A&D Waiver Services: Coverage And Limitations

Waiver services are provided to prevent institutional placement, provide for the greatest degree of independence possible, enhance quality of life, encourage individual choice, and achieve and maintain community integration. (7-1-26) 01. Adult Day Health. Supervised, structured services provided outside the participant’s home in a non-institutional, community-based setting, and encompassing health and social services, recreation, supervision for safety, and assistance with ADL needed to ensure optimal function of the participant. Services do not include room and board payments. (7-1-26) 02. Adult Residential Care. A range of services provided in a homelike, noninstitutional setting that includes licensed Residential Assisted Living Facilities and CFHs. Administrative oversight must be provided for all services provided or available in these settings. Payment does not include room and board. The number of residents in a setting is limited by an amount in the Idaho Medicaid Provider Handbook, unless otherwise authorized by the Department. Services are provided in a congregate setting and include: (7-1-26) a. Medication assistance, to the extent permitted under State law; (7-1-26) b. Assistance with ADL; (7-1-26) c. Meals, including special diets; (7-1-26) d. Housekeeping; (7-1-26) e. Laundry; (7-1-26) f. Transportation; (7-1-26) g. Opportunities for socialization for participants in a RALF; (7-1-26) h. Recreation; and (7-1-26) i. Assistance with personal finances. (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 542 Page 121 03. Specialized Medical Equipment and Supplies. (7-1-26) a. Devices, controls, or appliances enabling a participant to increase their abilities to perform ADL, or to perceive, control, or communicate with the environment in which they live; and (7-1-26) b. Items necessary for life support, ancillary supplies and equipment necessary for the proper functioning of such items, and DME and non-DME not available under State Plan or EPSDT. (7-1-26) 04. Non-Medical Transportation (NMT). Transportation enabling a participant to access waiver and other community services and resources. Whenever possible, non-paid supports or public transit providers are used. (7-1-26) 05. Attendant Care. Services involving tasks dealing with the functional needs of the participant and accommodating their needs for long-term maintenance, supportive care, or ADL. These services include personal assistance and medical tasks that can be done by unlicensed persons or delegated to an unlicensed person by a licensed health care professional or the participant. Services are based on a participant’s abilities and limitations, regardless of age, medical diagnosis, or other category of disability. Assistance may be hands-on assistance or prompts to perform a task. (7-1-26) 06. Chore Services. Include intermittent assistance or chore activities when necessary to maintain functional use of the participant’s home or to provide a clean, sanitary, and safe environment. Services are only available when neither the participant, nor anyone else in the home, is capable of performing or financially providing for them, and when no other non-paid support, landlord, agency, or third-party payer is willing or able to provide. Services are limited to those provided in a home rented or owned by the participant. For rental property, the Department examines the lease agreement for landlord responsibilities prior to any authorization of service. (7-1-26) 07. Companion Services. In-home services that include non-medical care, supervision, and socialization provided to a functionally impaired adult ensuring the safety and well-being of a person who cannot be left alone due to their condition. The provider may live with a participant. The provider may provide cuing and occasional assistance ADL and perform light housekeeping tasks that are incidental to the care and supervision of the participant, but the primary responsibility is to provide companionship and be accessible in case of emergency. (7-1-26) 08. Consultation (Self-Direction). Services provided by a PAA to a participant or family member to increase their skills as an employer or manager of their own care. Services are directed at achieving the highest level of independence and self-reliance possible for the participant and the participant’s family by consulting with the participant and family to gain a better understanding of the special needs of the participant and the role of the caregiver. (7-1-26) 09. Home-Delivered Meals. Meals delivered to the participant’s home that promote adequate nutrition. Participants can receive one (1) to two (2) meals per day when they rent or own a home, are alone for extended periods with no caregiver, and are unable to prepare a meal without assistance. (7-1-26) 10. Homemaker Services. Performing for or assisting the participant with essential errands and other routine housekeeping duties when no one else in the household is capable of performing these tasks. (7-1-26) 11. Environmental Accessibility Adaptations. Minor housing adaptations necessary for a