210-RICR-50-10-2. Self-Directed Care (version Adoption, 08/01/2012 to 11/27/2017)

Rhode Island Executive Office of Health and Human Services Medicaid Personal Choice Program August 1, 2012 Rhode Island Executive Office of Health & Human Services Medicaid Personal Choice Program Rules and Regulations TABLE OF CONTENTS Section One GENERAL PROVISIONS 1 Overview 1 Definitions 2 Section Two ADMINISTRATION AND ORGANIZATION 7 Agency Responsibilities 7 Medicaid Agency Responsibilities 7 Service Advisement Agency Responsibilities 7 Fiscal Agency Responsibilities 8 Budget Appeal Process 8 Involuntary Disenrollment 9 Voluntary Disenrollment 10 Disenrollment Appeal 10 Appeal Process 10 Section Three SERVICE PROVISION 11 Eligibility 11 Income 11 Resources 11 Post Eligibility Treatment of Income 11 Budget Development Process and Methodology 12 Assessment by Service Advisement Agency 13 Participant Directed Goods and Services 13 ATTACHMENT I 15 Six (6) Levels of Assistance 15 Functional Characteristics for Each ADL / IADL 15 Activity and Time Allotments 16 ADL Multipliers 17 IADL Multipliers 17 Medicaid 8/1/2012 Personal Choice Program 1 Rhode Island Executive Office of Health and Human Services Medicaid Personal Choice Program SECTION ONE GENERAL PROVISIONS I. Overview The Personal Choice Program (PCP) provides consumer-directed home and community- based services to Medicaid Long Term Care (LTC) eligible beneficiaries. Personal Choice is a Long Term Care service for individuals with disabilities who are over the age of eighteen (18) or elders aged sixty-five (65) or over who meet either a high or highest level of care. Services are geared toward reducing unnecessary institutionalization by providing specialized home and community-bases services to qualified Medical Assistance beneficiaries at an aggregate cost which is less than or equal to the cost of institutional or nursing facility care. Personal Choice is available to individuals who want to either return home or remain at home; for individuals who want to purchase their own care and services from a budget based on their individual functional needs; and for individuals who have the ability to self-direct care or who have a representative who is able to direct care for the participant. The goal of the Personal Choice Program is to provide a home and community-based program providing beneficiaries with the opportunity to exercise choice and control (i.e., hire, fire, supervise, manage) individuals who provide their personal care, and to exercise choice and control over a specified amount of funds in a beneficiary directed budget. Participants in the PCP are assigned to a Service Advisement Agency and Fiscal Agent to assist in making informed decisions that are consistent with their needs and reflect their unique individual circumstances. The following services supplement the existing scope of services covered by Medical Assistance, Medicare, and other programs and services available to beneficiaries in the PCP: • Service Advisement • Fiscal Intermediary Services • Personal Care Assistance • PCP Directed Goods and Services • Home Modifications • Home Delivered Meals • Personal Emergency Response Systems (PERS) • Special Medical Equipment (Minor Assistive Devices) PCP applicants must have the ability to manage their own personal care or if they are unable, must be willing to have a representative assist them in managing some or all of the program requirements. A representative is a person designated by the beneficiary to assist him/her in managing some or all facets of participation in the program. Beneficiaries cannot pay representatives from the PCP budget. PCP participants or their Medicaid 8/1/2012 Personal Choice Program 2 representatives hire personal care attendants (PCA) to provide personal care, and assistance with housekeeping, homemaking, and household chores. All Personal Care Attendants and beneficiary representatives that have direct contact with PCP beneficiaries must submit to a National and a RI Bureau of Criminal Identification (BCI) screening and an Abuse Registry Record Check annually to be authorized to provide PCP assistance to PCP beneficiaries under the PCP. To participate in the PCP as the beneficiary’s representative or in a provider (PCA) capacity, there must be no evidence of criminal activity in the BCI record check. This condition also applies to the members of a provider’s household if the PCP beneficiary resides or receives services in the provider’s home. Evidence of criminal activity is defined as a conviction or plea of nolo contendere in any criminal matter or the fact that the individual has outstanding or pending charges, related to any types of Disqualifying Criminal Convictions as cited in both the Personal Choice Participant/Representative Manual