WSR 06-11-018

PROPOSED RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES
(Aging and Disability Services Administration)

[ Filed May 4, 2006, 3:21 p.m. ]

Original Notice.

Preproposal statement of inquiry was filed as WSR 05-05-080.

Title of Rule and Other Identifying Information: New WAC 388-106-1400 through 388-106-1480, new freedom consumer directed services (NFCDS); and amending WAC 388-106-0010 Long-term care services -- Definitions, 388-106-0015 What long-term care services does the department provide?, 388-106-0040 Who can provide long-term care services?, 388-106-0055 What is the purpose of an assessment?, and 388-106-0130 How does the department determine the number of hours I may receive for in-home care?

Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane, behind Goodyear Tire. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on June 27, 2006, at 10:00 a.m.

Date of Intended Adoption: Not earlier than June 28, 2006.

Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m., on June 27, 2006.

Assistance for Persons with Disabilities: Contact Stephanie Schiller, DSHS Rules Consultant, by June 23, 2006, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.

Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The aging and disability services administration will be offering new freedom consumer directed services (NFCDS). Rules on this program are needed to provide a description of the program, eligibility criteria, types of services, the enrollment/disenrollment process, and additional information.

Reasons Supporting Proposal: See above.

Statutory Authority for Adoption: RCW 74.08.090, 74.09.520, 74.39A.030.

Statute Being Implemented: RCW 74.08.090, 74.09.520, 74.39A.030, 42 C.F.R. 441.301(b)(6)(i).

Rule is not necessitated by federal law, federal or state court decision.

Name of Proponent: Department of social and health services, governmental.

Name of Agency Personnel Responsible for Drafting, Implementation and Enforcement: Rosemary Biggins, P.O. Box 45600, Olympia, WA 98504-5600, (360) 725-2466.

No small business economic impact statement has been prepared under chapter 19.85 RCW. The department has analyzed the proposed rules and determined that no new costs will be imposed on small businesses or nonprofits.

A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Tiffany Sevruk, Home and Community Services Division, P.O. Box 45600, Olympia, WA 98504-5600, phone (360) 725-2538, fax (360) 407-7582, e-mail sevruta@dshs.wa.gov.

May 2, 2006

Andy Fernando, Manager

Rules and Policies Assistance Unit

3661.2
AMENDATORY SECTION(Amending WSR 06-05-022, filed 2/6/06, effective 3/9/06)

WAC 388-106-0010   What definitions apply to this chapter?   "Ability to make self understood" means how you make yourself understood to those closest to you; express or communicate requests, needs, opinions, urgent problems and social conversations, whether in speech, writing, sign language, symbols, or a combination of these including use of a communication board or keyboard:

(a) Understood: You express ideas clearly;

(b) Usually understood: You have difficulty finding the right words or finishing thoughts, resulting in delayed responses, or you require some prompting to make self understood;

(c) Sometimes understood: You have limited ability, but are able to express concrete requests regarding at least basic needs (e.g. food, drink, sleep, toilet);

(d) Rarely/never understood. At best, understanding is limited to caregiver's interpretation of client specific sounds or body language (e.g. indicated presence of pain or need to toilet.)

"Activities of daily living (ADL)" means the following:

(a) Bathing: How you take a full-body bath/shower, sponge bath, and transfer in/out of tub/shower.

(b) Bed mobility: How you move to and from a lying position, turn side to side, and position your body while in bed, in a recliner, or other type of furniture.

(c) Body care: How you perform with passive range of motion, applications of dressings and ointments or lotions to the body and pedicure to trim toenails and apply lotion to feet. In adult family homes, contracted assisted living, enhanced adult residential care, and enhanced adult residential care-specialized dementia care facilities, dressing changes using clean technique and topical ointments must be performed by a licensed nurse or through nurse delegation in accordance with chapter 246-840 WAC. Body care excludes:

(i) Foot care if you are diabetic or have poor circulation; or

(ii) Changing bandages or dressings when sterile procedures are required.

(d) Dressing: How you put on, fasten, and take off all items of clothing, including donning/removing prosthesis.

(e) Eating: How you eat and drink, regardless of skill. Eating includes any method of receiving nutrition, e.g., by mouth, tube or through a vein.

(f) Locomotion in room and immediate living environment: How you move between locations in your room and immediate living environment. If you are in a wheelchair, locomotion includes how self-sufficient you are once in your wheelchair.

(g) Locomotion outside of immediate living environment including outdoors: How you move to and return from more distant areas. If you are living in a boarding home or nursing facility (NF), this includes areas set aside for dining, activities, etc. If you are living in your own home or in an adult family home, locomotion outside immediate living environment including outdoors, includes how you move to and return from a patio or porch, backyard, to the mailbox, to see the next-door neighbor, etc.

(h) Walk in room, hallway and rest of immediate living environment: How you walk between locations in your room and immediate living environment.

(i) Medication management: Describes the amount of assistance, if any, required to receive medications, over the counter preparations or herbal supplements.

