Definitions

(1) As used in these rules: (a) “Administrative Costs” are the allowable percentage of the service rate that includes, for example, the costs for administrative salaries and benefits, home office costs, office supplies and printing, phone and other communication, travel and conference, advertising, professional services, licensure and dues, legal and accounting fees, interest, depreciation, occupancy, general liability insurance, equipment and administrative vehicles. (b) “Costs” are estimated calculations of the average expense incurred by a provider in 2004 based on information available at that time and are not intended to fully account for every expense that may have been incurred by any particular provider at or since that time in delivering a waiver service. Costs include adjustments based on funding approved by the General Assembly to increase certain components of these calculations, including primarily, wages for direct support staff. Costs may be adjusted as determined by DIDD and TennCare, subject to the availability of funding in each year’s Appropriation Bill. (c) “Direct Service Costs” are the costs for direct service such as staff salaries and benefits, overtime, direct supervision wages and benefits, contracted direct service/temporary help, training, recruiting/advertising, drug testing, background checks, Hepatitis B and TB tests, and other costs for direct service staff bonuses and employee appreciation events. (d) “Direct Support Professional (DSP) Reimbursement Rate” means the estimated calculation of the cost of wages paid to DSPs employed by providers to deliver services requiring hands-on assistance and supervision including adjustments based on funding approved by the General Assembly to increase DSP wages. (e) “Fading” is an essential component of the provision of job coaching services. Fading uses a combination of strategies such as job and task analysis, on-the-job training, including systematic instruction, use of assistive technology or other adaptive aids, and engagement of natural supports (assistance from co-workers or others) to allow the waiver participant to independently perform as much of his/her employment or self- employment roles and responsibilities as possible, without the engagement of paid support. Fading is possible when a waiver participant achieves greater independence and/or inter-dependence performing his/her job, thereby reducing the need for the job coach. METHODOLOGY UTILIZED TO DETERMINE PAYMENTS TO CHAPTER 0465-01-02 SERVICE PROVIDERS (RATE STRUCTURE) (f) “Full Time Equivalent (FTE)” means the total cost for one direct support staff for forty hours. It includes direct service costs, non-direct program costs, administrative costs, and twenty (20) annual days of payment to cover waiver participant absences. (g) “Job Coach” is a person employed by a provider agency who meets the additional qualifications specified by DIDD or TennCare and has the skills and competencies needed to identify and provide services and supports that assist a waiver participant in maintaining individualized integrated employment that pays at least minimum wage, but ideally not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities, or in maintaining self-employment, and that supports the development of the waiver participant’s independence in performing employment or self-employment job functions using a fading plan. (h) “Job Developer” is a person employed by a provider agency who meets the additional qualifications specified by DIDD or TennCare and has the skills and competencies needed to support a waiver participant in obtaining an individualized competitive or customized job in an integrated employment setting in the general workforce, for which the waiver participant is compensated at or above the minimum wage, but ideally not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities or achievement of individualized self-employment consistent with the waiver participant’s personal and career goals. (i) “Non-Direct Program Costs” is the allowable percentage of the service rate that includes the costs for multi-site supervisors and benefits, training, off site computer/file storage, depreciation/amortization, internal monitoring, agency case management, personal funds management, healthcare oversight, specific assistance to waiver participants-room and board, specific assistance to waiver participants-non-room and board, transportation of waiver participants, staff travel, facility maintenance, facility supplies, habilitation supplies. (j) “Productivity Assumptions” is a calculation which takes into account the amount of a paid job coach or job developer’s time that will not be spent providing direct services, including administrative tasks (e.g. documentation, staff meetings), training, holidays, vacation, sick leave, and other emergencies, as well as the absentee rate of waiver participants receiving services which impact the billable hours of support in a typical day. (k) “Rate” is the amount paid per person to approved service providers for each unit of a DIDD service that is provided. A rate unit may be a portion of an hour, a day, a month, an item or a job, depending on the type of service. (l) “Rate Levels” are the series of rates for residential, day and other services that are based on a waiver participant’s needs and the size or site of the service setting. (m) “Rate Level Factor” is the multiplier applied to the FTE daily cost that reflects intensity of support need and number of persons receiving services. Rate level factors were based on licensure requirements for staffing and professional judgment of estimated hours of direct support staff assistance required for waiver participants at each rate level. (n) “Rate Setting Methodology” is the manner in which the rates for residential, day and other services are calculated or determined. METHODOLOGY UTILIZED TO DETERMINE PAYMENTS TO CHAPTER 0465-01-02 SERVICE PROVIDERS (RATE STRUCTURE) (o) “Special Needs Adjustment” is an additional payment that may, within the discretion of the Department and subject to resource availability, be added to the residential rate for a waiver participant in appropriate circumstances (e.g. periodic crisis that require additional support). (p) “Usual and customary” is the amount paid for a service in a geographic area based on what providers in the area usually charge for the same or similar service. (q) “Value-based adjustment” is an adjustment made to a rate of reimbursement or to one or more components used to calculate a rate of reimbursement that is intended to incentivize (and reward) certain qualitative aspects of the delivery of services or service outcomes (e.g. fading in the provision of job coaching or smaller group size in the provision of supported employment-small group). (2) Waiver services (for which rate setting methodologies are set forth in these rules) shall be defined as set for the in the Section 1915(c) waiver application approved by the federal Centers for Medicare and Medicaid Services.