Ala. Admin. Code r. 560-X-35-.02

Current through Register Vol. 43, No. 1, October 31, 2024

Section 560-X-35-.02 - Description Of Services

Home and Community-Based Services (HCBS) under the Home and Community-Based Waiver for Persons with Intellectual Disabilities (ID Waiver) 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 ID Waiver will provide health, social, and related support needed to ensure optimal functioning of individuals with intellectual disabilities within a community setting. The Administering Agency may provide or subcontract for any HCBS under the ID Waiver. To qualify for Medicaid reimbursement, each individual HCBS must be necessary to prevent institutionalization of the waiver recipient. Each provider of HCBS 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 ID Waiver. The following are specific HCBS available under the ID Waiver:

(1) Residential Habilitation Services

(a) Residential Habilitation shall mean a type of residential service selected by the person supported, offering individualized services and supports that enable the person supported to acquire, retain, or improve skills necessary to reside in a community-based setting and which supports each resident's independence and full integration into the community, and ensures each resident's choice and rights.

(b) Residential Habilitation Services may be provided either in a certified community setting or in the waiver recipient's residence (family home, own home or apartment).

(c) Residential Habilitation Services provide care, supervision, and skills training in activities of daily living, home management and community integration in group homes.

(d) In-home Residential Habilitation Services provide care, supervision, and skills training in activities of daily living, home management and community integration to a waiver participant in their own homes, but not in group homes or other facilities. The place of service will primarily be the person's home but may include training in the community to promote opportunities for inclusion, socialization, and recreation.

(e) Residential and In-home Habilitation services include 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.

(f) Residential and In-home Habilitation services will be delivered/supervised by a Qualified Intellectual Disabilities Professional (QIDP) in coordination with the waiver's recipient's approved plan of care.

(g) In-Home Residential Habilitation Services can also be delivered by a Habilitation Aide. The Habilitation Aide will work under supervision and direction of a QIDP.

(h) A Habilitation Aide will be required to be certified by the provider agency as having completed a course of instruction provided or approved by the ADMH. Retraining will be conducted as needed, but at least annually.

(i) In-Home Habilitation Service is limited to 8 hours per day and cannot overlap other services.

(j) In-Home Habilitation Services are not available for new waiver participants. Current waiver participants receiving this service will continue at the current assessed need.

(k) Transportation costs to transport individuals to day programs, social events or community activities when public transportation and/or transportation covered under the Medicaid state plan are not available will be included in payments made to providers of residential habilitation. In-home Habilitation service workers may transport consumers in their own vehicles as an incidental component of this service.

(2) Supported Living Services

(a) Supported Living Services shall mean services that include training and assistance in maintaining a home of one's own, or a home shared with other freely chosen housemates, in the community. A home of one's own means a residence not owned or controlled by any waiver service provider. Supported Living Services supports include supports for maintaining home tenancy or ownership, managing money, preparing meals, shopping, maintaining positive relationships with neighbors, opportunities for participation in and contribution to the local community, supports to maintain personal appearance and hygiene, supports for interpersonal and social skills building through experience with family, friends and members of the broader community, and other activities needed to maintain and improve the capacity of an individual with an intellectual disability to live in the community. The service shall support and maximize the person's independence through use of teaching, training, technology and facilitation of natural supports.

(b) The service shall support the individual's full integration into the community, ensure the person's choice and rights, and comport fully with standards applicable to HCBS settings delivered under Section 1915(c) of the Social Security Act, including the provision of opportunities to seek employment and work in competitive integrated settings, engage in community life, and control personal resources. Further, supports shall be provided in a manner which ensures an individual's rights of privacy, dignity, respect and freedom from coercion and restraint; and which optimizes individual initiative, autonomy, and independence in making life choices.

(c) Supported Living Services also includes oversight and assistance in managing self-administered medication and/or medication administration as permitted under Alabama's Nurse Practice Act and performance of other non-complex health maintenance tasks, as permitted by State law.

