PERMANENT RULES
SOCIAL AND HEALTH SERVICES
(Aging and Disability Services Administration)
Effective Date of Rule: Thirty-one days after filing.
Purpose: The division of developmental disabilities has received initial approval from the federal Centers for Medicare and Medicaid Services (CMS) to implement four home and community based service (HCBS) waivers, which replaced the community alternatives program (CAP) waiver. These rules will clarify eligibility, service array, utilization, provider qualifications, client appeal rights and access to services. This filing includes a new chapter 388-845 WAC. When effective, these rules replace the emergency rules filed as WSR 05-19-044.
Statutory Authority for Adoption: RCW 71A.12.030, 71A.12.12 [71A.12.120].
Other Authority: Chapter 71A.12 RCW.
Adopted under notice filed as WSR 05-17-055 on August 9, 2005.
Changes Other than Editing from Proposed to Adopted Version: The wording in WAC 388-845-0035, 388-845-0040 and 388-845-0045 has been changed to read "enrolled in a waiver."
WAC 388-845-0050 has been changed to reflect that all requests for enrollment in a waiver are documented in a DDD database.
WAC 388-845-0051 has been expanded to clarify that notice will be sent for a denial of a request to be enrolled in a waiver.
WAC 388-845-0050(2) has been changed to read: "When there is capacity to enroll additional people in a waiver, WAC 388-845-0045 describes how DDD will determine who will be enrolled."
WAC 388-845-0065(2) has been changed to read: "Your eligibility for nonwaiver state-only funded DDD services..."
A cross-reference to WAC 388-845-1500 has been added to WAC 388-845-0710.
Cross-reference to WAC 388-845-1505 and 388-845-1510 have been added to WAC 388-845-0750.
WAC 388-845-3080 (1)(a) and 388-845-3085 (1)(a) have been changed to read: "Identify more available natural supports."
WAC 388-845-3080(4) and 388-845-3085(3) have been changed to read: "... you will remain eligible for nonwaiver DDD services but access to state-only funded DDD services is limited by the availability of funding ..."
A final cost-benefit analysis is available by contacting Steve Brink, P.O. Box 5310, Olympia, WA 98507-5310, phone (360) 725-3416, fax (360) 407-0955, e-mail brinksc@dshs.wa.gov. There are no changes to the preliminary cost-benefit analysis.
Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 131, Amended 0, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.
Number of Sections Adopted at Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.
Number of Sections Adopted on the Agency's Own Initiative: New 0, Amended 0, Repealed 0.
Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.
Number of Sections Adopted Using Negotiated Rule Making: New 131, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 0, Repealed 0.
Date Adopted: December 9, 2005.
Andy Fernando, Manager
Rules and Policies Assistance Unit
3373.17DDD HOME AND COMMUNITY BASED SERVICES WAIVERS
"Aggregate Services" means a combination of services subject to the dollar limitations in the Basic and Basic Plus waivers.
"CAP waiver" means the Community Alternatives Program waiver.
"CARE" means the Comprehensive Assessment and Reporting Evaluation.
"DDD" means the division of developmental disabilities, a division within the aging and disability services administration of the department of social and health services.
"Department" means the department of social and health services.
"Employment/Day Program Services" means community access, person-to-person, prevocational services or supported employment services subject to the dollar limitations in the Basic and Basic Plus waivers.
"HCBS Waivers" means home and community based services waivers.
"ICF/MR" means an Intermediate Care Facility for the Mentally Retarded.
"Plan of Care (POC)" means the primary tool DDD uses to determine and document your needs and to identify services to meet those needs.
"Providers" means an individual or agency who is licensed, certified and/or contracted to provide services to you.
"Respite Assessment" means a series of questions about you and your caregiver used to determine the amount of respite care available to you.
"SSI" means Supplemental Security Income, an assistance program administered by the federal Social Security Administration for blind, disabled and aged individuals.
"SSP" means State Supplementary Payment, a benefit administered by the department intended to augment an individual's SSI.
"State Funded Services" means services that are funded entirely with state dollars.
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(2) Certain federal regulations are "waived" enabling the provision of services in the home and community to individuals who would otherwise require the services provided in an ICF/MR as defined in chapters 388-835 and 388-837 WAC.
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(1) Basic waiver;
(2) Basic Plus waiver;
(3) CORE waiver; and
(4) Community Protection waiver.
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(1) You have been determined eligible for DDD services per RCW 71A.10.020(3).
(2) You have been determined to meet ICF/MR level of care per WAC 388-845-0070 through 388-845-0090.
(3) You meet disability criteria established in the Social Security Act.
(4) You meet financial eligibility requirements as defined in WAC 388-515-1510.
(5) You choose to receive services in the community rather than in an ICF/MR facility.
(6) You have a need for waiver services as identified in your plan of care.
(7) You are not residing in hospital, jail, prison, nursing facility, ICF/MR, or other institution.
