403 Neb. Admin. Code, ch. 6, § 004

Current through September 17, 2024

Section 403-6-004 - AVAILABLE SERVICES, LIMITATIONS, AND PROVIDER TYPES

004.01SERVICE TYPES. The following services are available:

(A) Assistive Technology;

(B) Child Day Habilitation;

(C) Community Integration;

(D) Day Supports;

(E) Environmental Modifications Assessment;

(F) Family and Caregiver Training;

(G) Family and Peer Mentoring Supports;

(H) Home Modifications;

(I) Homemaker;

(J) Independent Living;

(K) Participant Directed Goods and Services;

(L) Personal Emergency Response System (PERS);

(M) Respite;

(N) Supported Family Living;

(O) Transportation; and

(P) Vehicle Modifications.

004.02SERVICE DESCRIPTIONS SPECIFIC TO FAMILY SUPPORT WAIVER.

004.02(A)ASSISTIVE TECHNOLOGY. The use of assistive technology enables participants who reside in their own homes to increase their abilities to perform activities of daily living (ADL) in their home or to perceive, control, or communicate with the environment they live in, thereby decreasing their need for assistance from others as a result of limitations due to disability. Providers shall provide and maintain assistive technology in accordance with applicable building codes or applicable standards of manufacturing, design, and installation. Providers shall provide appropriate training to the participant in the use of the assistive technology.

004.02(A)(i)LIMITATIONS. The following limitations apply to Assistive Technology:

(1) The Department may require an on-site assessment of an environmental concern including an evaluation of functional necessity with appropriate Medicaid-enrolled professional providers. The Department may use a third party to assess the proposed modifications and the need for the modifications to ensure the cost-effectiveness and quality of a product. This assessment will be funded by the Environmental Modification Assessment services; and as such, it will be reimbursed separately;

(2) Assistive Technology is limited to devices, controls, or appliances to assist the participant to perceive, control, or communicate with the environment they live in;

(3) The amount of prior authorized services is based on the participant's need as documented in the participant's person-centered plan and within the participants' approved annual budget;

(4) Assistive Technology is reimbursed per item directly to the Medicaid-enrolled provider or the manufacturer;

(5) Providers may not exceed their charges to the public when billing the Waiver. A provider who offers a discount to certain individuals (for example, students, senior citizens, etc.) must apply the same discount to the participants who would otherwise qualify for the discount; and

(6) Damaged, stolen, or lost items not covered by insurance or warranty may only be replaced once every two years.

004.02(A)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.02(B)CHILD DAY HABILITATION. A habilitative service that provides teaching and staff supports to meet the age-appropriate needs of a child due to a disability or special health conditions. Child Day Habilitation takes place in the community, separate from the participant's private family residents, in a provider setting approved, registered, or licensed by the Nebraska Department of Health and Human Services.

004.02(B)(i)LIMITATIONS. The following limitations apply to Child Day Habilitation:

(1) Participants receiving Child Day Habilitation cannot be authorized concurrently with Community Integration within the same person-centered service plan;

(2) Child Day Habilitation is available for participants living in their private family residence who are under 21 years of age;

(3) The rates for this service do not include the basic cost of childcare unrelated to a child's disability;

(4) Child Day Habilitation only covers necessary services and supports associated with the child's physical, medical, personal care, or behavioral needs not included in regular childcare;

(5) Child Day Habilitation cannot exceed a weekly amount of 70 hours for participants living in their private family residence. A week is defined as 12:00 AM Monday through 11:59 PM Sunday;

(6) Child Day Habilitation is reimbursed at an hourly rate;

(7) Child Day Habilitation may be provided by a relative who is not legally responsible for the participant; and

(8) This service cannot be provided during school hours set by the local school district for the participant.

004.02(B)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.02(C)COMMUNITY INTEGRATION. Community Integration is a habilitative service.