(j) Toilet use: How you use the toilet room, commode, bedpan, or urinal, transfer on/off toilet, cleanse, change pad, manage ostomy or catheter, and adjust clothes.

(k) Transfer: How you move between surfaces, i.e., to/from bed, chair, wheelchair, standing position. Transfer does not include how you move to/from the bath, toilet, or vehicle.

(l) Personal hygiene: How you maintain personal hygiene, including combing hair, brushing teeth, shaving, applying makeup, washing/drying face, hands (including nail care), and perineum (menses care). Personal hygiene does not include hygiene in baths and showers.

"Aged person" means a person sixty-five years of age or older.

"Agency provider" means a licensed home care agency or a licensed home health agency having a contract to provide long-term care personal care services to you in your own home.

"Application" means a written request for medical assistance or long-term care services submitted to the department by the applicant, the applicant's authorized representative, or, if the applicant is incompetent or incapacitated, someone acting responsibly for the applicant. The applicant must submit the request on a form prescribed by the department.

"Assessment details" means a summary of information that the department entered into the CARE assessment describing your needs.

"Assessment or reassessment" means an inventory and evaluation of abilities and needs based on an in-person interview in your own home or your place of residence, using CARE.

"Assistance available" means the amount of informal support available if the need is partially met. The department determines the amount of the assistance available using one of four categories:

(a) Less than one-fourth of the time;

(b) One-fourth to one-half of the time;

(c) Over one-half of the time to three-fourths of the time; or

(d) Over three-fourths but not all of the time.

"Assistance with body care" means you need assistance with:

(a) Application of ointment or lotions;

(b) Trimming of toenails;

(c) Dry bandage changes; or

(d) Passive range of motion treatment.

"Assistance with medication management" means you need assistance managing your medications. You are scored as:

(a) Independent if you remember to take medications as prescribed and manage your medications without assistance.

(b) Assistance required if you need assistance from a nonlicensed provider to facilitate your self-administration of a prescribed, over the counter, or herbal medication, as defined in chapter 246-888 WAC. Assistance required includes reminding or coaching you, handing you the medication container, opening the container, using an enabler to assist you in getting the medication into your mouth, alteration of a medication for self-administration, and placing the medication in your hand. This does not include assistance with intravenous or injectable medications. You must be aware that you are taking medications.

(c) Self-directed medication assistance/administration if you are a person with a functional disability who is capable of and who chooses to self-direct your medication assistance/administration.

(d) Must be administered if you must have medications placed in your mouth or applied or instilled to your skin or mucus membrane. Administration must either be performed by a licensed professional or delegated by a registered nurse to a qualified caregiver (per chapter 246-840 WAC). Intravenous or injectable medications may never be delegated. Administration may also be performed by a family member or unpaid caregiver if facility licensing regulations allow.

"Authorization" means an official approval of a departmental action, for example, a determination of client eligibility for service or payment for a client's long-term care services.

"Blind person" means a person determined blind as described under WAC 388-511-1105 by the division of disability determination services of the medical assistance administration.

"Categorically needy" means the status of a person who is eligible for medical care under Title XIX of the Social Security Act. See WAC 388-475-0100 and chapter 388-513 WAC.

"Client" means an applicant for service or a person currently receiving services from the department.

"Current" means a behavior occurred within seven days of the CARE assessment date, including the day of the assessment. Behaviors that the department designates as current must include information about:

(a) Whether the behavior is easily altered or not easily altered; and

(b) The frequency of the behavior.

"Decision making" means your ability and actual performance in making everyday decisions about tasks or activities of daily living. The department determines whether you are:

(a) Independent: Decisions about your daily routine are consistent and organized; reflecting your lifestyle, choices, culture, and values.

(b) Modified independence/difficulty in new situations: You have an organized daily routine, are able to make decisions in familiar situations, but experience some difficulty in decision making when faced with new tasks or situations.

(c) Moderately impaired/poor decisions; unaware of consequences: Your decisions are poor and you require reminders, cues and supervision in planning, organizing and correcting daily routines. You attempt to make decisions, although poorly.

(d) Severely impaired/no or few decisions: Decision making is severely impaired; you never/rarely make decisions.

"Department" means the state department of social and health services, aging and disability services administration or its designee.

"Designee" means area agency on aging.

"Difficulty" means how difficult it is or would be for you to perform an instrumental activity of daily living (IADL). This is assessed as:

(a) No difficulty in performing the activity;

(b) Some difficulty in performing the activity (e.g., you need some help, are very slow, or fatigue easily); or

(c) Great difficulty in performing the activity (e.g., little or no involvement in the activity is possible).

"Disabling condition" means you have a medical condition which prevents you from self performance of personal care tasks without assistance.

"Estate recovery" means the department's process of recouping the cost of Medicaid and long-term care benefit payments from the estate of the deceased client. See chapter 388-527 WAC.

