D.C. Mun. Regs. tit. 29, r. 29-9035

Current through Register Vol. 71, No. 49, December 6, 2024

Rule 29-9035 - INDIVIDUAL-DIRECTED GOODS AND SERVICES

9035.1

In order to receive Medicaid reimbursement, individual-directed goods and services shall only be provided to IFS Waiver beneficiaries who are enrolled as participants in the My Life, My Way program and when purchased from the participant-directed services (PDS) budget.

9035.2

All individuals and vendors providing individual-directed goods and services shall meet the following minimum qualifications:

(a) Be at least eighteen (18) years of age;

(b) Be able to demonstrate to the participant that the individual/vendor has:

(1) The capacity to perform the requested work;

(2) The ability to successfully communicate with the participant; and

(3) The necessary professional or commercial licenses and accreditations required by federal and District law.

9035.3

No individual or vendor shall be reimbursed by Medicaid for any individual-directed good or service that is not:

(a) Documented in the participant's ISP and PDS budget; and

(b) Approved by DDS.

9035.4

An individual or vendor selected by a participant to provide individual-directed goods or services on a recurrent basis shall be required to enter into a District of Columbia Medicaid provider agreement prior to providing the goods or services, if applicable.

9035.5

The Vendor Fiscal/Employer Agent Financial Management Services (VF/EA FMS)-Support Broker entity shall verify that an individual or vendor selected by the participant to provide individual-directed goods and services meets all applicable requirements set forth in §§ 9035.2 and 9035.3 at the time of enrollment into the VF/EA FMS-Support Broker entity's provider payment system and thereafter, as necessary in accordance with the ISP.

9035.6

Allowable goods and services shall include the following:

(a) Fitness memberships;

(b) Fitness items that can be purchased at most retail stores;

(c) Toothbrushes or electric toothbrushes;

(d) Weight loss program services (other than food);

(e) Dental services recommended by a licensed dentist and not covered by health insurance;

(f) Nutritional supplements recommended by a professional licensed in the relevant field;

(g) Therapeutic swimming or horseback riding with recommendation from licensed professional;

(h) Fees for activities that promote community integration that are not solely for entertainment and recreational purposes;

(i) Fingerprinting, drug testing costs needed for the person to be considered for a job but not otherwise covered;

(j) Non-post-secondary educational classes that are open to the general public and that offer the opportunity for community integration and engagement while the person is engaged in skill building or a hobby (for example, cooking class, fitness class, money management, art), excluding services that are otherwise available through a program funded under the Individuals with Disabilities Education Act (IDEA);

(k) Cleaning service from firms or individuals to clean the waiver participant's personal areas, including bedroom, bathroom, and kitchen;

(l) Food preparation service and delivery of prepared foods (does not provide payment for the food);

(m) Small electric appliances which allow the participant to safely prepare meals;

(n) Laundry service from a laundromat or other provider; and

(o) Funding up to five hundred dollars ($500) that participants may choose to support staff recruitment and advertisement efforts such as developing and printing flyers and using staffing registries.

9035.7

Participants in the My Life, My Way program may purchase individual-directed goods and services that are included in their ISP, meet the requirements of §§ 9035.6 and 9035.10, are within their PDS budget to purchase, and do not exceed the cost of twenty-five hundred dollars ($2,500).

9035.8

Goods and services may not be purchased from a waiver participant's spouse, legally responsible person, or relative.

9035.9

These services shall be reimbursed only if approved in the participant's ISP based on recommendations from the support team and where appropriate, assessment and professional recommendations; and not otherwise available under the participant's private health insurance (if applicable), the IFS waiver; the Medicaid State plan or through other resources, including services available to an individual under a program funded through Section 110 enacted September 26, 1973 (Pub. L. 93-112; 29 USC §§ 720et seq.), or Section 602(16) and (17) of the Individuals with Disabilities Education Act, 20 USC §§ 1401(16) and (71), enacted October 30, 1990 (Pub. L. 91-230; 20 USC §§ 1400et seq.).

9035.10

For purposes of Medicaid reimbursement, non-allowable goods and services shall include the following:

(a) Experimental or prohibited treatments;

(b) Items used solely for entertainment or recreational purposes, such as televisions, video recorders, DVD players, monthly cable fees; monthly telephone fees; vacation expenses, lottery tickets, alcoholic beverages, tobacco/nicotine products, illegal drugs (including cannabis), movie tickets, and spa treatments;

(c) Goods or services with costs that significantly exceed community norms for the same or similar good or service;

(d) Expenses related to routine daily living, including groceries, rent, or mortgage payments, utility payments, home maintenance, gifts, pets (excluding service animals), and other items as determined by the Department;

(e) Items and services that are excluded from receiving Federal Financial Participation, including but not limited to services provided while a participant is an inpatient of a hospital, nursing facility, or ICF/IID;

(f) Goods or services or items provided to or benefiting persons other than the member;

(g) Goods or services that are otherwise covered by the Waiver or the Medicaid State Plan Services; additional units or costs beyond the maximum allowable for any waiver good or service or Medicaid State Plan good or service, with the exception of a second wheelchair; copayment for medical services; over-the-counter medications; homeopathic services; and

(h) Tuition; educational services otherwise available through a program funded under the Individuals with Disabilities Education Act (IDEA), including private tuition.

D.C. Mun. Regs. tit. 29, r. 29-9035

Final Rulemaking published at 71 DCR 10475 (8/23/2024)