and Provider Manual available through the Medicaid Agency or obtained on its website: www.ohhs.ri.gov. II. Definitions The following terms, which are listed alphabetically, are used in determining eligibility for the Personal Choice Program. ACTIVITIES OF DAILY LIVING SKILLS (ADLS) - Everyday routines generally involving functional mobility and personal care, such as bathing, dressing, eating, toileting, mobility and transfer. APPLICANT - New applicants for Medical Assistance as well as current recipients at any point in which eligibility is determined or redetermined. CRITICAL INCIDENT - A “Critical Incident” is any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety or well being of a beneficiary. Additional information and clarification concerning Critical Incidents can be found in the Personal Choice Program Provider Manual. ENVIRONMENTAL MODIFICATIONS (Home Accessibility Adaptations) - Those physical adaptations to the private residence of the participant or the participant’s family, required by the participant’s service plan, that are necessary to ensure the health, welfare and safety of the participant or that enable the participant to function with greater independence in the home. Such adaptations include the installation of ramps and grab- bars, widening of doorways, modification of bathroom facilities, or the installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the participant. Excluded are those adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the participant. Adaptations that add to the total square footage of the home are excluded from this benefit except when necessary to complete an adaptation (e. g. in order to improve entrance/egress to a residence or to Medicaid 8/1/2012 Personal Choice Program 3 configure a bathroom to accommodate a wheel chair). All services shall be provided in accordance with applicable State or local building codes and are prior approved on an individual basis by OHHS/Medicaid. FISCAL INTERMEDIARY SERVICES (FI) - Fiscal Intermediary services are designed to assist the participant in allocating funds as outlined in the Individual Service and Spending Plan and to facilitate employment of personal assistance staff by the participant. HOME MODIFICATIONS - Equipment and/or adaptations to an individual’s residence to enable the individual to remain in his/her home or place of residence, and ensure safety, security, and accessibility. HOME DELIVERED MEALS (Meals on Wheels) - The delivery of hot meals and shelf staples to the waiver recipient’s residence. Meals are available to individuals unable to care for their nutritional needs because of a functional dependency/disability and who require this assistance to live in the community. Meals provided under this service will not constitute a full daily nutritional requirement. Meals must provide a minimum of one- third of the current recommended dietary allowance. Provision of home delivered meals will result in less assistance being authorized for meal preparation for individual participants, if applicable. INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADL) - The activities often performed by a person who is living independently in a community setting during the course of a normal day, such as managing money, shopping, telephone use, travel in community, housekeeping, preparing meals, and taking medications correctly. MEDICAID ELIGIBILITY - Rhode Island’s Medicaid program, also known as the Rhode Island Medical Assistance (MA) Program, is the federal/state program created to provide medical coverage to low income people. Eligibility is almost always related to economic need, and Medicaid applicants need to show that their income and resources fall below certain levels. These levels may be different, depending on what kind of Medicaid benefits are involved. Not everyone who cannot afford to pay for medical care will be eligible for Medicaid, however. • Categorically Needy – Since the Medicaid program was designed to supplement existing welfare programs, it covers people who traditionally have been eligible for benefits through those programs. These are the aged, blind, or permanently and totally disabled; as well as pregnant women, and dependent children and their caretaker relatives. • Medically Needy – These are people who would qualify as “categorically needy” (that is, they are aged, blind, disabled, dependent children, etc.) but for the fact that their income exceeds the financial eligibility levels set by the state. If someone like this has regular medical expenses that, when deducted from their income, bring their income down to the “categorically needy” levels, they can be covered as “Medically Needy.” Medicaid 8/1/2012 Personal Choice Program 4 MEDICAL NECESSITY or Medically Necessary Service - Medical, surgical, or