WSR 20-02-044

EMERGENCY RULES

DEPARTMENT OF

SOCIAL AND HEALTH SERVICES

(Developmental Disabilities Administration)

[Filed December 23, 2019, 9:12 a.m., effective December 28, 2019]

Effective Date of Rule: December 28, 2019.

Purpose: The developmental disabilities administration (DDA) is amending sections in chapter 388-845 WAC as part of the administration's waiver renewal process. These emergency rules reflect changes approved by the Centers for Medicare and Medicaid Services (CMS) on July 30, 2019, effective September 1, 2019. This second emergency rule filing is necessary to keep these rules in effect until DDA completes the permanent rule-making process.

DDA filed a CR-102 Proposed rule making on December 3, 2019, as WSR 19-24-082. A public hearing is scheduled for January 22, 2020.

Citation of Rules Affected by this Order: Amending WAC 388-845-0030, 388-845-0055, 388-845-0230, 388-845-0415, 388-845-0425, 388-845-0900, 388-845-0910, 388-845-1100, 388-845-1110, 388-845-1150, 388-845-1190, 388-845-1191, 388-845-1192, 388-845-1800, 388-845-1805, 388-845-1810, 388-845-2000, 388-845-2005, 388-845-2010, 388-845-2160, and 388-845-2170.

Statutory Authority for Adoption: RCW 71A.12.030.

Other Authority: RCW 71A.12.120, 42 C.F.R. 441 Subpart G.

Under RCW 34.05.350 the agency for good cause finds that state or federal law or federal rule or a federal deadline for state receipt of federal funds requires immediate adoption of a rule.

Reasons for this Finding: DDA must not authorize waiver services unless they are part of a waiver application approved by CMS. CMS has approved DDA's individual and family services waiver application. Enacting these rules on an emergency basis is necessary for DDA to provide the services approved by CMS. If DDA does not immediately enact these rules, DDA risks losing federal funding.

Number of Sections Adopted in Order to Comply with Federal Statute: New 0, Amended 0, Repealed 0; Federal Rules or Standards: New 0, Amended 21, Repealed 0; or Recently Enacted State Statutes: New 0, Amended 0, Repealed 0.

Number of Sections Adopted at the Request of a Nongovernmental Entity: New 0, Amended 0, Repealed 0.

Number of Sections Adopted on the Agency's own Initiative: New 0, Amended 0, Repealed 0.

Number of Sections Adopted in Order to Clarify, Streamline, or Reform Agency Procedures: New 0, Amended 0, Repealed 0.

Number of Sections Adopted using Negotiated Rule Making: New 0, Amended 0, Repealed 0; Pilot Rule Making: New 0, Amended 0, Repealed 0; or Other Alternative Rule Making: New 0, Amended 21, Repealed 0.

Date Adopted: December 18, 2019.

Katherine I. Vasquez

Rules Coordinator

AMENDATORY SECTION(Amending WSR 16-17-009, filed 8/4/16, effective 9/4/16)

WAC 388-845-0030Do I meet criteria for HCBS waiver-funded services?

(1) You meet criteria for DDA HCBS waiver-funded services if you meet all of the following:

(a) You have been determined eligible for DDA services per RCW 71A.10.020.

(b) You have been determined to meet ICF/IID level of care per WAC 388-845-0070, 388-828-3060 and 388-828-3080.

(d) You meet financial eligibility requirements as defined in WAC 182-515-1510.

(e) You choose to receive services in the community rather than in an ICF/IID facility.

(f) You have a need for monthly waiver services or monthly monitoring as identified in your person-centered service plan/individual support plan.

(g) You are not residing in hospital, jail, prison, nursing facility, ICF/IID, or other institution.

(h) Additionally, for the children's intensive in-home behavioral support (CIIBS) waiver-funded services:

(i) You are age eight or older and under the age of eighteen for initial enrollment and under age twenty-one for continued enrollment;

(ii) You have been determined to meet CIIBS program eligibility per chapter 388-828 WAC prior to initial enrollment only;

(iii) You live with your family; and

(iv) Your parent/guardian(s) and primary caregiver(s), if other than parent/guardian(s), have signed the participation agreement.

(2) For the individual and family services waiver ((funded services)), you must meet the criteria in subsection (1) of this section and also((:

(a)))live in your family home((; and

(b) Are age three or older)).