"Home health agency" means a licensed:

(a) Agency or organization certified under Medicare to provide comprehensive health care on a part-time or intermittent basis to a patient in the patient's place of residence and reimbursed through the use of the client's medical identification card; or

(b) Home health agency, certified or not certified under Medicare, contracted and authorized to provide:

(i) Private duty nursing; or

(ii) Skilled nursing services under an approved Medicaid waiver program.

"Income" means income as defined under WAC 388-500-0005.

"Individual provider" means a person employed by you to provide personal care services in your own home. See WAC 388-71-0500 through 388-71-05909.

"Disability" is described under WAC 388-511-1105.

"Informal support" means a person or resource that is available to provide assistance without home and community program funding. The person or resource providing the informal support must be age 18 or older.

"Institution" means medical facilities, nursing facilities, and institutions for the mentally retarded. It does not include correctional institutions. See medical institutions in WAC 388-500-0005.

"Instrumental activities of daily living (IADL)" means routine activities performed around the home or in the community and includes the following:

(a) Meal preparation: How meals are prepared (e.g., planning meals, cooking, assembling ingredients, setting out food, utensils, and cleaning up after meals). NOTE: The department will not authorize this IADL to plan meals or clean up after meals. You must need assistance with actual meal preparation.

(b) Ordinary housework: How ordinary work around the house is performed (e.g., doing dishes, dusting, making bed, tidying up, laundry).

(c) Essential shopping: How shopping is completed to meet your health and nutritional needs (e.g., selecting items). Shopping is limited to brief, occasional trips in the local area to shop for food, medical necessities and household items required specifically for your health, maintenance or well-being. This includes shopping with or for you.

(d) Wood supply: How wood is supplied (e.g., splitting, stacking, or carrying wood) when you use wood as the sole source of fuel for heating and/or cooking.

(e) Travel to medical services: How you travel by vehicle to a physician's office or clinic in the local area to obtain medical diagnosis or treatment-includes driving vehicle yourself, traveling as a passenger in a car, bus, or taxi.

(f) Managing finances: How bills are paid, checkbook is balanced, household expenses are managed. The department cannot pay for any assistance with managing finances.

(g) Telephone use: How telephone calls are made or received (with assistive devices such as large numbers on telephone, amplification as needed).

"Long-term care services" means the services administered directly or through contract by the aging and disability services administration and identified in WAC 388-106-0015.

"Medicaid" is defined under WAC 388-500-0005.

"Medically necessary" is defined under WAC 388-500-0005.

"Medically needy (MN)" means the status of a person who is eligible for a federally matched medical program under Title XIX of the Social Security Act, who, but for income above the categorically needy level, would be eligible as categorically needy. Effective January 1, 1996, an AFDC-related adult is not eligible for MN.

"New Freedom Consumer Directed Services (NFCDS)" means a mix of services and supports to meet needs identified in the participant's assessment and identified in a New Freedom Spending Plan, within the limits of the individual budget, that provide participants with flexibility to plan, select, and direct the purchase of goods and services to meet identified needs. Participants have a meaningful leadership role in:

(a) The design, delivery and evaluation of services and supports;

(b) Exercising control of decisions and resources, making their own decisions about health and well being;

(c) Determining how to meet their own needs;

(d) Determining how and by whom these needs should be met; and

(e) Monitoring the quality of services received.

"New Freedom Consumer Directed Services (NFCDS) Participant" means a participant who is an applicant for or currently receiving services under the NFCDS waiver.

"New Freedom Spending Plan(NFSP)" means the plan developed by the participant, within the limits of an individual budget, that details the participant's choices to purchase specific NFCDS and provides required federal Medicaid documentation.

"Own home" means your present or intended place of residence:

(a) In a building that you rent and the rental is not contingent upon the purchase of personal care services as defined in this section;

(b) In a building that you own;

(c) In a relative's established residence; or

(d) In the home of another where rent is not charged and residence is not contingent upon the purchase of personal care services as defined in this section.

"Past" means the behavior occurred from eight days to five years of the assessment date. For behaviors indicated as past, the department determines whether the behavior is addressed with current interventions or whether no interventions are in place.

"Personal aide" is defined in RCW 74.39.007.

"Personal care services" means physical or verbal assistance with activities of daily living (ADL) and instrumental activities of daily living (IADL) due to your functional limitations. Assistance is evaluated with the use of assistive devices.

"Physician" is defined under WAC 388-500-0005.

"Plan of care" means assessment details and service summary generated by CARE.

"Provider or provider of service" means an institution, agency, or person:

(a) Having a signed department contract to provide long-term care client services; and

(b) Qualified and eligible to receive department payment.

"Residential facility" means a licensed adult family home under department contract or licensed boarding home under department contract to provide assisted living, adult residential care or enhanced adult residential care.

