96, EXPIRED: 10-23-04 New. #8195, INTERIM, eff 10-29-04, EXPIRED: 4-27-05 New. #8424, eff 9-1-05 (from He-M 517.09) ; ss by #10454, eff 10-31-13; ss by #13988, eff 5-30-24 (formerly He-M 517.10)