AMENDATORY SECTION(Amending WSR 16-17-009, filed 8/4/16, effective 9/4/16)

WAC 388-845-0055How do I remain eligible for the waiver?

(1) Once you are enrolled in a DDA HCBS waiver, you can remain eligible if you continue to meet eligibility criteria in WAC 388-845-0030, and:

(a) You complete a reassessment with DDA at least once every twelve months to determine if you continue to meet all of these eligibility requirements;

(b) You must either receive a waiver service at least once in every thirty consecutive days, as specified in WAC 182-513-1320(3), or your health and welfare needs require monthly monitoring, which will be documented in your client record;

(2) For the children's intensive in-home behavioral supports waiver, you must meet the criteria in subsection (1) of this section and:

(a) Be under age twenty-one;

(b) Live with your family; and

(c) Have an annual participation agreement signed by your parent/guardian(s) and primary caregiver(s), if other than parent/guardian(s).

(3) For the individual and family services waiver, you must meet the criteria in subsection (1) of this section and((:

(a)))live in ((the))your family home((; and

(b) Be age three or over)).

AMENDATORY SECTION(Amending WSR 18-14-001, filed 6/20/18, effective 7/21/18)

WAC 388-845-0230What services are available under the individual and family services (IFS) waiver?

(1) The following services are available under the individual and family services (IFS) waiver:

SERVICE	YEARLY LIMIT
Assistive technology Community engagement Environmental adaptions Occupational therapy Peer mentoring Person-centered plan facilitation Physical therapy Positive behavior support and consultation Respite care Skilled nursing Specialized clothing Specialized medical equipment and supplies	Total cost of waiver services must not exceed annual allocation determined by the person-centered service plan
Specialized psychiatric services Speech, hearing, and language services Staff and family consultation and training Supported parenting services ((Therapeutic equipment and supplies )) Transportation Vehicle modifications Wellness education
Risk assessment	Limits determined by DDA. Costs are excluded from the annual allocation.
BEHAVIORAL HEALTH STABILIZATION SERVICES: Crisis diversion bed services Positive behavior support and consultation Specialized psychiatric services	Limits determined by behavioral health professional or DDA. Costs are excluded from the annual allocation.

(2) Your IFS waiver services annual allocation is based upon the DDA assessment under chapter 388-828 WAC. The DDA assessment determines your service level and annual allocation based on your assessed need. Annual allocations are as follows:

(a) Level 1 = one thousand two hundred dollars;

(b) Level 2 = one thousand eight hundred dollars;

(d) Level 4 = three thousand six hundred dollars.

AMENDATORY SECTION(Amending WSR 16-17-009, filed 8/4/16, effective 9/4/16)

WAC 388-845-0415What is assistive technology?

Assistive technology consists of items, equipment, or product systems, not related to a client's physical health, that are used to increase, maintain, or improve functional capabilities of waiver participants, as well as ((services))supports to directly assist the participant ((and caregivers)) to select, acquire, and use the technology. Assistive technology is available in the CIIBS and IFS waivers, and includes the following:

(1) The evaluation of the needs of the waiver participant, including a functional evaluation of the participant in the participant's customary environment;

(2) Purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices;

(3) Selecting, designing, fitting, customizing, adapting, applying, retaining, repairing, or replacing assistive technology devices;

(4) Coordinating and using other therapies, interventions, or services with assistive technology devices, such as those associated with existing education and rehabilitation plans and programs;

(5) Training or technical assistance for the participant and/or if appropriate, the participant's family; and

(6) Training or technical assistance for professionals, including individuals providing education and rehabilitation services, employers, or other individuals who provide services to, employ, or are otherwise involved in the assistive technology related life functions of individuals with disabilities.

AMENDATORY SECTION(Amending WSR 18-14-001, filed 6/20/18, effective 7/21/18)

WAC 388-845-0425Are there limits to the assistive technology you may receive?

The assistive technology you may receive has the following limits:

(1) Assistive technology is limited to additional services not otherwise covered under the medicaid state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

(2) Clinical and support needs for assistive technology ((are))must be identified in your DDA assessment and documented in the person-centered service plan.