"Self performance for ADLs" means what you actually did in the last seven days before the assessment, not what you might be capable of doing. Coding is based on the level of performance that occurred three or more times in the seven-day period and does not include support provided as defined in WAC 388-106-0010. Your self performance level is scored as:

(a) Independent if you received no help or oversight, or if you needed help or oversight only once or twice;

(b) Supervision if you received oversight (monitoring or standby), encouragement, or cueing three or more times;

(c) Limited assistance if you were highly involved in the activity and given physical help in guided maneuvering of limbs or other non-weight bearing assistance on three or more occasions. For bathing, limited assistance means physical help is limited to transfer only;

(d) Extensive assistance if you performed part of the activity, but on three or more occasions, you needed weight bearing support or you received full performance of the activity during part, but not all, of the activity. For bathing, extensive assistance means you needed physical help with part of the activity (other than transfer);

(e) Total dependence if you received full caregiver performance of the activity and all subtasks during the entire seven-day period from others. Total dependence means complete nonparticipation by you in all aspects of the ADL; or

(f) Activity did not occur if you or others did not perform an ADL over the last seven days before your assessment. The activity may not have occurred because:

(i) You were not able (e.g., walking, if paralyzed);

(ii) No provider was available to assist; or

(iii) You declined assistance with the task.

"Self performance for IADLs" means what you actually did in the last thirty days before the assessment, not what you might be capable of doing. Coding is based on the level of performance that occurred three or more times in the thirty-day period. Your self performance is scored as:

(a) Independent if you received no help, set-up help, or supervision;

(b) Set-up help/arrangements only if on some occasions you did your own set-up/arrangement and at other times you received help from another person;

(c) Limited assistance if on some occasions you did not need any assistance but at other times in the last thirty days you required some assistance;

(d) Extensive assistance if you were involved in performing the activity, but required cueing/supervision or partial assistance at all times;

(e) Total dependence if you needed the activity fully performed by others; or

(f) Activity did not occur if you or others did not perform the activity in the last thirty days before the assessment.

"Service summary" is CARE information which includes: Contacts (e.g. emergency contact), services the client is eligible for, number of hours or residential rates, personal care needs, the list of formal and informal providers and what tasks they will provide, a provider schedule, referral needs/information, and dates and agreement to the services.

"SSI-related" is defined under WAC 388-475-0050.

"Status" means the amount of informal support available. The department determines whether the ADL or IADL is:

(a) Met, which means the ADL or IADL will be fully provided by an informal support;

(b) Unmet, which means an informal support will not be available to provide assistance with the identified ADL or IADL;

(c) Partially met, which means an informal support will be available to provide some assistance, but not all, with the identified ADL or IADL; or

(d) Client declines, which means you do not want assistance with the task.

"Supplemental Security Income (SSI)" means the federal program as described under WAC 388-500-0005.

"Support provided" means the highest level of support provided (to you) by others in the last seven days before the assessment, even if that level of support occurred only once.

(a) No set-up or physical help provided by others;

(b) Set-up help only provided, which is the type of help characterized by providing you with articles, devices, or preparation necessary for greater self performance of the activity. (For example, set-up help includes but is not limited to giving or holding out an item or cutting food);

(c) One-person physical assist provided;

(d) Two- or more person physical assist provided; or

(e) Activity did not occur during entire seven-day period.

"You/your" means the client.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.010 and 74.39A.020. 06-05-022, 388-106-0010, filed 2/6/06, effective 3/9/06. Statutory Authority: RCW 74.08.090, 74.09.520. 05-11-082, 388-106-0010, filed 5/17/05, effective 6/17/05.]


AMENDATORY SECTION(Amending WSR 06-05-022, filed 2/6/06, effective 3/9/06)

WAC 388-106-0015   What long-term care services does the department provide?   The department provides long-term care services through programs that are designed to help you remain in the community. These programs offer an alternative to nursing home care (which is described in WAC 388-106-0350 through 388-106-0360). You may receive services from any of the following:

(1) Medicaid personal care (MPC) is a Medicaid state plan program authorized under RCW 74.09.520. Clients eligible for this program may receive personal care in their own home or in a residential facility.

(2) Community options program entry system (COPES) is a Medicaid waiver program authorized under RCW 74.39A.030. Clients eligible for this program may receive personal care in their own home or in a residential facility.

(3) Medically needy residential waiver (MNRW) is a Medicaid waiver program authorized under RCW 74.39.041. Clients eligible for this program may receive personal care in a residential facility.

(4) Medically needy in-home waiver (MNIW) is a Medicaid waiver program authorized under RCW 74.09.700. Clients eligible for this program may receive personal care in their own home.

(5) Chore is a state-only funded program authorized under RCW 74.39A.110. Grandfathered clients may receive assistance with personal care in their own home.

(6) Volunteer chore is a state-funded program that provides volunteer assistance with household tasks to eligible clients.

(7) Program of all-inclusive care for the elderly (PACE) is a Medicaid/Medicare managed care program authorized under 42 CFR 460.2. Clients eligible for this program may receive personal care and medical services in their own home, in residential facilities, and in adult day health centers.

(8) Adult day health is a supervised daytime program providing skilled nursing and rehabilitative therapy services in addition to core services outlined in WAC 388-106-0800.

