Idaho Admin. Code r. 16.03.10.703

Current through August 31, 2023

Section 16.03.10.703 - ADULT DD WAIVER SERVICES: COVERAGE AND LIMITATIONS

01.Residential Habilitation. Residential habilitation services consist of an integrated array of individually tailored services and supports furnished to eligible participants. These services and supports are designed to assist the participants to reside successfully in their own homes, with their families, or in certified family homes. The services and supports that may be furnished consist of the following: (3-17-22)

a. Habilitation services aimed at assisting the individual to acquire, retain, or improve their ability to reside as independently as possible in the community or maintain family unity. Habilitation services include training in one (1) or more of the following areas: (3-17-22)

i. Self-direction, including the identification of and response to dangerous or threatening situations, making decisions and choices affecting the individual's life, and initiating changes in living arrangements or life activities; (3-17-22)

ii. Money management including training or assistance in handling personal finances, making purchases, and meeting personal financial obligations; (3-17-22)

iii. Daily living skills including training in accomplishing routine housekeeping tasks, meal preparation, dressing, personal hygiene, self-administration of medications, and other areas of daily living including proper use of adaptive and assistive devices, appliances, home safety, first aid, and emergency procedures; (3-17-22)

iv. Socialization including training or assistance in participation in general community activities and establishing relationships with peers with an emphasis on connecting the participant to their community. (Socialization training associated with participation in community activities includes assisting the participant to identify activities of interest, working out arrangements to participate in such activities and identifying specific training activities necessary to assist the participant to continue to participate in such activities on an on-going basis. Socialization training does not include participation in non-therapeutic activities that are merely diversional or recreational in nature); (3-17-22)

v. Mobility, including training or assistance aimed at enhancing movement within the person's living arrangement, mastering the use of adaptive aids and equipment, accessing and using public transportation, independent travel, or movement within the community; (3-17-22)

vi. Behavior shaping and management includes training and assistance in appropriate expressions of emotions or desires, assertiveness, acquisition of socially appropriate behaviors; or extension of therapeutic services that consist of reinforcing physical, occupational, speech and other therapeutic programs. (3-17-22)

b. Personal Assistance Services necessary to assist the individual in daily living activities, household tasks, and such other routine activities as the participant or the participant's primary caregiver(s) are unable to accomplish on their own behalf. (3-17-22)

c. Skills training to teach waiver participants, family members, alternative family caregiver(s), or a participant's roommate or neighbor to perform activities with greater independence and to carry out or reinforce habilitation training. Services are focused on training and are not designed to provide substitute task performance. Skills training is provided to encourage and accelerate development in independent daily living skills, self-direction, money management, socialization, mobility and other therapeutic programs. (3-17-22)

02.Chore Services. Chore services include the following services when necessary to maintain the functional use of the home or to provide a clean, sanitary, and safe environment. (3-17-22)

a. Intermittent Assistance may include the following: (3-17-22)

i. Yard maintenance; (3-17-22)

ii. Minor home repair; (3-17-22)

iii. Heavy housework; (3-17-22)

iv. Sidewalk maintenance; and (3-17-22)

v. Trash removal to assist the participant to remain in the home. (3-17-22)

b. Chore activities may include the following: (3-17-22)

i. Washing windows; (3-17-22)

ii. Moving heavy furniture; (3-17-22)

iii. Shoveling snow to provide safe access inside and outside the home; (3-17-22)

iv. Chopping wood when wood is the participant's primary source of heat; and (3-17-22)

v. Tacking down loose rugs and flooring. (3-17-22)

c. These services are only available when neither the participant, nor anyone else in the household, is capable of performing or financially providing for them, and where no other relative, caregiver, landlord, community volunteer, agency, or third-party payer is willing to provide them, or is responsible for their provision. (3-17-22)

d. In the case of rental property, the landlord's responsibility under the lease agreement will be examined prior to any authorization of service. Chore services are limited to the services provided in a home rented or owned by the participant. (3-17-22)

