Idaho Admin. Code r. 16.03.10.328

Current through September 2, 2024

Section 16.03.10.328 - AGED AND DISABLED WAIVER SERVICES: PROCEDURAL REQUIREMENTS

01.Role of the Department. The Department will provide for the administration of the UAI, and the development of the initial individual service plan. The Department will review and approve all individual service plans, and will authorize Medicaid payment by type, scope, and amount.

a. Services that are not in the individual service plan approved by the Department are not eligible for Medicaid payment.

b. Services more than those in the approved individual service plan are not eligible for Medicaid payment.

c. The earliest date that services may be approved by the Department for Medicaid payment is the date that the participant's individual service plan is signed by the participant or their designee.

02.Pre-Authorization Requirements. All waiver services must be pre-authorized by the Department. Authorization will be based on the information from:

a. The UAI;

b. The individual service plan developed by the Department; and

c. Any other medical information that verifies the need for nursing facility services in the absence of the waiver services.

03.UAI Administration. The UAI will be administered, and the initial individual service plan developed, by the Department.

04.Individual Service Plan. All waiver services must be authorized by the Department in the Region where the participant will be residing and services provided based on a documented individual service plan.

a. The initial individual service plan is developed by the Department, based on the UAI, in conjunction with:

i. The waiver participant, with efforts made by the Department to maximize the participant's involvement in the planning process by providing them with information and education regarding their rights;

ii. The guardian, when appropriate;

iii. The supervising nurse or case manager, when appropriate; and

iv. Others identified by the waiver participant.

b. The individual service plan must include the following:

i. The specific type, amount, frequency, and duration of Medicaid-reimbursed waiver services to be provided;

ii. Supports and service needs that are to be met by the participant's family, friends, neighbors, volunteers, church, and other community services;

iii. The providers of waiver services when known;

iv. Documentation that the participant has been given a choice between waiver services and institutional placement; and

v. The signature of the participant or their legal representative, agreeing to the plan.

c. The individual service plan must be revised and updated at least annually, based upon treatment results or a change in the participant's needs.

d. All services reimbursed under the Aged and Disabled Waiver must be authorized by the Department prior to the payment of services.

e. The individual service plan, which includes all waiver services, is monitored by the Personal Assistance Agency, participant, family, and the Department.

05.Service Delivered Following a Documented Plan of Care. All services that are provided must be based on a documented plan of care.

a. The plan of care is developed by the plan of care team that includes:

i. The waiver participant with efforts made to maximize their participation on the team by providing them with information and education regarding their rights;

ii. The guardian when appropriate;

iii. Service provider identified by the participant or guardian; and

iv. May include others identified by the waiver participant.

b. The plan of care must be based on an assessment process approved by the Department.

c. The plan of care must include the following:

i. The specific types, amounts, frequency, and duration of Medicaid-reimbursed waiver services to be provided;

ii. Supports and service needs that are to be met by the participant's family, friends, and other community services;

iii. The providers of waiver services;

iv. Goals to be addressed within the plan year;

v. Activities to promote progress, maintain functional skills, or delay or prevent regression;

vi. The signature of the participant or their legal representative; and

vii. The signature of the agency or provider indicating that they will deliver services according to the authorized service plan and consistent with home and community-based requirements.

d. The plan must be revised and updated by the plan of care team based upon treatment results or a change in the participant's needs. A new plan must be developed and approved annually.

e. The Department's Nurse Reviewer monitors the plan of care and all waiver services.

f. The plan of care may be adjusted during the year with an addendum to the plan. These adjustments must be based on changes in a participant's need or demonstrated outcomes. Additional assessments or information may be clinically necessary. Adjustment of the plan of care is subject to prior authorization by the Department.

06.Individual Service Plan and Plan of Care. The development and documentation of the individual service plan and plan of care must meet the person-centered planning requirements described in Sections 316 and 317 of these rules.

07.Provider Records. Records will be maintained on each waiver participant.

a. Each service provider must document each visit made or service provided to the participant, and will record the following:

i. Date and time of visit;

ii. Services provided during the visit;

iii. Provider observation of the participant's response to the service if appropriate to the service provided, including any changes in the participant's condition; and

iv. Length of visit, including time in and time out if appropriate to the service provided. Unless the Department determines that the participant is unable to do so, the service delivery will be verified by the participant as evidenced by their signature on the service record.

b. The provider is required to keep the original service delivery record. A copy of the service delivery record will be maintained and available in a format accessible to the participant. Failure to maintain documentation according to these rules will result in the recoupment of funds paid for undocumented services.

c. The individual service plan initiated by the Department must specify which waiver services are required by the participant. The plan will contain all elements required by Subsection 328.04.a. of this rule and a copy of the most current individual service plan will be maintained in the participant's home and will be available to all service providers and the Department. A copy of the current individual service plan and UAI will be available from the Department to each individual service provider with a release of information signed by the participant or legal representative.

d. Record requirements for participants in RALFs are under IDAPA 16.03.22, "Residential Assisted Living Facilities."

e. Record requirements for participants in CFHs are under IDAPA 16.03.19, "Certified Family Homes."

f. EVV Systems as described in Section 041 of these rules will not take the place of documentation requirements of Subsection 328.07 of this rule, but maybe used to generate documentation retained in the participant's home.

08.Provider Responsibility for Notification. The service provider is responsible to notify the Department, physician or authorized provider, or case manager, and family if applicable, when any significant changes in the participant's condition are noted during service delivery. Such notification will be documented in the service record.

09.Records Retention. Personal Assistance Agencies, and other providers are responsible to retain their records for five (5) years following the date of service.

10.Requirements for a Fiscal Intermediary (FI). Participants of PCS will have one (1) year from the date that services begin in their geographic region to obtain the services of an FI and become an employee in fact or to use the services of an agency. Provider qualifications are under Section 329 of these rules.

Idaho Admin. Code r. 16.03.10.328

Effective July 1, 2024