other services required for the prevention, diagnosis, cure or treatment of a health related condition including services necessary to prevent a detrimental change in either medical or mental health status. MINOR ENVIRONMENTAL MODIFICATIONS - Minor modifications to the home may include grab bars, versa frame (toilet safety frame), handheld shower and/or diverter valve, raised toilet seats and other simple devises or appliances such as eating utensils, transfer bath bench, shower chair, aids for personal care (e.g. teachers) and standing poles to improve home accessibility adaptation, health or safety. PARTICIPANT DIRECTED GOODS AND SERVICES - Services, equipment or supplies not otherwise provided through this program or through the Medicaid State Plan that address an identified need and are in the approved Individual Service Plan (including improving and maintaining the individual’s opportunities for full membership in the community) and meet the following requirements: the item or service would decrease the need for other Medicaid services; AND/OR promote inclusion in the community; AND/OR the item or service would increase the individual’s ability to perform ADLs or IADLs; AND/OR increase the person’s safety in the home environment; AND, alternative funding sources are not available. Individual Goods and Services are purchased from the individual’s self-directed budget through the fiscal intermediary when approved as part of the ISP. Examples include a laundry service for a person unable to launder and fold clothes or a microwave for a person unable to use a stove due to his/her disability. This will not include any good/service that would be restrictive to the individual or strictly experimental in nature. PERSONAL CARE ASSISTANCE SERVICES - Provide direct support in the home or community, to individuals in performing tasks they are functionally unable to complete independently due to disability, based on the Individual Service and Spending Plan. Personal Assistance Services include: • Participant assistance with activities of daily living, such as grooming, personal Hygiene, toileting bathing, and dressing • Assistance with monitoring health status and physical condition • Assistance with preparation and eating of meals (not the cost of the meals itself) • Assistance with housekeeping activities (bed making, dusting, vacuuming, laundry, grocery shopping, cleaning) • Assistance with transferring, ambulation; use of special mobility devices assisting the participant by directly providing or arranging transportation (If providing transportation, the PCA must have a valid driver’s license and liability coverage as verified by the FI). PERSONAL EMERGENCY RESPONSE (PERS) - PERS is an electronic device that enables certain individuals at high risk of institutionalization to secure help in an emergency. The individual may also wear a portable “help” button to allow for mobility. The system is connected to the person’s phone and programmed to signal a response center once a “help” button is activated. This service includes coverage for installation Medicaid 8/1/2012 Personal Choice Program 5 and a monthly service fee. Providers are responsible to insure the upkeep and maintenance of the devices/systems. SERVICE ADVISEMENT TEAM - The Service Advisement Team, consisting of the Service Advisor, a Nurse and a Mobility Specialist, will focus on empowering participants to define and direct their own personal assistance needs and services. • Service Advisor – Will possess either a bachelor’s degree or an associate’s degree in Human Services or any health related field and the skills and experience gained through providing case management, independent living counseling or other community living services to people with disabilities or elders. The Service Advisor will assess for initial eligibility for the program, and reassess on an annual basis, assist in identifying and removing barriers to improve independence, assist in developing, implementing and monitoring Personal Choice services, provide training and assistance to participant or representative, and maintain contact via telephone and face-to-face meetings. • Nurse - Will possess a current Rhode Island Registered Nurse (RN) or Licensed Practical Nurse (LPN) license. The nurse will evaluate the participant’s medical condition annually using the Personal Choice nursing assessment, provide educational opportunities to address issues raised during the medical assessment, and assist participants in identifying and accessing available community resources in the areas of wellness and health promotion and/or maintenance. • Mobility Specialist - May be a licensed Physical or Occupational Therapist and/or a certified Assistive Technology Practitioner as certified by RESNA (Rehabilitation