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(1) DDD must address your assessed health and welfare needs in your plan of care, as specified in WAC 388-845-3055.
(2) You have access to DDD paid services that are provided within the scope of your waiver, subject to the limitations in WAC 388-845-0110 and WAC 388-845-0115.
(3) DDD will provide waiver services you need and qualify for within your waiver.
(4) DDD will not deny or limit your waiver services based on a lack of funding.
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(1) First priority will be given to current waiver participants assessed to require a different waiver because their needs have increased and these needs cannot be met within the scope of their current waiver.
(2) DDD may also consider any of the following populations in any order:
(a) Priority populations as identified and funded by the legislature.
(b) Persons DDD has determined to be in immediate risk of ICF/MR admission due to unmet health and safety needs.
(c) Persons identified as a risk to the safety of the community.
(d) Persons currently receiving services through state-only funds.
(e) Persons on an HCBS waiver that provides services in excess of what is needed to meet their identified health and welfare needs.
(f) Persons who were previously on an HCBS waiver since April 2004 and lost waiver eligibility per WAC 388-845-0060(9).
(3) For the Basic waiver only, DDD may consider persons who need the waiver services available in the Basic waiver to maintain them in their family's home.
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(1) Your request for waiver enrollment will be documented by DDD in a statewide database.
(2) When there is capacity available to enroll additional people in a waiver, WAC 388-845-0045 describes how DDD will determine who will be enrolled.
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(1) DDD completes a reassessment at least every twelve months to determine if you continue to meet all of the eligibility requirements in WAC 388-845-0030.
(2) You must receive a waiver service at least once in every thirty consecutive days, as specified in WAC 388-513-1320 (3)(b).
(3) Your plan of care, CARE assessment/reassessment and respite assessment/reassessment must be done in person.
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(1) You no longer meet one of the requirements listed in WAC 388-845-0030;
(2) You no longer need waiver services;
(3) You do not use a waiver service at least once in every thirty consecutive days;
(4) You are on the Community Protection waiver and choose not to be served by a certified residential community protection provider-intensive supported living services (CP-ISLS);
(5) You choose to disenroll from the waiver;
(6) You reside out of state;
(7) You cannot be located or do not make yourself available for the annual waiver reassessment of eligibility;
(8) You refuse to participate with DDD in:
(a) Service planning;
(b) Required quality assurance and program monitoring activities; or
(c) Accepting services agreed to in your plan of care as necessary to meet your health and safety needs.
(9) You are residing in a hospital, jail, prison, nursing facility, ICF/MR, or other institution and remain in residence at least one full calendar month, and are still in residence:
(a) At the end of the twelfth month following the effective date of your current plan of care, as described in WAC 388-845-3060; or
(b) On March 31st, the end of the waiver fiscal year, whichever date occurs first.
(10) Your needs exceed the maximum funding level or scope of services under the Basic or Basic Plus waiver as specified in WAC 388-845-3080; or
(11) Your needs exceed what can be provided under the CORE or Community Protection waiver as specified in WAC 388-845-3085.
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(1) DDD cannot guarantee continuation of your current services, including Medicaid eligibility.
(2) Your eligibility for nonwaiver state-only funded DDD services is based upon availability of funding and program eligibility for a particular service.
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(2) If you are age six through twelve, you need major or moderate support in seven of nine of the tasks in (3) below.
(3) The form indicates certain tasks that require major support and which require moderate or major support.
(a) Major support for:
(i) Dressing and grooming self;
(ii) Toileting self.
(b) Major or moderate support for:
(i) Eating;
(ii) Mobility;
(iii) Communication;
(iv) Making choices and taking responsibility;
(v) Exploring one's environment;
(vi) Supports needed to meet therapy and health needs; or
(vii) Family/caregiver support required to maintain the child at home.
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(1) If you do not have a qualifying score for determining ICF/MR level of care using the department approved assessment, you may provide DDD other current information that provides evidence of your need for waiver services.
(2) This additional information may include occupational therapy (OT), physical therapy (PT), psychological, nursing, social work, speech and hearing, or other professional evaluations that reflect current needs.
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(1) If you were on the CAP waiver as of March 2004, your initial assignment to the Basic, Basic Plus, CORE, or Community Protection waiver was based on:
(a) Services you received from DDD in October 2002 through September 2003; and
(b) Services you were authorized to receive in October, November and December 2003.
(2) If you are new to a waiver since April 1, 2004, assignment is based on your assessment and service plan.
(3) Additional criteria apply to the assignment to the Community Protection waiver.
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(1) You have been identified by DDD as a person who meets one or more of the following:
(a) You have been convicted of or charged with a crime of sexual violence as defined in chapter 71.09 RCW;
(b) You have been convicted of or charged with acts directed towards strangers or individuals with whom a relationship has been established or promoted for the primary purpose of victimization, or persons of casual acquaintance with whom no substantial personal relationship exists;
(c) You have been convicted of or charged with a sexually violent offense and/or predatory act, and may constitute a future danger as determined by a qualified professional;
(d) You have not been convicted and/or charged, but you have a history of stalking, sexually violent, predatory and/or opportunistic behavior which demonstrates a likelihood to commit a sexually violent and/or predatory act based on current behaviors that may escalate to violence, as determined by a qualified professional; or
(e) You have committed one or more violent crimes.