(((2)))(3) DDA requires your treating professional's written recommendation regarding your need for the technology. This recommendation must take into account that:

(a) The treating professional has personal knowledge of and experience with the requested assistive technology; and

(b) The treating professional has recently examined you, reviewed your medical records, and conducted a functional evaluation of your use of the equipment and determined its effectiveness in meeting your identified need.

(((3)))(4) Assistive technology requires prior approval by the DDA regional administrator or designee.

(((4)))(5) DDA may require a written second opinion from a DDA-selected professional.

(((5)))(6) The dollar amounts for your individual and family services (IFS) waiver annual allocation limit the amount of assistive technology you are authorized to receive.

(((6)))(7) Assistive technology excludes any item that is for recreational or diversion purposes such as a television, cable, or DVD player.

AMENDATORY SECTION(Amending WSR 18-14-001, filed 6/20/18, effective 7/21/18)

WAC 388-845-0900What are environmental adaptations?

(1) Environmental adaptations provide physical adaptations ((within the physical structure of the home, or outside the home to provide access to the home. The need must be identified by the DDA assessment and the participant's))to the dwelling required by the individual's person-centered service plan((.))needed to:

(a) Ensure the health, welfare, and safety of the individual;

(b) Enable the individual who would otherwise require institutionalization to function with greater independence in the dwelling; and

(c) Increase the individual's independence inside the dwelling or outside the dwelling to provide access to the dwelling.

(2) Examples of environmental adaptions include installing stair lifts, installing ramps and grab bars, widening doorways, modifying the individual's primary bathroom, or installing specialized electrical or plumbing systems necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the individual.

(3) Environmental adaptions are available in all of the DDA HCBS waivers.

(((3) An environmental adaption must be necessary to:

(a) Maintain the health, welfare, and safety of the participant, the participant's caregiver, or both; or

(b) Increase the participant's independence in the home.))

(4) Only the children's intensive in-home behavioral support (CIIBS) and individual and family services (IFS) waivers may include adaptations to the ((home))dwelling necessary to prevent or repair property destruction caused by the participant's behavior, as addressed in the participant's positive behavior support plan.

AMENDATORY SECTION(Amending WSR 18-14-001, filed 6/20/18, effective 7/21/18)

WAC 388-845-0910What limits apply to environmental adaptations?

The following service limits apply to environmental adaptations:

(1) Clinical and support needs for an environmental ((adaptations))adaption must be identified in the waiver participant's DDA assessment and documented in the person-centered service plan.

(2) Environmental adaptations require prior approval by the DDA regional administrator or designee and must be supported by itemized and written bids from licensed contractors. For an adaptation that costs:

(a) One thousand five hundred dollars or less, one bid is required;

(b) More than one thousand five hundred dollars and equal to or less than five thousand dollars, two bids are required; or

(3) All bids must include:

(a) The cost of all required permits and sales tax; and

(b) An itemized and clearly outlined scope of work.

(4) DDA may require an occupational therapist, physical therapist, or construction consultant to review and recommend an appropriate environmental adaptation statement of work prior to the waiver participant soliciting bids or purchasing adaptive equipment.

(5) Environmental adaptations to the home are excluded if they are of general utility without direct ((medical or remedial)) benefit to the individual related to their developmental disability, such as cosmetic improvements to the dwelling, or general home improvements, such as carpeting, roof repair, or central air conditioning.

(6) Environmental adaptations must meet all local and state building codes. Evidence of any required completed inspections must be submitted to DDA prior to ((authorizing))final payment for work.

(7) The condition of the dwelling or other projects in progress in the dwelling may prevent or limit some or all environmental adaptations at the discretion of DDA.

(8) Location of the dwelling in a flood plain, landslide zone, or other hazardous area may limit or prevent any environmental adaptations at the discretion of DDA.

(9) Written consent from the dwelling landlord is required prior to starting any environmental adaptations for a rental property. The landlord must not require removal of the environmental adaptations at the end of the waiver participant's tenancy as a condition of the landlord approving the environmental adaptation to the waiver participant's dwelling.

(10) Environmental adaptations must not add to the total square footage of the ((home))dwelling.

(11) The dollar amounts for aggregate services in your basic plus waiver or the dollar amount of your annual IFS allocation limit the amount of service you may receive.

(12) For core, community protection, and CIIBS waivers, annual environmental adaptation costs must not exceed twelve thousand one hundred ninety-two dollars.

