Idaho Admin. Code r. 16.03.10.523

Current through September 2, 2024

Section 16.03.10.523 - CHILDREN'S DD HCBS STATE PLAN OPTION: COVERAGE AND LIMITATIONS

All children's DD HCBS must be identified on a plan of service developed by the family-centered planning team. The following services must be prior authorized and are reimbursable when provided in accordance with these rules.

01.Respite. Respite provides supervision to the participant on an intermittent or short-term basis because of the need for relief of the primary unpaid caregiver or in response to a family emergency or crisis. Respite may be provided by a DDA or by an independent respite provider. An independent respite provider may be a relative of the participant. Payment for respite does not include room and board. Respite may be provided in the participant's home, the private home of the independent respite provider, a DDA, or in the community. The following limitations apply:

a. Respite must not be provided on a continuous, long-term basis as a daily service that would enable an unpaid caregiver to work.

b. Respite must only be offered to participants living with an unpaid caregiver who requires relief.

c. Respite cannot exceed fourteen (14) consecutive days.

d. Respite must not be provided at the same time other Medicaid services are being provided with the exception of when an unpaid caregiver is receiving family education.

e. The respite provider must not use restraints on participants, other than physical restraints in the case of an emergency. Physical restraints may be used in an emergency to prevent injury to the participant or others and must be documented in the participant's record.

f. When respite is provided as group respite, the following applies:

i. When group respite is center-based, there must be a minimum of one (1) qualified staff providing direct services to every two (2) to six (6) participants. As the number and severity of the participants with functional impairments or behavioral needs increase, the participant ratio must be adjusted accordingly.

ii. When group respite is community-based, there must be a minimum of one (1) qualified staff providing direct services to every two (2) to six (6) participants. As the number and severity of the participants with functional impairments or behavioral needs increase, the participant ratio in the group must be adjusted accordingly.

g. Respite cannot be provided as center-based by an independent respite provider. An independent respite provider may only provide group respite when the following are met:

i. The independent respite provider is a relative; and

ii. The service is delivered in the home of the participants or the independent respite provider.

02.Community-Based Supports. Community-based supports provides assistance to a participant by facilitating the participant's independence and integration into the community. This service provides an opportunity for participants to explore their interests, practice skills learned in other therapeutic environments, and learn through interactions in typical community activities. Integration into the community enables participants to expand their skills related to activities of daily living and reinforces skills to achieve or maintain mobility, sensory-motor, communication, socialization, personal care, relationship building, and participation in leisure and community activities. Community-based supports must:

a. Not supplant services provided in school or therapy, or supplant the role of the primary caregiver;

b. Ensure the participant is involved in age-appropriate activities in environments typical peers access according to the ability of the participant; and

c. Have a minimum of one (1) qualified staff providing direct services for up to six (6) participants when provided as group community-based supports. As the number and severity of the participants with functional impairments or behavioral needs increase, the staff participant ratio must be adjusted accordingly.

03.Family Education. Family education is professional assistance to family members, or others, who participate in caring for the eligible participant to help them better meet the needs of the participant by providing an orientation to developmental disabilities and to educate families on generalized strategies for behavioral modification and intervention techniques specific to the participant's diagnosis. It offers education that is specific to the needs of the family and participant as identified on the plan of service.

a. Family education providers must maintain documentation of the training in the participant's record including the provision of activities outlined in the plan of service.

b. Family education may be provided in a group setting not to exceed five (5) participants' families.

04.Family-Directed Community Supports (FDCS). Families of participants eligible for the children's DD HCBS state plan option may choose to direct their individualized budget rather than receive the traditional services described in Subsections 523.01 through 523.04 of this rule when the participant lives at home with their parent or legal guardian. All services provided under FDCS option must be delivered on a one-to-one basis, must be identified on a plan of service developed by the family-centered planning team, and must be prior authorized. Additional requirements for this option are outlined in Sections 520 through 522, Subsections 523.05-06 524.01-03, 524.07-10, and 525.01, and Section 528, of these rules, and IDAPA 16.03.13, "Consumer-Directed Services."

05.Limitations.

a. Children's DD HCBS state plan option services are limited by the participant's individualized budget amount.

b. Services offered in IDAPA 16.03.09, "Medicaid Basic Plan Benefits," may not be authorized under these rules.

c. Duplication of services cannot be provided. Services are considered duplicate when:

i. An adaptive equipment and support service address the same goal;

ii. Multiple adaptive equipment items address the same goal;

iii. Goals are not separate and unique to each service provided; or

iv. When more than one (1) service is provided at the same time, unless otherwise authorized.

d. For the children's DD HCBS state plan option listed in Subsections 523.01, 523.02, and 523.03 of this rule, the following are excluded for Medicaid payment:

i. Vocational services;

ii. Educational services; and

iii. Recreational services.

06.HCBS Compliance. Providers of children's DD HCBS are responsible for ensuring that they meet the setting quality requirements described in Section 313 of these rules, as applicable, and must comply with associated Department quality assurance activities. The Department may take enforcement actions as described in IDAPA 16.03.09, "Medicaid Basic Plan Benefits," Section 205, if the provider fails to comply with any term or provision of the provider agreement, or any applicable state or federal regulation.

Idaho Admin. Code r. 16.03.10.523

Effective March 17, 2022