(2) You receive or agree to receive residential services from certified residential community protection provider-intensive supported living services (CP-ISLS); and
(3) You comply with the specialized supports and restrictions in your:
(a) Plan of care (POC);
(b) Individual instruction and support plan (IISP); and/or
(c) Treatment plan provided by DDD approved certified individuals and agencies.
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(1) A service must be offered in your waiver and authorized in your plan of care.
(2) Mental health stabilization services may be added to your plan of care after the services are provided.
(3) Waiver services are limited to services required to prevent ICF/MR placement.
(4) The cost of your waiver services cannot exceed the average daily cost of care in an ICF/MR.
(5) Waiver services cannot replace or duplicate other available paid or unpaid supports or services.
(6) Waiver funding cannot be authorized for treatments determined by DSHS to be experimental.
(7) The Basic and Basic Plus waivers have yearly limits on some services and combinations of services. The combination of services is referred to as aggregate services or employment/day program services.
(8) Your choice of qualified providers and services is limited to the most cost effective option that meets your assessed needs.
(9) Services provided out-of-state, other than in recognized bordering cities, are limited to respite care and personal care during vacations.
(a) You may receive services in a recognized out-of-state bordering city on the same basis as in-state services.
(b) The only recognized bordering cities are:
(i) Coeur d'Alene, Moscow, Sandpoint, Priest River and Lewiston, Idaho; and
(ii) Portland, The Dalles, Hermiston, Hood River, Rainier, Milton-Freewater and Astoria, Oregon.
(10) Other out-of-state waiver services require an approved exception to rule before DDD can authorize payment.
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(1) You are not eligible for state-only funding for DDD services; and
(2) You are not eligible for Medicaid personal care.
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| BASIC WAIVER | SERVICES | YEARLY LIMIT |
| AGGREGATE SERVICES: | May not exceed $1425 per year on any combination of these services | |
| Behavior management and consultation | ||
| Community guide | ||
| Environmental accessibility adaptations | ||
| Occupational therapy | ||
| Physical therapy | ||
| Specialized medical equipment/supplies | ||
| Specialized psychiatric services | ||
| Speech, hearing and language services | ||
| Staff/family consultation and training | ||
| Transportation | ||
| EMPLOYMENT/DAY PROGRAM SERVICES: | May not exceed $6500 per year | |
| Community access | ||
| Person-to-person | ||
| Prevocational services | ||
| Supported employment | ||
| Sexual Deviancy Evaluation | Limits are determined by DDD | |
| Respite care | Limits are determined respite assessment | |
| Personal care | Limits are determined by CARE assessment | |
| MENTAL HEALTH STABILIZATION SERVICES: | Limits are determined by a mental health professional or DDD | |
| Behavior management and consultation | ||
| Mental health crisis diversion bed services | ||
| Skilled nursing | ||
| Specialized psychiatric services | ||
| Emergency assistance is only for services contained in the Basic waiver | $6000 per year; Preauthorization required |
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| BASIC PLUS WAIVER | SERVICES | YEARLY LIMIT |
| AGGREGATE SERVICES: | May not exceed $6070 per year on any combination of these services | |
| Behavior management and consultation | ||
| Community guide | ||
| Environmental accessibility adaptations | ||
| Occupational therapy | ||
| Physical therapy | ||
| Skilled nursing | ||
| Specialized medical equipment/supplies | ||
| Specialized psychiatric services | ||
| Speech, hearing and language services | ||
| Staff/family consultation and training | ||
| Transportation | ||
| EMPLOYMENT/DAY PROGRAM SERVICES: | May not exceed $9500 per year | |
| Community access | ||
| Person-to-person | ||
| Prevocational services | ||
| Supported employment | ||
| Adult foster care (adult family home) | Determined per department rate structure | |
| Adult residential care (boarding home) | ||
| MENTAL HEALTH STABILIZATION SERVICES: | Limits determined by a mental health professional or DDD | |
| Behavior management and consultation | ||
| Mental health crisis diversion bed services | ||
| Skilled nursing | ||
| Specialized psychiatric services | ||
| Personal care | Limits determined by the CARE assessment | |
| Respite care | Limits are determined by respite assessment | |
| Sexual Deviancy Evaluation | Limits are determined by DDD | |
| Emergency assistance in only for services contained in the Basic Plus waiver | $6000 per year; Preauthorization required |
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| CORE WAIVER | SERVICES | YEARLY LIMIT |
| Behavior management and consultation | Determined by the Plan of Care, not to exceed the average cost of an ICF/MR for any combination of services | |
| Community guide | ||
| Community transition | ||
| Environmental accessibility adaptations | ||
| Occupational therapy | ||
| Respite care | ||
| Sexual deviancy evaluation | ||
| Skilled nursing | ||
| Specialized medical equipment/supplies | ||
| Specialized psychiatric services | ||
| Speech, hearing and language services | ||
| Staff/family consultation and training | ||
| Transportation | ||
| Residential habilitation | ||
| Community access | ||
| Person-to-person | ||
