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 130.265 - Residential habilitation services

Universal Citation: 7 AK Admin Code 130.265

Current through November 28, 2024

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

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

(A) children with complex medical conditions;

(B) adults with physical and developmental disabilities;

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

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

(4) receive prior authorization; and

(5) meet the requirements specified in this section for

(A) family home habilitation services described in (b) of this section;

(B) supported-living habilitation services described in (d) of this section;

(D) in-home support habilitation services described in (h) of this section

(b) The department will consider residential habilitation services to be family home habilitation services if

(1) the family home habilitation services site

(A) is a residence licensed as an assisted living home or a foster home under AS 47.32; and

(B) provides 24-hour care;

(2) the recipient's primary caregiver

(A) lives with the recipient in the same residence;

(B) is not a member of the recipient's immediate family, or an individual within duty to support the recipient under state law; and

(C) provides the oversight, care, and support needed by the recipient to prevent risk of institutionalization of that recipient; and

(3) the health, safety, and welfare of a recipient living in a family home habilitation services site for the purpose of receiving services under this subsection are not at risk because of the primary caregiver's other obligations.

(c) The department will pay for family home habilitation services under (b) of this section subject to the following limitations:

(1) a recipient's care coordinator must demonstrate, to the department's satisfaction in the recipient's support plan developed under 7 AAC 130.217 and 7 AAC 130.218, that the following criteria were evaluated to determine that a family home habilitation services site is appropriate to provide services to the recipient:

(A) the needs of the recipient, including the need for specialized medical technology;

(B) the capacity of the primary caregiver to provide services for the specified needs of the recipient;

(C) the adequacy of the provider's plan for primary caregiver training, recipient safety, service monitoring, and oversight regarding the number of individuals living at the site;

(D) the suitability of the physical site for the recipient;

(E) the number and the relationship to the primary caregiver of other individuals living at the site, and whether any medical conditions or behavioral characteristics of

(i) those individuals could create a risk to the health, safety, and welfare of the recipient; and

(ii) the recipient could create a risk to the health, safety, and welfare of those individuals;

(F) the ability of other individuals living at the site to provide self-care;

(G) the degree to which any adults and children living at that site, regardless of whether those individuals receive any form of financial support from a public or private source, are dependent upon the primary caregiver for their health, safety, and welfare; and

(H) the nature of any complaints regarding the physical site, quality of care, the primary caregiver, or others living at the site, and how the provider certified in accordance with 7 AAC 130.220(a)(1)(E) resolved those complaints.

(2) the department will authorize payment for services in a family home habilitation services site for not more than three recipients, if each recipient was evaluated and approved to receive services in accordance with the criteria in this subsection, and unless the director of the departmental division responsible for home and community-based waiver services waives the limit on the number of recipients

(A) to allow siblings of the recipient to live at the same site; or

(B) because the provider certified in accordance with 7 AAC 130.220(a)(1)(E) demonstrates to the department's satisfaction that the primary caregiver's obligations to a larger number of individuals, including any adults or children dependent upon the caregiver, will not jeopardize the health, safety, and welfare of the recipient or other dependents; the director will base the decision to waive the limit on the number of recipients in the home on an evaluation of the criteria in (1) of this subsection;

(3) when family home habilitation services are authorized for a recipient, the department will not make separate payment for service site;

(A) chore services under 7 AAC 127.087;

(B) family-directed respite care services under 7 AAC 130.280;

(D) meal services under 7 AAC 130.295; or

(E) services provided by another resident of a family home habilitation

(4) a provider certified in accordance with 7 AAC 130.220(a)(1)(E) shall

(A) notify the department, the recipient's care coordinator, and the recipient or recipient's representative

(i) 30 days before moving a recipient from, or replacing the primary caregiver at, a family home habilitation services site that was evaluated using the criteria under this subsection; and

(ii) not later than one business day after any unplanned relocation or replacement of the primary caregiver, if the provider determined that the relocation or replacement was necessary to protect the recipient's health, safety, and welfare;

(B) consult with the recipient's care coordinator and the recipient or recipient's representative to evaluate whether the criteria specified in this subsection will be met if the recipient is relocated or the primary caregiver is replaced, or are met in the event of an unplanned relocation of the recipient or unplanned replacement of the primary caregiver; and

(i) the criteria in this subsection were evaluated in regard to the needs of the recipient;

(ii) the relocation site meets the needs of the recipient; and

(iii) the primary caregiver at the relocation site or the primary caregiver replacement is capable of providing family home habilitation services to the recipient.

(d) The department will consider residential habilitation services to be supported-living habilitation services if the services are provided on a one-to-one basis to a recipient 18 years of age or older living full-time in that recipient's private residence.

(e) The department will pay for supported-living habilitation services under (d) of this section subject to the following limitations:

(1) the department will not pay for more than 18 hours per day of supported-living habilitation services from all providers combined, unless the department determines that the recipient is unable to benefit from

(A) other home and community-based waiver services; or

(B) services provided by natural supports;

(2) the department will approve other direct care services for a recipient under (d) of this section, if the recipient's care coordinator confirms in writing and the department is satisfied that those services do not supplant or duplicate services provided by natural supports; for purposes of this paragraph, "direct care services" includes

(A) personal care services under 7 AAC 125.010 - 7 AAC 125.199;

(B) chore services under 7 AAC 127.087;

(D) meal services under 7 AAC 130.295.

(f) The department will consider residential habilitation services to be group-home habilitation services if those services are provided to a recipient 18 years of age or older living full-time in a residence licensed as an assisted living home for two or more residents under AS 47.32 that provides 24-hour care.

(g) The department will pay for group-home habilitation services under (f) of this section subject to the following limitations:

(1) a recipient of group-home habilitation services is subject to the limitation in 7 AAC 130.260(c) on day habilitation services;

(2) services rendered by the group-home habilitation staff, whether in the group home or in the community, may not be billed separately as day habilitation services under 7 AAC 130.260;

(3) if a recipient is eligible for group-home habilitation services, the department will not make separate payment for

(A) chore services under 7 AAC 127.087;

(B) respite services under 7 AAC 130.280;

(D) meal services under 7 AAC 130.295; or

(E) services provided by another resident of the group home.

(h) The department will consider residential habilitation services to be in-home support habilitation services if they are provided on a one-to-one basis to a recipient younger than 18 years of age living full-time in that recipient's private residence where an unpaid primary caregiver resides.

(i) The department will pay for in-home support habilitation services under (h) of this section, subject to the following limitations:

(1) the department will not pay for more than 18 hours per day of in-home support habilitation services from all providers combined unless the department determines that the recipient is unable to benefit from

(A) other home and community-based waiver services; or

(B) services provided by natural supports;

(2) when in-home support habilitation services are authorized for the recipient, the department will not make separate payment for

(A) personal care services under 7 AAC 125.010 - 7 AAC 125.199 or 7 AAC 127.090 - 7 AAC 127.140;

(B) chore services under 7 AAC 127.087;

(D) meal services under 7 AAC 130.295; or

(E) services provided by another resident of the home or by the primary unpaid caregiver.

(j) A provider of residential habilitation services under this section may not compel a recipient to be absent from an assisted living home, foster home, or group home for the convenience of the provider.

(k) The department may authorize personal care services at the place of employment for a recipient of family home habilitation services or group-home habilitation services, if that place of employment is separate from the recipient's residence, subject to the provisions of 7 AAC 125.050(a)(3) and 7 AAC 127.045.

Authority:AS 47.05.010

AS 47.07.030

AS 47.07.036

AS 47.07.040

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