Current through Register Vol. 43, No. 02, November 27, 2024
Home and Community-Based Services (HCBS) under the Home and
Community-Based Living at Home (LAH) Waiver for persons with Intellectual
Disabilities 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 LAH Waiver will
provide health, social, and related support needed to ensure optimal
functioning of individuals with intellectual disabilities within a community
setting. The operating agency may provide or subcontract for any services
provided in this waiver. To qualify for Medicaid reimbursement each individual
HCBS must be necessary to prevent institutionalization. Each provider of
services 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 LAH Waiver. The following are specific HCBS available under
the LAH Waiver:
(1) In-Home Residential
Habilitation Training Services
(a) In-Home
Residential Habilitation Training Services provide care, supervision, and
skills training in activities of daily living (ADL)s, home management and
community integration.
(b) In-Home
Residential Habilitation Training Service includes the following:
1. Habilitation 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. Training and
intervention may consist of incidental learning in addition to formal training
plans, and will also encompass modification of the physical and/or social
environment, meaning, changing factors that impede progress (e.g. moving a
chair, substituting velcro closures for buttons or shoe laces, changing
peoples' attitudes toward the waiver recipient, opening a door for someone,
etc.) and provision of direct support, as alternatives to formal habilitative
training.
2. Habilitation supplies
and equipment; and
3.
Transportation costs to transport waiver recipients to day programs, social
events or community activities, when public transportation or transportation
covered under the Medicaid State Plan is not available, accessible or desirable
due to the functional limitations of the waiver recipient, will be included in
payments made to providers of Residential Habilitation. Residential
Habilitation service workers may transport waiver recipients in their own
vehicles as an incidental component of In-Home Residential Habilitation
Training Service.
(c)
In-Home Residential Habilitation Training Services are provided to waiver
recipients in their own homes, but not in group homes or other
facilities.
(d) A unit of service
is 15 minutes. The place of service will primarily be the waiver recipient's
home, but may include services in the community to promote opportunities for
inclusion, socialization, and recreation.
(e) In-Home Residential Habilitation Training
Service goals must relate to identified, planned goals. Training and
supervision of staff by a Qualified Intellectual Disabilities Professional
(QIDP) shall assure the staff is prepared to carry out the necessary training
and support functions to achieve these goals. Initial training requirements
must be met prior to the staff beginning work. Additional training to
specifically address and further the goals in the waiver recipient's plan may
occur on the job. Waiver recipients and family members shall be included in the
planning, and shall be offered and encouraged to use the opportunity to
participate in the training and supervision of the staff.
(f) In-Home Residential Habilitation Training
Service excludes the following:
1. Services,
directly or indirectly, provided by a member of the waiver recipient's
immediate family;
2. Routine care
and supervision which would be expected to be provided by a family
member;
3. Activities or
supervision for which a payment is made by a source other than Medicaid;
and
(g) Providers of
Residential Habilitation must be certified by the Department of Mental
Health.
(2) Day
Habilitation Services
(a) Day Habilitation
Service includes planning, training, coordination, and support to enable and
increase independent functioning, physical health and development,
communication development, cognitive training, socialization, community
integration, domestic and economic management, behavior management,
responsibility and self-direction. Staff may provide assistance/training in
daily living activities and instruction in the skills necessary for independent
pursuit of leisure time/recreation activities. Social and other adaptive skills
building activities such as expressive therapy, prescribed use of art, music,
drama or movement may be used to modify ineffective learning patterns and/or
influence change in behavior.
(b)
The provider for Day Habilitation Services can be reimbursed based on eight
levels of services.
(c)
Transportation cost to transport waivers recipients to places such as day
programs, social events or community activities when public transportation
and/or transportation covered under the State Plan is not available, accessible
or desirable due to the functional limitations of the waiver recipients, will
be included in the rate paid to providers for this service. Day Habilitation
Service workers may transport waiver recipients in their own vehicles as an
incidental component of this service. Providers of Day Habilitation Services
must be certified by the Department of Mental Health.
(3) Prevocational Services
(a) Prevocational Services are aimed at
preparing waiver recipients for paid or unpaid employment, but are not job-task
oriented. Services include teaching such concepts as compliance, attendance,
task completion, problem solving and safety. Prevocational Services are
provided to waiver recipients not expected to be able to join the general work
force or participate in a transitional sheltered workshop within one year
(excluding supported employment programs).
(b) When compensated, waiver recipients are
paid at less than 50 percent of the minimum wage.