| Prevocational services | ||
| Supported employment | ||
| MENTAL HEALTH STABILIZATION SERVICES: | Limits determined by a mental health professional or DDD | |
| Behavior management and consultation | ||
| Mental health crisis diversion bed services | ||
| Skilled nursing | ||
| Specialized psychiatric services | ||
| Personal care | Limited by CARE assessment |
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| COMMUNITY PROTECTION WAIVER | SERVICES | YEARLY LIMIT |
| Behavior management and consultation | Determined by the Plan of Care, not to exceed the average cost of an ICF/MR for any combination of services | |
| Community transition | ||
| Environmental accessibility adaptations | ||
| Occupational therapy | ||
| Physical therapy | ||
| Sexual deviancy evaluation | ||
| Skilled nursing | ||
| Specialized medical equipment and supplies | ||
| Specialized psychiatric services | ||
| Speech, hearing and language services | ||
| Staff/family consultation and training | ||
| Transportation | ||
| Residential habilitation | ||
| Person-to-person | ||
| Prevocational services | ||
| Supported employment | ||
| MENTAL HEALTH STABILIZATION SERVICES: | Limits determined by a mental health professional or DDD | |
| Behavioral management and consultation | ||
| Mental health crisis diversion bed services | ||
| Skilled nursing | ||
| Specialized psychiatric services |
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WAIVER SERVICES DEFINITIONS
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(1) AFH services are defined and limited per chapter 388-106 WAC and chapter 388-71 WAC governing Medicaid personal care and the comprehensive assessment and reporting evaluation (CARE).
(2) Rates are determined by and limited to department published rates for the level of care generated by CARE.
(3) AFH reimbursement cannot be supplemented by other department funding.
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(1) An ARC is a licensed boarding home for seven or more unrelated adults.
(2) Services include, but are not limited to, individual and group activities; assistance with arranging transportation; assistance with obtaining and maintaining functional aids and equipment; housework; laundry; self-administration of medications and treatments; therapeutic diets; cuing and providing physical assistance with bathing, eating, dressing, locomotion and toileting; stand-by one person assistance for transferring.
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(1) Be a licensed boarding home;
(2) Be contracted with ADSA to provide ARC services; and
(3) Have completed the required and approved DDD specialty training.
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(1) ARC services are defined and limited by boarding home licensure and rules in chapter 388-78A WAC, and chapter 388-106 WAC and chapter 388-71 WAC governing Medicaid personal care and the comprehensive assessment and reporting evaluation (CARE).
(2) Rates are determined and limited to department published rates for the level of care generated by CARE.
(3) ARC reimbursement cannot be supplemented by other department funding.
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(a) Strategies for effectively relating to caregivers and other people in the waiver participant's life; and
(b) Direct interventions with the person to decrease aggressive, destructive, and sexually inappropriate or other behaviors that compromise their ability to remain in the community (i.e., training, specialized cognitive counseling).
(2) Behavior management and consultation may also be provided as a mental health stabilization service in accordance with WAC 388-845-1150 through 388-845-1160.
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(1) Marriage and family therapist;
(2) Mental health counselor;
(3) Psychologist;
(4) Sex offender treatment provider;
(5) Social worker;
(6) Registered nurse (RN) or licensed practical nurse (LPN);
(7) Psychiatrist;
(8) Psychiatric advanced registered nurse practitioner (ARNP);
(9) Physician assistant working under the supervision of a psychiatrist;
(10) Registered counselor; or
(11) Polygrapher.
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(1) DDD and the treating professional will determine the need and amount of service you will receive, subject to the limitations in subsection (2) below.
(2) The dollar limitations for aggregate services in your Basic and Basic Plus waiver limit the amount of service unless provided as a mental health stabilization service.
(3) DDD reserves the right to require a second opinion from a department-selected provider.
(4) Behavior management and consultation not provided as a mental health stabilization service requires prior approval by DDD.
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(1) If you are age sixty-two or older, this service is available to assist you to participate in activities, events and organizations in the community in ways similar to others of retirement age.
(2) This service is available to adults in the Basic, Basic Plus, and CORE waiver.
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(1) You must be age sixty-two or older.
(2) You cannot be authorized to receive community access services if you receive pre-vocational services or supported employment services.
(3) The dollar limitations for employment/day program services in your Basic or Basic Plus waiver limit the amount of service you may receive.
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(2) The dollar limitations for aggregate services in your Basic or Basic Plus waiver limit the amount of service you may receive.
