13-007 Code Vt. R. 13-174-007-X
Current through August, 2024
The following terms are defined for the purpose of these regulations.
A young child with a developmental disability is a child who has one of the three following conditions:
Anoxia
Degenerative central nervous system disease (such as Tay Sachs syndrome)
Encephalitis
Fetal alcohol syndrome
Fragile X syndrome
Inborn errors of metabolism (such as untreated PKU)
Traumatic brain injury
Multisystem developmental disorder
Shaken baby syndrome
Trisomy 21, 18, and 13
Tuberous sclerosis
Communication
Social/emotional development
Motor development
Daily living skills
Communication
Social/emotional development
Motor development
Daily living skills.
The determination of whether a school-age child or adult has an Autism Spectrum Disorder and is a person with a developmental disability for the purpose of these regulations requires documentation of the following components:
"Autism Spectrum Disorder" means the same as it is defined in the current DSM. People receiving services as of the effective date of these regulations who were found eligible with a diagnosis of pervasive developmental disorder under previous versions of the DSM continue to be eligible for services if they continue to present the symptoms that resulted in the diagnosis. Autism Spectrum Disorder means the same as the term "autism" in the Developmental Disabilities Act.
New applicants must be assessed using the DSM criteria in effect at the time of application. An assessment to determine whether an individual has an Autism Spectrum Disorder shall include all of the following components:
"Significant deficits in adaptive behavior" means deficits in adaptive functioning which result in:
"Manifested before age 18" means that the impairment and resulting significant deficits in adaptive behavior were observed before age 18. Evidence that the impairment and resulting significant deficits in adaptive behavior occurred before the age 18 may be based upon records, information provided by the individual, and/or information provided by people who knew the individual in the past.
Assessment tools and methods shall be selected to meet the individual needs and abilities of the person being assessed.
The Commissioner may make exceptions to the requirements of the program access criteria in Section 3.1, in order to promote the purposes of the Developmental Disabilities Act if the exception will not deprive other people who meet the criteria for being recipients of needed services or benefits (e.g., when funds are provided by another state, or by another Vermont state agency or department).
People with developmental disabilities who were receiving services on July 1, 1996, shall continue to receive services consistent with their needs and the System of Care Plan and these regulations.
Any person who leaves services for one year or longer for any reason and later reapplies for services shall be assessed based upon the eligibility criteria in effect on the date of the person's reapplication.
Based on the answers to the questions in Section 4.5(c), the DA shall seek or authorize funding for services to meet identified needs or shall determine that the individual is not eligible for the requested funding for services. The procedures for authorizing funding or services are described in the System of Care Plan. Services and the funding amount authorized shall be based upon the most cost-effective method of meeting an individual's assessed needs, the eligibility criteria listed in Section 4.7, as well as guidance in the System of Care Plan and current Medicaid Manual for Developmental Disabilities Services. When determining cost effectiveness, consideration shall be given to circumstances in which less expensive service methods have proven to be unsuccessful or there is compelling evidence that other methods would be unsuccessful.
The Department's programs reflect its current priorities for providing services for Vermont residents with developmental disabilities. The availability of the Department's current programs, which are described below, is subject to the limits of the funding appropriated by the Legislature on an annual basis. The nature, extent, allocation and timing of services are addressed in the SOCP, and additional details, limitations and requirements for each program are included in the SOCP, the current Medicaid Manual for Developmental Disabilities Services and in specific Division guidelines. Programs will be continued and new programs will be developed based on annual demographic data obtained regarding Vermont residents with developmental disabilities, the use of existing services and programs, the identification of the unmet needs in Vermont communities and for individual residents of Vermont, and the reasons for any gaps in service.
The Bridge Program is an Early Periodic Screening, Diagnosis and Treatment (EPSDT) service that provides support to families in need of care coordination to help them access and/or coordinate medical, educational, social or other services for their children with developmental disabilities.
Individuals who meet the criteria for developmental disability as defined in these regulations.
Vermont Medicaid eligible as determined by Department of Vermont Health Access.
