Alaska Administrative Code
Title 7 - Health and Social Services
Part 8 - Medicaid Coverage and Payment
Chapter 130 - Medicaid Coverage; Home and Community-Based Waiver Services
Article 2 - Home and Community-Based Waiver Services; Nursing Facility and ICF/MR Level of Care
7 AAC 130.260 - Day habilitation services

Universal Citation: 7 AK Admin Code 130.260

Current through November 28, 2024

(a) The department will pay for day habilitation services that

(1) are provided to a recipient in one of the following recipient categories:

(A) children with complex medical conditions, if the recipient is three years of age or older;

(B) adults with physical and developmental disabilities:

(2) are provided in accordance with the department's Day Habilitation Services Conditions of Participation, adopted by reference in 7 AAC 160.900;

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(3) are approved under 7 AAC 130.217 and 7 AAC 130.218 as part of the recipient's support plan; and

(4) receive prior authorization.

(b) The department will consider habilitation services to be day habilitation services if the services

(1) are provided in a residential or community-based setting, to a recipient individually or as a member of a group; a day habilitation service may not duplicate a service provided in residential settings that bill for daily rate services;

(2) include round-trip transportation for the recipient between the recipient's residence and the site where services are provided unless the recipient's support plan reflects that other transportation will be provided;

(3) provide active teaching or training that assists the recipient to acquire, retain, or improve the self-help, socialization, and adaptive skills necessary to live independently, autonomously, and fully integrated in home and community-based settings; the skills may additionally do one or more of the following:

(A) reinforce the skills taught in school, therapy, or other settings;

(B) help mitigate the impact of a degenerative condition and regression of skills and functioning caused by the progression of that condition;

(4) do not duplicate or replace services that are provided under 7 AAC 125, 7 AAC 127, or this chapter;

(5) do not

(A) replace, enhance, or supplement services for which the recipient is eligible under 20 U.S.C. 1400- 1482 (Individuals with Disabilities Education Act), or 29 U.S.C. 701- 796/ (Rehabilitation Act);

(B) provide only companionship for or supervision of a recipient; or

(6) for each recipient, provide

(A) active teaching or training based on goals that are meaningful to the recipient, outcome-based, and have the explicit purpose of developing or retaining skills and functioning reasonably necessary for community integration;

(B) activities that the recipient has a capacity to engage in and benefit from and that are appropriate for the recipient's needs, abilities, and interests as identified through a person-centered planning process that includes review of relevant assessments;

(C) the least restrictive environment appropriate for that recipient, including in the recipient's home or in another private residence; the day habilitation services provided in all residential settings combined

(i) may not be more than 10 percent of the total units of service approved for a plan year; and

(ii) must be justified and approved in the recipient's support plan; and

(D) opportunities that promote connections to natural supports or the greater community, including distance delivery; the day habilitation services provided by distance delivery

(i) may not be more than 10 percent of the total units of service approved for a plan year; and

(ii) must be justified and approved in the recipient's support plan.

(c) The department will only pay for a maximum of 624 hours each year of all types of day habilitation services from all providers combined. The department may approve a limited amount of additional day habilitation services if

(1) the department finds that

(A) the recipient's current physical or behavioral condition places the recipient at risk of institutionalization or incarceration if additional day habilitation services are not provided;

(B) the recipient's support plan and records indicate that the recipient has a critical need for additional day habilitation services because of one or more of the following:

(i) the recipient has an acute or degenerative physical condition that necessitates participation in activities to maintain or improve that condition that are available only in the community;

(ii) the recipient exhibits behaviors that create a risk of physical harm to the recipient or others that can only be mitigated by the development of skills related to appropriate behavior in the community;

(iii) the recipient's one-to-one support provided under 7 AAC 130.267 was recently terminated, and the recipient needs to learn skills required for living successfully in the community; or

(iv) the recipient's release from an intermediate care facility for individuals with intellectual disabilities or the criminal justice system within the current or prior support plan year increases the need for additional day habilitation services for teaching or training skills for community integration; and

(C) the recipient's medical, social, educational, or other records support the recipient's need for, and capacity to engage in and benefit from, additional active teaching or training; those records include the following:

(i) the current and prior year assessments under 7 AAC 130.213;

(ii) the current and prior year support plans;

(iii) records maintained under 7 AAC 105.230(d);

(iv) direct service case notes;

(2) the request for additional day habilitation services is submitted in a recipient's support plan that

(A) describes how the recipient's physical or behavioral condition and one or more of the circumstances in (1)(B) of this subsection justify additional services;

(B) identifies goals related to the skills specified in (b)(3) of this section and explains why additional services in a day habilitation setting are necessary to reach the recipient's goals;

(C) lists interventions used or in use to address the recipient's condition and whether each intervention was successful or unsuccessful; and

(D) indicates how additional day habilitation services will not duplicate or supplant other services rendered to the recipient.

(d) Notwithstanding (b)(l) of this section, the department will waive the requirement for provision of day habilitation services in a non-residential setting if the provider documents to the department's satisfaction, in a format provided by the department,

(1) the unavailability of a suitable non-residential setting in the community or location in which the services are to be provided, except that services under this section may not be provided in the private residence of a recipient; and

(2) the setting where day habilitation services are to be provided will

(A) offer opportunities for activities appropriate for the recipient population to be served; and

(B) be delivered in a manner that protects recipient health, safety, and welfare.

(e) In this section,

(1) "critical need" means the condition resulting from the recipient's circumstances that would result in institutionalization within the support plan year if additional day habitation services are not approved;

(2) "limited amount" means day habilitation services

(A) that exceed 624 hours in a plan year; and

(B) for which the department determines, on an hour-by-hour basis, that a recipient can reasonably be expected to engage in and benefit from active teaching or training, given that recipient's physical or behavioral condition.

Authority:AS 47.05.010

AS 47.07.030

AS 47.07.040

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