Current through Register Vol. 43, No. 02, November 27, 2024
Home and Community-Based Services (HCBS) under the Home and
Community-Based Waiver for Persons with Intellectual Disabilities (ID Waiver)
are defined as Title XIX Medicaid-funded services provided to individuals with
intellectual disabilities who, without these services, would require services
in an intermediate care facility for individuals with intellectual disabilities
(ICF/IID). These HCBS under the ID Waiver will provide health, social, and
related support needed to ensure optimal functioning of individuals with
intellectual disabilities within a community setting. The Administering Agency
may provide or subcontract for any HCBS under the ID Waiver. To qualify for
Medicaid reimbursement, each individual HCBS must be necessary to prevent
institutionalization of the waiver recipient. Each provider of HCBS must have a
signed provider contract, meet provider qualifications and comply with all
applicable state and federal laws and regulations. Services that are
reimbursable through Medicaid's EPSDT Program shall not be reimbursed as HCBS
under the ID Waiver. The following are specific HCBS available under the ID
Waiver:
(1) Residential Habilitation
Services
(a) Residential Habilitation shall
mean a type of residential service selected by the person supported, offering
individualized services and supports that enable the person supported to
acquire, retain, or improve skills necessary to reside in a community-based
setting and which supports each resident's independence and full integration
into the community, and ensures each resident's choice and rights.
(b) Residential Habilitation Services may be
provided either in a certified community setting or in the waiver recipient's
residence (family home, own home or apartment).
(c) Residential Habilitation Services provide
care, supervision, and skills training in activities of daily living, home
management and community integration in group homes.
(d) In-home Residential Habilitation Services
provide care, supervision, and skills training in activities of daily living,
home management and community integration to a waiver participant in their own
homes, but not in group homes or other facilities. The place of service will
primarily be the person's home but may include training in the community to
promote opportunities for inclusion, socialization, and recreation.
(e) Residential and In-home Habilitation
services include training and intervention in the areas of self-care,
sensory/motor development, interpersonal skills, communication, behavior
shaping, community living skills, mobility, health care, socialization,
community inclusion, money management, pursuit of leisure and recreational
activities and household responsibilities.
(f) Residential and In-home Habilitation
services will be delivered/supervised by a Qualified Intellectual Disabilities
Professional (QIDP) in coordination with the waiver's recipient's approved plan
of care.
(g) In-Home Residential
Habilitation Services can also be delivered by a Habilitation Aide. The
Habilitation Aide will work under supervision and direction of a
QIDP.
(h) A Habilitation Aide will
be required to be certified by the provider agency as having completed a course
of instruction provided or approved by the ADMH. Retraining will be conducted
as needed, but at least annually.
(i) In-Home Habilitation Service is limited
to 8 hours per day and cannot overlap other services.
(j) In-Home Habilitation Services are not
available for new waiver participants. Current waiver participants receiving
this service will continue at the current assessed need.
(k) Transportation costs to transport
individuals to day programs, social events or community activities when public
transportation and/or transportation covered under the Medicaid state plan are
not available will be included in payments made to providers of residential
habilitation. In-home Habilitation service workers may transport consumers in
their own vehicles as an incidental component of this service.
(2) Supported Living Services
(a) Supported Living Services shall mean
services that include training and assistance in maintaining a home of one's
own, or a home shared with other freely chosen housemates, in the community. A
home of one's own means a residence not owned or controlled by any waiver
service provider. Supported Living Services supports include supports for
maintaining home tenancy or ownership, managing money, preparing meals,
shopping, maintaining positive relationships with neighbors, opportunities for
participation in and contribution to the local community, supports to maintain
personal appearance and hygiene, supports for interpersonal and social skills
building through experience with family, friends and members of the broader
community, and other activities needed to maintain and improve the capacity of
an individual with an intellectual disability to live in the community. The
service shall support and maximize the person's independence through use of
teaching, training, technology and facilitation of natural supports.
(b) The service shall support the
individual's full integration into the community, ensure the person's choice
and rights, and comport fully with standards applicable to HCBS settings
delivered under Section 1915(c) of the Social Security Act, including the
provision of opportunities to seek employment and work in competitive
integrated settings, engage in community life, and control personal resources.
Further, supports shall be provided in a manner which ensures an individual's
rights of privacy, dignity, respect and freedom from coercion and restraint;
and which optimizes individual initiative, autonomy, and independence in making
life choices.
(c) Supported Living
Services also includes oversight and assistance in managing self-administered
medication and/or medication administration as permitted under Alabama's Nurse
Practice Act and performance of other non-complex health maintenance tasks, as
permitted by State law.
(d)
Supported Living Services are appropriate for people who need intermittent
staff support to remain in their own home and do not require 24/7
staffing.