Engineering and Assistive Technology Society of North America). The mobility specialist will evaluate on an annual basis the participant’s ability to function within their home and in the community and make recommendations on any home modifications or equipment recommended in the assessment. They will also provide training and education in the safe use of any equipment or modifications for both the participant and any caregivers identified. SPECIAL MEDICAL EQUIPMENT (MINOR ASSISTIVE DEVICES) – Include the following: • Devices, controls, or appliances, specified in the plan of care, which enable participants to increase their ability to perform activities of daily living; • Devices, controls, or appliances that enable the participant to perceive, control, or communicate with the environment in which they live; including such other durable and non-durable medical equipment not available under the State Plan that is necessary to address participant functional limitations. Items reimbursed with waiver funds are in addition to any medical equipment and supplies furnished under the State Plan and exclude those items that are not of direct medical or remedial benefit to the participant. All items shall meet applicable standards of manufacture, design and installation. Provision of Specialized Medical Equipment Medicaid 8/1/2012 Personal Choice Program 6 requires prior approval on an individual basis by Medicaid. SUPPORTS FOR CONSUMER DIRECTION (SUPPORTS FACILITATION) - Focuses on empowering participants to define and direct their own personal assistance needs and services; guides and supports, rather than directs and manages, the participant through the service planning and delivery process. Medicaid 8/1/2012 Personal Choice Program 7 SECTION TWO ADMINISTRATION AND ORGANIZATION I. Agency Responsibilities A. Medicaid Agency Responsibilities 1. Minimum assessment components will be specified by the 2. Medicaid Agency and be maintained in both the Personal Choice Participant/Representative Manual and Provider Manual available through the Medicaid Agency or obtained on its website: www.ohhs.ri.gov. The Office of Institutional and Community Services and Supports (OICSS) reviews and determines level of care based on information provided by the Service Advisement Agency. The applicant is clinically eligible for the Personal Choice Program if either a “high” or “highest” level of care is approved. 3. OICSS staff are responsible for the following: a. Approve Budgets and Individual Service and Spending Plans; b. Authorization of Participant-Directed Goods and Services; c. Provide Personal Choice Participants with notice of budget amount; d. Monitor and conduct quarterly audits of service advisement and fiscal intermediary agencies. 4. The OICSS reviews and approves the assessment and Individual Service and Spending Plan (ISSP) for each PCP participant before services begin. 5. Any changes made to a PCP participant’s ISSP must be forwarded to OICSS for review and approval. 6. Once the ISSP is approved the OICSS will notify the appropriate Service Advisement Agency who will inform the Fiscal Agency and beneficiary that the ISSP will be implemented. 7. The Medicaid Agency is responsible for the review of reported Critical Incidents with the Advisement Agency to determine feasibility of continuing participation in the Personal Choice Program. 8. If Medicaid Fraud is either known or suspected, the Medicaid Agency will refer the case to the appropriate unit as outlined in the Medicaid Personal Choice Program Provider Manual (http://www.ohhs.ri.gov/). B. Service Advisement Agency Responsibilities 1. The Personal Choice Program (PCP) is reviewed for appropriateness to the needs of the applicant. The applicant is then screened to determine his/her long term care needs. The PCP is only open to beneficiaries who have “high” or “highest” LTC needs. 2. Written documentation of the assessment will be maintained by the Service Advisement Agency, such as the functional, mobility and health assessments. 3. The Service Advisor will provide the participant/representative with a copy of the approved budget and the approved ISSP. 4. Review and assess the PCP beneficiary’s LTC needs annually and assist in gathering the documents needed for EOHHS/DHS annual certification process. Such assessments may be conducted earlier if a beneficiary’s circumstances Medicaid 8/1/2012 Personal Choice Program 8 change. 5. Refers prospective PCP participants who have the required level of LTC need to the Medicaid Office of Medical Review (OMR) for a full determination of clinical eligibility. 6. Assist the PCP beneficiary’s in developing and implementing their Individual Service and Spending Plan (ISSP). 