Nebraska Administrative Code
Topic - HEALTH AND HUMAN SERVICES SYSTEM
Title 480 - HOME AND COMMUNITY-BASED SERVICES
Chapter 2 - PROGRAM REVIEW AND ADMINISTRATION
Section 480-2-002 - DEFINITIONS

002.01 ACTIVITIES OF DAILY LIVING (ADL). Refer to Title 471 Nebraska Administrative Code (NAC) .

002.02 ADULT. For the purposes of Medicaid and Home and Community-Based Services, an adult is an individual age 18 or older.

002.03 AGED. For the purposes of Medicaid and Home and Community-Based Services, an aged individual is age 65 or older.

002.04 AGENCY PROVIDER. Providers who have one or more employees or will be subcontracting any one or part of the service for which they are requesting approval.

002.05 ASSESSMENT. A process which includes receiving referrals, gathering information, interviewing, and jointly determining participant strengths, needs and desired outcomes.

002.06 AUTHORIZED REPRESENTATIVE. A person appointed by the participant to sign documentation or apply for benefits on their behalf.

002.07 CAREGIVER. A provider, either formal or informal who assists, and assumes responsibility for the care of the participant.

002.08 CHILD. For the purposes of Medicaid and Home and Community-Based Services, a child is an individual age 17 or younger.

002.09 COMMON CARRIER Any person who or which undertakes to transport passengers or household goods for the general public in intrastate commerce by motor vehicle for hire, whether over regular or irregular routes, upon the highways of this state.

002.10 DEPARTMENT. The Department of Health and Human Services as established by the Health and Human Services Act. For the purposes of these regulations, a reference to the Department also includes a reference to the designee of the Department.

002.11 DEPARTMENT STAFF. Employees of the Department or its designees.

002.12 ESCORT. A person who accompanies or personally assists a participant who is unable to travel or wait alone. This may include assistance to and from a vehicle or place of destination, supervision, or support.

002.13 EXEMPT TRANSPORTATION PROVIDER. Transportation carriers exempted from Nebraska Public Service Commission certification as defined in Neb. Rev. Stat. §§ 75-303 to 75-303.03.

002.14 HEALTH MAINTENANCE ACTIVITIES. Noncomplex interventions which can be safely performed according to exact direction, which do not require alteration of the standard procedure, and for which the results and participant responses are predictable.

002.15 HOME AND COMMUNITY-BASED SERVICES. Services not otherwise furnished under the State's Medicaid plan which are furnished under a waiver granted under the provisions of 42 CFR Subpart G.

002.16 INDIVIDUAL PROVIDER. Providers who have no employees. Individual providers are independent contractors and not employees of the Department or the State of Nebraska. For the purpose of Federal Insurance Contribution Act (FICA) withholding, the provider is considered an employee of the participant.

002.17 INDIVIDUAL TRANSPORTATION PROVIDER. An individual carrier who meets the requirements of Neb. Rev. Stat. § 75-303(11),(12),or (13), has an approved service provider agreement with the Department and is chosen by the participant.

002.18 INFORMAL SUPPORTS. Unpaid supports that are provided voluntarily to the individual in lieu of Waiver services and supports. Informal supports are typically provided by friends, family members, or other persons in the community and can include services such as cleaning or transportation. Informal supports may include support provided by or to another person which results in a benefit that is shared by the participant.

002.19 INSTITUTIONAL SETTING. An institutional setting is a medical facility where a person may reside on a short- or long-term basis, including a hospital, nursing facility, institution for developmental disabilities, or an institution for mental diseases. For the purposes of Home and Community-Based Services, any institution will be presumed to be an institutional setting if it has the following attributes: located in a publicly or privately operated facility that provides inpatient institutional treatment; located in a building on the grounds of, or adjacent to, a public institution; or the location has the effect of isolating individuals receiving Home and Community-Based Services from the broader community of individuals not receiving Home and Community-Based Services.

002.20 INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL). Tasks that are performed in the regular course of independent living. The tasks include the following but are not limited to:

002.21 NOTICE OF ACTION. Written notice to the participant, legal representative, or provider, which includes a statement of what action will be taken, the reason for the intended action, and the specific policy manual reference that supports the action or the change in federal or state law that requires the action.

002.22 NURSING FACILITY. A facility licensed by the Department's Regulation and Licensure Unit as a nursing facility.

002.23 PARTICIPANT. An individual either applying for or receiving Waiver services. For the purposes of these regulations, a reference to a participant may include the participant's guardian, legal representative, or any person authorized to act on the participant's behalf.

002.24 PERSON-CENTERED PLAN (PCP). An individualized, written plan for each participant documenting the provision of services and supports that takes into consideration each participant's strengths, needs, priorities, and resources. This plan describes the full range of services to be furnished (regardless of funding source), their frequency, and the type of provider - formal or informal - who will furnish each.

002.25 PRIOR AUTHORIZATION. A process that is employed to control the use of covered services. When services are subject to prior authorization, payment is not made unless approval for the service is obtained in advance by Department staff.

002.26 PROVIDER IDENTIFICATION NUMBER. A nine digit federal identification (FID) number or a nine digit Social Security number (SSN).

002.27 RESIDENT SERVICE AGREEMENT (RSA). An assisted living provider must evaluate each resident and have a written service agreement negotiated with the resident and authorized representative, if applicable, to delineate the services to be provided to meet the needs identified in the evaluation, in accordance with 175 Nebraska Administrative Code (NAC) 4-006.06.

002.28 SERVICE PROVIDER AGREEMENT. A legally binding document which may include service specific agreements, description of service to be provided, and the maximum rate(s) allowed for each service. The responsibilities of the provider and of the Department are stated in the agreement. Refer to 471 NAC 2-000.

002.29 SHARE OF COST (SOC). A participant's monthly financial out-of-pocket obligation for medical services when the participant's income exceeds the program limits. When a participant has excess income resulting in a share of cost, the amount of the share of cost is deducted from the Medicaid payment to the provider. The participant is obligated to pay the share of cost amount to the provider in order to receive services.

002.30 SPECIALIZED ASSISTED LIVING (SAL). A licensed assisted living facility which delivers specialized services to residents. In order to provide Waiver services to otherwise qualified residents, the following criteria must be met:

002.31 TARGETED CASE MANAGEMENT. An individualized, goal-oriented process, based on participant choices, which makes the best use of resources to maximize independence and attain the level of care that is consistent with the participant's level of need.

002.32 TRAUMATIC BRAIN INJURY (TBI). A non-degenerative, non-congenital insult to the brain from an external mechanical force, possibly leading to permanent or temporary impairment of cognitive, physical, and psychosocial functions, with an associated diminished or altered state of consciousness. This term does not apply to brain injuries induced or caused by birth trauma.

002.33 WAIVER. Medicaid Home and Community-Based services are commonly referred to as Waiver services. The reference comes from Section 1915(c) of the Social Security Act which allows normal Medicaid rules to be waived in order to provide additional services in the participant's residence.

002.34 WAIVER CAPACITY. A term used to describe the maximum unduplicated number of individuals who may participate in a Waiver during the year.