(e) Individuals receiving
Supported Living Services may choose to receive services in a shared living
arrangement. Other persons in the shared living arrangement may need differing
levels of support, differing types of waiver services, or may participate in
different HCBS programs, as permitted in state licensure law and regulation, as
long as there is a willing, qualified provider who can safely and appropriately
meet the needs of each individual in the home. No more than 3 persons receiving
services will be permitted per residence.
(f) Reimbursement for Supported Living
Services shall not include the cost of maintenance of the dwelling. Residential
expenses (e.g., phone cable TV, food, rent, mortgage, home/renter's insurance,
etc.) shall be paid by the person(s) supported and other residents in the home
(if applicable), through mutual agreement reached by the persons sharing the
dwelling.
(3) Day
Habilitation Services
(a) Day Habilitation
Services are services which involve the provision of regularly scheduled
activities in non-residential settings, separate from the member's residence or
other residential living arrangement. Activities focus on assistance with
acquisition, retention, or improvement in self-help, socialization and adaptive
skills that enhance social integration and outcomes. Activities are designed to
foster the acquisition of positive social skills and interpersonal competence,
greater independence and ability to exercise and communicate personal choices
and preferences. Day Habilitation Services also provides assistance that
supports community participation including achievement of valued social roles
that reflect a member's individualized interests and desires with regard to
type(s) of community involvement and community contributions the member
prefers.
(b) Day Habilitation
Services focus on enabling the member to attain and maintain his or her maximum
potential and shall be coordinated with any needed therapies in the member's
person-centered services and support plan, such as physical, occupational, or
speech therapy.
(c) Day
Habilitation Services are expected to be furnished in a variety of settings in
the community, except for the member's residence, that may utilize a
provider-owned or controlled setting as a hub or base. Day Habilitation
settings must comply fully with the HCBS Settings Rule, therefore ensuring each
member's Day Habilitation service plan includes opportunities to participate in
a variety of community-based activities that are consistent with the purpose
and intended outcome of the service and that facilitate the member's
interactions with people from the broader community.
(d) The provider for Day Habilitation
Services can be reimbursed based on four levels of Day/Community Habilitation
and four levels of Day/Community Habilitation Transportation. Reimbursement
rates are associated with each level, based on the associated minimum staffing
ratios needed to support persons with different ICAP scores and whether the
service is delivered in a facility-based (provider controlled) setting or an
integrated community setting, taking account of the more intensive staffing
ratios and different costs that are applicable for services delivered in
integrated community settings.
(e)
Day Habilitation Services cannot exceed five hours per day. Day Habilitation
Services may not be used to provide activities involving paid work, including
any situation where work done by a member is required to be paid under state
and federal labor laws.
(f)
Transportation between the Day Habilitation facility and one or more integrated
community sites for integrated service delivery time is always included in the
service and accounted for in the rate for the service. Transportation between
the member's place of residence and the Day Habilitation facility, or site
where the member starts and ends Day Habilitation services each day, shall
either be, included as a component part of Day Habilitation or arranged for the
member in another way. If this transportation is provided by the Day
Habilitation provider, the cost of this transportation shall be included and
accounted for in the rate paid to the provider. All providers of transportation
shall ensure that the provider qualifications for specialized (community)
transportation are met.
(4) Prevocational Services
(a) Prevocational services are designed to
create a path to competitive integrated employment, which includes competitive
integrated self-employment and customized employment or customized
self-employment that otherwise meets the criteria for being competitive and
integrated. Competitive integrated employment is employment that meets all of
the following criteria:
1. Ensures
compensation is at least the locally established minimum wage where the member
works.
2. Occurs in a location
typically found in the community.
3. Enables the member to interact with
co-workers and customers to the same extent as a person without a disability
filling a similar position.
4. For
wage employment, ensures the employer of record is the business or organization
benefitting from the work done by the member.
5. Offers the member an individualized
position.
(b)
Prevocational services involve the provision of learning and skill-building
experiences, including community-based volunteering for an organization other
than the service provider, where a member can develop general,
non-job-task-specific strengths and skills that contribute to employability in
competitive integrated employment. Services are intended to develop and teach
general skills for competitive integrated employment, including but not limited
to: ability to communicate effectively with supervisors, coworkers and
customers; generally accepted community workplace conduct and dress; ability to
follow directions; ability to attend to tasks; workplace problem solving skills
and strategies; and general workplace safety and mobility training.
(c) Prevocational services are expected to be
furnished in a variety of settings in the community, except for the member's
residence or other waiver-funded residential settings. While a provider may
utilize a provider-owned or controlled setting as a hub or base for service
delivery, and that setting may include individuals without disabilities who are
not receiving HCBS, prevocational services must be delivered consistent with
all of the requirements of the HCBS Setting Rule, therefore ensuring each
individual's Prevocational service plan includes opportunities to participate
in a variety of community-based activities that are consistent with the purpose
and intended outcome of the service and that facilitate the individual's access
to the broader community and interactions, in the broader community, with
people not receiving HCBS.