03.Respite Care. Respite care includes short-term breaks from care giving responsibilities to non-paid caregivers. The caregiver or participant is responsible for selecting, training, and directing the provider. While receiving respite care services, the waiver participant cannot receive other services that are duplicative in nature. Respite care services provided under this waiver do not include room and board payments. Respite care services may be provided in the participant's residence, the private home of the respite provider, the community, a developmental disabilities agency, or an adult day health facility. (3-17-22)

04.Supported Employment. Supported employment consists of competitive work in integrated work settings for individuals with the most severe disabilities for whom competitive employment has not traditionally occurred; or for whom competitive employment has been interrupted or intermittent as a result of a severe disability. Because of the nature and severity of their disability, these individuals need intensive supported employment services or extended services in order to perform such work. (3-17-22)

a. Supported employment services rendered under the waiver are not available under a program funded by either the Rehabilitation Act of 1973, as amended, or the Individuals with Disabilities Education Act (IDEA). Documentation must be maintained in the file of each individual receiving this service verifying that the service is not otherwise available or funded under the Rehabilitation Act of 1973 as amended, or the IDEA. (3-17-22)

b. Federal Financial Participation (FFP) cannot be claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following: incentive payments made to an employer of waiver participants to encourage or subsidize the employers' participation in a supported employment program; payments that are passed through to beneficiaries of supported employment programs; or payments for vocational training that are not directly related to a waiver participant's supported employment program. (3-17-22)

05.Non-Medical Transportation. Non-medical transportation enables a waiver participant to gain access to waiver and other community services and resources. (3-17-22)

a. Non-medical transportation is offered in addition to medical transportation required in IDAPA 16.03.09, "Medicaid Basic Plan Benefits," and will not replace it. (3-17-22)

b. Whenever possible, family, neighbors, friends, or community agencies who can provide this service without charge or public transit providers will be utilized. (3-17-22)

06.Environmental Accessibility Adaptations. Environmental accessibility adaptations include minor housing adaptations that are necessary to enable the participant to function with greater independence in the home, or without which, the participant would require institutionalization or have a risk to health, welfare, or safety. Such adaptations may include: (3-17-22)

a. The installation of ramps and lifts, widening of doorways, modification of bathroom facilities, or installation of electric and plumbing systems that are necessary to accommodate the medical equipment and supplies necessary for the welfare of the waiver participant, but must exclude those adaptations or improvements to the home that are not of direct medical or remedial benefit to the participant, such as carpeting, roof repair, or central air conditioning. (3-17-22)

b. Unless otherwise authorized by the Department, permanent environmental modifications are limited to a home that is the participant's principal residence, and is owned by the participant or the participant's nonpaid family. (3-17-22)

c. Portable or non-stationary modifications may be made when such modifications can follow the participant to their next place of residence or be returned to the Department. (3-17-22)

07.Specialized Medical Equipment and Supplies. (3-17-22)

a. Specialized medical equipment and supplies include: (3-17-22)

i. Devices, controls, or appliances that enable a participant to increase their abilities to perform activities of daily living, or to perceive, control, or communicate with the environment in which they live; and (3-17-22)

ii. Items necessary for life support, ancillary supplies and equipment necessary for the proper functioning of such items, and durable and non-durable medical equipment not available under the Medicaid State Plan. (3-17-22)

b. Items reimbursed with waiver funds are in addition to any medical equipment and supplies furnished under the Medicaid State Plan and exclude those items that are not of direct medical or remedial benefit to the participant. (3-17-22)

08.Personal Emergency Response System (PERS). PERS is an electronic device that enables a waiver participant to secure help in an emergency. The participant may also wear a portable "help" button to allow for mobility. The system is connected to the participant's phone and programmed to signal a response center once a "help" button is activated. The response center is staffed by trained professionals. This service is limited to participants who: (3-17-22)

a. Rent or own a home, or live with unpaid caregivers; (3-17-22)

b. Are alone for significant parts of the day; (3-17-22)

c. Have no caregiver for extended periods of time; and (3-17-22)

d. Would otherwise require extensive, routine supervision. (3-17-22)

