Alliance has a limited amount of state funds to pay for treatment services so entry requirements and benefit maximums may be different than the Medicaid requirements for the same service. Individuals not covered by Non-Medicaid who are seeking state-funded services may be placed on a waiting list when:
- Demand for service exceeds available resources (non-Medicaid funds only), or
- Service capacity is reached as evidenced by no available provider for the state-funded service.
The Utilization Management Department is notified when providers report openings in service capacity, or funding for services becomes available, then works with providers to identify potential individuals from their waiting list. The provider and Alliance UM staff will consider the following factors when selecting waiting list individuals for services:
- Service need (consumer meets medical necessity for service)
- Risk factors such as health and/or safety issues
- Risk of hospitalization or a higher level of care if the need is not addressed.
- Whether the resources identified are adequate to meet the individual’s needs.
- If other funding sources are available to meet the individual’s need.
- Length of time the individual has been waiting.
Some state-funded services, such as Respite Care for Developmental Disabilities and Adult Developmental Vocational Program (ADVP), are not based on income.
Every individual enrolled with Alliance is evaluated to determine their ability to pay for state-funded services. The combination of an individual’s adjusted gross income and the number of dependents will show if they have the ability to pay. An individual meets financial eligibility if household income is at or below 300% of the federal poverty level and there are no assets or third-party funding or insurance available to pay for services. If an individual’s income exceeds this amount, the individual will be required to pay 100% of the cost for the state-funded services provided to him or her.