(d)
Reimbursement rates are associated with the minimum staffing ratios needed to
support persons based on whether the service is delivered in a facility-based)
provider controlled) setting or an integrated community setting, taking into
account of the different staffing ratios and different costs that are
applicable for services delivered in integrated community settings.
(e) Transportation between the individual's
place of residence and the provider facility, or site where the individual
starts and ends Prevocational services each day, is included as a component
part of the service or arranged for the individual in another way.
Transportation during the service is always a component part of the
service.
(f) Prevocational services
are not otherwise available to the member, in a timeframe that is otherwise
typical, through a program funded by ADRS under the section 110 of the
Rehabilitation Act of 1973 or, for individuals ages 18-22, through a program
funded under the Individuals with Disabilities Education Act (IDEA)
(20
U.S.C. 1401 et seq).
(5) Supported Employment Services
(a) There are three variations of Supported
Employment Services:
1) Individual
Assessment/Discovery
3) Individual.
1. Individual Assessment/Discovery is a
one-time, time-limited, targeted service designed to help a waiver recipient
who wishes to pursue individualized, integrated employment or self-employment.
Discovery may involve a comprehensive analysis of the waiver recipient's
history; interviews with family, friends and support staff; observing the
waiver recipient performing work skills; and career research in order to
determine the waiver recipient's career interests, talents, skills, support
needs and choice; and the writing of a Personal Profile Frames which will begin
with the development of an employment plan.
2. Employment Small Group often consists of
groups of waiver recipients being supported in enclave or mobile work crew
activities. Employment Small Group are services and training activities
provided in regular business, industry, and community settings for groups of
two to eight workers with disabilities.
3. Employment Individual services are the
ongoing supports to waiver recipients who, because of their disabilities, need
intensive on-going support to obtain and maintain an individual job in
competitive or customized employment, or self-employment, in an integrated work
setting in the general workforce for which a waiver recipient is compensated at
or above the minimum wage, but not less than the customary wage and level of
benefits paid by the employer for the same or similar work performed by
individuals without disabilities. Employment Individual includes two distinct
services: Job Developer and Job Coach.
(i) The
Job Developer duties include, but are not limited to, marketing the Supported
Employment Service and the waiver recipient's skills; negotiating hours or
location to meet the abilities of the waiver recipient; and job
placement.
(ii) The Job Coach
enters once placement has been arranged. The Job Coach duties include, but are
not limited to, assisting with training of waiver recipients in supported work
to perform specific jobs consistent with their abilities; teaching waiver
recipients associated work skills, responsibilities and behaviors not related
to the specific job being performed; and providing continued ongoing support to
waiver recipient's in supported work.
(b) Supported Employment Services
are conducted in a variety of settings, particularly work sites in which
persons without disabilities are employed.
(c) Supported Employment Services also
include activities needed to sustain paid employment by waiver recipients,
including supervision and training.
(d) When Supported Employment Services are
provided at a work site in which persons with disabilities are employed,
payment will be made only for the adaptations, supervision and training
required by waiver recipients as a result of their disabilities, and will not
include payment for the supervisory activities rendered as a normal part of the
business settings.
(e) Supported
Employment Services are not available to waiver recipients eligible for
benefits under a program funded by either Section 110 of the Rehabilitation Act
of 1973, or Section 602 (16) and (17) of the Education of the Handicapped
Act.
(f) Transportation will be
provided between the waiver recipient's place of residence and the site of the
habilitation services or between habilitation sites (in cases where the waiver
recipient receives Rehabilitation Training Services in more than one place) as
a component part of habilitation services. The cost of this transportation is
included in the rate paid to providers of the appropriate type of habilitation
services.
(6)
Occupational Therapy Services.
(a)
Occupational Therapy Services include the evaluation of a waiver recipient to
determine level of functioning by applying diagnostic and prognostic tasks and
guiding and treating waiver recipients in the prescribed therapy to secure
and/or obtain necessary function.
(b) Therapists may also provide consultation
and training to staff or caregivers (such as a waiver recipient's family and/or
foster family).
(c) Services must
be prescribed by a physician and provided on an individual basis. The need for
service must be documented in the case record. Services must be listed on the
waiver recipient's approved plan of care, provided and billed in 15-minute
increments.
(d) Occupational
Therapy Services under the waiver are not available to children under the age
of 21 when provided as the result of an EPSDT screening, because this service
is covered under the State Plan. Group therapy will not be
reimbursed.
(7) Speech
and Language Therapy Services
(a) Speech and
Language Therapy Services include screening and evaluation of waiver recipients
with speech and hearing impairments.
1.
Comprehensive Speech and Language Services are prescribed when indicated by
screening results.
