Idaho Admin. Code r. 16.03.10.326

Current through September 2, 2024

Section 16.03.10.326 - AGED AND DISABLED WAIVER SERVICES: COVERAGE AND LIMITATIONS

01.Adult Day Health. 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 ADL needed to ensure the optimal functioning of the participant. Adult day health services provided under this waiver will not include room and board payments.

02.Adult Residential Care Services. Consist of a range of services provided in a homelike, non-institutional setting that includes RALFs and CFHs. Payment is not made for the cost of room and board, including the cost of building maintenance, upkeep, and improvement.

a. These services are provided in a congregate setting licensed under IDAPA 16.03.22, "Residential Assisted Living Facilities," that include:

i. Medication assistance, to the extent permitted under State law;

ii. Assistance with ADL;

iii. Meals, including special diets;

iv. Housekeeping;

v. Laundry;

vi. Transportation;

vii. Opportunities for socialization;

viii. Recreation; and

ix. Assistance with personal finances.

x. Administrative oversight must be provided for all services provided or available in this setting.

xi. A documented individual service plan must be negotiated between the participant or their legal representative, and a facility representative.

b. These services are provided in a setting licensed under IDAPA 16.03.19, "Certified Family Homes," that include:

i. Medication assistance, to the extent permitted under State law;

ii. Assistance with ADL;

iii. Meals, including special diets;

iv. Housekeeping;

v. Laundry;

vi. Transportation;

vii. Recreation; and

viii. Assistance with personal finances.

ix. Administrative oversight must be provided for all services provided or available in this setting.

x. A documented individual service plan must be negotiated between the participant or their legal representative, and a facility representative.

03.Specialized Medical Equipment and Supplies.

a. Devices, controls, or appliances that enable a participant to increase their abilities to perform ADL, or to perceive, control, or communicate with the environment in which they live; and

b. 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.

c. 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.

04.Non-Medical Transportation. Enables a waiver participant to gain access to waiver and other community services and resources.

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.

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

05.Attendant Care. Services provided under a Medicaid Home and Community-Based Services waiver that involve personal and medically oriented tasks dealing with the functional needs of the participant and accommodating the participant's needs for long-term maintenance, supportive care, or ADL. These services may include personal assistance and medical tasks that can be done by unlicensed persons, or delegated to an unlicensed person by a licensed health care professional or the participant. Services are based on the participant's abilities and limitations, regardless of age, medical diagnosis, or other category of disability. This assistance may take the form of hands-on assistance (performing a task for the person) or cuing to prompt the participant to perform a task.

06.Chore Services. Include the following when necessary to maintain the functional use of the home, or to provide a clean, sanitary, and safe environment:

a. Intermittent assistance may include the following:

i. Yard maintenance;

ii. Minor home repair;

iii. Heavy housework;

iv. Sidewalk maintenance; and

v. Trash removal to assist the participant to remain in the home.

b. Chore activities may include the following:

i. Washing windows;

ii. Moving heavy furniture;

iii. Shoveling snow to provide safe access inside and outside the home;

iv. Chopping wood when wood is the participant's primary source of heat; and

v. Tacking down loose rugs and flooring.

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.

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.

07.Companion Services. Include non-medical care, supervision, and socialization provided to a functionally impaired adult. Companion services are in-home services to ensure the safety and well-being of a person who cannot be left alone because of frail health, a tendency to wander, inability to respond to emergency situations, or other conditions that would require a person on-site. The service provider, who may live with the participant, may provide voice cuing and occasional assistance with toileting, personal hygiene, dressing, and other ADL. Providers may also perform light housekeeping tasks that are incidental to the care and supervision of the participant. However, the primary responsibility is to provide companionship and be there in case they are needed.

08.Consultation. Services to a participant or family member that are provided by a Personal Assistance Agency to a participant or family member to increase their skills as an employer or manager of their own care. Such services are directed at achieving the highest level of independence and self-reliance possible for the participant and the participant's family. Services include consulting with the participant and family to gain a better understanding of the special needs of the participant and the role of the caregiver.