(d) Supported Living Services are appropriate for people who need intermittent staff support to remain in their own home and do not require 24/7 staffing.

(e) Individuals receiving Supported Living Services may choose to receive services in a shared living arrangement. Other persons in the shared living arrangement may need differing levels of support, differing types of waiver services, or may participate in different HCBS programs, as permitted in state licensure law and regulation, as long as there is a willing, qualified provider who can safely and appropriately meet the needs of each individual in the home. No more than 3 persons receiving services will be permitted per residence.

(f) Reimbursement for Supported Living Services shall not include the cost of maintenance of the dwelling. Residential expenses (e.g., phone cable TV, food, rent, mortgage, home/renter's insurance, etc.) shall be paid by the person(s) supported and other residents in the home (if applicable), through mutual agreement reached by the persons sharing the dwelling.

(3) Day Habilitation Services

(a) Day Habilitation Services are services which involve the provision of regularly scheduled activities in non-residential settings, separate from the member's residence or other residential living arrangement. Activities focus on assistance with acquisition, retention, or improvement in self-help, socialization and adaptive skills that enhance social integration and outcomes. Activities are designed to foster the acquisition of positive social skills and interpersonal competence, greater independence and ability to exercise and communicate personal choices and preferences. Day Habilitation Services also provides assistance that supports community participation including achievement of valued social roles that reflect a member's individualized interests and desires with regard to type(s) of community involvement and community contributions the member prefers.

(b) Day Habilitation Services focus on enabling the member to attain and maintain his or her maximum potential and shall be coordinated with any needed therapies in the member's person-centered services and support plan, such as physical, occupational, or speech therapy.

(c) Day Habilitation Services are expected to be furnished in a variety of settings in the community, except for the member's residence, that may utilize a provider-owned or controlled setting as a hub or base. Day Habilitation settings must comply fully with the HCBS Settings Rule, therefore ensuring each member's Day Habilitation service plan includes opportunities to participate in a variety of community-based activities that are consistent with the purpose and intended outcome of the service and that facilitate the member's interactions with people from the broader community.

(d) The provider for Day Habilitation Services can be reimbursed based on four levels of Day/Community Habilitation and four levels of Day/Community Habilitation Transportation. Reimbursement rates are associated with each level, based on the associated minimum staffing ratios needed to support persons with different ICAP scores and whether the service is delivered in a facility-based (provider controlled) setting or an integrated community setting, taking account of the more intensive staffing ratios and different costs that are applicable for services delivered in integrated community settings.

(e) Day Habilitation Services cannot exceed five hours per day. Day Habilitation Services may not be used to provide activities involving paid work, including any situation where work done by a member is required to be paid under state and federal labor laws.

(f) Transportation between the Day Habilitation facility and one or more integrated community sites for integrated service delivery time is always included in the service and accounted for in the rate for the service. Transportation between the member's place of residence and the Day Habilitation facility, or site where the member starts and ends Day Habilitation services each day, shall either be, included as a component part of Day Habilitation or arranged for the member in another way. If this transportation is provided by the Day Habilitation provider, the cost of this transportation shall be included and accounted for in the rate paid to the provider. All providers of transportation shall ensure that the provider qualifications for specialized (community) transportation are met.

(4) Prevocational Services

(a) Prevocational services are designed to create a path to competitive integrated employment, which includes competitive integrated self-employment and customized employment or customized self-employment that otherwise meets the criteria for being competitive and integrated. Competitive integrated employment is employment that meets all of the following criteria:

1. Ensures compensation is at least the locally established minimum wage where the member works.

2. Occurs in a location typically found in the community.

3. Enables the member to interact with co-workers and customers to the same extent as a person without a disability filling a similar position.

4. For wage employment, ensures the employer of record is the business or organization benefitting from the work done by the member.