(c) Activities included in Prevocational
Services are not primarily directed at teaching specific job skills, but at
underlying habilitative goals, such as attention span and motor skills. All
Prevocational Services will be reflected in the waiver recipient's plan of care
as directed to habilitative, rather than explicit employment
objectives.
(d) Providers of
Prevocational Services must be certified by the Department of Mental
Health.
(e) Prevocational Services
are not available under a program funded under section 110 of the
Rehabilitation Act of 1973 or section 602(16) and (17) of the Individuals with
Disabilities Education Act (20 U.S.C. 1401 [16]
and [17]).
(4) 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 target 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 support to waiver recipients 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
recipients in supported work.
(b) Supported Employment Services are
conducted in a variety of settings, particularly, work sites in which persons
without disabilities are employed. Supported employment includes activities
needed to sustain paid work by waiver recipients, including supervision and
training.
(c) When Supported
Employment Services are provided at a work site in which persons without
disabilities are employed, payment will be made only for the adaptations,
supervision and training required by individuals receiving waiver services as a
result of their disabilities. Payment for the supervisory activities rendered
as a normal part of the business setting will not be made.
(d) 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.
(e) Medicaid reimbursement shall not be
claimed for incentive payments, subsidies, or unrelated vocational training
expenses such as the following:
1. Incentive
payments made to an employer to encourage or subsidize the employer's
participation in a supported employment program;
2. Payments that are passed through to users
of supported employment programs; or
(f) Payments for vocational training that is
not directly related to an individual's supported employment program.
(g) 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 habilitation 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.
(h) Supported Employment Transportation
Services can be authorized, under special circumstances, intended to be limited
in scope, duration, and not to exceed the annual cap.
(i) Providers of supported employment must be
certified by the Department of Mental Health.
(5) Occupational Therapy Services
(a) Occupational Therapy Services are the
application of occupation-oriented or goal-oriented activity to achieve optimum
functioning, to prevent dysfunction, and to promote health. Occupational
Therapy Services include assisting in 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 functioning.
(b) Therapists may also provide consultation
and training to staff or caregivers (such as waiver recipient's family and /or
foster family). Services to direct caregivers will be allowed when the service
to caregivers is for the direct benefit of the waiver recipient and is
necessary to enable the waiver recipient to be cared for outside of an
institution.
(c) Services must be
prescribed by a physician and be 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 and be provided and billed in 15
minute increments. Occupational therapy is covered under the State Plan for
eligible waiver recipients as a result of an EPSDT screening. Therefore, this
service is limited to waiver recipients age 21 and over. Group therapy will not
be reimbursed.
(d) Providers of
service must maintain a service log that documents specific days on which
Occupational Therapy Services were delivered.
(6) Speech and Language Therapy Services
(a) Speech and Language Therapy Services are
diagnostic, screening, preventive, corrective services provided on an
individual basis, when referred by a physician (M.D., D.O.).
(b) These services may include:
1. Screening and evaluation of waiver
recipients' speech and hearing functions and comprehensive speech and language
evaluations when so indicated;
2.
Participation in the continuing interdisciplinary evaluation of waiver
recipients for purposes of implementing, monitoring and following up on waiver
recipients' habilitation programs; and
3. Treatment services as an extension of the
evaluation process that include:
(i)
Consulting with others working with the waiver recipient for speech education
and improvement,
(ii) Designing
specialized programs for developing a waiver recipient's communication skills
comprehension and expression.
(c) Therapists may also provide training to
staff and caregivers (such as a waiver recipient's family and/or foster
family). Services to direct caregivers will be allowed when the service to
caregivers is for the direct benefit of the waiver recipient and is necessary
to enable the waiver recipient to be cared for outside of an
institution.
(d) Speech and
Language Therapy Services must be listed on the care plan and prescribed by a
physician. The need for service must be documented in the case record. Services
shall be provided and billed as an encounter unit of service. Speech and
Language Therapy Services are covered under the State Plan for eligible waiver
recipients as a result of an EPSDT screening. Therefore, this service is
limited to waiver recipients age 21 and over. Group therapy will not be
reimbursed.
(e) Providers of
service must maintain a service log that documents specific days on which
Speech and Language Therapy Services were delivered.
(7) Physical Therapy Services
(a) Physical Therapy Services are
physician-prescribed treatment of a waiver recipient by the employment of
effective properties of physical measures and the use of therapeutic exercises
and rehabilitative procedures with or without assistive devices, for the
purpose of preventing, correcting, or alleviating a physical or mental
disability. Physical Therapy Services include assisting in the evaluation of a
waiver recipient to determine level of functioning by applying diagnostic and
prognostic tasks and providing treatment training programs that are designed
to:
1. Preserve and improve abilities for
independent function, such as range of motion, strength, tolerance,
coordination and facility performing activities of daily living; and
2. Prevent irreducible progressive
disabilities through means such as the use of orthotic and prosthetic
appliances, assistive and adaptive devices, positioning, behavior adaptations
and sensory stimulation.
