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Options for Designing Service Coverage: General Considerations 73individuals who reside in ICFs/MR.Adult day health: Health, therapy, and social servicesneeded to ensure an individual’s optimal functioning,furnished in an outpatient setting, four ormore hours per day on a regularly scheduled basis,for one or more days per week.These services are generally provided to olderpersons at senior centers or similar communityfacilities. Most states require that adult health programshave medical personnel available on site toSupported Employment Services in Colorado’sHCBS Waiver Program for People withDevelopmental DisabilitiesThe following are included in Colorado’s supportedemployment services:• Individualized assessment that may include communityorientation and job exploration• Individualized job development and placementservices that produce an appropriate job match forthe individual and his/her employer• Ongoing support, training, and facilitation in jobfinding, job skill acquisition, job retention, careerdevelopment, and work-related activities• Intervention and training needed to benefit fromsupported employment services and other supportsthat would help remove or diminish commonbarriers to participation in employment and to thebuilding of community relationships.address health care needs. Coverage of these servicesis nearly universal in HCBS waiver programsthat serve seniors with severe impairments.As a component of adult day health services,states have the option to cover transportationbetween the individual’s place of residence andthe adult day health center.Services for individuals with seriouspersistent mental illnessA state may cover three specialized services forindividuals who have serious persistent mentalillness: (a) clinic services; (b) day treatment orother partial hospitalization services; and (c) psychiatricrehabilitation services. These services alsomay be offered in HCBS waiver programs servingother target populations that include individualswho have a “dual diagnosis” (e.g., mental retardationand a psychiatric condition). Clinic andday treatment services are primarily for diagnosisand treatment of mental illness. In contrast, psychiatricrehabilitation services are aimed primarilyat achieving maximum reduction of physical ormental disability and restoration of maximumfunctioning.The standard HCFA definitions of these servicesencompass a wide range of assistance to individualswho have a mental illness and are in keepingwith contemporary views on mental health services.These views stress the need not only to treatthe mental illness but also to assist individuals tofunction in their communities.Clinic services: Outpatient mental health therapyand treatment.States that select this option may offer mentalhealth clinic services to HCBS waiver participants.The advantage of covering these services under anHCBS waiver program is that they may be furnishedin locations other than clinic sites. 31Day treatment or other partial hospitalization services:Services necessary for diagnosis or treatmentof an individual’s mental illness. These servicescan include diagnostic services, psychotherapy,family counseling, occupational and activitytherapy, medications, and training and educationof the individual.Day treatment services are akin to outpatientmental health services. Their purpose is to maintainthe individual’s condition and functionallevel and to prevent relapse or hospitalization.Partial hospitalization services are very similar toa hospital inpatient program, except the individualdoes not stay in the hospital 24 hours a day.With respect to adult services, day treatment is aterm sometimes used interchangeably with partialhospitalization. But for children, it often means afacility-based day program that includes schooling,with supplemental mental health rehabilitationand/or counseling as well. The scope of servicesa state may furnish under an HCBS waiver
74 UNDERSTANDING MEDICAID HOME AND COMMUNITY SERVICES: A PRIMERprogram is relatively broad. And unlike theMedicaid state plan clinic option, these servicesare not restricted to particular sites.Psychiatric rehabilitation services: Medical or remedialservices for maximum reduction of physicalor mental disability and restoration of maximumfunctioning. Specific services include (a)restoration and maintenance of daily living skills(grooming, personal hygiene, cooking, nutrition,health and mental health education, medicationmanagement, money management, and maintenanceof the living environment), (b) social skillstraining in appropriate use of community services,(c) development of appropriate personal supportnetworks, (d) therapeutic recreational services(focused on therapeutic intervention ratherthan diversion 32 ), and (e) telephone monitoringand counseling services.Psychiatric rehabilitation services integrate theprovision of clinical mental health services withprovision of other supports to address the fullrange of needs an individual with a mental illnessmight have. Day treatment services, in contrast,are confined largely to clinical services.Health-related servicesThis category covers a variety of skilled servicesthat persons with disabilities or chronic conditionsmay need but that either cannot be provided,or are provided on a more limited basis, under thestate plan.Skilled nursing: Services within the scope of astate’s Nurse Practice Act that are provided by aregistered professional nurse, or by a licensedpractical or vocational nurse under the supervisionof a registered nurse.This option enables a state to cover nursing servicesnot available through the Medicaid state plan.Frequently, it is used in states where the NursePractice Act dictates that nurses perform variousservices on behalf of consumers (administer medicationsand injections, change feeding tubes, andso forth).Private duty nursing: Individual and continuouscare (in contrast to part-time or intermittent care)provided by licensed nurses within the scope ofstate law.Private duty nursing is similar to skilled nursingexcept that it is more intensive and can cover situationswhen a nurse must be with the person forextended periods throughout the day—including24-hour-a-day coverage if needed to attend to theperson’s health care needs.Extended state plan services: States may providethe same health and other services as availablethrough the state plan, without the limitations onamount, duration, and scope specified in the plan.These services will be provided under the stateplan until the plan limitations have been reached.They can include physician services; home healthnursing services; physical and occupational therapyservices; speech, language, and hearing services;prescribed drugs; dental services; vision services;and other state plan services.A state might choose to include these services inits HCBS waiver program because its state planlimits either the amount or scope of the services.(A) A state might limit the number of times anindividual can receive physical therapy services,for example. By covering physical therapy as an“extended state plan” service, a state could providefor additional visits. (B) Or a state mayrequire that physical and occupational therapy beprovided only on a restorative basis (e.g., to individualswho have lost function as the result of anillness or accident). These therapies can also bevaluable for individuals with permanent disabilities,however, because they can prevent deteriorationand improve functioning. 33 An HCBS waiverprogram can include such coverage. 34Assistive devices, adaptive aids, andequipment; home and vehicle modificationsEnvironmental accessibility adaptations: Thosephysical adaptations to the home that either (a) arenecessary to ensure the health, welfare, and safetyof individuals or (b) enable them to function moreindependently in the home and without whichthey would require institutionalization.Home adaptations can almost never be coveredunder the Medicaid state plan. But Medicaid permitsa wide range of adaptations under anapproved waiver program.
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IntroductionPeople of all ages with
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