5. Offers the member an individualized position.

(b) Prevocational services involve the provision of learning and skill-building experiences, including community-based volunteering for an organization other than the service provider, where a member can develop general, non-job-task-specific strengths and skills that contribute to employability in competitive integrated employment. Services are intended to develop and teach general skills for competitive integrated employment, including but not limited to: ability to communicate effectively with supervisors, coworkers and customers; generally accepted community workplace conduct and dress; ability to follow directions; ability to attend to tasks; workplace problem solving skills and strategies; and general workplace safety and mobility training.

(c) Prevocational services are expected to be furnished in a variety of settings in the community, except for the member's residence or other waiver-funded residential settings. While a provider may utilize a provider-owned or controlled setting as a hub or base for service delivery, and that setting may include individuals without disabilities who are not receiving HCBS, prevocational services must be delivered consistent with all of the requirements of the HCBS Setting Rule, therefore ensuring each individual's Prevocational service plan includes opportunities to participate in a variety of community-based activities that are consistent with the purpose and intended outcome of the service and that facilitate the individual's access to the broader community and interactions, in the broader community, with people not receiving HCBS.

(d) Reimbursement rates are associated with the minimum staffing ratios needed to support persons based on whether the service is delivered in a facility-based) provider controlled) setting or an integrated community setting, taking into account of the different staffing ratios and different costs that are applicable for services delivered in integrated community settings.

(e) Transportation between the individual's place of residence and the provider facility, or site where the individual starts and ends Prevocational services each day, is included as a component part of the service or arranged for the individual in another way. Transportation during the service is always a component part of the service.

(f) Prevocational services are not otherwise available to the member, in a timeframe that is otherwise typical, through a program funded by ADRS under the section 110 of the Rehabilitation Act of 1973 or, for individuals ages 18-22, through a program funded under the Individuals with Disabilities Education Act (IDEA) (20 U.S.C. 1401 et seq).

(5) Supported Employment Services

(a) There are three variations of Supported Employment Services:

1) Individual Assessment/Discovery

2) Small Group and

3) Individual.

1. Individual Assessment/Discovery is a one-time, time-limited, targeted 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 supports to waiver recipients who, because of their disabilities, need intensive on-going support to 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 recipient's in supported work.

(b) Supported Employment Services are conducted in a variety of settings, particularly work sites in which persons without disabilities are employed.

(c) Supported Employment Services also include activities needed to sustain paid employment by waiver recipients, including supervision and training.

(d) When Supported Employment Services are provided at a work site in which persons with disabilities are employed, payment will be made only for the adaptations, supervision and training required by waiver recipients as a result of their disabilities, and will not include payment for the supervisory activities rendered as a normal part of the business settings.

(e) 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.

(f) 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 Rehabilitation Training 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.

(6) Occupational Therapy Services.

(a) Occupational Therapy Services include 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 function.

(b) Therapists may also provide consultation and training to staff or caregivers (such as a waiver recipient's family and/or foster family).

(c) Services must be prescribed by a physician and 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, provided and billed in 15-minute increments.

(d) Occupational Therapy Services under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan. Group therapy will not be reimbursed.

(7) Speech and Language Therapy Services

(a) Speech and Language Therapy Services include screening and evaluation of waiver recipients with speech and hearing impairments.

1. Comprehensive Speech and Language Services are prescribed when indicated by screening results.

(b) Speech and Language Therapy Services provide treatment for waiver recipients who require speech improvement and speech education. These are specialized programs designed for developing each waiver recipient's communication skills in comprehension, including speech, reading, auditory training, and skills in expression.

(c) Therapists may also provide training to staff and caregivers (such as a waiver recipient's family and/or foster family).

(d) Speech and Language Therapy Services under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan.

(8) Physical Therapy Services

(a) Physical Therapy Services include services, which assist in the determination of a waiver recipient's level of functioning by applying diagnostic and prognostic tasks and providing treatment training programs.

1. Physical Therapy Services preserve and improve abilities for independent function, such as range of motion, strength, tolerance, coordination, and activities of daily living.

2. Physical Therapy Services also helps with progressive disabilities through means such as the use of orthotic prosthetic appliances, assistive and adaptive devices, positioning, behavior adaptations and sensory stimulation.