Individual must be under the age of 22. Care coordination is available in all counties either through the Bridge Program or through an Integrating Family Services (IFS) program administered by the Department of Mental Health. Children who are receiving care coordination, case management or service coordination from another AHS-funded source listed in the Bridge Program Guidelines are not eligible to receive Bridge Program Care Coordination.
Individuals who meet the criteria for developmental disability as defined in these regulations.
None
The goods and services requested must be related to the person's disability and meet the Division's Special Services Fund Guidelines.
The Employment Conversion Initiative is intended to support people to convert their community supports funding to work supports.
Individuals who meet the criteria for developmental disabilities as defined in these regulations.
Vermont Medicaid eligible as determined by Department of Vermont Health Access.
Individuals with HCBS funding who must have transferred at least 50% of their existing community supports funding to work supports.
Family Managed Respite (FMR) funding is allocated by DAs to provide families with a break from caring for their child with a disability, up to age 21. Respite can be used as needed, either planned or in response to a crisis.
Individual with a developmental disability or eligible to receive services from Children's Mental Health Services.
Vermont Medicaid eligible as determined by Department of Vermont Health Access.
FMR is available to children up to, but not including, age 21 living with their biological/adoptive families or legal guardian and who are not receiving HCBS funding.
Flexible Family Funding (FFF) provides funding for families caring for a family member with a developmental disability at home. Funding is provided to eligible families of individuals with developmental disabilities to help pay for any legal good or activity that the family chooses such as respite, assistive technology, home modification, or individual and household needs. These income-based funds, determined by a sliding scale, are used at the discretion of the family. FFF is available at DAs in all counties.
Individuals who meet the criteria for developmental disability as defined in these regulations.
Income-based on sliding fee scale outlined in Flexible Family Funding Guidelines.
An individual who lives with their family (i.e., unpaid biological, adoptive and/or step-parents, adult siblings, grandparents, aunts/uncles, nieces/nephews and legal guardians) or an unpaid family member who lives with and supports an individual with a developmental disability is eligible. Individuals living independently or with their spouse, and those receiving HCBS are not eligible.
These Department approved programs provide lifelong learning and teaching experiences to adults with developmental disabilities and increases the individual's ability to become an expert in topics of interest through supported research, inquiry, community networking and full examination of a topic.
Individuals who meet the criteria for developmental disabilities as defined in these regulations.
Vermont Medicaid-eligible as determined by Department of Vermont Health Access.
Access is limited to the geographic area where the approved program is provided.
Developmental Disabilities HCBS are long term services and supports provided throughout the state by private, non-profit developmental disabilities services providers, or through self/family-management, to adults and children with developmental disabilities with the most intensive needs. Individual HCBS budgets are based on an all-inclusive daily rate that combines all applicable services and supports provided to the individual in accordance with their assessed needs plus associated administrative costs. Services and supports may include: Service Coordination, Community Supports, Employment Supports, Respite Supports, Clinical Services, Supportive Services, Crisis Services, Home Supports and Transportation Services.
Abbreviated definitions of these services are included in Part 1. Full definitions are included in the current System of Care Plan and the current Medicaid Manual for Developmental Disabilities Services.
Individuals who meet the criteria for developmental disability as defined in these regulations.
Vermont Medicaid-eligible as determined by Department of Vermont Health Access.
The following describes the criteria to access HCBS under the Public Safety funding priority:
Vermont has one six-person ICF/DD. This residence enables Vermont to provide comprehensive and individualized health care and rehabilitation services to individuals, as an alternative to HCBS, to promote their functional status and independence at an ICF/DD level of care.
Vermont Medicaid eligible as determined by Department of Vermont Health Access.
Access to the ICF/DD is based upon availability of a bed and prioritization of referrals by the operating DA and the Division.
One time funds are generated from the new and returned caseload dollars for the Equity and Public Safety funding pools. One time funds are used to address short term needs and cannot be used for long term needs. When there are one-time funds available, a portion of those funds shall be distributed to agencies. The amount and timing of distribution is at the discretion of the Department.
Individuals who meet the criteria for developmental disabilities as defined in these regulations.
Vermont Medicaid eligible as determined by Department of Vermont Health Access.
