PDFWAC 388-845-0110

What are the limits to the waiver services you may receive?

The following limits apply to the waiver services you may receive:
(1) A service must be available in your waiver and address an unmet need identified in your DDA assessment and person-centered service plan.
(2) Stabilization services may be added to your person-centered service plan after the services have been provided.
(3) Waiver services are limited to services required to prevent placement in an intermediate care facility for individuals with intellectual disabilities (ICF/IID).
(4) The daily cost of your waiver services must not exceed the average daily cost of care in an ICF/IID.
(5) Waiver services must not replace or duplicate other available paid or unpaid supports or services. Before DDA will cover a service through waiver services, you must first request and be denied all applicable covered benefits through private insurance, medicare, the medicaid state plan, and other resources.
(6) Waiver funding must not be authorized for treatments determined by DSHS to be experimental or investigational under WAC 182-531-0050.
(7) For the individual and family services (IFS) waiver, basic plus waiver, and children's intensive in-home behavioral support waiver, services must not exceed the yearly limits specified in these programs for specific services or combinations of services.
(8) Your choice of qualified providers and services is limited to the most cost-effective option that meets your unmet need identified in your DDA assessment and person-centered service plan.
(9) Services, with the exception of respite care, must be provided in integrated settings.
(10) Services provided out-of-state, other than in recognized bordering cities, are limited to respite care during vacations of not more than 30 consecutive days.
(11) You may receive services in a recognized out-of-state bordering city under WAC 182-501-0175.
(12) Other out-of-state waiver services require an approved exception to rule before DDA will authorize payment.
(13) Waiver services do not cover:
(a) Copays;
(b) Deductibles;
(c) Dues;
(d) Membership fees; or
(e) Subscriptions.
(14) Waiver services do not cover a product unless the product is:
(a) The most basic model of the product available that can meet your health and safety need related to your intellectual or developmental disability;
(b) The least restrictive means for meeting that need; and
(c) Requested by you.
[Statutory Authority: RCW 71A.12.030, 71A.12.120, and 42 C.F.R. 441.301 (c)(6). WSR 23-18-035, § 388-845-0110, filed 8/29/23, effective 9/29/23. Statutory Authority: RCW 71A.12.030 and 71A.12.120. WSR 21-19-108, § 388-845-0110, filed 9/20/21, effective 10/21/21. Statutory Authority: RCW 71A.12.030, 71A.12.120, 42 C.F.R. 441 Subpart G. WSR 18-14-001, § 388-845-0110, filed 6/20/18, effective 7/21/18. Statutory Authority: 2014 c 139, 2014 c 166, 2015 3rd sp.s. c 4, RCW 71A.12.030, and 71A.12.120. WSR 16-17-009, § 388-845-0110, filed 8/4/16, effective 9/4/16. Statutory Authority: RCW 71A.12.030 and 2012 c 49. WSR 13-24-045, § 388-845-0110, filed 11/26/13, effective 1/1/14. Statutory Authority: RCW 71A.12.030, 71A.12.120 and Title 71A RCW. WSR 07-20-050, § 388-845-0110, filed 9/26/07, effective 10/27/07. Statutory Authority: RCW 71A.12.030, 71A.12.12 [ 71A.12.120] and chapter 71A.12 RCW. WSR 06-01-024, § 388-845-0110, filed 12/13/05, effective 1/13/06.]