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(2) Community transition services include:
(a) Security deposits (not to exceed the equivalent of two month's rent) that are required to obtain a lease on an apartment or home;
(b) Essential furnishings such as a bed, a table, chairs, window blinds, eating utensils and food preparation items;
(c) Moving expenses required to occupy and use a community domicile;
(d) Set-up fees or deposits for utility or service access (e.g., telephone, electricity, heating); and
(e) Health and safety assurances, such as pest eradication, allergen control or one-time cleaning prior to occupancy.
(3) Community transition services are available in the CORE and Community Protection waivers.
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(2) Providers of community transition services for individuals in the Community Protection waiver must meet the requirements as a provider of residential habilitation services contained in WAC 388-845-1510.
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(a) Diversional or recreational items such as televisions, cable TV access, VCRs, MP3, CD or DVD players; and
(b) Computers whose use is primarily diversional or recreational.
(2) Community transition services are available only to individuals that are moving from an institution to a community setting and are enrolled in either the CORE or Community Protection waiver.
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(1) You involuntarily lose your present residence for any reason either temporary or permanent;
(2) You lose your present caregiver for any reason, including death;
(3) There are changes in your caregiver's mental or physical status resulting in the caregiver's inability to perform effectively for the individual; or
(4) There are significant changes in your emotional or physical condition that requires a temporary increase in the amount of a waiver service.
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(1) Prior authorization is required based on a reassessment of your plan of care to determine the need for emergency services;
(2) Payment authorizations are reviewed every thirty days and cannot exceed six thousand dollars per twelve months based on the effective date of your current plan of care (POC);
(3) Emergency services are limited to the scope of services in your waiver;
(4) Emergency Assistance may be used for interim services until:
(a) The emergency situation has been resolved; or
(b) You are transferred to alternative supports that meet your assessed needs; or
(c) You are transferred to an alternate waiver that provides the service you need.
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(a) Ensure the health, welfare and safety of the individual; or
(b) Enable the individual who would otherwise require institutionalization to function with greater independence in the home.
(2) Environmental accessibility adaptations may include the installation of ramps and grab bars, widening of doorways, modification of bathroom facilities, or installing specialized electrical and/or plumbing systems necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the individual.
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(1) Prior approval by DDD is required.
(2) Environmental accessibility adaptations or improvements to the home are excluded if they are of general utility without direct medical or remedial benefit to the individual, such as carpeting, roof repair, central air conditioning, etc.
(3) Environmental accessibility adaptations cannot add to the total square footage of the home.
(4) The dollar limitations for aggregate services in your Basic or Basic Plus waiver limit the amount of service you may receive.
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(2) The department does not pay for treatment determined by DSHS to be experimental;
(3) The department and the treating professional determine the need for and amount of service you can receive:
(a) The department reserves the right to require a second opinion from a department-selected provider.
(b) The department will require evidence that you have accessed your full benefits through Medicaid and private insurance before authorizing this waiver service.
(4) The dollar limitations for aggregate services in your Basic or Basic Plus waiver limit the amount of service you may receive.
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(1) DDD certified residential agencies per Chapter 388-101 WAC; or
(2) Other department licensed or certified agencies.
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(2) These services are available in all four HCBS waivers administered by DDD as mental health stabilization services in accordance with WAC 388-845-1150 through 388-845-1160.
(3) The costs of mental health crisis diversion bed services do not count toward the dollar limits for aggregate services in the Basic and Basic Plus waivers.
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(1) Behavior management and consultation;
(2) Skilled nursing services;
(3) Specialized psychiatric services; or
(4) Mental health crisis diversion bed services.
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(2) The costs of mental health stabilization services do not count toward the dollar limitations for aggregate services in the Basic and Basic Plus waiver.
(3) Mental health stabilization services require prior approval by DDD or its designee.
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(2) The dollar limitations for employment/day program services in your Basic or Basic Plus waiver limit the amount of service you may receive.
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(2) All individual providers and homecare agency providers must meet provider qualifications for in-home caregivers in WAC 388-71-0500 through 388-71-0556.
(3) Providers of personal care services for adults must comply with the training requirements in these rules governing Medicaid personal care providers in WAC 388-71-05670 through 388-71-05799.
(4) Natural, step, or adoptive parents can be the personal care provider of their adult child age eighteen or older.
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(2) The maximum hours of personal care you may receive are determined by the approved department assessment for Medicaid personal care services.
(a) Provider rates are limited to the department established hourly rates for in-home Medicaid personal care.
(b) Homecare agencies must be licensed through the department of health and contracted with DDD.
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(1) You must be age twenty-one and graduated from high school or age twenty-two or older.
(2) You are not expected to be competitively employed within one year (excluding supported employment programs).
(3) You cannot be authorized to receive prevocational services if you receive community access services or supported employment services.
(4) The dollar limitations for employment/day program services in your Basic or Basic Plus waiver limit the amount of service you may receive.
