23 Miss. Code. R. 208-2.6

Current through December 10, 2024

Rule 23-208-2.6 - Covered Services

A. The Division of Medicaid covers the following services through the Independent Living (IL) Waiver:

1. Case Management services are mandatory services provided by a Registered Nurse (RN) and/or a Case Manager and include the following activities:

a) Must initiate and oversee the process of assessment and reassessment of the participant's level of care and review the Plan of Services and Supports (PSS) to ensure services specified on the PSS are appropriate and reflective of the participant's individual needs, preferences, and goals.

b) Must assist waiver applicants/participants in gaining access to needed waiver and other State plan services, as well as needed medical, social, educational, and other services, regardless of the funding source for the services to which access is gained.

c) Are responsible for ongoing monitoring of the provision of services included in the participant's PSS.

d) Must conduct quarterly face-to-face reviews to determine the appropriateness and adequacy of the services and to ensure that the services furnished are consistent with the nature and severity of the participant's disability and make monthly phone contact with the person to ensure that services remain in place without issue and to identify any problems or changes that are required. More frequent visits are expected in the event of alleged abuse, neglect or exploitation of waiver participants.

e) Are responsible for ensuring that all personal care attendants for the waiver meet basic competencies that include both academic requirements (i.e. infection control, principles of safety, disability awareness, etc.) and functional requirements (i.e. bathing, transferring, skin care, dressing, bowel and bladder programs).

B. Case Management must be provided by Registered Nurses (RN) and Rehabilitation Counselors who must meet the following qualifications:

The Registered Nurse must:

Have a current and active unencumbered Registered Nurse license to practice in the state of Mississippi or be working in Mississippi on a privilege with a valid compact RN license; and

Have at least one (1) year of experience with the aged and/or individuals with disabilities; and

Not have a history of a criminal offense which precludes him/her from working with the vulnerable population; and

Not appear on the Mississippi Nurse Aide Abuse Registry or the Office of Inspector General (OIG) exclusion list.

The Rehabilitation Counselor must:

Possess at a minimum a Bachelor's degree in Rehabilitation Counseling or other related field; and

Have one (1) year of experience working with individuals with disabilities; and

Be free of a history of a criminal offense which would preclude him/her from working with a vulnerable population; and

Not appear on the Nurse Aide Abuse Registry or the Office of the Inspector General's (OIG) exclusion list.

Mississippi Department of Rehabilitation Services (MDRS) is responsible for validating qualifications of the Registered Nurse and Rehabilitation Counselor. MDRS must subscribe with the Mississippi Board of Nursing to receive immediate electronic notification of adverse or disciplinary action taken occurring against nurse employees.

MDRS must verify provider qualifications upon hire and at least annually.

C. Personal Care Attendant (PCA) services are non-medical, hands-on care of both a supportive and health related nature. PCA services are provided to meet daily living needs to ensure adequate support for optimal functioning at home or in the community, but only in non-institutional settings.

1. PCA services must be provided in accordance with the approved PSS, cannot be purely diversional in nature, and may include:

a) Support for activities of daily living such as, but not limited to, bathing (sponge/ tub), personal grooming and dressing, personal hygiene, toileting, transferring, and assisting with ambulation.

b) Assistance with housekeeping that is directly related to the person's disability, and which is necessary for the health and well-being of the person such as, but not limited to, changing bed linens, straightening area used by the person, doing the personal laundry of the person, preparation of meals for the person, cleaning the person's equipment such as wheelchairs or walkers.

c) Food shopping, meal preparation and assistance with eating, but does not include the cost of the meals themselves;

d) Support for community participation by accompanying and assisting the person as necessary to access community resources; participate in community activities; including appointments, shopping, and community recreation/leisure resources, and socialization opportunities, but does not include the price of the activities themselves.

2. If the person/representative has not located or chosen a PCA within six months after admission to the waiver, or after being without a PCA for six (6) consecutive months, the person is reevaluated for the need for waiver services to determine if the waiver can meet the needs of this person.

D. Specialized Medical Equipment and Supplies include devices, controls, or appliances, specified in the PSS, which enable individuals to increase their abilities to perform activities of daily living, or to perceive, control, or communicate with the environment in which they live.

1. The need for use of such items must be documented in the assessment/case file, ordered by a physician and approved on the PSS.

2. Items reimbursed with waiver funds are in addition to specialized medical equipment and supplies furnished under Medicaid State Plan. Items not of direct medical or remedial benefit to the person are excluded.

3. Specialized medical equipment and supplies must meet the applicable standards of manufacture, design and installation.

4. Requests for specialized medical equipment and supplies must be evaluated by the Mississippi Department of Rehabilitation Services (MDRS) counselor or the Division of Medicaid to determine if an Assistive Technology (AT) evaluation and recommendation is needed. If an AT evaluation is performed, it must be submitted to the Division of Medicaid along with the PSS and the request for specialized medical equipment and/or supplies for approval.

5. Medicaid waiver funds are utilized as the payor of last resort.

E. Transition Assistance Services are provided to a Mississippi Medicaid eligible nursing facility (NF) resident to assist in transitioning from the nursing facility into the IL Waiver program.