7. Monitor PCP beneficiary’s to ensure health and safety, satisfaction, adequacy of current spending plan, and progress toward participant goals in accordance with the guidelines developed by the Medicaid agency. This monitoring shall include regular home visits and annual assessments. Documentation of such program monitoring shall be provided to OICCS. 8. Minimum monitoring guidelines shall be maintained in accordance with the guidelines established by the Medicaid Agency and as outlined in the Provider agreement. These guidelines are posted on the Medicaid website, http://www.ohhs.ri.gov/. 9. Completion of the Critical Incident Reporting form as outlined in the Personal Choice Provider Manual, within twenty-four (24) hours of the reported incident. 10. If Medicaid Fraud is either known or suspected, the Service Advisement Agency will refer the case to the appropriate unit as outlined in the Personal Choice Program Provider Manual (http://www.ohhs.ri.gov/). C. Fiscal Agency Responsibilities 1. Oversee budget spending by PCP Medicaid beneficiary/representative to ensure compliance with the ISSP. 2. Act as a conduit between employer (beneficiary/representative) and the Medicaid Agency. The beneficiary/representative shall sign all applicable forms allowing the fiscal agency to conduct business on behalf of the Medicaid eligible participant. 3. The fiscal agency shall not reimburse the beneficiary/representative for any Service provider who does not pass a criminal background check or abuse registry screening. 4. Assist participant/representative in obtaining worker’s compensation coverage for their employees. 5. Perform all necessary payroll functions, including but not limited to processing payroll, payroll taxes (including quarterly and year end), W-4’s, 1099’s, etc. 6. Recoup from PCA’s any wages paid for hours not worked (i.e. wages paid when participant was hospitalized). II. Budget Appeal Process An opportunity for a hearing is granted to a Medicaid eligible PCP participant or representative when aggrieved by an agency action resulting in suspension, reduction, discontinuance, or termination of a service, budget, or when a requested adjustment to the budget is denied. The initial approved budget amount can not be appealed by the PCP beneficiary. If the PCP beneficiary is not in agreement with the initial budget, the PCP beneficiary can request an adjustment with the Service Advisor to increase the budget. Medicaid 8/1/2012 Personal Choice Program 9 If the beneficiary disagrees with the Service Advisor’s decision on the adjustment to the budget, the beneficiary can appeal the decision with the Medicaid Agency. A Notice of Agency Action will be forwarded to the PCP participant by the Service Advisor indicating the effective date of the action, the reason for the action, and the rights to appeal (refer to DHS Code of Rules, General Provisions Rule 0110, subsection 0110.30.20 for information about the appeal and hearing process.) Any request for appeal will be scheduled with the Medicaid Agency. A. Involuntary Disenrollment 1. When a Medicaid eligible participant is involuntarily disenrolled from the Personal Choice Program, the participant is referred back to the Medicaid Long Term Care field office to explore other available options. 2. The Medicaid Agency notifies the participant in writing that they intend to remove the participant from the Personal Choice Program, the reason for disenrollment, and informs the participant that services will be provided through Medicaid Long Term Care via a home health agency. 3. The beneficiary will be involuntarily disenrolled from the PCP if he/she looses either Medicaid financial eligibility or level or care eligibility. 4. Disenrollment is determined by the Service Advisement Agency, based on assessment in conjunction with the policy and procedure of that Agency, and/or the receipt of information from the Fiscal Intermediary or the Medicaid office. Involuntary disenrollment may also occur when: a. The beneficiary or representative is unable to self-direct purchase and payment of long-term care. b. A representative proves incapable of acting in the best interest of the participant, can no longer assist participant, and no replacement is available. c. The beneficiary or representative fails to comply with legal/financial obligations as an “employer” of domestic workers and/or is unwilling to participate in advisement training or training to remedy non-compliance. d. The beneficiary or representative is unable to manage the monthly spending as evidenced by: repeatedly submitting time sheets for unauthorized budgeted amount of care; underutilizing the monthly budget, which results in inadequate services; and/or continuing attempts to spend budget funds on non- allowable items and services. e. The beneficiary’s health and well-being is not maintained through the actions