(b) Physical Therapists may also provide consultation and training to staff or caregivers (such as a waiver recipient's family and/or foster family).

(c) Physical Therapy Services under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan.

(d) Physical Therapy requires a physician's prescription and documentation in the form of an initial assessment and development of a treatment plan with established goals that must be present in the case record and must justify the need for service.

(e) Services must be listed on the care plan and be provided and billed in 15-minute units of service.

(9) Positive Behavior Support Services

(a) Positive Behavior Support Services provides 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 Therapy shall place primary emphasis on the development of desirable adaptive behavior rather than merely the elimination or suppression of undesirable behavior.

(b) A BSP 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 Services 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 Services 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 under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan.

(10) 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.

(11) Respite Care Services

(a) Respite Care Services are given to waiver recipients unable to care for themselves on a short-term basis because of the absence or need for relief of those persons normally providing the care. Respite care may be provided in the waiver recipient's home, place of residence, or a facility approved by the State which is not a private residence.

(b) Respite Care Services may be provided up to a maximum of 1080 hours or 45 days per waiver year.

(c) Respite Care Services cannot be provided by a family member.

(d) Out-of-home respite care 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 may be provided in a JCAHO Accredited Hospital or Residential Treatment Facility (RTF). While a waiver recipient is receiving out-of-home respite, no additional Medicaid reimbursement will be made for other services in the institution.

(e) 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.

(12) Personal Care Services

(a) Personal Care Services are services provided to assist residents with activities 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 assistance with shopping, 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 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.

(c) No payment will be paid for Personal Care Services furnished by a member of the immediate family (i.e., 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.

(d) 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. Personal Care Services cannot be self-directed for children under the age of 21 on the State Plan.

(e) Personal care is limited to no more than 12 hours/48 units each day for individuals living in the home with relatives or caregivers. The number of hours provided may exceed the 12 hours/48 per day for those individuals who live independently and assessed needs indicate the need for additional support and/or for participant whose hours need to exceed the 12 hours can be provided, but the approval should be based on the emergent need (i.e. illness or death of the primary caregiver). A record of the Personal Care visit will be captured by an Electronic Visit Verification Monitoring System.

(f) Personal Care Services under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan.

(g) 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 support the waiver recipient's need to access the community and not merely to provide transportation. The Personal Care Transportation service will provide transportation in 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. Personal Care Transportation is not intended to replace generic transportation nor to be used merely for convenience.

(13) Environmental Accessibility Adaptations Services

(a) Environmental Accessibility Adaptations Services are those physical adaptations to the home, required by the waiver recipients' 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.

1. 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 are 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.

(b) Environmental Accessibility Adaptions Services may be directed by waiver recipients or family but must adhere to all the traditional service rules.

(14) 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 ADMH. Specialized Medical supplies 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. Specialized Medical Supplies Services cannot be self-directed for children under the age of 21 under the State Plan.

(d) Specialized Medical Supplies Services under the waiver is not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan.

(15) 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 Alabama 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. Skilled Nursing Service consists of nursing procedures that meet the waiver recipient's health needs as ordered by a physician. Skilled Nursing Services will be billed by the hour. There is no restriction on the place of Skilled Nursing Services.

(b) Skilled Nursing Services may also be self-directed when provided to a waiver recipient participant or family, which is self-directing Personal Care Services. Personal Care Services include training and supervision related to medical care and/or assistance with ordinarily self-administered medications to be provided by the personal care worker.

(c) Skilled Nursing Services cannot be self-directed for children under the age of 21 under the State Plan.

(d) Skilled Nursing Services under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan. A record of the RN/LPN visit will be captured by an Electronic Visit Verification Monitoring system.

(16) Assistive Technology Services

(a) Assistive Technology Services means an item or piece of equipment (including any equipment not covered by Medicaid State Plan Services), service animal or product system, whether acquired commercially, modified or customized that is used to increase, maintain, or improve functional capabilities of participants. Assistive Technology Services means a service that directly assist an individual in the selection, acquisition, or use of an assistive technology device.