(b) Therapists may also provide consultation
and training to staff or caregivers (such as waiver recipient's family and/or
foster family).
(c) Services to
direct caregivers will be allowed when the service to caregivers is for the
direct benefit of the waiver recipient and is necessary to enable the waiver
recipient to be cared for outside of an institution.
(d) Documentation in the case record must
justify the need for this service. Services must be listed on the care plan and
be provided and billed in 15 minute increments. Physical therapy is covered
under the State Plan for eligible waiver recipients as a result of an EPSDT
screening. Therefore, Physical Therapy Services are limited to waiver
recipients age 21 and over. Group therapy will not be reimbursed.
(e) Providers of Physical Therapy Services
must maintain a service log that documents specific days on which Physical
Therapy Services were delivered.
(8) Positive Behavior Support Services
(a) Positive Behavior Support Services
provide 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 Support Services shall place primary
emphasis on the development of desirable adaptive behavior rather than merely
the elimination or suppression of undesirable behavior.
(b) A behavior management plan 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
Service 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 Service 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 can be directed by waiver recipients or
family but must adhere to all the traditional service rules.
(9) Respite Care Services
(a) Respite Care Services are provided in or
outside a family's home to temporarily relieve the unpaid primary caregiver.
Respite Care Services provide short-term care for a brief period of rest or
relief for the family from day-to-day care giving.
(b) Respite is intended for waiver recipients
whose primary caregivers typically are the same persons day after day (e.g.
family members and/or adult family foster care providers), and is provided
during those portions of the day when the caregivers typically provide care.
Relief needs of hourly or shift staff workers will be accommodated by staffing
substitutions, plan adjustments, or location changes, and not by Respite Care
Service. Respite care typically is scheduled in advance, but it can also serve
as relief in a crisis situation. In an instance of crisis relief, out-of-home
respite can also allow time and opportunity for assessment, planning and
intervention to try to re-establish the waiver recipient in their home, or if
necessary, to locate another home for them.
(c) Some waiver recipients are
institutionalized because their community supports become exhausted, or because
they are unsure of how to cope with an increasingly challenging behavior, or
due to the loss/incapacitation of a caregiver. The scope of out of home respite
will allow quick response to place the person in an alternate setting and
provide intensive evaluation and planning for return, with or without
additional intervention and supports. Planning will be made for alternate
residential supports if return is not possible.
(d) Respite Care Service is dependent on the
individual's needs as set forth in the plan of care and requires approval by
the Division of Developmental Disabilities, subject to review by the Alabama
Medicaid Agency. The limitation on either in-home or out-of-home Respite Care
Services shall be 1080 hours or 45 days per waiver recipient per waiver
year.
(e) Out-of-home Respite Care
Services 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
Services may be provided in a JCAHO Accredited Hospital or Residential
Treatment Facility (RTF). While a waiver recipient is receiving Out-of-Home
Respite Care Services, no additional Medicaid reimbursement will be made for
other services in the institution.
(f) 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.
(10) Personal
Care Services
(a) Personal Care Services
provide assistance with any activity 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 shopping, banking, 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 under the Living
at Home Waiver may also include general supervision and protective oversight
reasonable to the accomplishment of health, safety and inclusion. The worker
may directly perform some activities and support the waiver recipient in
learning how to perform others; the planning team (composed at minimum of the
waiver recipient and family, and a case manager or community specialist) shall
determine the composition of the Personal Care Service and assure it does not
duplicate, nor is duplicated by, any other service provided to the waiver
recipient.
(c) A written
description of what the personal care worker will provide to the waiver
recipient is required to be submitted to the state as part of or in addition to
the waiver recipient's approved plan of care, and will require approval by the
Division of Developmental Disabilities and be subject to review by the Single
State Agency for Medicaid.
(d)
While in general, Personal Care Services will not be approved for a waiver
recipient living in a group home or other residential setting, the Division of
Developmental Disabilities may approve it for specific purposes that are not
duplicative.
(e) The plan of care
or an addendum shall specify any special requirements for training, more than
basic training, which may be needed to support the waiver recipient. Parents
and other caretakers shall be key informers on the matter of special training,
and will be encouraged to participate in the training and supervision of the
worker.