Recipients and individuals who meet clinical and financial eligibility who are not current recipients of funding to meet one of the needs listed below:
The Post-Secondary Education Initiative (PSEI) is a program funded through a combination of grants and HCBS funding that assists transition age youth 18 to 28 with developmental disabilities to engage in typical college experiences through self-designed education plans that lead to marketable careers in competitive employment and independent living. Supports are arranged with the Department's approved PSEI college support organizations to provide academic, career and independent living skill development through a peer mentoring model.
Individuals who meet the criteria for developmental disability as defined in these regulations.
Vermont Medicaid eligible as determined by the Department of Vermont Health Access.
Adults who have graduated from high school or have a GED who have been accepted for enrollment in post-secondary programs facilitated by the PSEI support programs. The individual must also have access to resources that are needed to participate beyond what is provided by the PSEI program.
PASRR Specialized Services are available to individuals living in a nursing facility and who needs additional services related to their developmental disability (e.g., social, behavior, communication) that are beyond the scope of the nursing facility.
Individual with a developmental disability or related condition as defined by Federal PASRR regulations.
None
Individual over 18 years of age living in a nursing facility and having been determined to be in need of Specialized Services through PASRR evaluation.
These Department approved projects prepare student-interns who are in their last year of high school with technical skills through internship rotations at a host business location. The cornerstone of these projects is immersion in a single business for the entire school year where students learn career development skills through job coaching and direct guidance provided by the business' department managers.
Individuals who meet the criteria for developmental disability as defined in these regulations (see exceptions in Access Criteria Section (l)(1)(C).
Vermont Medicaid eligible as determined by Department of Vermont Health Access.
This program serves students in their last year of high school who have been determined to have developmental disabilities. If space allows, adults between the ages of 21 and 28 may apply to the program on a case-by-case basis. In addition, if space allows, students who receive special education and do not have developmental disabilities, but do have other challenges that are supported by an Individual Education Plan (IEP), may apply on a case-by-case basis.
This fund pays for unanticipated services and for small expenses directly related to the well-being of individuals receiving public guardianship services. Access to funds is at the discretion of the Division's Office of Public Guardian.
Clinic and Rehabilitation services are mental health services provided within a community mental health or developmental disability service setting for individuals who are not receiving HCBS funding. Services include:
* diagnosis and evaluation (D & E)
* individual psychotherapy
* group therapy
* emergency care
* Medication Evaluation, Management and Consulting Services (Chemotherapy, med-Check)
Individuals who meet the criteria for developmental disabilities as defined in these regulations.
Vermont Medicaid eligible as determined by Department of Vermont Health Access.
Access to these service is determined by the agency based upon need and available resources. An agency may not bill for these services and HCBS on the same day.
Targeted Case Management (TCM) is a Medicaid State Plan service that provides assessment, care planning, referral and monitoring. Services are provided by the agency and designed to assist adults and children to gain access to needed services.
Individuals who meet the criteria for developmental disability as defined in these regulations.
Vermont Medicaid eligible as determined by Department of Vermont Health Access.
TCM is available for adults age 21 and over, and children under 21 when the agency has exhausted Bridge Program funding. An agency may not bill for TCM and HCBS or other Medicaid funded case management services on the same day.
The Division may invest in initiatives that enhance the overall system of support for people with developmental disabilities and their families. The Division may use funding to support initiatives that shall enhance choice and control, and increase opportunities for individuals receiving developmental disabilities services and their families. The timing and amount of funding for any initiative shall be identified in the System of Care Plan. For all special initiatives, specific outcome measures will be required and results will be reported by DDSD.
A child receiving limited services as the result of a diagnosis of Autism Spectrum Disorder does not need to be reassessed to confirm the diagnosis of ASD at the time he or she enters first grade. An adaptive behavior assessment is required at this time to confirm the child continues to have significant deficits in adaptive behavior as defined in Part 2..
A person with a developmental disability whose application for services or supports is denied, in whole or in part, because the person's needs do not meet the funding priorities outlined in section 4.7 shall be added to a waiting list maintained by the agency or Supportive ISO, as applicable. The agency or Supportive ISO shall notify an applicant that his or her name has been added to the waiting list, and explain the rules for periodic review of the needs of people on the waiting list.