and/or inaction of the participant or representative. f. The beneficiary or representative fails to maintain a safe working environment for personal care. g. The Medicaid agency receives complaint of beneficiary self-neglect, neglect or other abuse. h. Either the beneficiary or representative refuse to cooperate with minimum program oversight activities, even when staff has made efforts to accommodate the beneficiary. i. The beneficiary or representative fails to pay the amount determined in the post eligibility treatment of income, as described in the EOHHS Code of Medicaid 8/1/2012 Personal Choice Program 10 Rules, Section 0392.15, to the fiscal agency. j. There is evidence that Medicaid funds were used improperly/illegally according to local, state or federal regulations. k. A beneficiary or representative fails to notify both the Service Advisement agency and the Fiscal Intermediary of any change of address and/or telephone number within ten (10) days of the change. B. Voluntary Disenrollment 1. A participant or participant representative may request discharge from the Personal Choice Program with a thirty (30) day written notice to the advisement agency. 2. A participant representative must provide both the Service Advisement agency and Fiscal Intermediary with a thirty (30) day written notice stating why they are no longer able to provide representative services. C. Disenrollment Appeal 1. The Service Advisement Agency and the Fiscal Intermediary Agency shall inform the participant in writing of an involuntary disenrollment with the reason and provides the participant with a Medicaid appeal procedure and request forms. 2. The PCP participant has the right to appeal utilizing the standard appeals process as described the DHS Code of Rules, General Provisions Rule 0110, subsection 0110.30.20. D. Appeal Process 1. An opportunity for a hearing is granted to an applicant/recipient or his/her designated representative, when a person is aggrieved by an agency action resulting in suspension, reduction, discontinuance, termination of a beneficiaries service or budget, or a requested adjustment to the budget is denied. 2. A Notice of Agency Action will be forwarded to the applicant/recipient. The Notice will indicate the effective date of the action, the reason for the action, and notify the applicant/recipient of his/her rights to appeal. See the DHS Code of Rules, General Provisions Rule, Section 0110, subsection 0110.30.20, for information about the appeal and hearing process. Medicaid 8/1/2012 Personal Choice Program 11 SECTION THREE SERVICE PROVISION I. Eligibility A. All general eligibility rules for Medicaid LTC contained in the DHS Code of Rules, Sections 0304 – 0310, apply to the PCP. Additional eligibility requirements for the PCP are as follows: 1. Beneficiaries who are either aged (age sixty-five (65) and older) or who have a disability and are at least eighteen (18) years old and are determined to have “high” or “highest” need for level of care and ; 2. Individuals who have demonstrated the ability and competence to direct their own care or have a qualified designated representative to direct care, and want to either return or remain in their home. 3. Individuals who have been determined to be Developmentally Disabled and are receiving services via the Department of Behavioral Healthcare, Developmental Disabilities, and Hospitals (DBHDDH) and are interested in the Personal Choice Program must be approved by DBHDDH and EOHHS Medicaid. 4. The Determination of the Period of Continuous Institutionalization (POCI) is the first day of the month that a married applicant files an application AND meets a level of care (high or highest). B. Income 1. All income eligibility rules contained the DHS Code of Rules, Sections 0386 – 0390, and as amended from time to time, apply. If Medically Needy eligible, the applied income cannot exceed the cost of services. C. Resources 1. All resource rules contained in the DHS Code of Rules, Sections 0380 – 0384, and as amended from time to time, apply. D. Post Eligibility Treatment of Income 1. Single Applicant: • DHS Code of Rules, Section 0396.10.20, is used for personal needs deduction for Categorical and Medically Needy persons. • DHS Code of Rules, Sections 0396.15.05 and 0396.10.05, are used in determining applied income. 2. Married Applicant: DHS Code of Rules, Section 0392.15, is used to determine the income of a married applicant with a community spouse. 3. Eligibility Determinations a. The Medicaid Long Term Care/Adult Services (LTC/AS) Unit determines eligibility and calculates the beneficiary’s income to be allocated to the cost of care as necessary. Neither the Supplemental Security Income (SSI) payment itself nor any of the other income of an SSI recipient or former SSI recipients who are Categorically Needy under 1619(b) of the Social Security Act may be allocated to offset the cost of the Personal Choice Program. Medicaid 8/1/2012 Personal Choice Program 12 b. For other beneficiaries participating in the PCP, income is reviewed for accuracy. 