DDRS Waiver Manual

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FSW CIH MFP- CIH • • • INsite Code Natl. Code 1 2 3 4 Rate Unit/ Size Unit/$ Limit Service Description Personal Response System, Maintain S5161 U7 U5 $52.07 1.00/Unit 1 Unit/Month PRSM • • • PHTH Physical Therapy G0151 U7 U5 UA $18.12 .25/Hour • • • PV02 Pre-Vocational (2:1) T2015 U7 U5 U2 $8.48 1.00/Hour • • • PV04 Pre-Vocational (4:1) T2015 U7 U5 U4 $8.48 1.00/Hour • • • PV06 Pre-Vocational (6:1) T2015 U7 U5 U6 $4.72 1.00/Hour • • • PVO8 Pre-Vocational (8:1) T2015 U7 U5 UA $4.72 1.00/Hour • • • PV10 Pre-Vocational (10:1) T2015 U7 U5 UB $4.72 1.00/Hour • • • PV12 Pre-Vocational (12:1) T2015 U7 U5 UC $3.00 1.00/Hour • • • PV14 Pre-Vocational (14:1) T2015 U7 U5 UD $3.00 1.00/Hour • • • PV16 Pre-Vocational (16:1) T2015 U7 U5 U9 $3.00 1.00/Hour • • • PSTF Psychological Therapy, Family 90846 U7 U5 $17.27 .25/Hour • • • PSTG Psychological Therapy, Group 90853 U7 U5 $4.81 .25/Hour • • • PSTI Psychological Therapy, Individual H0004 U7 U5 U3 $15.45 .25/Hour • • • RETH Recreational Therapy H2032 U7 U5 U2 $10.78 .25/Hour Rent & Food for Unrelated Live-In • • R&F Caregiver T2025 U7 U5 $545.00 1.00/Month Residential Habilitation Services, • • RH1O Level 1 (35 or fewer Hrs/Week) T2016 U7 U5 UA $24.90 1.00/Hour Residential Habilitation Services, • • RH2O Level 2 (Over 35 Hrs/Week) T2016 U7 U5 $20.92 1.00/Hour RHD Daily Level 1 (2 Person Setting, • • RD1 Algo Level 3) T2016 U7 U5 UN UA $163.17 1.0/Day 1 Unit/Day RHD Daily Level 2 (2 Person Setting, • • RD2 Algo Level 4) T2016 U7 U5 UN UB $230.12 1.0/Day 1 Unit/Day RHD Daily Level 3 (2 Person Setting, • • RD3 Algo Level 5) T2016 U7 U5 UN UC $251.04 1.0/Day 1 Unit/Day RHD Daily Level 4 (3 Person Setting, • • RD4 Algo Level 3) T2016 U7 U5 UP UA $163.17 1.0/Day 1 Unit/Day RHD Daily Level 5 (3 Person Setting, • • RD5 Algo Level 4) T2016 U7 U5 UP UB $211.29 1.0/Day 1 Unit/Day RHD Daily Level 6 (3 Person Setting, • • RD6 Algo Level 5) T2016 U7 U5 UP UC $230.12 1.0/Day 1 Unit/Day RHD Daily Level 7 (4 Person Setting, • • RD7 Algo Level 3) T2016 U7 U5 UQ UA $152.71 1.0/Day 1 Unit/Day RHD Daily Level 8 (4 Person Setting, • • RD8 Algo Level 4) T2016 U7 U5 UQ UB $196.64 1.0/Day 1 Unit/Day RHD Daily Level 9 (4 Person Setting, • • RD9 Algo Level 5) T2016 U7 U5 UQ UC $209.20 1.0/Day 1 Unit/Day • • • RNUR Respite Nursing Care, RN T1005 U7 U5 TD $7.79 .25/Hour • • • RNUR Respite Nursing Care, LPN T1005 U7 U5 TE $5.91 .25/Hour • • • RSPO Respite Care Services S5151 U7 U5 $24.90 1.00/Hour Specialized Medical Equip/Supply, • • ATCH Install T2029 U7 U5 NU Individual 1.00/Unit Specialized Medical Equip/Supply, • ATCH Install T2029 U7 U5 NU Individual 1.00/Unit $7,500 Lifetime Specialized Medical Equip/Supply, • • • ATCM Maintain T2029 U7 U5 U8 Individual 1.00/Unit $500/Year • • • SPTH Speech Therapy 92507 U7 U5 UA $18.12 .25/Hour Structured Family Caregiving, Level • • AF01 1 T2033 U7 U5 U1 $51.87 1.00/Day 1 Unit/Day Structured Family Caregiving, Level • • AF02 2 T2033 U7 U5 U2 $75.67 1.00/Day 1 Unit/Day Structured Family Caregiving, Level • • AF03 3 T2033 U7 U5 U3 $102.87 1.00/Day 1 Unit/Day • TRNO Transportation T2002 U7 U5 $5.00 1.00/Trip 2 Trips/Day 2 • • TRNO Transportation, Level 1 T2002 U7 U5 $5.00 1.00/Trip Trips/Day,$2500/Year 88
FSW CIH MFP- CIH INsite Code Service Description Natl. Code 1 2 3 4 Rate Unit/ Size Unit/$ Limit 2 • • TRN2 Transportation, Level 2 T2002 U7 U5 U2 $20.00 1.00/Trip Trips/Day,$5000/Year 2 • • TRN3 Transportation, Level 3 T2002 U7 U5 U3 $40.00 1.00/Trip Trips/Day,$7500/Year • • VMOD Vehicle Modification, Install T2039 U7 U5 Individual 1.00/Unit $15,000 Lifetime • VMOD Vehicle Modification, Install T2039 U7 U5 Individual 1.00/Unit $7,500 Lifetime • • • VMOM Vehicle Modification, Maintain T2039 U7 U5 U8 Individual 1.00/Unit $500/Year • • WEL1 Wellness Coordination Tier 1 T2022 U7 U5 U1 $52.77 1.00/Month 1 Unit/Month • • WEL2 Wellness Coordination Tier 2 T2022 U7 U5 U2 $111.96 1.00/Month 1 Unit/Month • • WEL3 Wellness Coordination Tier 3 T2022 U7 U5 U3 $223.92 1.00/Month 1 Unit/Month • • • WPA Workplace Assistance T1020 U7 U5 $26.37 