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(1) Residential habilitation services include assistance:
(a) With personal care and supervision; and
(b) To learn, improve or retain social and adaptive skills necessary for living in the community.
(2) Residential habilitation services may provide instruction and support addressing one or more of the following outcomes:
(a) Health and safety;
(b) Personal power and choice;
(c) Competence and self-reliance;
(d) Positive recognition by self and others;
(e) Positive relationships; and
(f) Integration into the physical and social life of the community.
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(1) Individuals contracted with DDD to provide residential support as a "companion home" provider;
(2) Individuals contracted with DDD to provide training as an "alternative living provider";
(3) Agencies contracted with DDD and certified per chapter 388-101 WAC;
(4) State-operated living alternatives (SOLA);
(5) Licensed and contracted group care homes, group training homes, foster homes, child placing agencies, staffed residential homes or adult residential rehabilitation centers per WAC 246-325-0012.
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(2) None of the following can be paid for under the CORE or Community Protection waiver:
(a) Room and board;
(b) The cost of building maintenance, upkeep, improvement, modifications or adaptations required to assure the health and safety of residents, or to meet the requirements of the applicable life safety code;
(c) Activities or supervision already being paid for by another source;
(d) Services provided in your parent's home unless you are receiving alternative living services for a maximum of six months to transition you from your parent's home into your own home.
(3) The following persons cannot be paid providers for your service:
(a) Your spouse;
(b) Your natural, step, or adoptive parents if you are a child age seventeen or younger;
(c) Your natural, step, or adoptive parent unless your parent is certified as a residential agency per chapter 388-101 WAC or is employed by a certified or licensed agency qualified to provide residential habilitation services.
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(1) You live in a private home with an unpaid caregiver; or
(2) You live with a paid caregiver who is:
(a) A natural, step or adoptive parent;
(b) A contracted companion home provider; or
(c) A licensed children's foster home provider.
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(1) Your live-in caregiver is a relative as defined in WAC 388-825-345(2);
(2) You were living with this caregiver in January 2005;
(3) Your relative caregiver was receiving payment from the department as your caregiver in January 2005; and
(4) You were enrolled in the Basic, Basic Plus, or CORE Waiver in January 2005.
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(1) Individual's home or place of residence;
(2) Relative's home;
(3) Licensed children's foster home;
(4) Licensed, contracted and DDD certified group home;
(5) State operated living alternative (SOLA) and other DDD certified supported living settings;
(6) Licensed boarding home contracted as an adult residential center;
(7) Adult residential rehabilitation center;
(8) Licensed and contracted adult family home;
(9) Children's licensed group home, licensed staffed residential home, or licensed childcare center;
(10) Other community settings such as camp, senior center, or adult day care center.
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(1) Individuals meeting the provider qualifications under chapter 388-825 WAC;
(2) Homecare/home health agencies, licensed under chapter 246-335 WAC, Part 1;
(3) Licensed and contracted group homes, foster homes, child placing agencies, staffed residential homes and foster group care homes;
(4) Licensed and contracted adult family home;
(5) Licensed and contracted adult residential care facility;
(6) Licensed and contracted adult residential rehabilitation center under WAC 246-325-012;
(7) Licensed childcare center under chapter 388-295 WAC;
(8) Licensed child daycare center under chapter 388-295 WAC;
(9) Adult daycare centers contracted with DDD;
(10) Certified provider per chapter 388-101 WAC when respite is provided within the DDD contract for certified residential services; or
(11) Other DDD contracted providers such as community center, senior center, parks and recreation, summer programs, adult day care.
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(1) If you are in the Basic or Basic Plus waiver, a respite care assessment will determine how much respite you can receive per WAC 388-845-3005 through WAC 388-845-3050.
(2) If you are in the CORE waiver, the plan of care (POC), not the respite assessment, will determine the amount of respite care you can receive.
(3) Prior approval by DDD is required to exceed fourteen days per month.
(4) Respite cannot replace:
(a) Daycare while a parent or guardian is at work; and/or
(b) Personal care hours available to you. When determining your unmet need, DDD will first consider the personal care hours available to you.
(5) Respite providers have the following limitations and requirements:
(a) If respite is provided in a private home, the home must be licensed unless it is the client's home or the home of a relative of specified degree per WAC 388-825-345;
(b) The respite provider cannot be the spouse of the caregiver receiving respite if the spouse and the caregiver reside in the same residence; and
(c) If you receive respite from a provider who requires licensure, the respite services are limited to those age-specific services contained in the provider's license.
(6) Your caregiver cannot provide paid respite services for you or other persons during your respite care hours.
(7) If you require respite from a licensed practical nurse (LPN) or a registered nurse (RN), services may be authorized as skilled nursing services per WAC 388-845-1700 using an LPN or RN. If you are in the Basic Plus waiver, skilled nursing services are limited to the dollar limits of your aggregate services per WAC 388-845-0210. The dollar limit governing aggregate services does not apply to skilled nursing services provided as part of mental health stabilization services per WAC 388-845-1100(2).