4. Confirming MA Eligibility Status The Service Advisement Agency and Fiscal Intermediary Agency must confirm the beneficiary’s eligibility before PCP services are initiated and at the time of each reassessment of a beneficiary’s needs. 5. Redetermination of Eligibility The Long Term Care/Adult Service (LTC/AS) Unit redetermines the Medicaid eligibility of PCP participants each year, unless a change occurs prior to the annual redetermination date. An example of this change includes, but is not limited to: the inheritance of money; the transfer of an asset; or the death of a spouse, which results in a change in income. II. Budget Development Process and Methodology Personal Choice monthly budgets are based upon an assessment of participant need for hands on assistance or supervision with ADL’s (such as bathing, toileting, dressing, grooming, transfers, mobility, skincare, and/or eating)and IADL’s (such as communication, shopping, housework, meal preparation, and/or shopping). The Assessment of Need rates the participant’s level of assistance required to complete each task, and the number of times the task is performed. If there is a particular condition or characteristic in addition to the disability, the participant may require the need for more time to complete a particular task. These conditions and/or characteristics do not apply to all ADL/IADL tasks; they only apply if the condition would have a direct impact on the performance of the task. Information on the applicable conditions and/or characteristics can be located in the PCP Provider Service Manual and the Participant Guide, located on the Medicaid website, http://www.ohhs.ri.gov/. A. Determine Monthly Budget Amount Each Activity of Daily Living (ADL) and Instrumental Activity of Daily Living (IADL) has an amount of unit and/or functional time allowed to complete the task. The monthly figures for each ADL/IADL are added together to form a monthly budget. The Personal Choice Program is a self-directed program, as such, worker’s compensation insurance and administrative costs are deducted from the PCP participant’s monthly budget. a. Unit Time - the amount of time allowed to complete the task if the participant is unable to participate and requires total assistance with the task. • Activity and Time Allotments, in minutes, are referenced in Attachment I. b. Functional Time - the amount of time allowed to complete the task if the participant is unable to participate and requires total assistance with the task and certain conditions or characteristics are present. • The Functional characteristics for each ADL/IADL are listed in Attachment I. Medicaid 8/1/2012 Personal Choice Program 13 B. EOHHS will implement a budget re-assessment for any budget which is decreased by five hundred dollars ($500). This second level re-assessment will be conducted by an EOHHS Nurse and Social Worker in the home of the beneficiary. C. Additional information concerning participant conditions and characteristics related to certain tasks may be found in the Participant Manual and/or the Provider Manual, available upon request or on the Medicaid website (http://www.ohhs.ri.gov/). III. Assessment by Service Advisement Agency An assessment measuring Activities of Daily Living (ADLS) and Instrumental Activities of Daily Living (IADLS) is conducted to determine participant needs. In accordance with the Service Provider agreements, a budget is developed based on the amount and level of assistance required, frequency of the task, and presence of any secondary conditions that would require a need for more time to complete the task. There are six (6) levels of assistance for each activity as referenced in Attachment I. In addition to medical information and self-reporting, the assessor may observe or request that the participant demonstrate their ability to complete a task. The budget amount is determined by the Medicaid Agency and may be subject to change. The budget funds are set aside by Medicaid for the purchase of assistance to meet individual participant needs. The participant determines what services are required and the amount the participant is willing to pay for those services from their budget. Participants determine the hourly wage for PCA, which can range from minimum wage up to $15.00 per hour. It is based solely on tasks such as bathing, dressing, toileting, etc. and is determined based on the amount of assistance the individual needs to complete the task, and time allotted for each task. The budget does not allow for