(b)
Speech and Language Therapy Services provide treatment for waiver recipients
who require speech improvement and speech education. These are specialized
programs designed for developing each waiver recipient's communication skills
in comprehension, including speech, reading, auditory training, and skills in
expression.
(c) Therapists may also
provide training to staff and caregivers (such as a waiver recipient's family
and/or foster family).
(d) Speech
and Language Therapy Services under the waiver are not available to children
under the age of 21 when provided as the result of an EPSDT screening, because
this service is covered under the State Plan.
(8) Physical Therapy Services
(a) Physical Therapy Services include
services, which assist in the determination of a waiver recipient's level of
functioning by applying diagnostic and prognostic tasks and providing treatment
training programs.
1. Physical Therapy
Services preserve and improve abilities for independent function, such as range
of motion, strength, tolerance, coordination, and activities of daily
living.
2. Physical Therapy
Services also helps with progressive disabilities through means such as the use
of orthotic prosthetic appliances, assistive and adaptive devices, positioning,
behavior adaptations and sensory stimulation.
(b) Physical Therapists may also provide
consultation and training to staff or caregivers (such as a waiver recipient's
family and/or foster family).
(c)
Physical Therapy Services under the waiver are not available to children under
the age of 21 when provided as the result of an EPSDT screening, because this
service is covered under the State Plan.
(d) Physical Therapy requires a physician's
prescription and documentation in the form of an initial assessment and
development of a treatment plan with established goals that must be present in
the case record and must justify the need for service.
(e) Services must be listed on the care plan
and be provided and billed in 15-minute units of service.
(9) Positive Behavior Support Services
(a) Positive Behavior Support Services
provides systematic functional behavior analysis, behavior support plan (BSP)
development, consultation, environmental manipulation and training to implement
the BSP for waiver recipients whose maladaptive behaviors are significantly
disrupting their progress in habilitation, self-direction or community
integration, whose health is at risk, and/or who may otherwise require movement
to a more restrictive environment. Positive Behavior Support Services may
include consultation provided to families, other caretakers, and habilitation
services providers. Positive Behavior Therapy shall place primary emphasis on
the development of desirable adaptive behavior rather than merely the
elimination or suppression of undesirable behavior.
(b) A BSP may only be used after positive
behavioral approaches have been tried, and its continued use must be reviewed
and re-justified in the case record every thirty (30) days. The unit of service
is 15 minutes.
(c) The Positive
Behavior Support Service has three service provider levels: two professional
levels and one technical level, each with its own procedure code and rate of
payment. The Positive Behavior Support Service levels are distinguished by the
supervision requirements and qualifications of the provider. Both professional
and technical level service providers may perform tasks within both service
categories, adhering to supervision requirements that are described under
provider qualifications.
1. Level 1
professional providers are required to have advanced degrees, specialization,
and board certification in behavior analysis.
2. Level 2 professional providers are
required to have advanced degrees and specialization with three years of
experience working with waiver recipients. Professional providers at Level 2
who do not have a Doctorate degree require supervision by a Level 1
professional provider.
3. Level 3
technical providers are required to be either a QIDP or a Board-Certified
Assistant Behavior Analyst (BCABA). Level 3 technical providers require
supervision by either a Level 1 professional provider or a Level 2 professional
Doctoral provider.
(d)
Positive Behavior Support Services tasks include the development of a BSP and
implementation of the BSP in accordance with functional behavior
analyses.
(e) Providers of Positive
Behavior Support Services must maintain a service log that documents specific
days on which services are delivered. Group therapy will not be
reimbursed.
(f) The maximum units
of Positive Behavior Support Services per year of both professional and
technician level units combined cannot exceed 1200 and the maximum units of
service of professional level cannot exceed 800.
(g) Positive Behavior Support Services under
the waiver are not available to children under the age of 21 when provided as
the result of an EPSDT screening, because this service is covered under the
State Plan.
(10)
Companion Services
(a) Companion Services are
non-medical supervision and socialization, provided to a functionally impaired
adult. Companions may assist the waiver recipient with such tasks as meal
preparation, and shopping, but may not perform these activities as discrete
services.
1. The provision of Companion
Services does not entail hands-on medical care.
2. Companions may perform light housekeeping
tasks which are incidental to the care and supervision of the waiver
recipient.
3. Companion Services
are provided in accordance with a therapeutic goal in the waiver recipient's
approved plan of care and is not merely diversional in nature.
4. Companion Services must be necessary to
prevent institutionalization of the waiver recipient.
(b) Companion Services can be directed by
waiver recipients or family but must adhere to all the traditional service
rules.
(11) Respite Care
Services
(a) Respite Care Services are given
to waiver recipients unable to care for themselves on a short-term basis
because of the absence or need for relief of those persons normally providing
the care. Respite care may be provided in the waiver recipient's home, place of
residence, or a facility approved by the State which is not a private
residence.