1.00/Hour Section 10.3: Adult Day Services Service Definition Adult Day Services (ADS) are community-based group programs designed to meet the needs of adults with impairments through individual plans of care. These structured, comprehensive, non-residential programs provide health, social, recreational, and therapeutic activities, supervision, support services, and personal care. Meals and/or nutritious snacks are required. The meals need not constitute the full daily nutritional regimen. However, each meal must meet one-third of the daily Recommended Dietary Allowance. These services must be provided in a congregate, protective setting in one of three available levels of service: Basic, Enhanced, or Intensive. Individuals attend Adult Day Services on a planned basis. A maximum of 12 hours per day shall be allowable. The three levels of Adult Day Services are Basic, Enhanced and Intensive. A half-day unit is defined as one unit of three hours to a maximum of five hours per day. Two units is more than five hours to a maximum of eight hours per day. A maximum of two half-units per day is allowed. A quarter-hour unit is defined as 15 minutes. It is billable only if fewer than three hours or more than eight hours of ADS have been provided on the same day. A maximum of 16 quarter-hour units per day are allowed. Reimbursable Activities Adult Day Services may be used in conjunction with Transportation Services. Basic Adult Day (Level 1) includes: Monitor and/or supervise all activities of daily living (ADLs) defined as dressing, bathing, grooming, eating, walking, and toileting with hands-on assistance provided as needed. Comprehensive, therapeutic activities. Health assessment and intermittent monitoring of health status. Monitor medication or medication administration. 89
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2016 DDRS Waiver Manual Our Mission
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Section 1: Roles and Responsibiliti
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Section 7.5: State Authorization of
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Section 10.23: Psychological Therap
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Section 1.1: The Centers for Medica
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ules or standards that may affect t
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Information Sharing The Individual
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Here are some tips on what to discu
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6. Does each person have his or her
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Section 3: Additional Medicaid Prog
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HCBS waiver services. HCBS waiver p
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Section 4.1: Medicaid Waiver Overvi
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Section 4.4: Coordination with Medi
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personal beliefs and customs, ensur
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Section 5.1: Request for Applicatio
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Internet access, call toll free 1-8
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understanding and use of language,
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If an individual declines the offer
Page 37 and 38: waiver slot when it appears that th
Page 39 and 40: Five calendar days to interview and
Page 41 and 42: The individual or guardian has sign
Page 43 and 44: Section 6: Objective Based Allocati
Page 45 and 46: adjustments to the allocation amoun
Page 47 and 48: BMAN Reserve $0 $0 $2,620.80 $5,241
Page 49 and 50: An individual’s behavioral condit
Page 51 and 52: An individual or the individual’s
Page 53 and 54: Your Appeal Right as an Applicant f
Page 55 and 56: Section 7.1: Level of Care Re-Evalu
Page 57 and 58: RN/LPN, who must be actively involv
Page 59 and 60: o Children receiving adoption assis
Page 61 and 62: including the DDRS Case Management
Page 63 and 64: When the individual “Re-Enters”