(9) Adult day care is a supervised daytime program providing core services, as defined under WAC 388-106-0800.

(10) GAU-funded residential care is a state-funded program authorized under WAC 388-400-0025. Clients eligible for this program may receive personal care services in an adult family home or an adult residential care facility.

(11) Residential care discharge allowance is a service that helps eligible clients to establish or resume living in their own home.

(12) Private duty nursing is a Medicaid service that provides an alternative to institutionalization in a hospital or nursing facility setting. Clients eligible for this program may receive at least four continuous hours of skilled nursing care on a day to day basis in their own home.

(13) Senior Citizens Services Act (SCSA) is a program authorized under chapter 74.38 RCW. Clients eligible for this program may receive community-based services as defined in RCW 74.38.040.

(14) Respite program is a program authorized under RCW 74.41.040 and WAC 388-106-1200. This program provides relief care for unpaid family or other caregivers of adults with a functional disability.

(15) Programs for persons with developmental disabilities are discussed in chapter 388-823 through 388-853 WAC.

(16) Nursing facility.

(17) Medicare/Medicaid Integration Project (MMIP) is a DSHS prepaid managed care program, authorized under 42 CFR Part 438, that integrates medical and long-term care services for clients who are sixty-five years of age or older and eligible for Medicare (Parts A and B) and Medicaid.

(18) New Freedom Consumer Directed Services (NFCDS) is a Medicaid waiver program authorized under RCW 74.39A.030.

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.010 and 74.39A.020. 06-05-022, 388-106-0015, filed 2/6/06, effective 3/9/06. Statutory Authority: RCW 74.08.090, 42 C.F.R. 441.302(a), Social Security Act, Section 1915(c) waiver rules, 42 C.F.R. 438. 05-19-045, 388-106-0015, filed 9/15/05, effective 10/16/05. Statutory Authority: RCW 74.08.090, 74.09.520. 05-11-082, 388-106-0015, filed 5/17/05, effective 6/17/05.]


AMENDATORY SECTION(Amending WSR 05-11-082, filed 5/17/05, effective 6/17/05)

WAC 388-106-0040   Who can provide long-term care services?   The following types of providers can provide long-term care services:

(1) Individual providers (IPs), who provide services to clients in their own home. IPs must meet the requirements outlined in WAC 388-71-0500 through 388-71-05909.

(2) Home care agencies, who provide services to clients in their own home. Home care agencies must be licensed under chapter 70.127 RCW and chapter 246-336 WAC and contracted with area agency on aging.

(3) Residential providers, which include licensed adult family homes and boarding homes, who contract with the department to provide assisted living, adult residential care, and enhanced adult residential care services (which may also include specialized dementia care).

(4) Providers who have contracted with the department to perform other services.

(5) In the case of New Freedom Consumer Directed Services (NFCDS), providers meeting NFCDS HCBS waiver requirements contracting with a department approved provider of fiscal management services.

[Statutory Authority: RCW 74.08.090, 74.09.520. 05-11-082, 388-106-0040, filed 5/17/05, effective 6/17/05.]


AMENDATORY SECTION(Amending WSR 05-11-082, filed 5/17/05, effective 6/17/05)

WAC 388-106-0055   What is the purpose of an assessment?   The purpose of an assessment is to:

(1) Determine eligibility for long-term care programs;

(2) Identify your strengths, limitations, and preferences;

(3) Evaluate your living situation and environment;

(4) Evaluate your physical health, functional and cognitive abilities;

(5) Determine availability of informal supports and other nondepartment paid resources;

(6) Determine need for intervention;

(7) Determine need for case management activities;

(8) Determine your classification group that will set your payment rate for residential care or number of hours of in-home care;

(9) Determine need for referrals; and

(10) Develop a plan of care, as defined in WAC 388-106-0010.

(11) In the case of New Freedom Consumer Directed Services, the purpose of an assessment is to determine functional eligibility and for the participant to develop the New Freedom Spending Plan, as defined in WAC 388-106-0010.

[Statutory Authority: RCW 74.08.090, 74.09.520. 05-11-082, 388-106-0055, filed 5/17/05, effective 6/17/05.]


AMENDATORY SECTION(Amending WSR 06-05-022, filed 2/6/06, effective 3/9/06)

WAC 388-106-0130   How does the department determine the number of hours I may receive for in-home care?   (1) The department assigns a base number of hours to each classification group as described in WAC 388-106-0125.

(2) The department will deduct from the base hours to account for your informal supports, as defined in WAC 388-106-0010, as follows:

(a) The CARE tool determines the adjustment for informal supports by determining the amount of assistance available to meet your needs, assigns it a numeric percentage, and reduces the base hours assigned to the classification group by the numeric percentage. The department has assigned the following numeric values for the amount of assistance available for each ADL and IADL:

Meds Self Performance Status Assistance Available Value

Percentage

Self administration of medications Rules for all codes apply except independent is not counted Unmet N/A 1
Met N/A 0
Decline N/A 0
Partially met <1/4 time .9
1/4 to 1/2 time .7
1/2 to 3/4 time .5
>3/4 time .3
Unscheduled ADLs Self Performance Status Assistance Available Value

Percentage

Bed mobility, transfer, walk in room, eating, toilet use Rules apply for all codes except: Did not occur/client not able and Did not occur/no provider = 1;

Did not occur/client declined and independent are not counted.

