Payment under the SPED program and the Medicaid waiver program

1. The department shall establish provider rates for home and community-based service in accordance with a procedure that factors in: a. Whether a provider is an individual or an agency; and b. The range of rates submitted by various providers. 2. The rate for a specific qualified service provider is established at the time the provider agreement is signed. 3. The department shall grant a request for a rate decrease when the department receives a written request for the decrease from the qualified service provider. 4. The department shall grant in full or in part, or shall deny, a request for a rate increase when the department receives a written request for the rate increase from the qualified service provider. 5. The department shall determine the maximum amount allowable per eligible individual each month for a specific service. 6. The department shall establish the aggregate maximum amount allowable per eligible individual each month for all services. The aggregate maximum amount per eligible individual depends on whether the eligible individual is receiving services under the SPED program, under the Medicaid waiver program, or under both programs. 7. The department or designee may grant approval to exceed the monthly service program maximum for a specific eligible individual who is only receiving SPED funds and no Medicaid funds if the eligible individual has a special or unique circumstance; the SPED-eligible individual is not eligible for Medicaid; and the need for additional service program funds will not initially exceed three months. Under emergency conditions, the department may grant a one-time extension not to exceed an additional three months. 8. The department may grant approval to exceed the monthly service program maximum for a specific eligible individual who is receiving SPED funds and Medicaid funds or only Medicaid funds if the eligible individual has a special or unique circumstance; and the need for additional service program funds does not exceed three months. Under emergency conditions, the department may grant a one-time extension not to exceed an additional three months. 9. The department's designee shall notify the eligible individual of the department's determination regarding the request to exceed the monthly service program maximum. If the department denies the request to exceed the monthly aggregate maximum, the department's designee shall inform the eligible individual in writing of the reason for the denial, the eligible individual's right to appeal, and the appeal process, as provided in chapter 75-01-03. 10. The department will grant approval to exceed the monthly program maximum or service maximum for eligible individuals receiving SPED funds or Medicaid funds, or both, whose service units exceed the program caps as a result of the qualified service provider rate increase. This extension is limited to eligible individuals who were receiving services prior to July 1, 2007. 11. Upon written application and good cause shown to the satisfaction of the department, the department may grant a variance to the three months extension and one-time extension limitation in subsections 7 and 8 upon such terms as the department may prescribe, except no variance may permit or authorize a danger to the health or safety of a client and no variance may be granted except at the discretion of the department. A refusal to grant a variance is not subject to appeal.