004.02(C)(i)LIMITATIONS. The following limitations apply to Community Integration:

(1) This service may be authorized in combination with Day Supports service in the same person-centered service plan, but the service may not be provided and billed for concurrently. The total combined hours for these services may not exceed a weekly amount of 35 hours. A week is defined as 12:00 am Monday through 11:59 pm Sunday;

(2) Participants may not perform paid work activities or unpaid activities in which others are typically paid, but may perform hobbies in which minimal money is received or volunteer activities;

(3) Participants receiving Community Integration cannot receive Child Day Habilitation;

(4) Community Integration is reimbursed at an hourly rate. The Community Integration provider is in the community providing a combination of habilitation supports, protective oversight, and supervision to bill in hourly units;

(5) Transportation required in the provision of Community Integration is included in the rate. Non-medical transportation to the site at which Community Integration begins is not included in the rate. Non-medical transportation from the site at which Community Integration ends is not included in the rate; and

(6) This service cannot be provided during school hours set by the local school district for the participant. This limitation includes any and all public education programs funded under the Individuals with Disabilities Education Act (IDEA). Regular school hours and days apply for a child who receives home schooling.

004.02(C)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.02(D)DAY SUPPORT. Day Support Services provide person-centered activities. Day Support services are regularly scheduled activities, formalized training, and staff supports for the acquisition, retention, or improvement in:

(1) Self-help;

(2) Behavioral skills;

(3) Adaptive skills;

(4) Social development;

(5) Activities of daily living (ADL); and

(6) Community living.

004.06(D)(i)LIMITATIONS. The following limitations apply to Day Support.

(1) This service may be authorized in combination with Community Integration service in the same person-centered service plan. The total combined hours for these services may not exceed a weekly amount of 35 hours;

(2) Day Support may not provide for the payment of services that are vocational in nature (i.e., for the primary purpose of producing goods or performing services);

(3) Day Support is reimbursed at an hourly rate;

(4) Transportation to and from the Day Support setting to integrated community activities during the Day Support service hours is included in the reimbursement rate. When the provider transports participants, the provider must ensure that all participants are transported in a safe and comfortable manner that meets the needs of each participant;

(5) This service cannot be provided during school hours set by the local school district for the participant. This limitation includes any, and all public education programs funded under the Individuals with Disabilities Education Act (IDEA). Regular school hours and days apply for a child who receives home schooling; and

(6) This service must not overlap with, supplant, or duplicate other comparable services provided through Medicaid State Plan or Home and Community-Based Waiver services, or Vocational Rehabilitation programs.

004.02(D)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified Providers.

004.02(E)ENVIRONMENTAL MODIFICATION ASSESSMENT. Is used to enable a participant to integrate more fully into the community while ensuring the health, welfare and safety of a participant

004.04(E)(i)LIMITATIONS. The following limitations apply to Environmental Modification Assessment:

(1) The amount of prior authorized services is based on the participant's need as documented in the participant's person-centered service plan, and within the participant's approved annual budget;

(2) Environmental Modification Assessment is reimbursed at a flat rate per completed assessment not to exceed the amount charged to the general public; and

(3) Environmental Modification Assessments may be provided by a relative but not a person legally responsible for the participant.

004.02(E)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.02(F)FAMILY CAREGIVER TRAINING. Provides individualized training and education to the unpaid caregiver currently living in the family home to assist in understanding and addressing the participants' needs by building upon their own skills. Family Caregiver Training service may address such areas as:

(1) Understanding the disability of the participant supported;

(2) Achieving greater competence and confidence in providing support;

(3) Developing or enhancing key parenting strategies;

(4) Other areas so that the unpaid caregiver can most effectively support the participant's desired goals and outcomes as described in the person-centered service plan.

004.02(F)(i)LIMITATIONS. The following limitations apply to Family Caregiver Training:

(1) The amount of prior authorized services is based on the participant's need as documented in the person-centered service plan and within the participant's approved annual budget;

(2) Educational and training programs, workshops, and conference registration costs for the unpaid caregiver is limited up to $500.00 per annual budget year;

(3) This service may not be provided in order to train or educate paid caregivers; and

(4) This service must not overlap with, supplant, or duplicate other comparable services provided through the Medicaid State plan, including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT), or Home and Community-Based Services (HCBS) Waiver.

004.02(F)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified Providers.

004.02(G)FAMILY AND PEER MENTORING. Provides mentors who have shared experiences with the participant, the family, or both, that will provide support and guidance by sharing experiences, strategies, and resources. Family and Peer Mentoring may not be self-directed.