Unmet N/A 1
Met N/A 0
Decline N/A 0
Partially met <1/4 time .9
1/4 to 1/2 time .7
1/2 to 3/4 time .5
>3/4 time .3
Scheduled ADLs Self Performance Status Assistance Available Value

Percentage

Dressing,

personal hygiene,

bathing

Rules apply for all codes except: Did not occur/client not able and Did not occur/no provider = 1;

Did not occur/client declined and independent are not counted.

Unmet N/A 1
Met N/A 0
Decline N/A 0
Partially met <1/4 time .75
1/4 to 1/2 time .55
1/2 to 3/4 time .35
>3/4 time .15
IADLs Self Performance Status Assistance Available Value

Percentage

Meal preparation,

Ordinary housework,

Essential shopping*

Rules for all codes apply except independent is not counted. Unmet N/A 1
Met N/A 0
Decline N/A 0
Partially met <1/4 time .3
1/4 to 1/2 time .2
1/2 to 3/4 time .1
>3/4 time .05
IADLs Self Performance Status Assistance Available Value

Percentage

Travel to medical Rules for all codes apply except independent is not counted. Unmet N/A 1
Met N/A 0
Decline N/A 0
Partially met <1/4 time .9
1/4 to 1/2 time .7
1/2 to 3/4 time .5
>3/4 time .3
Key:

> means greater than

< means less than

*Results in 5% deduction for each IADL from the base hours. Remaining hours may be used for completion of household and personal care tasks.


(b) To determine the amount of reduction for informal support, the value percentage is divided by the number of qualifying ADLs and IADLs needs. The result is value A. Value A is then subtracted from one. This is value B. Value B is divided by three. This is value C. Value A and Value C are summed. This is value D. Value D is multiplied by the "base hours" assigned to your classification group and the result is base in-home care hours reduced for informal supports.

(3) Also, the department will adjust in-home base hours for the following shared living circumstances:

(a) If there is more than one client living in the same household, the status under subsection (2)(a) of this section must be met or partially met for the following IADLs:

(i) Meal preparation,

(ii) Housekeeping,

(iii) Shopping, and

(iv) Wood supply.

(b) If you and your paid provider live in the same household, the status under subsection (2)(a) of this section must be met for the following IADLs:

(i) Meal preparation,

(ii) Housekeeping,

(iii) Shopping, and

(iv) Wood supply.

(c) When there is more than one client living in the same household and your paid provider lives in your household, the status under subsection (2)(a) of this section must be met for the following IADLs:

(i) Meal preparation,

(ii) Housekeeping,

(iii) Shopping, and

(iv) Wood supply.

(4) After deductions are made to your base hours, as described in subsections (2) and (3), the department may add on hours based on your living environment:


Condition Status Assistance Available Add On Hours
Offsite laundry facilities, which means the client does not have facilities in own home and the caregiver is not available to perform any other personal or household tasks while laundry is done. Unmet N/A 8
Client is >45 minutes from essential services (which means he/she lives more than 45 minutes one-way from a full-service market). Unmet N/A 5
Met N/A 0
Partially met <1/4 time 5
between 1/4 to 1/2 time 4
between 1/2 to 3/4 time 2
>3/4 time 2
Wood supply used as sole source of heat. Unmet N/A 8
Met N/A 0
Declines N/A 0
Partially met <1/4 time 8
between 1/4 to 1/2 time 6
between 1/2 to 3/4 time 4
>3/4 time 2

(5) In the case of New Freedom Consumer Directed Services (NFCDS), the department determines hours as described in WAC 388-106-1450.

(6) The result of actions under subsections (2), (3), and (4) is the maximum number of hours that can be used to develop your plan of care. The department must take into account cost effectiveness, client health and safety, and program limits in determining how hours can be used to meet your identified needs. In the case of New Freedom Consumer Directed Services (NFCDS), a New Freedom Spending Plan (NFSP) is developed in place of a plan of care.

(((6))) (7) You and your case manager will work to determine what services you choose to receive if you are eligible. The hours may be used to authorize:

(a) Personal care services from a home care agency provider and/or an individual provider.

(b) Home delivered meals (i.e. a half hour from the available hours for each meal authorized).

(c) Adult day care (i.e. a half hour from the available hours for each hour of day care authorized).

(d) A home health aide if you are eligible per WAC 388-106-0300 or WAC 388-106-0500.

(e) A private duty nurse (PDN) if you are eligible per WAC 388-71-0910 and WAC 388-71-0915 or WAC 388-551-3000 (i.e. one hour from the available hours for each hour of PDN authorized).

(f) The purchase of New Freedom Consumer Directed Services (NFCDS).

