Adult Dd Services: Provider Reimbursement

Providers are reimbursed on a fee-for-service basis based on a participant budget. (7-1-26) 01. Individualized Budget. The Department sets an individualized budget annually for each participant and notifies them of their set budget amount as part of the eligibility process. Notification includes information on appealing the set budget amount. Individualized budgets may be re-evaluated at the participant’s request when there are documented changes in their condition with medical necessity for services not reflected in the current inventory of needs. (7-1-26) 02. Exception Review. Service plans or addenda requesting services exceeding the assigned budget authorized by the assessor are reviewed and authorized by the Department. Requests are authorized when one (1) of the following is met: (7-1-26) a. Services requested on the plan or addendum are needed to assure participant health and safety or to mitigate a documented health or safety risk. (7-1-26) b. Supported employment is needed for the participant to obtain or maintain employment. (7-1-26) 03. Supported Living Levels of Support. Reimbursement for supported living is based on the participant's assessed level of support need. All service plans for supported living must include community integration goals that provide for maintained or enhanced independence, quality of life, and self-determination. As a participant’s independence increases and they are less dependent on supports, they must transition to less intense supports. (7-1-26) a. High support is for participants who require twenty-four (24) hour per day supports and supervision. A blend of one-to-one and group staffing is allowed. Developmental therapy, ADH, and NMT are included in this daily rate. (7-1-26) b. Intense support is for participants who require one-on-one, twenty-four (24) hour per day supports and supervision. Requests for a blend of one-on-one and group staffing will be reviewed on a case-by-case basis. Developmental therapy, ADH, and NMT are included in this daily rate. To qualify for intense support, participants must be evaluated to meet one of the following criteria: (7-1-26) i. Recent felony convictions or charges for offenses related to the serious injury or harm of another IDAHO ADMINISTRATIVE CODE IDAPA 16.03.26 Department of Health & Welfare Medicaid Plan Benefits Section 580 Page 138 person. (7-1-26) ii. History of predatory sexual offenses and at high risk to re-offend. (7-1-26) iii. Documented, sustained history of serious aggressive behavior showing a pattern of causing harm to themselves or others. (7-1-26) iv. Chronic or acute medical conditions that are so complex or unstable that one-to-one staffing is required to provide frequent interventions and constant monitoring, without which would require placement in a NF, hospital, or ICF/IID with twenty-four- (24) hour on-site nursing. (7-1-26) c. Hourly support is for individuals whose needs can be met with less than twenty-four (24) hour per day support. The combination of hourly supported living, developmental therapy, supported employment, and ADH cannot exceed the maximum set daily amount established by the Department, except when: (7-1-26) i. A participant is eligible for high support; (7-1-26) ii. Supported employment is included in the service plan, causing the combination to exceed the daily limit; (7-1-26) iii. Documentation confirming the Person-Centered Planning team explored other options including lower-cost services and supports; and (7-1-26) iv. A participant's health and safety needs can be met using hourly services. (7-1-26) 575. – 579. (RESERVED) SUB-PART: CHILDREN’S DD HCBS STATE PLAN OPTION (Sections 580-589)