An individual or family member who is allowed to manage services must sign an agreement with a Supportive ISO. The Department shall provide an approval form for agreements. The agreement must set out the responsibilities of the individual or family member and the responsibilities of the Supportive ISO.
An individual or family member who manages services must be capable of and carry out the following functions:
For existing recipients who are self/family managing who have a new need as determined by a new needs assessment and need an increase in services and funding, the Supportive ISO develops and submits proposals to the Supportive ISO funding committee and then to the appropriate statewide funding committee. For complex situations, the Supportive ISO may consult with an independent evaluator, the Division or the local DA to determine strategies regarding how an individual's needs may best be met. This may include a collaborative effort between the Supportive ISO and DA regarding assessments and funding proposals as needed.
When an individual or family member manages services, the Supportive ISO shall:
An individual or family member may manage some services and let an agency manage some services. That is called shared-managing. The agency is responsible for providing information and guidance to the individual or family member regarding his or her responsibilities for share-management. An individual or family member who share-manages with an agency must do all of the following:
For all supports and services funded by Medicaid, the income and resource rules of Department of Vermont Health Access (DVHA) governing eligibility for Medicaid programs apply, and are incorporated here by reference.
Medicaid developmental disabilities funding does not cover room and board, clothing, or personal effects.
To the extent authorized by the System of Care Plan, the Commissioner may provide non-Medicaid funds to subsidize the excess costs of a recipient's rent or house payment, if the recipient is unable to afford the cost.
The parents of a child under age 18 with a developmental disability are financially responsible for costs not covered by any Medicaid program or funded by the Department, specifically: housing; food; clothing; nonmedical transportation; personal items; and child care necessary for a parent to work.
The purpose of these regulations is to ensure that people with developmental disabilities who have specialized health care needs receive safe and competent care while living in home and community settings funded by the Department.
The determination that a care procedure is a "special care procedure" has three components:
The determination of competence is a determination that a person demonstrates adequate knowledge to perform a task, including use of equipment and basic problem-solving skills. Competence includes capability, and adequate understanding.
Ongoing monitoring by a nurse ensures that a special care provider's skills and knowledge continue to be current. The individual's specialized care plan shall include monitoring requirements, including expectations for monitoring the performance of special care procedures and patient outcomes at least annually.
NOTE: A provider outside the network (i.e. not enrolled in Medicaid) cannot be reimbursed by Medicaid.
Note: Collaborative decisions of any type made by multi-disciplinary groups that include MCE and non-MCE members such as local interagency teams (LIT), the State Interagency Team (SIT), the State or Local Team for Functionally Impaired, and the Case Review Committee (CRC) are not actions of the MCE and therefore are not governed by these regulations.
The agency and the Department shall render a final MCE decision.
Training is an ongoing process that helps ensure safety and quality services and reflects the principles of services of the Developmental Disabilities Act of 1996, generally accepted best practices, and promising practices and the priorities of the System of Care Plan and these regulations.
The principles of supporting people to have valued roles in their community including:
* The dignity of valued roles
* Sharing ordinary places
* Making choices and the dignity of risk
* Relationships in living a full life
* Making contributions to others
The principles of person-centered thinking including:
* How to respectfully address significant issues of health or safety while supporting choice
* How to sort what is important for people from what is important to the people we support
* How rituals and routines play a role in what is important to the people we support
* The importance of having power with rather than power over the people we support;
Before working alone with an individual who receives support funded by the Department, each worker shall be trained and demonstrate knowledge in (a) through (e) of this section. The employer of record, whether recipient, family, shared living provider or agency, is responsible for providing or arranging for this training for their workers. The agency or Supportive ISO is responsible for verifying that the employer of record has provided or arranged for this training.
In order to receive funds administered by the Department to provide services or supports to people with developmental disabilities, providers shall be certified to enable the Department to ensure that an agency can meet certain standards of quality and practice.