(f) When Personal Care
Services are provided to minor children living with their parents or guardians,
it shall not supplant the cost and provision of support ordinarily provided by
parents to children without disabilities, nor shall it supplant educationally
related services and support that is the responsibility of local education
authorities. Otherwise, the only limitation on hours provided is the waiver
recipient's documented need for Personal Care Services as an alternative to
institutional care and the reasonable cost effectiveness of his or her
plan.
(g) There is no restriction
on the place of service so long as the waiver recipient is eligible for the LAH
Waiver in that setting and no duplication of payment occurs. This would
preclude personal care being provided in, for instance, a day habilitation or
respite setting where payment would already be made for the same services.
Payment is for a 15 minute unit of service, not including worker's time of
travel to and from the place of work.
(h) No payment will be paid for Personal Care
Services furnished by a member of the immediate family (e.g., 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. Any
other relatives, or friends, who are employed to provide services shall meet
the qualifications for providers of care and, as for all other personal care
workers, payment shall only be made for services actually rendered. Employment
of a relative or friend shall be noted and justified in the waiver recipient's
record by the provider agency.
(i)
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.
(j) 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.
(k) 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 be needed to support the
waiver recipient in accessing the community, and not merely to provide
transportation. The Personal Care Transportation service will provide
transportation into 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 nor the Medicaid non-emergency
medical transportation program. The planning team must also assure the most
cost effective means of transportation, which would include public transport
where available. Transportation by a personal care attendant is not intended to
replace generic transportation nor to be used merely for convenience.
(11) Environmental
Accessibility Adaptations Services
(a)
Environmental Accessibility Adaptations Services will provide physical
adaptations to the home, required by the waiver recipient's 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.
(b)
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 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.
(c) The waiver recipient's home may be a
house or an apartment that is owned, rented or leased. Environmental
Accessibility Adaptations to the work environment covered by the Americans with
Disabilities Act, or those that are the responsibility of other agencies are
not covered. Covered Environmental Accessibility Adaptations of rented or
leased homes should be those extraordinary alterations that are uniquely needed
by the waiver recipient and for which the property owner would not ordinarily
be responsible.
(d) Environmental
Accessibility Adaptations Services may be directed by waiver recipients or
family but must adhere to all the traditional service rules.
(e) Total costs of Environmental
Accessibility Adaptations Services shall not exceed $5,000 per waiver year, per
waiver recipient.
(12)
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 Department of Mental Health.
Specialized Medical Supplies Services 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.
(13) Specialized Medical Equipment Services
(a) Specialized Medical Equipment Services
include devices, controls, or appliances, specified in the waiver recipient's
approved plan of care, which enable waiver recipients to increase their ability
to perform activities of daily living, or to perceive, control, or communicate
with the environment in which they live. Specialized Medical Equipment Services
include items that are necessary for life support, ancillary supplies and
equipment necessary to the proper functioning of such items, and durable and
non-durable medical equipment not available under the Medicaid State Plan.
Specialized Medical Equipment 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
waiver recipient. Invoices for Specialized Medical Equipment must be maintained
in the case record. Specialized Medical Equipment must be necessary to prevent
institutionalization of the waiver recipient. All items shall meet applicable
standards of manufacturer, design, and installation. Costs are limited to 5,000
per waiver recipient, per year.
(b)
Specialized Medical Equipment Services may be directed by waiver recipients or
family but must adhere to all the traditional service rules.
(14) 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 State's 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.
(b) Skilled Nursing Services consist of
nursing procedures that meet the waiver recipient's health needs as ordered by
a physician.
(c) Skilled Nursing
Services will be billed by the hour. There is no restriction on the place of
service.
(d) Skilled Nursing
Services may also be self-directed when provided to a waiver recipients or
family which is self-directing Personal Care Services. Skilled Nursing Services
includes training and supervision related to medical care and/or assistance
with ordinarily self-administered medications to be provided by the personal
care worker.
(15)
Community Specialist Services
(a) Community
Specialist Services are a time limited, task specific service that can include
professional observation and assessment, individualized program design and
implementation, training of waiver recipients and family members, consultation
with caregivers and other agencies, and monitoring and evaluation of planning
and service outcomes as needed to facilitate and implement the Person Centered
Plan. Community Specialist Services may also include, at the choice of the
waiver recipient or family, advocating for the consumer and assisting him or
her in locating and accessing both wavier and non-waiver services and supports.
The Community Specialist will serve as both a qualified planner and, at the
consumer's or family's request, a broker. The functions outlined for Community
Specialist Services differs from case management in the skill level and
independence of the specialist, as well as the focus on self-determination and
advocacy for the individual.