09.Home Delivered Meals. Home delivered meals are meals that are delivered to a participant's home to promote adequate participant nutrition. One (1) to two (2) meals per day may be provided to a participant who: (3-17-22)

a. Rents or owns a home; (3-17-22)

b. Is alone for significant parts of the day; (3-17-22)

c. Has no caregiver for extended periods of time; and (3-17-22)

d. Is unable to prepare a meal without assistance. (3-17-22)

10.Skilled Nursing. Skilled nursing includes intermittent or continuous oversight, training, or skilled care that is within the scope of the Nurse Practice Act. Such care must be provided by a licensed registered nurse, or licensed practical nurse under the supervision of a licensed registered nurse licensed to practice in Idaho. (3-17-22)

11.Behavior Consultation/Crisis Management. Behavior Consultation/Crisis Management services that provide direct consultation and clinical evaluation of participants who are currently experiencing or may be expected to experience, a psychological, behavioral, or emotional crisis. This service may provide training and staff development related to the needs of a participant. These services also provide emergency back-up involving the direct support of the participant in crisis. (3-17-22)

12.Adult Day Health. Adult day health is a supervised, structured service generally furnished four (4) or more hours per day on a regularly scheduled basis, for one (1) or more days per week. It is provided outside the home of the participant in a non-institutional, community-based setting, and it encompasses health services, social services, recreation, supervision for safety, and assistance with activities of daily living needed to ensure the optimal functioning of the participant. Adult day health services provided under this waiver will not include room and board payments. (3-17-22)

13.Self-Directed Community Supports. Participants eligible for the DD Waiver may choose to self-direct their individualized budget rather than receive the traditional waiver services described in this section of rule. The requirements for this option are outlined in IDAPA 16.03.13, "Consumer-Directed Services." (3-17-22)

14.Place of Service Delivery. Waiver services may be provided in home and community settings as described in Section 312 of these rules. Approved places of services include the participant's personal residence, a certified family home, day habilitation/supported employment program, or community. The following living situations are specifically excluded as a place of service for waiver services: (3-17-22)

a. Licensed skilled, or intermediate care facilities, certified nursing facility (NF) or hospital; and (3-17-22)

b. Licensed Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID); and (3-17-22)

c. Residential Assisted Living Facility. (3-17-22)

d. Additional limitations to specific services are listed under that service definition. (3-17-22)

15.Transition Services. Transition Services include goods and services that enable a participant residing in a nursing facility, hospital, IMD, or ICF/IID to transition to a community-based setting. A participant is eligible to receive transition services immediately following discharge from a qualified institution after residing within that institution for a minimum of forty-five (45) days. (3-17-22)

a. Qualified Institutions include the following: (3-17-22)

i. Skilled, or Intermediate Care Facilities; (3-17-22)

ii. Nursing Facility; (3-17-22)

iii. Licensed Intermediate Care Facility for the Persons with Intellectual Disabilities (ICF/IID); (3-17-22)

iv. Hospitals; and (3-17-22)

v. Institutions for Mental Diseases (IMD). (3-17-22)

b. Transition services may include the following goods and services: (3-17-22)

i. Security deposits that are required to obtain a lease on an apartment or home; (3-17-22)

ii. Cost of essential household furnishings, including furniture, window coverings, food preparation items, and bed/bath linens; and (3-17-22)

iii. Set-up fees or deposits for utility or service access, including telephone, electricity, heating and water; (3-17-22)

iv. Services necessary for the individual's health and safety such as pest eradication and one-time cleaning prior to occupancy; (3-17-22)

v. Moving expenses; and (3-17-22)

vi. Activities to assess need, arrange for and procure transition services. (3-17-22)

c. Excluded goods and services. Transition services do not include ongoing expenses, real property, ongoing utility charges, decor, or diversion/recreational items such as televisions, DVDs, and computers. (3-17-22)

d. Service limitations. Transition services are limited to a total cost of two thousand dollars ($2,000) per participant and can be accessed every two (2) years, contingent upon a qualifying transition from an institutional setting. Transition services are furnished only to the extent that the person is unable to meet such expense or when the support cannot be obtained from other sources. (3-17-22)

Idaho Admin. Code r. 16.03.10.703