460 IAC 19-1-3 Provider approval

Sec. 3. In order to be approved by the division to provide assisted living Medicaid waiver services, an applicant shall do the following: (1) Complete an application form prescribed by the division. (2) Submit evidence that the applicant: (A) Has a license required by IC 16-28 and 410 IAC 16.2-5 for each facility at which assisted living Medicaid waiver services will be provided. (B) Has registered each facility at which assisted living services will be provided as a housing with services establishment under IC 12-10-15. (3) Indicate what level of services the applicant will provide. (4) Submit a written and signed statement that the applicant will comply with the provisions of this article. (5) Submit a written and signed statement that assisted living Medicaid waiver services will not be provided at a facility that is not licensed pursuant to IC 16-28 and 410 IAC 16.2-5. (6) Submit a written and signed statement that assisted living Medicaid waiver services will not be provided at a facility that is not registered as a housing with services establishment under IC 12-10-15. (7) Submit a written and signed statement that the applicant will provide services to a recipient as set out in the recipient's plan of care.