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(1) Be a certified sexual offender treatment provider (SOTP); and
(2) Meet the standards contained in WAC 246-930-030 (education required prior to examination) and WAC 246-930-040 (professional experience required prior to examination).
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(2) The costs of sexual deviation evaluations do not count toward the dollar limits for aggregate services in the Basic or Basic Plus waivers.
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(2) Services include nurse delegation services provided by a registered nurse, including the initial visit, follow-up instruction, and/or supervisory visits.
(3) These services are available in all four HCBS waivers administered by DDD as mental health stabilization services in accordance with WAC 388-845-1150 through 388-845-1160.
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(1) Skilled nursing services require prior approval by DDD.
(2) The department and the treating professional determine the need for and amount of service.
(3) The department reserves the right to require a second opinion by a department-selected provider.
(4) Skilled nursing services provided as a mental health stabilization service require prior approval by DDD or its designee.
(5) The dollar limitation for aggregate services in your Basic Plus waiver limit the amount of skilled nursing services unless provided as a mental health stabilization service.
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(2) Included are devices, controls, appliances, and items necessary for life support; ancillary supplies and equipment necessary to the proper functioning of such items; and durable and nondurable medical equipment not available through Medicaid under the Medicaid state plan.
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(1) Prior approval by the department is required for each authorization.
(2) The department reserves the right to require a second opinion by a department-selected provider.
(3) Items reimbursed with waiver funds shall be in addition to any medical equipment and supplies furnished under the Medicaid state plan.
(4) Items must be of direct medical or remedial benefit to the individual and necessary as a result of the individual's disability.
(5) Medications, prescribed or nonprescribed, and vitamins are excluded.
(6) The dollar limitations for aggregate services in your Basic or Basic Plus waiver limit the amount of service you may receive.
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(2) Service may be any of the following:
(a) Psychiatric evaluation,
(b) Medication evaluation and monitoring,
(c) Psychiatric consultation.
(3) These services are also available as a mental health stabilization service in accordance with WAC 388-845-1150 through 388-845-1160.
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(1) Psychiatrist;
(2) Psychiatric advanced registered nurse practitioner (ARNP); or
(3) Physician assistant working under the supervision of a psychiatrist.
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(2) The dollar limitations for aggregate service in your Basic and Basic Plus waiver limit the amount of specialized psychiatric services unless provided as a mental health stabilization service.
(3) Specialized psychiatric services provided as a mental health stabilization service require prior approval by DDD or its designee.
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service is available in all four HCBS waivers.
(2) Consultation and training is provided to families, direct staff, or personal care providers to meet the specific needs of the waiver participant as outlined in the individual's plan of care, including:
(a) Health and medication monitoring;
(b) Positioning and transfer;
(c) Basic and advanced instructional techniques;
(d) Positive behavior support; and
(e) Augmentative communication systems.
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(1) Audiologist;
(2) Licensed practical nurse;
(3) Marriage and family therapist;
(4) Mental health counselor;
(5) Occupational therapist;
(6) Physical therapist;
(7) Registered nurse;
(8) Sex offender treatment provider;
(9) Speech/language pathologist;
(10) Social worker;
(11) Psychologist;
(12) Certified American Sign Language instructor;
(13) Nutritionist;
(14) Registered counselor; or
(15) Certified dietician.
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(2) The dollar limitations for aggregate services in your Basic or Basic Plus waiver limit the amount of service you may receive.
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(1) Supported employment includes activities needed to sustain paid work by individuals
receiving waiver services, including supervision and training.
(2) Supported employment is conducted in a variety of settings; particularly work sites in which persons without disabilities are employed.
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(1) You must be age twenty-one and graduated from high school or age twenty-two or older.
(2) Payment will be made only for the adaptations, supervision, training, and support with the activities of daily living you require as a result of your disabilities.
(3) Payment is excluded for the supervisory activities rendered as a normal part of the business setting.
(4) You cannot be authorized to receive supported employment services if you receive community access services or prevocational services.
(5) The dollar limitations for employment/day program services in your Basic or Basic Plus waiver limit the amount of service you may receive.
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(1) Transportation provides the person access to waiver services, specified by the plan of care.
(2) Whenever possible, the person must use family, neighbors, friends, or community agencies that can provide this service without charge.
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(1) Transportation to/from medical or medically related appointments is a Medicaid transportation service and is to be considered and used first.
(2) Transportation is offered in addition to medical transportation but cannot replace Medicaid transportation services.
(3) Transportation is limited to travel to and from a waiver service.
(4) Transportation does not include the purchase of a bus pass.
(5) Reimbursement for provider mileage requires prior approval by DDD and is paid according to contract.
(6) This service does not cover the purchase or lease of vehicles.
(7) Reimbursement for provider travel time is not included in this service.