(b) Respite Care
Services may be provided up to a maximum of 1080 hours or 45 days per waiver
year.
(c) Respite Care Services
cannot be provided by a family member.
(d) Out-of-home respite care may be provided
in a certified group home or ICF/IID. In addition, if the waiver recipient is
less than 21 years of age, out-of-home respite care may be provided in a JCAHO
Accredited Hospital or Residential Treatment Facility (RTF). While a waiver
recipient is receiving out-of-home respite, no additional Medicaid
reimbursement will be made for other services in the institution.
(e) Medicaid reimbursement shall not be
claimed for the cost of room and board except when provided as part of respite
care furnished in a facility approved by the State that is not a private
residence.
(12) Personal
Care Services
(a) Personal Care Services are
services provided to assist residents with activities of daily living (ADL) or
instrumental activity of daily living (IADL). Assistance for ADLs includes
bathing, toileting, transfer and ambulation, skin care, grooming, dressing,
extension of therapies and exercise, routine care of adaptive equipment
primarily involving cleaning as needed, meal preparation, assistance with
eating, and incidental household cleaning and laundry. IADLs include assistance
with shopping, budgeting, using public transportation, social interaction,
recreation, and leisure activities. Assistance with IADLs includes
accompaniment, coaching and minor problem-solving necessary to achieve the
objectives of increased independence, productivity and inclusion in the
community.
(b) Personal Care
Services can also include supporting a waiver recipient at an integrated
worksite where the waiver recipient is paid a competitive wage. Personal Care
Services at an integrated worksite must be billed under a separate code to
distinguish it from other Personal Care Services.
(c) No payment will be paid for Personal Care
Services furnished by a member of the immediate family (i.e., parents, spouses,
children) living in the home or who have a legal obligation to provide Personal
Care Services. Siblings who do not reside in the home with the waiver recipient
can be paid to provide Personal Care Services to the waiver
recipient.
(d) Personal Care
Services may be self-directed to allow waiver recipients and their families to
recruit, hire, train, supervise, and if necessary to discharge, their own
personal care workers. Personal Care Services cannot be self-directed for
children under the age of 21 on the State Plan.
(e) Personal care is limited to no more than
12 hours/48 units each day for individuals living in the home with relatives or
caregivers. The number of hours provided may exceed the 12 hours/48 per day for
those individuals who live independently and assessed needs indicate the need
for additional support and/or for participant whose hours need to exceed the 12
hours can be provided, but the approval should be based on the emergent need
(i.e. illness or death of the primary caregiver). A record of the Personal Care
visit will be captured by an Electronic Visit Verification Monitoring
System.
(f) Personal Care Services
under the waiver are not available to children under the age of 21 when
provided as the result of an EPSDT screening, because this service is covered
under the State Plan.
(g) Personal
Care Transportation
1. Personal care
attendants may transport waiver recipients in their own (the attendant's)
vehicles as an incidental component of the personal care service. In order for
this component to be reimbursed, the personal care attendant must support the
waiver recipient's need to access the community and not merely to provide
transportation. The Personal Care Transportation service will provide
transportation in the community to shop, attend recreational and civic events,
go to work, and participate in
People First and other
community building activities. Additional payment will be made for mileage and
the provider's cost of an insurance waiver to cover any harm that might befall
the waiver recipient as a result of being transported.
2. The attendant must have a valid Alabama
driver's license and his/her own insurance coverage as required by State law.
The provider agency shall assure the attendant has a good driving record and is
in-serviced on safety procedures when transporting a waiver
recipient.
3. Personal Care
Transportation shall not replace transportation that is already reimbursable
under Day or Residential Habilitation Services. Personal Care Transportation is
not intended to replace generic transportation nor to be used merely for
convenience.
(13) Environmental Accessibility Adaptations
Services
(a) Environmental Accessibility
Adaptations Services are those physical adaptations to the home, required by
the waiver recipients' approved plan of care, which are necessary to ensure the
health, welfare and safety of the waiver recipient, or which enable the waiver
recipient to function with greater independence in the home and without which,
the waiver recipient would require institutionalization.
1. Environmental Accessibility Adaptation
Services may include adaptations which are necessary to accommodate the medical
equipment and supplies necessary for the welfare of the waiver recipient and
may include the installation of ramps and grab-bars, widening of doorways,
modification of bathroom facilities, or installation of specialized electric
and plumbing systems. Environmental Accessibility Adaptation Services shall
exclude those adaptations or improvements to the home which are of general
utility and are not of direct medical or remedial benefit to the waiver
recipient, such as carpeting, roof repair, central air conditioning, adding
square footage to the home, etc. All Environmental Accessibility Adaptation
Services shall be provided in accordance with applicable State or local
building codes.