companionship, watching, or general supervision of a participant. Access to the budget is available to the participant by computer via the Consumer Directed Module (CDM) or upon request to the Service Advisement Agency. IV. Participant Directed Goods and Services A. Participants may also set aside a specified amount of their budget each month to purchase services, equipment and supplies not otherwise provided through the Medicaid State Plan that address an identified need, are in the approved Individual Service and Spending Plan (ISSP), and meet the following requirements: 1. alternative funding sources are not available; AND 2. the item or service would decrease the need for other Medicaid services; and/or 3. the item or service would promote inclusion in the community; and/or 4. the item or service would increase the individual’s ability to perform ADLs/IADLs; and/or 5. the item or service would increase the person’s safety in the home environment. Medicaid 8/1/2012 Personal Choice Program 14 B. Limitations: 1. some items or services that are medical in nature require a physician’s order. 2. items must be necessary to ensure the health, welfare and safety of the individual, or must enable the individual to function with greater independence in the home or community, and to avoid institutionalization. 3. items for entertainment purposes are not covered. 4. items cannot duplicate equipment provided under Medicaid-funded primary and acute care system or through other sources of funding (i.e. Medicare, private insurance). 5. items purchased whose goal is to lessen the need for assistance from a caregiver will result in a redetermination of need for caregiver assistance. C. Additional information for the beneficiary can be found in Attachment I or in the PCP Participant Guide, located on the Medicaid website, http://www.ohhs.ri.gov/. Medicaid 8/1/2012 Personal Choice Program 15 ATTACHMENT I A. Six (6) Levels of Assistance: Independent Participant is independent in completing the task safely. Set-Up Participant requires brief supervision, cueing, reminder and/or set-up assistance to perform the task. Minimum Participant is actively involved in the activity, requires some hands-on assistance for completion, thoroughness or safety. Needs verbal or physical assistance with 25% of the task. Moderate Participant requires extensive hands-on assistance, but is able to assist in the process. Needs verbal or physical assistance with 50% of the task. Extensive Participant requires verbal or physical assistance with 75% of the task. Total Assistance Participant cannot participate or assist in the activity, and requires 100% assistance with the task. Not Applicable This task does not apply to this participant. B. Functional Characteristics for Each ADL / IADL: ADL/IADL Functional Characteristics Bowel Behavioral Issues, Limited ROM, Spasticity/Muscle Tone Dressing Behavioral Issues, Limited ROM, Spasticity/Muscle Tone Eating Behavioral Issues, Fine Motor Deficit, Spasticity/Muscle Tone Grooming Cognitive, Limited ROM, Spasticity/Muscle Tone Mobility Balance Problems, Decreased Endurance, Pain, Spasticity/Muscle Tone Shower Balance Problems, Behavioral Issues, Limited ROM, Spasticity/Muscle Tone Skin Care Open Wound Sponge Bath Behavioral Issues, Limited ROM, Spasticity/Muscle Tone Transfers Balance Problem, Limited ROM, Spasticity/Muscle Tone Tub Bath Balance Problem, Behavioral Issues, Limited ROM, Spasticity/Muscle Tone Urinary/Menses Behavioral Issues, Limited ROM, Spasticity/Muscle Tone Communications No Functional Characteristics Housework Participant Lives Alone Meal Preparation No Functional Characteristics Shopping No Functional Characteristics Medicaid 8/1/2012 Personal Choice Program 16 C. Activity and Time Allotments, in minutes: Activity Unit Time Functional Time Sponge Bath 30 45 Shower 20 40 Tub Bath 40 45 Dressing 15 20 Eating 20 40 Mobility 10 10 Urinary/Menses 10 15 Transfers 5 10 Grooming 8 8 Skin Care 10 10 Bowel 30 50 Meal Preparation 25 25 House Work 12.5 25 Communications 15 15 Shopping 60 60 Medications 2 5 Medicaid 8/1/2012 Personal Choice Program 17 D. ADL Multipliers: Level of Assistance Sponge Bath Shower Tub Bath Dressing Eating Mobility Urinary Menses Transfers Grooming Skin Care Bowel Total Assist 1 1 1 1 1 1 1 1 1 1 1 Maximum Assist .75 .75 .75 .75 .75 1 .75 1 .75 1 .75 Moderate Assist .5 .5 .5 .5 .5 .75 .5 .75 .5 .75 .5 Minimum Assistance .25 .25 .25 .25 .25 .75 .25 .75 .25 .25 .25 Set-Up Assistance .15 .15 .15 .15 .15 .20 .15 .20 .15 .20 .15 Independent 0 0 0 0 0 0 0 0 0 0 0 E. IADL Multipliers: Level of Assistance Meal Preparation Housework Communications Shopping Total Assist 1 1 1 1 Maximum Assist 1 1 1 1 Moderate Assist .75 .75 .75 1 Minimum Assistance .5 .5 .5 1 Set-Up Assistance .25 .25 .25 1 Independent 0 0 0 0