(8) Reimbursement to the provider is limited to transportation that occurs when you are with the provider.
(9) You are not eligible for transportation services if the cost and responsibility for transportation is already included in your waiver provider's contract and payment.
(10) The dollar limitations for aggregate services in your Basic or Basic Plus waiver limit the amount of service you may receive.
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ASSESSMENT AND PLAN OF CARE(1) You receive an initial and annual assessment of your needs using a department-approved form.
(a) The ICF-MR level of care assessment identifies your need for waiver services.
(b) The "comprehensive assessment reporting evaluation (CARE)" will determine your eligibility and amount of personal care services.
(c) If you are in the Basic or Basic Plus waiver, a DDD respite assessment will determine the amount of respite care available to you.
(2) From the assessment, DDD develops your waiver plan of care (POC) with you and/or your legal representative and others who are involved in your life such as your parent or guardian, advocate and service providers.
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(2) A respite assessment will then determine the amount of respite care available to you.
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(1) You cannot be the respondent for your own respite assessment.
(2) The department may select and interview additional respondents as needed to get complete and accurate information.
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(1) The level of monitoring you require, above and beyond what is typically required for persons of similar age;
(2) Circumstances in your primary caregiver's life that may impact his/her care giving ability;
(3) The effect of your disability on other household members;
(4) Your primary caregiver's care giving responsibilities for others;
(5) How many parents, legal representatives and/or primary caregivers live in the same household as you;
(6) Availability of others to provide your care; and
(7) Your disability related emotional or behavior issues and how that affects your caregiver; the frequency and severity of these issues; and what a caregiver does to help you manage these behaviors.
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(1) The respite lid represents the maximum number of respite hours you are authorized to receive in a twelve-month period.
(2) You may use as many respite hours as you need, up to your assessed respite lid.
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(2) Your plan must include:
(a) The services that you and DDD have agreed are necessary for you to receive in order to address your health and welfare needs as specified in WAC 388-845-3000;
(b) Both paid and unpaid services you receive or need;
(c) How often you will receive each waiver service; how long you will need it; and who will provide it; and
(d) Your signature on the plan indicating your agreement.
(3) You may choose any qualified provider for the service, who meets all of the following:
(a) Is able to meet your needs within the scope of their contract, licensure and certification;
(b) Is reasonably available;
(c) Meets provider qualifications in chapters 388-845 and 388-825 WAC for contracting; and
(d) Agrees to provide the service at department rates.
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(1) DDD will continue providing services as identified in your most current POC for up to thirty days from the date you were notified of the plan to implement your most current POC.
(2) After thirty days, unless you file an appeal, DDD will assume consent and implement the new POC without your signature or the signature of your legal representative.
(3) You will be provided written notification and appeal rights to this action to implement the new POC.
(4) Your appeal rights are in WAC 388-825-120 through 388-825-165.
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(a) Identify more available natural supports;
(b) Initiate an exception to rule to access available nonwaiver services not included in the Basic or Basic Plus waiver other than natural supports;
(c) Authorize emergency services up to six thousand dollars per year if your needs meet the definition of emergency services in WAC 388-845-0800.
(2) If emergency services and other efforts are not sufficient to meet your needs, you will be offered:
(a) An opportunity to apply for an alternate waiver that has the services you need;
(b) Priority for placement on the alternative waiver when there is capacity to add people to that waiver;
(c) Placement in an ICF/MR.
(3) If none of the options in subsections (1) and (2) above is successful in meeting your health and welfare needs, DDD may terminate your waiver eligibility.
(4) If you are terminated from a waiver, you will remain eligible for nonwaiver DDD services but access to state-only funded DDD services is limited by availability of funding.
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(a) Identify more available natural supports;
(b) Initiate an exception to rule to access available nonwaiver services not included in the CORE or Community Protection waiver other than natural supports;
(c) Offer you the opportunity to apply for an alternate waiver that has the services you need, subject to WAC 388-845-0045;
(d) Offer you placement in an ICF/MR.
(2) If none of the above options is successful in meeting your health and welfare needs, DDD may terminate your waiver eligibility.
(3) If you are terminated from a waiver, you will remain eligible for nonwaiver DDD services but access to state-only funded DDD services is limited by availability of funding.
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(2) If you live in a licensed facility, you participate from your earned and unearned income per rules in WAC 388-515-1510:
(a) If you have nonexempt income that exceeds the cost of your waiver services, you may keep the difference.
(b) If you are eligible for SSI, you pay only for room and board.
(c) If you are not eligible for SSI, you may be required to participate towards the cost of your waiver services in addition to your facility room and board rate.
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(1) Any denial, reductions, or termination of a service.
(2) A denial or termination of your choice of a qualified provider.
(3) Your termination from waiver eligibility.
(4) Denial of your request to receive ICF/MR services instead of waiver services.
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(2) If you want to appeal a department action, you must request an appeal within ninety days from receipt of the department notice of the action you are disputing.
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