Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 471 - NEBRASKA MEDICAL ASSISTANCE PROGRAM SERVICES
Chapter 12 - NURSING FACILITY REGULATIONS
Section 471-12-008 - SPECIALIZED ADD-ON SERVICES FOR CLIENTS WITH INTELLECTUAL DISABILITIES OR RELATED CONDITIONS RESIDING IN NURSING FACILITIES

Universal Citation: 471 NE Admin Rules and Regs ch 12 § 008

Current through September 17, 2024

008.01 SPECIALIZED ADD-ON SERVICES FOR CLIENTS WITH INTELLECTUAL DISABILITIES OR RELATED CONDITIONS RESIDING IN NURSING FACILITIES. Medically necessary services intended to assist the nursing facility clients in obtaining, maintaining, or improving developmental-age appropriate skills. These services include habilitative training and are not provided by the nursing facility. These services are identified through the preadmission screening and resident review (PASRR) Level II assessment. Specialized add-on services must result in a continuous, aggressive individualized plan of care and be recommended and monitored by the individual's interdisciplinary team. Each specialized add-on service must be prior authorized separately.

008.02 SPECIALIZED ADD-ON SERVICES.

008.02(A) HABILITATIVE SKILLS TRAINING. Habilitative skills training supports individuals to acquire new skills or increase skills in the areas of hygiene, self-advocacy, activities of daily living and communication. Habilitative skills can occur on-site but may be expanded to also occur in the community such as grocery stores, financial institutions, movie theatres, recreational centers or events, and social activities so the individual learns these skills in a variety of settings. Services are expected to include both formal training and opportunities to practice the skills in various settings. This service is provided with a staff to individual ratio of one to one. This service is provided to individuals in order to meet the goals and outcome measurements as outlined in the individual's plan of care. Habilitative skills training consists of:

(1) Identification of skill needs requiring training with regard to individual rights and due process, advocating for their own needs, desires, future life goals and participation in the development of their plan of care, communication skills, personal hygiene skills, dressing skills, laundry skills, bathing skills, and toileting skills;

(2) Development and implementation of formal training goals related to identified skill needs; and

(3) Monitor and revise goals according to the individual's response to training.

008.02(A)(i) LIMITATIONS. Limitations are as follows:

(1) Transportation is not included in the reimbursement rates. Transportation services can be billed separately for off-site habilitative skills only and is limited to travel to and from the habilitative service. The individual must be present in the vehicle.

(2) This service can be authorized in combination with but cannot be provided during the same time period as habilitative community inclusion.

(3) This service must exclude any services available through public education programs funded under the Individuals with Disabilities Education Act (IDEA). This includes services not otherwise available through public education programs in the individual's local school district, including after school supervision and daytime services when school is not in session. Services cannot be provided during the school hours set by the local school district for the individual. Regular school hours and days apply for a child who receives home schooling.

008.02(B) HABILITATIVE COMMUNITY INCLUSION. Habilitative community inclusion supports individuals to increase independence and inclusion in their community. This service must occur in the community in a nonresidential setting, outside of the nursing facility (NF). Making connections with community members is a strong component of this service provision. This service is provided with a staff to individual ratio of one to one. This service is provided to individuals in order to meet the goals and outcome measurements as outlined in the individual's plan of care. Habilitative community inclusion must be included in the individual's care plan. Habilitative community inclusion services consist of:

(1) Identification of needed skills with regard to access and use of community supports, services and activities;

(2) Development and implementation of formal training goals related to:

(a) Community transportation and emergency systems;

(b) Accessing and participation in community groups, volunteer organizations, and social settings; and

(3) Monitoring and revising goals according to the individual's response to training.

008.02(B)(i) LIMITATIONS. Limitations are as follows:

(1) Habilitative community inclusion can supplement, but cannot replace, activities that would otherwise be available as part of the nursing facility (NF) activities program;

(2) Transportation is not included in the reimbursement rate and must be billed separately and is limited to travel to and from the habilitative service. The individual must be present in the vehicle; and

008.02(C) EMPLOYMENT ASSISTANCE. Employment assistance supports the individual through habilitative training to obtain gainful employment in their community. The goal is to provide the skills, tools, and supports to enable the individual to seek and obtain employment. This service is provided with a staff to individual ratio of one to one and may be provided at the nursing facility or in the community. This service is provided to individuals in order to meet the goals and outcome measurements as outlined in the individual's plan of care. Employment assistance services consist of:

(1) Identification of the individual's job preferences and skill needs;

(2) Identification of available employment opportunities in their community;

(3) Development and implementation of formal training goals related to the individual's employment needs including application for employment, job readiness and preparation skills and appropriate work behavior; and

(4) Monitoring and revising goals according to the individual's response to training.