004.02(G)(i)LIMITATIONS. The following limitations apply to Family and Peer Monitoring:

(1) The amount of prior authorized services is based on the participant's need as documented in the person-centered service plan, and within the participant's approved annual budget;

(2) Family and Peer Mentoring is billed at an hourly rate;

(3) Mentors cannot mentor their own family members;

(4) Mentors cannot mentor other unpaid caregivers who reside in the family home;

(5) Transportation during the provision of Family and Peer Mentoring is included in the rate. Non-medical transportation to the site at which Family and Peer Mentoring begins is not included in the rate. Non-medical transportation from the site at which Family and Peer Mentoring ends is not included in the rate; and

(6) This service must not overlap with, supplant, or duplicate other comparable services provided through the Medicaid State plan, including EPSDT, or Medicaid Home and Community-Based Services (HCBS) Waiver.

004.02(G)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified Providers.

004.02(H)HOME MODIFICATIONS. Home Modifications are provided within the current footprint of the participant's residence. Such modifications include, but are not limited to, Installation of ramps, widening of doorways, modifications of bathroom facilities, and installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the participant.

004.02(H)(i)LIMITATIONS. The following limitations apply to Home Modifications:

(1) The Department may require an on-site assessment of the environmental concern including an evaluation of functional necessity with appropriate Medicaid enrolled professional providers. Division of Developmental Disabilities (DDD) may use a third party to assess the proposed modification and the need for the adaptation to ensure cost-effectiveness and quality of product. This assessment will be funded by the Environmental Modification Assessment service, and will be reimbursed separately;

(2) The amount of prior authorized services is based on the participant's need as documented in the service plan, and within the participant's approved annual budget;

(3) Proof of renter's insurance or homeowner's insurance may be requested;

(4) Evidence of application to secure government-subsidized housing through the U.S. Department of Housing and Urban Development or other Economic Assistance programs may be requested;

(5) Home Modifications may be provided by a relative but not a person legally responsible for the participant; and

(6) The services under this Waiver are limited to additional services not otherwise covered under the Medicaid State Plan, including Early and Periodic Screening, Diagnosis and Treatment (EPSDT), but consistent with Waiver objectives of avoiding institutionalization.

004.02(H)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.02(I)HOMEMAKER. The performance of general household activities that does not include direct-care supervision.

004.02(I)(i)LIMITATIONS. The following limitations apply to Homemaker:

(1) Homemaker has an annual cap of 520 hours;

(2) Homemaker and Independent Living cannot be authorized concurrently within the same person-centered service plan;

(3) Homemaker cannot duplicate or replace other supports available to the participant, including natural supports;

(4) Homemaker is reimbursed at an hourly rate;

(5) Transportation is not included in the reimbursement rate; and

(6) Homemaker requires the provider to use Electronic Visit Verification (EVV).

004.02(I)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.02(J)INDEPENDENT LIVING. Independent Living is provided in the participant's private home not in a residence owned or leased, operated, or controlled by a provider. Independent Living is a habilitative service providing individually tailored intermittent supports for a Waiver participant, which assists with the acquisition, retention, or improvement in skills related to living in their own private home and community.

004.02(J)(i)LIMITATIONS. The following limitations apply to Independent Living:

(1) Independent Living and Supported Family Living cannot be authorized concurrently within the same person-centered service plan;

(2) Independent Living is available for participants who are 19 years and older;

(3) Independent Living is provided in the participant's private home, not a provider-owned or leased, operated, or controlled residence;

(4) Independent Living may be provided to one, two, or three participants, based on the participants' assessed needs;

(5) The amount of prior authorized services is based on the participant's need as documented in the person-centered service plan, and within the participant's approved annual budget;

(6) Independent Living is reimbursed at an hourly rate;

(7) Independent Living is provided to an awake participant who requires less than 24-hours of support a day;

(8) Independent Living cannot exceed a weekly amount of 70 hours. A week is defined as 12:00 AM Monday through 11:59 PM Sunday;

(9) The rate structure for this service is determined based on the group size. Group sizes of one, two, or three are based on the participant's assessed needs;

(10) Independent Living requires the provider use Electronic Visit Verification (EVV); and

(11) Participants receiving Independent Living cannot have an active service authorization for Respite or Homemaker.

004.02(J)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.02(K)PARTICIPANT-DIRECTED GOODS AND SERVICES. Participant-Directed Goods include equipment or supplies that enable the participant to maintain or increase independence and promote opportunities for community living and inclusion. Participant-Directed Goods may be self-directed.