(b)
Environmental Accessibility Adaptions Services may be directed by waiver
recipients or family but must adhere to all the traditional service
rules.
(14) Specialized
Medical Supplies Services
(a) Specialized
Medical Supplies Services provide supplies that are necessary to maintain the
waiver recipient's health, safety, and welfare and to prevent further
deterioration of a condition such as decubitus ulcers. These supplies do not
include common over-the-counter personal care items such as toothpaste,
mouthwash, soap, shampoo, Q-tips, deodorant, etc.
(b) Specialized Medical Supplies Services
will only be provided when authorized by the waiver recipient's physician and
shall meet applicable standards of manufacturer, design and installation.
Providers of Specialized Medical Supplies Services will be those who have a
signed provider agreement with Medicaid and the ADMH. Specialized Medical
supplies are limited to a maximum of $1,800.00 per waiver recipient per year.
The operating agency must maintain documentation of items purchased for the
waiver recipient.
(c) Specialized
Medical Supplies Services may be directed by waiver recipients or family but
must adhere to all the traditional service rules. Specialized Medical Supplies
Services cannot be self-directed for children under the age of 21 under the
State Plan.
(d) Specialized Medical
Supplies Services under the waiver is not available to children under the age
of 21 when provided as the result of an EPSDT screening, because this service
is covered under the State Plan.
(15) Skilled Nursing Services
(a) Skilled Nursing Services are services
listed in the waiver recipient's approved plan of care which are within the
scope of the Alabama Nurse Practice Act and are provided by a registered
professional nurse, or licensed practical or vocational nurse under the
supervision of a registered nurse, licensed to practice in the State. Skilled
Nursing Service consists of nursing procedures that meet the waiver recipient's
health needs as ordered by a physician. Skilled Nursing Services will be billed
by the hour. There is no restriction on the place of Skilled Nursing
Services.
(b) Skilled Nursing
Services may also be self-directed when provided to a waiver recipient
participant or family, which is self-directing Personal Care Services. Personal
Care Services include training and supervision related to medical care and/or
assistance with ordinarily self-administered medications to be provided by the
personal care worker.
(c) Skilled
Nursing Services cannot be self-directed for children under the age of 21 under
the State Plan.
(d) Skilled Nursing
Services under the waiver are not available to children under the age of 21
when provided as the result of an EPSDT screening, because this service is
covered under the State Plan. A record of the RN/LPN visit will be captured by
an Electronic Visit Verification Monitoring system.
(16) Assistive Technology Services
(a) Assistive Technology Services means an
item or piece of equipment (including any equipment not covered by Medicaid
State Plan Services), service animal or product system, whether acquired
commercially, modified or customized that is used to increase, maintain, or
improve functional capabilities of participants. Assistive Technology Services
means a service that directly assist an individual in the selection,
acquisition, or use of an assistive technology device.
(b) A prescription from the participant's
physician is required for this service. Items reimbursed with waiver funds
shall be in addition to any medical equipment and supplies furnished under the
State Plan and shall exclude those items which are not of direct medical or
remedial benefit to the recipient. Cost are limited to $5,000 per waiver
recipient, per year.
(c) Assistive
Technology Services under the waiver are not available to children under the
age of 21 when provided as the result of an EPSDT screening, because this
service is covered under the State Plan.
(d) Assistive Technology Services may be
directed by waiver recipients or family but must adhere to all the traditional
service rules. Assistive Technology Services cannot be self-directed for
children under the age of 21 under the State Plan.
(e) Self-Directed Assistive Technology is
only available to those participants who are self-directing personal care,
companion and/or LPN/RN services.
(17) Crisis Intervention Services
(a) Crisis intervention Services provide
immediate therapeutic intervention, available to a waiver recipient on a
24-hour basis, to address personal, social, and/or behavioral problems which
otherwise are likely to threaten the health and safety of the waiver recipient
or of others and/or to result in the waiver recipient's removal from his
current living arrangement.
(b)
Crisis intervention Services may be provided in any setting in which the waiver
recipient resides or participates in a program. Crisis Intervention Services
include consultation with family members, providers, and other caretakers to
design and implement individualized crisis treatment plans and provide
additional direct services as needed to stabilize the situation.
(c) Crisis Intervention Services will respond
intensively to resolve crisis situations and prevent the dislocation of the
waiver recipient at risk such as individuals with intellectual disabilities who
are occasionally at risk of being moved from their residences to institutional
settings because of family's inability to cope with short term, intense crisis
situations. Crisis Intervention Services is a cost-effective alternative to
placement in an ICF/IID.
(d) Crisis
Intervention Services are expected to be of brief duration (8 weeks, maximum).
When Crisis Intervention Services of a greater duration are required, the
waiver recipient shall be transitioned to a more appropriate service program or
setting.