1. Transition Assistance services include the following:

a) Security deposits required to obtain a lease on an apartment or home.

b) Essential furnishings required to occupy and use a community domicile. Televisions or cable TV access are not essential furnishings.

c) Moving expenses.

d) Fees/deposits for utilities and service access for a telephone.

e) Health and safety assurances including, but not limited to, pest eradication, allergen control, or one-time cleaning prior to occupancy.

2. Transition Assistance is a one (1) time initial expense required for setting up a household and is capped at eight hundred dollars ($800.00) per lifetime. These expenses must be included in the approved PSS.

3. To be eligible for Transition Assistance, the beneficiary must meet all of the following criteria:

a) Be currently residing in a nursing facility whose services are paid for by the Division of Medicaid;

b) Have no other source to fund or obtain the necessary items/supports;

c) Be moving from a nursing facility where these items/services were provided;

d) Be moving to a residence where these items/services are not normally furnished.

4. Transition Assistance must be completed by the day the person relocates from the institution.

5. Persons whose NF stay is temporary or rehabilitative, or whose services are covered by Medicare or other insurance, wholly or partially, are not eligible for this service.

F. Environmental Accessibility Adaptations are physical adaptations to the home, required by the individual's PSS, necessary to ensure the health, welfare, and safety of the individual, or enables the individual to function with greater independence in the home.

1. Environmental accessibility adaptations must be included in the approved PSS.

2. Environmental accessibility adaptations include the following:

a) Installation of ramps and grab bars.

b) Widening of doorways.

c) Modification of bathroom facilities.

d) Installation of specialized electric and plumbing systems necessary to accommodate medical equipment and supplies.

3. Environmental accessibility adaptations exclude the following:

a) Adaptations or improvements to the home which are not of direct medical or remedial benefit to the beneficiary.

b) Adaptations which add to the square footage of the home.

4. Requests for environmental accessibility adaptations must be evaluated by the MDRS Rehabilitation Counselor to determine if an Assistive Technology (AT) evaluation is indicated. If an AT evaluation is performed, it must be submitted to the Division of Medicaid along with the PSS and the request for environmental accessibility adaptation.

5. MDRS must certify and document that providers meet the criteria/standards in the waiver.

G. Financial Management Service (FMS):

1. FMS is a support service to assist the waiver participant who chooses the Participant- Directed Personal Care service. Participant-Directed Personal Care service recognizes the waiver participant as the employer of record.

2. The waiver participant performs budgetary and employer functions and has the ability to negotiate salaries and benefits with the personal care attendants.

3. The FMS agent assists the waiver participant with employer and budget authority by ensuring federal, state and local employment taxes and labor and worker's compensation insurance rules related to household employment and payroll are implemented in an accurate and timely manner as related to the personal care attendant.

4. The FMS agent ensures that the necessary employer related duties and tasks, including payroll, are carried out. The service must ensure initial orientation and ongoing training is provided related to responsibilities of being an employer and adhering to legal requirements for employers.

5. The FMS provider must:

a) Serve as the participant's employer agent which is the IRS designation of the entity responsible for IRS related responsibilities on behalf of the participant.

b) Provide assistance determining personal care attendant wages and benefits.

c) Provide assistance in hiring by verifying employees' citizenship status, conducting criminal background checks, and verifying the employee is not on the Mississippi Nurse Aide Abuse Registry or the Office of Inspector General (OIG) exclusion lists.

d) Verify and maintain documentation of employee qualifications, citizenship status, and documentation of services delivered.

e) Provide education on recruiting, hiring and terminating employees as well as identifying the need for special skills and determining duties and schedules.

f) Ensure appropriate payment by:

1) Collecting timesheets,

2) Processing timesheets,

3) Processing payroll and payables, and

4) Making withholdings for and payment of applicable and federal, state and local employment related taxes.

g) Provide quarterly written reports to the waiver participant of all expenditures and the status of the waiver participant's budget.

h) Maintain a separate account for each waiver participant.

i) Make services available only to those persons deemed eligible and referred by MDRS,

j) Establish contact with the participant within five (5) working days of the referral from MDRS,

k) Conduct a face-to-face visit to initiate the FMS process within five (5) working days of establishing contact with the participant,

l) Conduct at least one (1) face-to-face meeting annually with each participant to review and update the overall function of the FMS,

m) Ensure Division of Medicaid (DOM) access to the participant's case files.

n) Employ staff members with knowledge, experience and abilities to sufficiently carry out the FMS component of service.

o) Have Medicaid provider agreements with the Division of Medicaid with the following requirements.

1) Have a minimum of five (5) years of billing and payroll experience relevant to participant-directed medical care,

2) Have a working knowledge of disability etiquette, psychology, and social aspects of disability, vulnerable persons act including reporting requirements, HCBS waivers, especially the plans of care, and W-2 employee tax reporting requirements. If the FMS lacks a working knowledge of disability etiquette, psychology and social aspects of disability, vulnerable person's act and home and community based waivers, training must be provided to ensure the FMS has a solid foundation for working with individuals with disabilities.

p) Develop and maintain policies and procedures for the delivery of Financial Management Services.

q) Have qualifications verified by DOM initially and monitored annually or more frequently as indicated.

23 Miss. Code. R. 208-2.6

42 U.S.C. 1396n; 42 C.F.R. §§ 440.180, 441.302; Miss. Code Ann. §§ 37-33-157, 43-13-117, 43-13-121.

Revised - 01/01/2013

Amended 9/1/2019