004.02(K)(i)RESTRICTIONS. Participant-Directed Goods may not be used for the following:

(1) Personal items not related to the participant's intellectual disability or developmental disability;

(2) Experimental or prohibited treatments (i.e., herbal supplements, shock therapy, clinical trials);

(3) Co-payment for medical services, over-the-counter medications, or homeopathic services;

(4) Training provided to paid or unpaid caregivers;

(5) Cost of travel, meals, and overnight lodging to attend training or conferences;

(6) Entertainment activities, including vacation expenses, food, alcohol, using tobacco or nicotine products, movie tickets, subscriptions, televisions and related equipment, and other items as determined by the Division of Developmental Disabilities (DDD);

(7) Expenses related to routine daily living, including groceries, rent or mortgage payments, utility payments, home maintenance, gifts, pets or other animals, insurance, vehicle maintenance, or any other transportation-related costs, self-employment/business-related expenses, and other items determined by Division of Developmental Disabilities (DDD);

(8) Equipment, supplies, or items that the participant has the funds to purchase; or

(9) Equipment, supplies, or items that are excluded from receiving Federal Financial Participation, including, but not limited to, room and board payments.

004.02(K)(ii)LIMITATIONS. The following limitations apply to Participant-Directed Goods and Services:

(1) The amount of prior authorized services is based on the participant's need as documented in the person-centered service plan, and within the participant's approved annual budget;

(2) Participant-Directed Goods must not otherwise be provided through other services offered in this Waiver;

(3) Providers shall not exceed their charges to the general public when billing the Waiver. A provider who offers a discount to certain individuals (for example, students, senior citizens, etc.) shall apply the same discount to the participants who would otherwise qualify for the discount; and

(4) This service shall not overlap with, supplant, or duplicate other comparable services provided through the Medicaid State Plan, including Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) or Medicaid Home and Community-Based Services (HCBS) Waiver.

004.02(K)(iii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified Providers.

004.02(L)PERSONAL EMERGENCY RESPONSE SYSTEM (PERS). Enables participants to secure help in an emergency.

004.02(L)(i)LIMITATIONS. The following limitations apply to Personal Emergency Response System (PERS):

(1) Personal Emergency Response System (PERS) cannot be authorized for a participant who resides in a residence that is provider-owned or leased, operated, or controlled;

(2) The amount of prior authorized services is based on the participant's need as documented in the participant's person-centered service plan, and within the participant's approved annual budget;

(3) Personal Emergency Response System (PERS) is reimbursed as a monthly rental fee or as a one-time installation fee; and

(4) This service must not overlap with, supplant, or duplicate other comparable services provided through the Medicaid State Plan or Medicaid Home and Community-Based Services (HCBS) Waiver.

004.02(L)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified Providers.

004.02(M)RESPITE. Respite includes assistance with activities of daily living (ADL), health maintenance, and supervision.

004.02(M)(i)LIMITATIONS. The following limitations apply to Respite:

(1) The amount of prior authorized services is based on the participant's need as documented in the person-centered service plan, and within the participant's approved annual budget;

(2) Respite provided in an institutional setting requires prior approval by the Department and is authorized only when no other option is available;

(3) Respite is reimbursed at an hourly rate;

(4) Any use of respite over eight hours within a 24-hour period is not reimbursable;

(5) Federal financial participation must not be claimed for the cost of room and board except when provided as a part of respite care furnished in a facility approved by Division of Developmental Disabilities (DDD) and not a private residence;

(6) Respite must not be provided during the school hours set by the local school district for the participant. Regular school hours and days apply for a child who receives home schooling;

(7) Respite must not be provided concurrently with other Medicaid Home and Community-Based Services (HCBS) Waiver;

(8) Respite must not be provided by any independent provider who lives in the same private residence as the participant or is a person legally responsible for the participant; and

(9) A Respite provider or provider staff must not provide respite to children and adults (18 years and older) at the same time and location, unless approved by Division of Developmental Disabilities (DDD) Central Office.