[Statutory Authority: RCW 74.08.090, 74.09.520, 74.39A.010 and 74.39A.020. 06-05-022, 388-106-0130, filed 2/6/06, effective 3/9/06. Statutory Authority: RCW 74.08.090, 74.09.520. 05-11-082, 388-106-0130, filed 5/17/05, effective 6/17/05.]


NEW SECTION
WAC 388-106-1400   What services may I receive under New Freedom Consumer Directed Services (NFCDS)?   You may use your individual budget to purchase services that address an identified need in the CARE assessment. Service categories are:

(1) Personal Assistance Services, defined as supports involving the labor of another person to help participants carry out activities they are unable to perform independently as identified in the CARE assessment. Services may be provided in the participant's home or in the community and may include:

(a) Direct personal care services defined as activities of daily living, as defined in WAC 388-106-0010;

(b) Delegated health related tasks, per WAC 388-71-05805 through 388-71-05830. Providers of direct personal care services may be asked to do nurse delegated tasks under supervision of a nurse;

(c) Homemaking, or assistance with instrumental activities of daily living (essential shopping, housework and meal preparation);

(d) Other tasks or assistance with activities that support independent functioning, and are necessary due to functional disability;

(e) Personal assistance with transportation.

(2) Treatment and Health Maintenance activities that:

(a) Are beyond the scope of the Medicaid State Plan that are necessary to promote the participant's health and ability to live and participate in the community;

(b) Are provided for the purpose of preventing further deterioration, or improving or maintaining the participant's current level of functioning; and

(c) Are performed or provided by people with specialized skill, registration, certification or licenses as required by state law.

(3) Individual Directed Goods, Services and Supports, defined as services, equipment or supplies not otherwise provided through this waiver or through the Medicaid State Plan, and address an identified need in the CARE assessment; and

(a) Will allow the participant to function more independently; or

(b) Increase safety and welfare; or

(c) Allow the person to perceive, control, or communicate with their environment.

(4) Environmental or vehicle modifications, defined as:

(a) Alterations to a participant's residence or vehicle that:

(i) Are necessary to accommodate the participant's disability and promote functional independence, health, safety and welfare; and

(ii) Are not adaptations or improvements, which are of general utility or add to the total square footage.

(b) Vehicles subject to modification must be owned by the participant or participant's family who reside with the participant; and

(i) Must be in good working condition, licensed, and insured according to Washington state law; and

(ii) Modifications demonstrate cost effectiveness when compared to available alternative transportation.

(5) Training and educational supports, which are supports beyond the scope of Medicaid State Plan services that are necessary to promote the participant's health and ability to live and participate in the community and maintains, slows decline, or improves functioning and adaptive skills. Examples include:

(a) Training or education on participant health issues, or personal skill development;

(b) Training/education to paid or unpaid caregivers related to the needs of the participant.

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NEW SECTION
WAC 388-106-1410   Am I eligible for New Freedom Consumer Directed Services (NFCDS)-funded services?   You are eligible for NFCDS-funded services if you reside in your own home and meet all of the following criteria. The department must assess your needs using CARE and determine that:

(1) You are in NFCDS HCBS waiver specified target groups of:

(a) Eighteen or older and blind or have a physical disability; or

(b) Sixty-five or older; and

(2) You meet financial eligibility requirements. This means the department will assess your finances, determine if your income and resources fall within the limits, and determine the amount you may be required to contribute, if any, toward the cost of your care as described in WAC 388-515-1505; and

(3) You:

(a) Are not eligible for Medicaid personal care services (MPC); or

(b) Are eligible for MPC services, but the department determines that the amount, duration, or scope of your needs is beyond what MPC can provide; and

(4) Your CARE assessment shows you need the level of care provided in a nursing facility as defined in WAC 388-106-0355; and

(5) You live in your own home, or will be living in your own home by the time NFCDS start.

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NEW SECTION
WAC 388-106-1415   When do New Freedom Consumer Directed Services (NFCDS) start?   Your eligibility for NFCDS begins the date the department authorizes services.

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NEW SECTION
WAC 388-106-1420   How do I remain eligible for New Freedom Consumer Directed Services (NFCDS)?   (1) In order to remain eligible for NFCDS, you must be in need of services in accordance with WAC 388-106-1410, as determined through a CARE assessment. The CARE assessment must be performed at least annually or more often when there are significant changes in your functional or financial circumstances.

(2) When eligibility statutes, regulations, and/or rules for NFCDS change, irrespective of whether your functional or financial circumstances have changed, if you do not meet the changed eligibility requirements, the department will terminate your NFCDS services.

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NEW SECTION
WAC 388-106-1425   How do I pay for New Freedom Consumer Directed Services (NFCDS)?   Depending on your income and resources, you may be required to pay participation toward the cost of your care, as described in WAC 388-515-1505. If you have nonexempt income that exceeds the cost of NFCDS services, you may keep the difference. Since you are receiving services in your own home, you are allowed to keep some of your income for a maintenance allowance.