(13) Damage prevention and repairs under the CIIBS and IFS waivers are subject to the following restrictions:

(a) Limited to the cost of restoration to the original function;

(b) Limited to the dollar amounts of the IFS waiver participant's annual allocation;

(c) Behaviors of waiver participants that resulted in damage to the dwelling must be addressed in a positive behavior support plan prior to the repair of damages;

(d) Repairs to personal property such as furniture and appliances are excluded; and

(e) Repairs due to normal wear and tear are excluded.

(14) The following adaptations are not covered as an environmental adaption:

(a) Building fences and fence repairs;

(b) Carpet or carpet replacement;

(d) Roof repair or siding;

(e) Deck construction or repair; and

(f) Jetted tubs or saunas.

(15) Environmental adaptions are limited to additional services not otherwise covered under the medicaid state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

AMENDATORY SECTION(Amending WSR 13-24-045, filed 11/26/13, effective 1/1/14)

WAC 388-845-1100What are behavioral health crisis diversion bed services?

Behavioral health crisis diversion bed services are ((temporary))short-term emergent residential ((and behavioral)) services that may be provided in a client's home, licensed or certified setting, or state operated setting. These services are available to eligible clients ((who are))whose current living situation is disrupted and the client is at risk of ((serious decline of mental functioning and who have been determined to be at risk of psychiatric hospitalization))institutionalization. These services are available in all ((four))five HCBS waivers administered by DDA as behavioral health stabilization services in accordance with WAC 388-845-1150 through 388-845-1160.

AMENDATORY SECTION(Amending WSR 16-17-009, filed 8/4/16, effective 9/4/16)

WAC 388-845-1110What are the limits of behavioral health crisis diversion bed services?

(1) Clinical and support needs for behavioral health crisis diversion bed services are limited to those identified in the waiver participant's DDA assessment and documented in the person-centered service plan((/individual support plan)).

(2) Behavioral health crisis diversion bed services are intermittent and temporary. ((The duration and amount of services you need to stabilize your crisis is determined by))A behavioral health professional ((and/or))may determine your need for behavioral health crisis diversion bed services. DDA determines the duration and amount of behavioral health crisis diversion bed services you will receive.

(3) ((These services are available in the CIIBS, basic plus, core, and community protection waivers administered by DDA as behavioral health stabilization services in accordance with WAC 388-845-1150 through 388-845-1160.

(4))) The costs of behavioral health crisis diversion bed services do not count toward the dollar amounts for aggregate services in the basic plus waiver or the annual allocation in the individual and family services waiver.

AMENDATORY SECTION(Amending WSR 18-14-001, filed 6/20/18, effective 7/21/18)

WAC 388-845-1150What are behavioral health stabilization services?

(1) Behavioral health stabilization services assist persons who are experiencing a behavioral health crisis.

(2) Behavioral health stabilization services are available in the basic plus, core, children's intensive in-home behavior support (CIIBS), individual and family services (IFS), and community protection waivers.

(3) A participant may be eligible for behavioral health stabilization services if:

(a) A behavioral health professional or DDA has determined the participant is at risk of institutionalization or hospitalization;

(b) The participant needs:

(i) Positive behavior support and consultation;

(ii) Specialized psychiatric services for people age twenty-one and older; or

(iii) Behavioral health crisis diversion bed services available to participants on the individual and family services, basic plus, core, CIIBS, and community protection waivers.

AMENDATORY SECTION(Amending WSR 16-17-009, filed 8/4/16, effective 9/4/16)

WAC 388-845-1190What is peer mentoring?

(1) Peer mentoring is a form of mentorship that takes place between a person who ((is living))has lived through ((the))an experience ((of having a developmental disability or family member of a person who has a developmental disability)) (peer mentor) and a person who is new to that experience (((the peer)) mentee). Peer mentors use their experience to inform, support, and train mentees to successfully navigate new experiences related to or impacted by their disability.

(2) A peer ((mentors utilize their personal experiences to))mentor may provide support and guidance to a waiver participant and the participant's family ((members of a waiver participant)).

(3) A peer ((mentors))mentor may ((orient))connect a waiver participant to local community services, programs, and resources and ((provide answers to participants'))answer participant questions or suggest other sources of support.