004.02(M)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.02(N)SUPPORTED FAMILY LIVING. Supported Family Living is a habilitative service that provides individually tailored intermittent teaching and supports to assist with the acquisition, retention, or improvement in skills related to living in the community. Supported Family Living includes adaptive skill development necessary to enable the participant to live in the most integrated setting appropriate to their needs. Providers of Supported Family Living generally do not perform these activities for the participant, except when not performing the activities pose a risk to the participant's health and safety. Supported Family Living is provided to the participant in the participant's family home, not a provider-owned or leased, operated, or controlled setting. A participant can choose to receive a portion of this service virtually. The participant must live with relatives in their private family home.

004.02(N)(i)LIMITATIONS. The following limitations apply to Supported Family Living:

(1) The total combined hours for virtual supports may not exceed a weekly amount of 10 hours and are included as part of the currently existing limit of 70 hours per week of services provided during the day;

(2) Use of virtual supports must be a person-centered decision and facilitate community integration and not risk leading to the isolation of the participant from the community or from interacting with other people;

(3) The amount of prior authorized services is based on the participant's need as documented in the participant's service plan, and within the participant's approved annual budget;

(4) Supported Family Living is reimbursed at an hourly rate and the provider must use Electronic Visit Verification (EVV);

(5) Supported Family Living cannot exceed a weekly amount of 70 hours; and

(6) This service must not overlap with, supplant, or duplicate other comparable services provided through the Medicaid State Plan or Medicaid Home and Community-Based Services (HCBS) Waiver.

004.02(N)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.02(O)TRANSPORTATION. Transportation is a service designed to foster greater independence and personal choice. Transportation enables participants to gain access to Waiver services, community activities, and resources, as specified by the participant's service plan. Transportation is not intended to replace formal or informal transportation options, such as the use of natural supports.

004.02(O)(i)LIMITATIONS. The following limitations apply to Transportation:

(1) This service does not include transportation to medical appointments available under the Medicaid State Plan or other federal and state transportation programs;

(2) This service does not include transportation to the site at which Child Day Habilitation begins and from the site at which Child Day Habilitation ends and is the primary caregiver's responsibility;

(3) Transportation is provided for a Waiver participant to get to and from a location only using the most direct route;

(4) Transportation is reimbursed per mile or cost of a bus pass;

(5) Transportation may be provided by a relative but not a person legally responsible for the participant;

(6) Agency provider mileage rate must not exceed the rate of reimbursement pursuant to Neb. Rev. Stat. § 81-1176 multiplied by three;

(7) Individual provider mileage rate is paid at the mileage rate of reimbursement pursuant to Neb. Rev. Stat. § 81-1176;

(8) The public transportation rate must not exceed purchase price by the public; and

(9) This service must not overlap with, supplant, or duplicate other comparable services provided through the Medicaid State Plan or Medicaid Home and Community-Based Services (HCBS) Waiver.

004.02(O)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.02(P)VEHICLE MODIFICATIONS. Vehicle Modifications are specified by the service plan as necessary to enable the participant to integrate more fully into the community and to ensure the health, welfare, and safety of the participant.

004.02(P)(i)LIMITATIONS. The following limitations apply to Vehicle Modifications:

(1) Vehicle Modifications have a budget cap of $10,000 per five-year period;

(2) Division of Developmental Disabilities (DDD) may require an on-site assessment of the environmental concern including an evaluation of functional necessity with appropriate Medicaid enrolled professional providers. Division of Developmental Disabilities (DDD) may use a third party to assess the proposed modification and need for the modification to ensure cost effectiveness and quality of product. This assessment will be funded by the Environmental Modification Assessment service and will be reimbursed separately. The cost of the Environmental Modification Assessment is not included in the $10,000 budget cap for Vehicle Modifications;

(3) The amount of prior authorized services is based on the participant's need as documented in the participant's person-centered service plan, and within the participant's approved annual budget;

(4) Proof of vehicle insurance may be requested;

(5) Providers must not exceed their charges to the public when billing the Waiver. A provider who offers a discount to certain individuals (for example, students, senior citizens, etc.) must apply the same discount to the participants who would otherwise qualify for the discount;

(6) When the vehicle is leased, the modification is transferrable to the next vehicle; and

(7) This service must not overlap with, supplant, or duplicate other comparable services provided through the Medicaid State Plan or Medicaid Home and Community-Based Services (HCBS) Waiver.

004.02(P)(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified Providers.

403 Neb. Admin. Code, ch. 6, § 004

Adopted effective 5/7/2024