Page 65 and 66: (RHS) under the Community Integrati
Page 67 and 68: Section 8.1: Appeal Request The fol
Page 69 and 70: Objective-based allocation (OBA): T
Page 71 and 72: administrative hearing must still b
Page 73 and 74: The person testifying should be the
Page 75 and 76: In all cases, the decision of the A
Page 77 and 78: Section 9.1: Overview The Family an
Page 79 and 80: Structural or environmental issues
Page 81 and 82: implemented in order to ensure that
Page 83 and 84: conducted by the ombudsman must als
Page 85 and 86: Section 10.24: Recreational Therapy
Page 87: Medicaid Waiver Services, Codes, an
Page 91 and 92: The Case Manager should give the co
Page 93 and 94: Aversive techniques - any technique
Page 95 and 96: Services delivered to persons who d
Page 97 and 98: where services are not rendered wit
Page 99 and 100: Section 10.7: Community Based Habil
Page 101 and 102: Activities that do not foster the a
Page 103 and 104: The system to be installed must be
Page 105 and 106: The monitoring base staff must have
Page 107 and 108: Electronic Monitoring may not be us
Page 109 and 110: Adaptations to service provider-own
Page 111 and 112: independence and are consistent wit
Page 113 and 114: Group supports delivered to individ
Page 115 and 116: o Small (4:1 or smaller) o Medium (
Page 117 and 118: The data may reside in multiple loc
Page 119 and 120: Providers must be able to indicate,
Page 121 and 122: programmed, constructive interactio
Page 123 and 124: The IBI Director will provide a nar
Page 125 and 126: As applicable, monthly/quarterly re
Page 127 and 128: participate in their communities, a
Page 129 and 130: Homeschooling, special education, a
Page 131 and 132: or before the fifteenth day of the
Page 133 and 134: o Medium (5:1 to 10:1) o Larger (la
Page 135 and 136: Services must address needs identif
Page 137 and 138: The following activities are not al
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maintaining natural supports, physi
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tool for individual assessment. The
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o o o o o Individuals receiving RHS
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(C) requires minimal residential ha
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as well the development, oversight,
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Available only under the Community
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Services furnished to a minor by a
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Section 10.30: Speech/Language Ther
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to be utilized in service plan deve
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Transportation services through the
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Bus passes or alternate methods of
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The participant requires assistance
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Service Standards The following ser
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Section 11: Request for Approval (R
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Choice of Provider The individual c
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Reimbursement Reimbursement is avai
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Modifications/Items - Non-Covered E
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Authority: 42 CFR §441.302 Section
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Total Cost $$$$$ 175
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Items - Covered Justification and d
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These requests should be extremely
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Choice of Provider The individual c
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Completed by an approved Medicaid W
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The case management entity, working
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DDRS Waiver Manual

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