(b) A prescription from the participant's physician is required for this service. Items 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 recipient. Cost are limited to $5,000 per waiver recipient, per year.

(c) Assistive Technology Services under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan.

(d) Assistive Technology Services may be directed by waiver recipients or family but must adhere to all the traditional service rules. Assistive Technology Services cannot be self-directed for children under the age of 21 under the State Plan.

(e) Self-Directed Assistive Technology is only available to those participants who are self-directing personal care, companion and/or LPN/RN services.

(17) 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 is 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 arises, 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 ID Waiver, since the need for the Crisis Intervention Services cannot accurately be predicted and planned for ahead of time.

(k) Specific Crisis Intervention Services 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 recipient's crisis situations; 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 caregiver, death of loved one, etc.

(l) Crisis Intervention Services under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan.

(18) 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.

(19) 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 is 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 category: 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.

(c) Transportation to and from activities and settings is a component of this service. Transportation is provided by the agency responsible for the service or by staff/family/or other natural support. Transportation provided through Community Experience Services is included in the cost of doing business and incorporated in the rate.

(d) Community Experience Services cannot be provided in the participant's home or during the same time the participant is receiving Residential Habilitation since community integration is part of that service. Community Experience Group should not be used to facilitate group activities that normally would be provided by the Day Habilitation provider.

(20) 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. Communication 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.

(21) Individual Directed Goods and Services

(a) Individual Directed Goods and Services are services, equipment or supplies not otherwise provided through the ID Waiver or through the Medicaid State Plan that address an identified need in the service plan and meet the following requirements: the item or service would decrease the need for other Medicaid services; 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's does not have the funds to purchase the item or service or the time or service is not available through another source.

(b) Individual Directed Goods and Services are required to meet the identified needs and outcomes in the waiver recipient's Person Centered Plan, or the most cost effective to meeting the assessed need, assures health, safety, and welfare, and are directly beneficial to the waiver recipient in achieving at least one of the following outcome: Improved cognitive, social, or behavioral functioning; maintain the waiver recipient's ability to remain in the community; enhance inclusion and family involvement; develop or help maintain personal, social, or physical skills; decrease dependency on formal supports services, and increase independence.

(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 recipient may use a commercial transportation agency.

(23) Personal Emergency Response System 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 be directed by waiver recipients or family but must adhere to all the traditional service rules.

(24) 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.

Ala. Admin. Code r. 560-X-35-.02

Rule effective July 9, 1985. Amended: effective November 18, 1987, June 6, 1990. Amended: Filed December 9, 19 96; effective January 14, 1997. Amended: February 5, 2001; effective March 12, 2001. Amended: Filed May 12, 2005; effective June 16, 2005. Amended: Filed January 11, 2008; effective February 15, 2008. Amended: Filed March 13, 2009, effective April 17, 2009. Amended: Filed June 12, 2012; effective July 17, 2012.

Amended by Alabama Administrative Monthly Volume XXXV, Issue No. 10, July 31, 2017, eff. 8/26/2017.

Amended by Alabama Administrative Monthly Volume XXXVI, Issue No. 12, September 28, 2018, eff. 10/26/2018.

Amended by Alabama Administrative Monthly Volume XXXVIII, Issue No. 04, January 31, 2020, eff. 3/16/2020.

Amended by Alabama Administrative Monthly Volume XXXIX, Issue No. 11, August 31, 2021, eff. 10/15/2021.

Amended by Alabama Administrative Monthly Volume XL, Issue No. 08, May 31, 2022, eff. 7/15/2022.

Author: Keisha Hawkins, Administrator, LTC Healthcare Reform Unit

Statutory Authority: Section 1915(c) Social Security Act; 42 C.F.R. § 441, Subpart G; Home- and Community-Based Waiver for the Persons with Intellectual Disabilities.