(4) Peer mentoring is available in the IFS waiver.

AMENDATORY SECTION(Amending WSR 16-17-009, filed 8/4/16, effective 9/4/16)

WAC 388-845-1191Who are qualified providers of peer mentoring?

((Qualified providers include organizations who are contracted))An individual or organization must contract with DDA to provide peer mentoring support and training to ((individuals))people with developmental disabilities or to families with a member with a developmental disability.

AMENDATORY SECTION(Amending WSR 16-17-009, filed 8/4/16, effective 9/4/16)

WAC 388-845-1192What ((limitations are there for))limits apply to peer mentoring?

(1) Support needs for peer mentoring are limited to those identified in the waiver participant's DDA assessment and documented in the person-centered service plan((/individual support plan)).

(2) DDA does not contract with a peer ((mentors cannot))mentor to mentor their own family ((members))member.

(3) ((The dollar amounts for the))A waiver participant's ((annual allocation in the IFS waiver limit the amount of)) peer mentoring ((service that))services are limited to the ((participant is authorized to receive))participant's annual IFS waiver allocation.

AMENDATORY SECTION(Amending WSR 16-17-009, filed 8/4/16, effective 9/4/16)

WAC 388-845-1800What are specialized medical equipment and supplies?

(1) Specialized medical equipment and supplies are durable and nondurable medical equipment, or equipment necessary to prevent institutionalization, not available through the medicaid ((or the)) state plan or are in excess of what is available through the medicaid state plan benefit which enables individuals ((to)):

(a) To increase their abilities to perform their activities of daily living; ((or))

(b) To perceive, control, or communicate with the environment in which they live; or

(c) On the IFS waiver only, to improve daily functioning through sensory integration when prescribed in a written therapeutic plan by the current treating professional.

(2) Durable medical equipment and medical supplies are defined in WAC 182-543-1000 and 182-543-5500 respectively.

(3) Also included are items necessary for life support and ancillary supplies and equipment necessary to the proper functioning of the equipment and supplies described in subsection (1) of this section.

(4) Specialized medical equipment and supplies include the maintenance and repair of specialized medical equipment not covered through the medicaid state plan.

(5) Specialized medical equipment and supplies are available in all DDA HCBS waivers.

AMENDATORY SECTION(Amending WSR 13-24-045, filed 11/26/13, effective 1/1/14)

WAC 388-845-1805Who are the qualified providers of specialized medical equipment and supplies?

(1) The provider of specialized medical equipment and supplies must be a medical equipment supplier contracted with DDA or have a state contract as a Title XIX vendor.

(2) For IFS only, the provider of specialized medical equipment and supplies under WAC 388-845-1800 (1)(c) must be contracted with DDA as a provider of specialized goods and services.

AMENDATORY SECTION(Amending WSR 18-14-001, filed 6/20/18, effective 7/21/18)

WAC 388-845-1810Are there limits to the specialized medical equipment and supplies you may receive?

The following limits apply to the specialized medical equipment and supplies you may receive:

(1) ((Clinical and))Habilitative support needs for specialized medical equipment and supplies are limited to those identified in your DDA person-centered assessment and documented in your person-centered service plan.

(2) Specialized medical equipment and supplies require prior approval by the DDA regional administrator or designee for each authorization.

(3) DDA may require a second opinion by a DDA-selected provider.

(4) Items must be of direct medical or remedial benefit to you and necessary as a result of your disability.

(5) Medications and vitamins are excluded.

(6) The dollar amounts for aggregate services in your basic plus waiver limit the amount of service you may receive.

(7) The dollar amounts for your annual allocation in your individual and family services (IFS) waiver limit the amount of service you may receive.

(8) Items excluded from specialized equipment and supplies include nonspecialized recreational equipment, such as trampolines, swing sets, and hot tubs.

(9) Specialized equipment and supplies are limited to additional services not otherwise covered under the medicaid state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

AMENDATORY SECTION(Amending WSR 18-14-001, filed 6/20/18, effective 7/21/18)

WAC 388-845-2000What is staff and family consultation and training?

(1) Staff and family consultation and training is professional assistance, not covered by the medicaid state plan, to families or direct service providers to help them ((better)) meet the individualized and specific needs of a participant as outlined in the participant's person-centered service plan and necessary to improve the participant's independence and inclusion in their community.