(b)
The provider must meet QIDP qualifications and be free of any conflict of
interest with other providers serving the waiver recipient. The Community
Specialist Services will assist the consumer and his caregivers to design and
implement specialized programs to enhance self-direction, independent living
skills, community integration, social, leisure and recreational skills, and
behavior management. A community specialist with expertise in person centered
planning may also be selected by the waiver recipient to facilitate the
interdisciplinary planning team meeting.
(c) Targeted case managers will continue to
perform traditional duties of intake, completion of paperwork regarding
eligibility, serving in the capacity of referral and resource locating,
monitoring and assessment.
(d) The
planning team shall first ensure that provision of Community Specialist
Services does not duplicate the provision of any other services, including
Targeted Case Management provided outside the scope of the waiver.
(e) The community specialist will frequently
be involved for only a short time (30 to 60 days); in such an instance, the
functions will not overlap with case management. If the waiver recipient or
family chooses to have the community specialist remain involved for a longer
period of time, it must be agreed upon by the team and extended on the waiver
recipient's approved plan of care. The need to extend the service must be fully
justified in writing by the case manager. Community Specialist Services are
limited to a 90-day period per waiver recipient per waiver year.
(f) The community specialist will share
information with the case manager quarterly in an effort to remain abreast of
the waiver recipient's needs and condition.
(g) A community specialist who facilitates
the planning meeting for a waiver recipient shall not have any conflict of
interest with any provider who may wish to serve the waiver
recipient.
(h) Community Specialist
Services are a cost effective and necessary alternative to placement in an
ICF/IID. A unit of service is 15 minutes.
(16) 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 are 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 arise, 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 LAH Waiver,
since the need for the Crisis Intervention Service cannot accurately be
predicted and planned for ahead of time.
(k) Specific Crisis Intervention Service
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's crisis situation; 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 care
giver, death of loved one, etc.
(17) Individual Directed Goods and Services
(a) Individual Directed Goods and Services
are services, equipment or supplies not otherwise provided through the LAH
Waiver or through the Medicaid State Plan that address an identified need in
the service plan (including improving and maintaining the waiver recipient's
opportunities for full membership in the community and meet the following
requirements: the item or service would decrease the need for other Medicaid
service; 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 does not have the funds to purchase the item or service or the
item or service is not available through another source.
(b) The limit on the amount of Goods and
Services that can be purchased is determined individually based on the balance
of the waiver recipient's saving account at the time of the request which is
maintained by the Financial Management Services Agency, but not to exceed
$10,000 annually.
(18)
Assistance in Community Integration Services
(a) The Assistance in Community Integration
Service enables waiver recipients to maintain their own housing as set forth in
the waiver recipient's approved plan of care.
Assistance in Community Integration Services must be provided
in the home or a community setting. Assistance in Community Integration Service
includes the following components:
1.
Conducting a community integration assessment identifying the waiver
recipient's preferences related to housing and needs for support to maintain
community integration.
2. Assisting
waiver recipient with finding and securing housing as needed. This may include
arranging for or providing transportation.
3. Assisting waiver recipient in securing
supporting documents/records, completing/submitting applicants, securing
deposits, and locating furnishings.
4. Developing an individualized community
integration plan based upon the assessment as part of the overall
Person-Centered Plan. Identify and establish short and long-term measurable
goal(s), and establish how goals will be achieved and how concerns will be
addressed.
5. Participating in
waiver recipients Person-Centered Plan meetings at re-determination and/or
revision plan meetings as needed.
6. Providing supports and interventions per
the waiver recipient's Person-Centered Plan (individualized community
integration portion). Identify any additional supports or services needed
outside the scope of Community Integration services and address among the
team.
7. Supports to assist the
waiver recipient in communicating 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. Assistance in Community Integration
Services will provide supports to preserve the most independent living
arrangement and/or assist the waiver recipient in locating the most integrated
option appropriate to the waiver recipient.
(19) 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.
(20) 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 are 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 categories: 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.
(21) Personal Emergency Response System
(PERS) 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) can
be directed by waiver recipients or family but must adhere to all the
traditional service rules.
(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 waiver recipient may use a commercial
transportation agency.
(23) 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.
(24) 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.
(25) 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. Communicating 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.
Entire chapter was repealed as per certification filed
December 7, 1995; effective January 11,
1996.
Author: Mattie Jackson, Associate Director,
Specialized Waiver Programs, LTC Healthcare Reform Division
Statutory Authority: Social Security Act
§1915(c); 42 C.F.R. Section 441, Subpart G-Home and Community-Based
Services: Waiver Requirements.