(e) Crisis Intervention
Services providers shall consist of a team under the direction and supervision
of a QIDP. All team members shall have at least one year of work experience in
serving individuals with intellectual disabilities and have a minimum of 40
hours training in crisis intervention techniques prior to providing Crisis
Intervention Services.
(f) A unit
of service is 15 minutes and must be provided by the waiver planning team,
directed by a graduate psychologist or licensed social worker.
(g) When the need for Crisis Intervention
Services arises, the service will be added to the waiver recipient's approved
plan of care.
(h) A separate crisis
intervention plan will be developed to define in detail the activities and
supports that will be provided.
(i)
All Crisis Intervention Services shall be approved by the regional community
service office of the ADMH prior to the service being initiated.
(j) Crisis Intervention Services will not
count against the $25,000 per waiver recipient per year cap in the ID Waiver,
since the need for the Crisis Intervention Services cannot accurately be
predicted and planned for ahead of time.
(k) Specific Crisis Intervention Services
components may include the following:
1.
Analyzing the psychological, social and ecological components of extreme
dysfunctional behavior or other factors contributing to the crisis;
2. Assessing which components are the most
effective targets of intervention for the short-term amelioration of the
crisis;
3. Developing and writing
an intervention plan;
4. Consulting
and, in some cases, negotiating with those connected to the crisis in order to
implement planned interventions, and following up to ensure positive outcomes
from interventions or to make adjustments to interventions;
5. Providing intensive direct supervision
when a waiver recipient is physically aggressive or there is concern that the
waiver recipient may take actions that threaten the health and safety of self
and others;
6. Assisting the waiver
recipient with self-care when the primary caregiver is unable to do so because
of the nature of the waiver recipient's crisis situations; and
7. Directly counseling or developing
alternative positive experiences for waiver recipients who experience severe
anxiety and grief when changes occur with job, living arrangement, primary
caregiver, death of loved one, etc.
(l) Crisis Intervention Services under the
waiver are not available to children under the age of 21 when provided as the
result of an EPSDT screening, because this service is covered under the State
Plan.
(18) Benefits and
Career Counseling Services
(a) Benefits and
Career Counseling Services comprise two distinct services: Benefits Reporting
Assistance (BRA) and Benefits Counseling.
1.
The BRA is designed to assist waiver recipients and their families to
understand general information on how SSI/SSDI benefits are affected by
employment. Once the waiver recipient enters employment, the BRA will be
available to answer questions, assist in the execution of the work incentive
plan, and assist with the submission of income statement and/or Impairment
Related Work Expenses to SSA as required to the extent needed as indicated by
the waiver recipient.
2. The
Benefits Counseling is a more intensive service provided by a Community Work
Incentives Coordinator (CWIC) who will provide intensive individualized
benefits counseling, benefits analysis, develop a work incentive plan and
ongoing benefits planning for a waiver recipient changing jobs or for career
advancement. The CWIC will work in conjunction with the BRA to develop
trainings and webinars based on SSA information provided and may assist or
provide trainings and education as needed.
(b) The Benefits Counselor must be a
Certified Work Incentives Counselor (CWIC) through a recognized training by the
Social Security Administration for delivery of Career Counseling Services. This
may include a level 5 security clearance from the Social Security
Administration/Department of Homeland Security due to Personally Identifiable
Information.
(19)
Community Experience Services
(a) Community
Experience Services are non-work-related activities that are customized to the
waiver recipient's desires to access and experience community participation.
Community Experience Services are provided outside of the waiver recipient's
residence and can be provided during the day, evening, or weekends. The intent
of Community Experience Services is to engage in activities that will allow the
waiver recipient to either acquire new adaptive skills or support the waiver
recipient in utilizing adaptive skills in order to become actively involved in
their community.
(b) Community
Experience Services has two distinct category: Individual and Group Community
Experience services.
1. Community Experience
Individual Services are provided to a waiver recipient, with a one-to-one staff
to waiver recipient ratio which is determined necessary through functional and
health risk assessments prior to approval. Additionally, a behavioral
assessment will need to support this specialized staffing if related to
behavioral challenges prior to approval.
2. Community Experience Group Services are
provided to groups of waiver recipients, with a staff to waiver recipient ratio
of one to two or more, but no greater than four (4) waiver
recipients.
(c)
Transportation to and from activities and settings is a component of this
service. Transportation is provided by the agency responsible for the service
or by staff/family/or other natural support. Transportation provided through
Community Experience Services is included in the cost of doing business and
incorporated in the rate.
(d)
Community Experience Services cannot be provided in the participant's home or
during the same time the participant is receiving Residential Habilitation
since community integration is part of that service. Community Experience Group
should not be used to facilitate group activities that normally would be
provided by the Day Habilitation provider.