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NEW SECTION
WAC 388-106-1430   Can I be employed and receive New Freedom Consumer Directed Services (NFCDS)?   You can be employed and receive NFCDS, per WAC 388-515-1505.

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NEW SECTION
WAC 388-106-1435   Who can direct New Freedom Consumer Directed Services (NFCDS)?   The NFCDS participant directs services. The participant can also designate a representative to assist them.

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NEW SECTION
WAC 388-106-1440   What is an individual budget?   An individual budget means the maximum amount of funding authorized by the department and allocated to the participant for the purchase of New Freedom Consumer Directed services.

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NEW SECTION
WAC 388-106-1445   How is the amount of the individual budget determined?   The department will calculate the individual budget amount after the NFCDS participant is assigned a classification resulting from completion of the comprehensive assessment reporting and evaluation tool, CARE. The calculation will be based on:

(a) The published hourly rate for individual provider personal care paid by the department multiplied by the number of hours generated by the assessment, multiplied by a factor of .95, plus an amount equal to the average per participant expenditures for non-personal care supports purchased in the COPES waiver. The average will be re-calculated in July of each year.

(b) If the participant selects a home care agency, an adjustment will be made for each hour of personal care identified in the NFSP for an amount equal to the difference between the published individual provider rate and home care agency rate.

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NEW SECTION
WAC 388-106-1450   Is the individual budget intended to fully meet all of my needs?   The program provides funds in an amount proportionate to the amount of resources you would receive through COPES, and gives you flexibility to self-direct the purchase of goods and services to meet your long-term care needs. The degree to which the budget meets your needs depends on the supports you identify and prioritize in your spending plan. Depending on your decisions, after your budget is exhausted, some of your needs may be unmet, or you may find other resources to address them.

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NEW SECTION
WAC 388-106-1455   What happens to unused funds from my individual budget?   Unused funds, up to three thousand dollars, may be held in reserve for future purchases documented in the NFSP. Reserves in excess of three thousand dollars may be maintained for planned purchases with approval from the department.

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NEW SECTION
WAC 388-106-1460   When can my New Freedom Spending Plan (NFSP) be denied?   Your NFSP may be denied when the plan you develop does not:

(a) Include services in the New Freedom definition;

(b) Address your needs as it relates to performance of Activities of Daily Living and Instrumental Activities of Daily Living;

(c) Include strategies and steps to address known critical risks;

(d) Identify the payment rate; or

(e) Adequately describe the service.

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NEW SECTION
WAC 388-106-1465   Who can deny my New Freedom Spending Plan (NFSP)?   Your plan can be denied by your New Freedom Consultant, who assists NFCDS participants to develop and use a New Freedom Spending Plan to:

(a) Meet identified needs;

(b) Address health and safety needs;

(c) Develop options to meet those needs;

(d) Make informed decisions about their individual budget; and

(e) Obtain identified supports and services.

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NEW SECTION
WAC 388-106-1470   Are there waiting lists for New Freedom Consumer Directed Services (NFCDS)?   The department will create a waiting list for NFCDS in accordance with caseload limits determined by legislative funding. Participants on the waiting list will gain access in the following order:

(1) Nursing home residents who are returning home and are assessed for NFCDS waiver services will be ranked first on the waiting list by date of application for services;

(2) Individuals living in the community with a higher level of need, as determined by the CARE assessment, will be ranked higher on the wait list over participants with a lower level of need; and

(3) When two or more individuals on the waiting list have equal need levels, the individual with the earlier application for NFCDS will have priority over later applications for services.

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NEW SECTION
WAC 388-106-1475   How do I end enrollment in New Freedom Consumer Directed Services (NFCDS)?   (1) You may choose to voluntarily end your enrollment from NFCDS without cause at any time. To do so, you must give notice to the department. If you give notice:

(a) Before the fifteenth of the month, the department will end your enrollment at the end of the month; or

(b) After the fifteenth, the department will end your enrollment the end of the following month.

(2) Your enrollment may also end involuntarily if you:

(a) Move out of the designated service area or are out of the service area for more than thirty consecutive days, unless you have documented the purpose of the longer absence in the NFSP; or

(b) Do not meet the terms for consumer direction of services outlined in the NFCDS enrollment agreement when:

(i) Even with help from a representative, you are unable to develop a NFSP or self-direct services or manage your individual budget or NFSP;

(ii) Any one factor or several factors of such a magnitude jeopardize the health, welfare, and safety of you and others, requiring termination of services under WAC 388-106-0047;

(iii) You become financially ineligible for Medicaid services; or

(iv) You no longer meet the nursing facility level of care requirement as defined in WAC 388-106-0355.

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NEW SECTION
WAC 388-106-1480   What are my hearing rights to appeal New Freedom Consumer Directed Services (NFCDS) actions?   You have a right to a hearing under WAC 388-106-1300 through 388-106-1310, and under chapter 388-02 WAC.

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Washington State Code Reviser's Office