(1) In order to maintain the program cost within the appropriated monies, the cost of service plans may be limited by the department collectively and individually.
(2) The total annual cost of services for each recipient, except as provided in (3), may not exceed a maximum amount set by the department based on the number of recipients and the amount of monies available to the program as authorized in appropriation by the Legislature.
(3) The total cost of services provided under a service plan for an individual may exceed the maximum amount set by the department if authorized by the department based on the department's determination that one or more of the following circumstances is applicable:
(a) the excess service need is short term and only a one time purchase is necessary;
(b) the excess service need is intensive services of 90 days or less which are necessary to:
(i) resolve a crisis situation which threatens the health and safety of the recipient;
(ii) stabilize the recipient following hospitalization or acute medical episode; or
(iii) prevent institutionalization during the absence of the normal caregiver;
(c) the excess service need is adult residential services; or
(d) the recipient has long term needs that result in the maximum amount being exceeded in minor amounts at various times.
(4) The cost of services to be provided under a service plan is determined prior to implementation of the proposed plan of care and may be revised as necessary after implementation.
(5) A cost determination for the services provided under a service plan may be made at any time that there is a significant revision in the service plan.
(6) The provider reimbursement rate for a covered service for home and community-based services for elderly and physically disabled persons, except as otherwise provided in ARM 37.40.1415, is stated in the department's fee schedule adopted and effective at 37.85.105. These fees are calculated based on:
(a) the biennial Legislative appropriation; and
(b) the estimated demand for covered services during the biennium.