(2) Staff and family consultation and training is available in all DDA HCBS waivers.

(3) ((Staff and family consultation and training is provided to families, direct staff, or personal care providers to meet the specific needs of a participant as outlined in the participant's person-centered service plan.

(4))) Staff and family consultation and training ((includes))is consultation and guidance about one or more of the following:

(a) Health and medication ((monitoring));

(b) Positioning and transfer;

(d) Positive behavior support;

(e) Augmentative communication systems;

(f) Diet and ((nutritional guidance))nutrition;

(g) Disability information and education;

(h) Strategies for effectively and therapeutically interacting with the participant;

(i) Environmental ((consultation))safety; ((and))

(j) Assistive technology safety; and

(k) For the basic plus, IFS, and CIIBS waivers only, individual and family counseling.

AMENDATORY SECTION(Amending WSR 16-17-009, filed 8/4/16, effective 9/4/16)

WAC 388-845-2005Who is a qualified provider of staff((/))and family consultation and training?

To provide staff((/))and family consultation and training, a provider must be contracted with DDA and one of the following licensed, registered, or certified professionals:

(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) Counselors registered or certified in accordance with chapter 18.19 RCW;

(15) Certified dietician;

(16) Recreation therapist registered in Washington and certified by the national council for therapeutic recreation;

(17) Providers listed in WAC 388-845-0506 and contracted with DDA to provide CIIBS intensive services;

(18) Certified music therapist (for CIIBS only);

(19) Psychiatrist; ((or))

(20) Professional advocacy organization; or

(21) Teacher certified under chapter 181-79A WAC.

AMENDATORY SECTION(Amending WSR 18-14-001, filed 6/20/18, effective 7/21/18)

WAC 388-845-2010Are there limits to the staff and family consultation and training you may receive?

(1) Staff and family consultation and training are limited to supports identified in your DDA assessment and documented in the person-centered service plan.

(2) Expenses to the family or provider for room and board or attendance, including registration, at conferences are excluded as a service under staff and family consultation and training.

(3) The dollar amounts for aggregate service in your basic plus waiver or the dollar amount of the annual allocation in your individual and family services (IFS) waiver limit the amount of staff and family consultation and training you may receive.

(4) Under the basic plus waiver, individual and family counseling is limited to family members who:

(a) Live with the participant; and

(b) Have been assaulted by the participant and the assaultive behavior was:

(i) Documented in the participant's person-centered service plan; and

(ii) Addressed in the participant's positive behavior support plan or therapeutic plan.

(5) Staff and family consultation and training does not provide training necessary to meet contractual licensing or certification requirements.

AMENDATORY SECTION(Amending WSR 16-17-009, filed 8/4/16, effective 9/4/16)

WAC 388-845-2160What is therapeutic equipment and supplies?

(1) Therapeutic equipment and supplies are only available in the CIIBS ((and IFS waivers))waiver.

(2) Therapeutic equipment and supplies are equipment and supplies that are necessary to implement a behavioral support plan or other therapeutic plan, designed by an appropriate professional, such as a sensory integration or communication therapy plan, and necessary in order to fully implement the therapy or intervention.

(3) Included are items such as a weighted blanket, supplies that assist to calm or redirect the individual to a constructive activity, or a vestibular swing.

AMENDATORY SECTION(Amending WSR 18-14-001, filed 6/20/18, effective 7/21/18)

WAC 388-845-2170Are there limits to your receipt of therapeutic equipment and supplies?

The following limits apply to your receipt of therapeutic equipment and supplies under the children's intensive in-home behavior support (CIIBS) ((and individual and family services (IFS) waivers))waiver:

(1) DDA requires your treating professional's written recommendation regarding your need for the service. This recommendation must take into account that the treating professional has recently examined you, reviewed your medical records, and conducted a functional evaluation.

(2) DDA may require a second opinion from a DDA-selected professional.

(3) ((The dollar amount of your annual allocation in your IFS waiver limits the amount of therapeutic equipment and supplies you are authorized to receive.

(4))) Therapeutic equipment and supplies requires a prior approval by the DDA regional administrator or designee.

(((5)))(4) Therapeutic equipment and supplies excludes nonspecialized recreational items such as trampolines, swing sets, and hot tubs.