participant to function with greater independence in their home, or without which, would require institutionalization or pose a risk to health, or safety including: (7-1-26) a. Installations or modifications necessary to accommodate medical equipment and supplies necessary for the health and safety of the participant but excludes those that are not of direct medical or remedial benefit to the participant. (7-1-26) b. Unless otherwise authorized, permanent modifications are limited to the participant's principal residence that is owned by the participant or their non-paid family. (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 542 Page 122 c. Portable or non-stationary modifications may be made when a participant or their non-paid family rents a home, and modifications follow a participant to their next residence. (7-1-26) 12. Personal Emergency Response System (PERS). Electronic devices enabling participants to secure help in an emergency which connects to a participant’s phone and is programmed to signal a response center when activated. The response center is staffed by trained professionals. PERS is limited to participants who rent or own a home, or live with unpaid caregivers, are alone for extended periods with no caregiver, and require extensive, routine supervision. (7-1-26) 13. Respite Care. Short-term breaks from caregiving responsibilities to non-paid caregivers. The caregiver or participant selects, trains, and directs the provider. While receiving respite care, participants cannot receive other duplicative services. Respite care does not include room and board payments. Services may be provided in a participant’s residence, CFH, DDA, RALF, or ADH facility. (7-1-26) 14. Skilled Nursing. Intermittent or continuous oversight, training, or skilled care within the scope of the Nurse Practice Act provided by an RN or LPN under the supervision of an RN. Services cannot be less cost- effective than a Home Health visit. (7-1-26) 15. Residential Habilitation. Habilitation services to help an individual acquire, retain, or improve their ability to reside as independently as possible in the community or maintain family unity, and includes training in one of the following: (7-1-26) a. Self-direction; (7-1-26) b. Money management; (7-1-26) c. Daily living skills; (7-1-26) d. Socialization not including participation in non-therapeutic activities that are diversional or recreational in nature; (7-1-26) e. Mobility; (7-1-26) f. Behavior shaping and management. (7-1-26) g. Personal assistance services that assist an individual in ADL, household tasks, and other routine activities as the participant or their primary caregivers are unable to accomplish on their own behalf. (7-1-26) h. Skills training to teach participants and supports to perform activities with greater independence and to reinforce habilitation training. (7-1-26) 16. Day Habilitation. Assistance with acquisition, retention, or improvement in self-help, socialization, and adaptive skills that take place in a non-residential setting. Services focus on enabling the participant to attain or maintain their maximum functional level and are coordinated with any physical, occupational, or speech- language therapy services listed in the plan of care. Services may reinforce skills taught in school, therapy, or other settings. (7-1-26) 17. Supported Employment. Competitive work in integrated work settings for individuals for whom competitive employment has not traditionally occurred, or when competitive employment is interrupted or intermittent due to severe disability. The nature and severity of an individual’s disability requires intensive supported employment services or extended services for them to work. This service is not available when funded under another program. (7-1-26) 18. Transition Services. Goods and services enabling a participant residing in a NF, hospital, IMD, or ICF/IID to transition to a community-based setting immediately following discharge from a qualified institution after a minimum of forty-five (45) days. (7-1-26) IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 543 Page 123 a. Services may include: (7-1-26) i. Security deposits required to obtain a lease on an apartment or home; (7-1-26) ii. Cost of essential household furnishings; (7-1-26) iii. Set-up fees or deposits for utility or service access; (7-1-26) iv. Services necessary for health and safety prior to occupancy; (7-1-26) v. Moving expenses; and (7-1-26) vi. Activities to assess need, arrange for, and procure transition services. (7-1-26) b. Exclusions. Ongoing expenses (including utilities), real property, décor, or entertainment and recreational items. (7-1-26) c. Limitations. A total cost of two thousand dollars ($2,000) per participant and only accessed every two (2) years, following a qualifying transition. Services are furnished when a participant is unable to meet an expense or when a support cannot be obtained from other sources. (7-1-26) 19. A&D Case Management. To assist participants with gaining and coordinating access to necessary care and services appropriate to the needs of the individual. (7-1-26)