The Department shall monitor certified providers through a variety of methods including, but not limited to, quality reviews, other on-site visits, review of critical incident reports and mortality reviews, investigation of complaints from recipients and the public, input from Department staff and staff or employees of other departments of AHS.
To be certified, an agency shall provide or arrange for services that achieve the following outcomes as specified in Guidelines for the Quality Review Process of Developmental Disabilities Services.
The Department shall evaluate and assess the success of programs using the following processes:
The information gathered shall be used for informing the continuation of programs, quality improvement, innovations in service delivery and policy development.
(04/15/2020, GCR 19-059)
For the purposes of this rule, the term:
Case management is a collaborative, person-centered process of assessment, identifying goals, planning and coordination of services, advocacy, options education and ongoing monitoring to meet a person's comprehensive needs, promoting quality and cost-effective outcomes. Case Management Services assist DAIL in monitoring the quality, effectiveness and efficiency of CFC services.
"Commissioner" means the Commissioner of the Department of Disabilities, Aging and Independent Living.
"Companion/Respite" means a home-based service that provides non-medical supervision and socialization for participants as determined by the needs of the individual, and which is limited in combination with Respite care.
(r) "Flexible Funds" means a home-based Moderate Needs Group service option that provides access to a limited amount of funds that may be used to purchase needed goods or services.
"Person-Centered Planning" means a process supporting the participant in accordance with 42 CFR Section 441.301(c)(1) that builds upon the person's capacity to engage in activities that promote community life and that honor the person's preferences, choices, and abilities and which involves families, friends, and professionals as the individual desires or requires.
DAIL encourages any applicant or participant who disagrees with a decision made by the State to contact State program staff person who made the decision to try to resolve the disagreement informally.
Choices for Care services approved for eligible participants include:
Individual service standards are managed by DAIL and can be found in the Choices for Care Program Manuals and align with the 1115 Global Commitment to Health waiver Special Terms and Conditions.
Choices for Care service rates and codes may be found on the Adult Services Division website or by contacting the Vermont Medicaid fiscal agent.
Wandering
Resists Care Symptom
Verbally Aggressive Behavior
Physically Aggressive Behavior Behavioral
Stage 3 or 4 Skin Ulcers
IV Medications
End Stage Disease
2nd or 3rd Degree Burns
Ventilator/ Respirator
Naso-gastric Tube Feeding
Parenteral Feedings
Suctioning
Dehydration
Aphasia
Vomiting
Quadriplegia
Chemotherapy
Septicemia
Cerebral Palsy
Respiratory Therapy
Open Lesions
Radiation Therapy
Internal Bleeding
Transfusions
Wound Care
Aspirations
Oxygen
Pneumonia
Dialysis
Multiple Sclerosis
Tracheotomy
Gastric Tube Feeding
Bathing
Dressing
Eating
Toilet Use
Physical Assistance to Walk
Gait Training
Speech
Range of Motion
Bowel or Bladder Training
Bathing
Dressing
Eating
Toilet Use Transferring Personal Hygiene
Constant or Frequent Wandering
Behavioral Symptoms
Physically Aggressive Behavior
Verbally Aggressive Behavior
Wound Care
Suctioning
Medication Injections
End Stage Disease
Parenteral Feedings
Tube Feedings
Severe Pain Management
If there is a question about whether or not resources or income are countable under this section, DAIL shall apply the SSI-related community Medicaid financial eligibility rules under HBEE.
13-007 Code Vt. R. 13-174-007-X
July 15, 1998 Secretary of State Rule Log #98-48; July 3, 2007 Secretary of State Rule Log #07-020 [amended and renumbered]; March 15, 2011 Secretary of State Rule Log #11-013; October 1, 2017 Secretary of State Rule Log #17-052 [ section 7.100 amended and renumbered from 13 110 011]; October 7, 2005 Secretary of State Rule Log #05-036; February 9, 2009 Secretary of State Rule Log #09-003; April 15, 2020 Secretary of State Rule Log #20-022 [ section 7.102 amended and renumbered from 13 110 008]
STATUTORY AUTHORITY:
18 V.S.A. §§ 8725, 8726