008.02(C)(i) LIMITATIONS. Limitations are as follows:

(1) The individual's service hours are determined by the assistance needed to reach employment goals;

(2) This service can be authorized in combination with but cannot be provided during the same time period as employment support;

(3) Transportation is not included in the reimbursement rate and must be billed separately and is limited to travel to and from the habilitative service. The individual must be present in the vehicle;

(4) This service must exclude any services available through public education programs funded under the Individuals with Disabilities Education Act (IDEA). This includes services not otherwise available through public education programs in the individual's local school district, including after school supervision and daytime services when school is not in session. Services cannot be provided during the school hours set by the local school district for the individual. Regular school hours and days apply for a child who receives home schooling; and

(5) No employment assistance or support services are available to a resident of a nursing facility through a program funded by the Rehabilitation Act of 1973 in Nebraska.

008.02(D) EMPLOYMENT SUPPORT. Employment support supports the individual through habilitative training to maintain integrated and gainful employment after the individual has secured employment. The goal is to provide the skills, tools, and supports necessary for the individual to maintain employment. This service is provided with a staff to individual ratio of up to 1:4 and must be provided in the community. This service is provided to individuals in order to meet the goals and outcome measurements as outlined in the individual's plan of care. Employment Support services consist of:

(1) Teaching appropriate work behavior related to punctuality, attendance and coworker relationships;

(2) Providing training and support for the individual to develop time management skills;

(3) Providing training and monitoring in order for the individual to learn the job tasks necessary to maintain employment;

(4) Providing social skills training in relation to the work environment; and

(5) Monitoring and revising goals according to the individual's response to training.

008.02(D)(i) LIMITATIONS. Limitations are as follows:

(1) Payment for employment support excludes the supervisory activities rendered as a normal part of the business setting.

(2) This service can be authorized in combination with but cannot be provided during the same time period as employment assistance.

(5) No employment assistance or support services are available to a resident of a nursing facility through a program funded by the Rehabilitation Act of 1973 in Nebraska.

008.02(E) NON-MEDICAL TRANSPORTATION. Non-medical transportation is provided in order for the individual to participate in specialized add-on services in a community setting.

008.02(E)(i) LIMITATIONS. Limitations are as follows:

(1) Transportation is limited to travel to and from a habilitative service according to the individual's plan of care.

(2) The individual must be present in the vehicle.

(3) Purchase or lease of vehicles is not covered under this service.

(4) Is a separately billable service for off-site habilitative skills, off-site employment assistance, employment support, and habilitative community inclusion.

008.02(F) PRIOR AUTHORIZATION. For each specialized add-on service a prior authorization request must be submitted by the person or agency providing the service. Medicaid must receive the prior authorization request within 15 calendar days of the start date of the service. The person or agency must provide the following as part of the prior authorization process:

(1) The individual or resident's Level II preadmission screening and resident review (PASRR) final summary determination which must include the recommended specialized add-on services;

(2) The individual or resident's plan of care which must include these specialized add-on services;

(3) Specify the formal goals and objectives that address the individual or resident's needs determined in the Level II preadmission screening and resident review (PASRR) final summary; and

(4) The frequency and duration of the service.

008.02(i) ADDITIONAL REQUIREMENTS. Specialized add-on services are provided only when prior authorized, recommended by the client's interdisciplinary team and are included in the client's plan of care. The interdisciplinary team includes but is not limited to the attending physician, a registered nurse and nurse aide with responsibility for the individual, a member of the food and nutrition services staff, to the extent possible the individual and the individual's representative, and other appropriate staff or professionals in disciplines as determined by the individual's needs or as requested by the individual. Specialized add-on services must meet professional standards of quality and be provided by qualified persons in accordance with each individual's written plan of care.

008.02(ii) PAYMENTS. Specialized add-on services are paid to the providers of specialized add-on services. Payments to providers for medically necessary services, including specialized add-on services in excess of limitations for covered services identified elsewhere in the state plan, or not listed as specialized add-on services according to the state plan, require pre-authorization.

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