(20) Housing Stabilization Services
(a) The Housing Stabilization Service enables
waiver recipients to maintain their own housing as set forth in the waiver
recipient's approved plan of care. Housing Stabilization Services must be
provided in the home or a community setting. Housing Stabilization Services
includes the following components:
1.
Conducting a Housing Coordination and Stabilization Assessment identifying the
waiver recipient's preferences related to housing and needs for support to
maintain housing, budgeting for housing/living expenses, obtaining/accessing
sources of income necessary for rent, home management, establishing credit and
understanding and meeting obligations of tenancy as defined in lease
terms.
2. Assisting waiver
recipients with finding and securing housing as needed. This may include
arranging or providing transportation.
3. Assisting waiver recipients in securing
supporting documents/records, completing/submitting applications, securing
deposits, and locating furnishings.
4. Developing an individual housing
stabilization plan based upon the Housing Coordination and Stabilization
Assessment as part of the overall Person-Centered Plan.
5. Participating in waiver recipient's
Person-Centered Plan meetings at redetermination and/or revision plan meetings
as needed.
6. Providing supports
and interventions per the waiver recipient's Person-Centered Plan
(individualized housing stabilization portion).
7. Communication with the landlord and/or
property manager regarding the waiver recipient's disability (if authorized and
appropriate), detailing accommodations needed, and addressing components of
emergency procedures involving the landlord and/or property manager.
8. If at any time the waiver recipient's
housing is placed at risk (e.g., eviction, loss of roommate, or loss of
income), Housing Stabilization Services will provide supports to retain housing
or locate and secure new housing or sources of income to continue
community-based supports which includes locating new housing, sources of
income. etc.
(21) Individual Directed Goods and Services
(a) Individual Directed Goods and Services
are services, equipment or supplies not otherwise provided through the ID
Waiver or through the Medicaid State Plan that address an identified need in
the service plan and meet the following requirements: the item or service would
decrease the need for other Medicaid services; and/or promote inclusion in the
community; and/or increase the waiver recipient's safety in the home
environment; the item or service is not illegal or otherwise prohibited by
Federal and State statutes and regulations, and the waiver recipient's does not
have the funds to purchase the item or service or the time or service is not
available through another source.
(b) Individual Directed Goods and Services
are required to meet the identified needs and outcomes in the waiver
recipient's Person Centered Plan, or the most cost effective to meeting the
assessed need, assures health, safety, and welfare, and are directly beneficial
to the waiver recipient in achieving at least one of the following outcome:
Improved cognitive, social, or behavioral functioning; maintain the waiver
recipient's ability to remain in the community; enhance inclusion and family
involvement; develop or help maintain personal, social, or physical skills;
decrease dependency on formal supports services, and increase
independence.
(22)
Supported Employment Transportation Services
(a) Supported Employment Transportation
Services permit waiver recipients' transportation to and from their place of
employment in the event that the support team is unable to facilitate
transportation through other means. Supported Employment Transportation
Services must be necessary to support the waiver recipient in work related
travel and cannot be reimbursed for merely transportation.
(b) Transportation must be provided by public
carriers (e.g., charter bus or metro transit bus) or private carriers (e.g.,
taxicab). The recipient may use a commercial transportation agency.
(23) Personal Emergency Response
System Services
(a) Personal Emergency
Response System Services (PERS) provides a direct telephonic or other
electronic communications link between waiver recipients and health
professionals to secure immediate assistance in the event of a physical,
emotional or environmental emergency. PERS may also include cellular telephone
service used when a conventional PERS is less cost-effective or is not
feasible. PERS may include installation, monthly fee (if applicable), upkeep
and maintenance of devices or systems as appropriate.
(b) The use of PERS requires assurance that
safeguards are in place to protect privacy, provide informed consent, and that
documented needs are addressed in the least restrictive manner. The waiver
recipient's Person-Centered Plan should identify options available to meet the
need of the waiver recipient in terms of preference while also ensuring health,
safety, and welfare.
(c) PERS be
directed by waiver recipients or family but must adhere to all the traditional
service rules.
(24)
Remote Support Services
(a) Remote Support
Services are services provided to recipients who are 18 years of age or older,
at their place of residence, by Remote Support staff housed at a remote
location and who are engaged with the recipient through equipment with the
capability for live, two-way communication.
(b) Remote Support Services shall be provided
in real time, not via a recording, by awake staff at a remote monitoring base
using an appropriate, stable, and reliable electronic connection.
(c) Remote Support Services are intended to
address a person's assessed needs in his/her residence and are to be provided
in a manner that promotes autonomy, minimizes dependence on paid support staff,
and reduces the need for in-person services that may be more
intrusive.
Author: Keisha Hawkins, Administrator, LTC
Healthcare Reform Unit
Statutory Authority: Section 1915(c) Social
Security Act; 42 C.F.R. § 441, Subpart G; Home- and Community-Based Waiver
for the Persons with Intellectual Disabilities.