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

a. Rents or owns a home;

b. Is alone for significant parts of the day;

c. Has no caregiver for extended periods of time; and

d. Is unable to prepare a meal without assistance.

10.Homemaker Services. Consist of performing for the participant, or assisting them with, or both, the following tasks: laundry, essential errands, meal preparation, and other routine housekeeping duties if there is no one else in the household capable of performing these tasks.

11.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:

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.

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 non-paid family.

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.

12.Personal Emergency Response System. 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:

a. Rent or own a home, or live with unpaid caregivers;

b. Are alone for significant parts of the day;

c. Have no caregiver for extended periods; and

d. Would otherwise require extensive, routine supervision.

13.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, a CFH, a DDA, a RALF, or an adult day health facility.

14.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 an RN, or LPN under the supervision of an RN, licensed to practice in Idaho. These services are not appropriate if they are less cost-effective than a Home Health visit.

15.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. The number of residents in a setting will be limited by an amount in the Idaho Medicaid Provider Handbook, unless otherwise authorized by the Department. The services and supports that may be furnished consist of the following:

a. Self-direction consists of identifying and responding to dangerous or threatening situations, making decisions and choices affecting the individual's life, and initiating changes in living arrangements or life activities;

b. Money management consists of training or assistance in handling personal finances, making purchases, and meeting personal financial obligations;

c. Daily living skills consist of 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 and appliances, as well as following home safety, first aid, and emergency procedures;

d. Socialization consists of 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 nontherapeutic activities that are merely diversional or recreational in nature;

e. Mobility consists of 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;

f. Behavior shaping and management consist of 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.

g. Personal assistance services necessary to assist the individual in daily living activities, household tasks, and such other routine activities as the person or the person's primary caregiver(s) is unable to accomplish on their own behalf. Personal assistance activities include direct assistance with grooming, bathing, and eating, assistance with medications that are ordinarily self-administered, supervision, communication assistance, reporting changes in the waiver participant's condition and needs, household tasks essential to health care at home to include general cleaning of the home, laundry, meal planning and preparation, shopping, and correspondence.

16.Day Habilitation. Consists of assistance with acquisition, retention, or improvement in self-help, socialization, and adaptive skills that take place in a non-residential setting, separate from the home or facility in which the participant resides. Services will normally be furnished four (4) or more hours per day on a regularly scheduled basis, for one (1) or more days per week, unless provided as an adjunct to other day activities included in a participant's plan of care. Day habilitation services will focus on enabling the participant to attain or maintain their maximum functional level and will be coordinated with any physical therapy, occupational therapy, or speech-language pathology services listed in the plan of care. In addition, day habilitation services may serve to reinforce skills or lessons taught in school, therapy, or other settings.

17.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 because of a severe disability. Because of the nature and severity of their disability, these individuals need intensive supported employment services or extended services to perform such work.

a. Supported employment services rendered under this 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.

b. Federal Financial Participation (FFP) cannot be claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

(1) incentive payments made to an employer of waiver participants to encourage or subsidize the employer's participation in a supported employment program,

(2) payments that are passed through to beneficiaries of a supported employment program, or

(3) payments for vocational training that is not directly related to a waiver participant's supported employment program.

18.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.

a. Qualified Institutions include the following:

i. Skilled, or Intermediate Care Facilities;

ii. Nursing Facilities;

iii. ICF/IID;

iv. Hospitals; and

v. Institutions for Mental Diseases (IMDs).

b. Transition services may include the following goods and services:

i. Security deposits that are required to obtain a lease on an apartment or home;

ii. Cost of essential household furnishings, including furniture, window coverings, food preparation items, and bed/bath linens;

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

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

v. Moving expenses; and

vi. Activities to assess need and arrange for and procure transition services.

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.

d. 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 participant is unable to meet such expense or when the support cannot be obtained from other sources.

Idaho Admin. Code r. 16.03.10.326

Effective July 1, 2024