4539617 Emergency and Proposed Rulemaking Governing Individualized Day Supports for Persons Enrolled in the Home and Community Based Services Waiver for Individuals with Intellectual and Developmental Disabilities

DEPARTMENT OF HEALTH CARE FINANCE

NOTICE OF EMERGENCY AND PROPOSED RULEMAKING

The Director of the Department of Health Care Finance (DHCF), pursuant to the authority set forth in an Act to enable the District of Columbia to receive federal financial assistance under Title XIX of the Social Security Act for a medical assistance program, and for other purposes, approved December 27, 1967 (81 Stat. 774; D.C. Official Code § 1-307.02 (2012 Repl. & 2013 Supp.)) and Section 6(6) of the Department of Health Care Finance Establishment Act of 2007, effective February 27, 2008 (D.C. Law 17-109; D.C. Official Code § 7-771.05(6) (2012 Repl.)), hereby gives notice of the adoption, on an emergency basis, of a new Section 1925, entitled “Individualized Day Supports Services”, of Chapter 19 (Home and Community-Based Services for Individuals with Intellectual and Developmental  Disabilities) of Title 29 (Public Welfare) of the District of Columbia Municipal Register (DCMR). 

 

These emergency and proposed rules establish standards governing reimbursement of individualized day supports services provided to participants in the Home and Community-Based Waiver Services for Individuals with Intellectual and Developmental Disabilities (ID/DD Waiver) and conditions of participation for providers.

 

The ID/DD Waiver was approved by the Council of the District of Columbia and renewed by the U.S. Department of Health and Human Services, Centers for Medicaid and Medicare Services for a five-year period beginning November 20, 2012.  Individualized day supports is a new service offered under the ID/DD Waiver. These services are structured habilitative day activities approved through an Individualized Support Plan and Plan of Care that support individuals in small community-based group settings. Services can be provided to persons who are transitioning into retirement; suffering from degenerative conditions; or for those who have previously participated in a day habilitation service setting and now wish to participate in a smaller, and more individualized setting.  These rules: (1) establish guidelines for the delivery of individualized day supports services; (2) establish enrollment requirements for professional providers of individualized day supports services; and (3) require providers to follow specific service delivery requirements to promote more efficient service utilization management practices.

 

Emergency action is necessary for the immediate preservation of the health, safety, and welfare of Waiver participants who are in need of individualized day support services.  Individualized day supports services provide crucial habilitation supports in the community to ensure that a person’s social skills are enhanced outside of his/her home to foster independence and encourage community integration.  These rules are essential because they establish the parameters for the delivery and monitoring of all individualized day supports services.  Publishing these rules on an emergency basis will mitigate any potential harm to a person’s welfare that may result from lack of access to these services as set forth in the approved Waiver. 

The emergency rulemaking was adopted on August 12, 2013 and became effective on that date.  The emergency rules shall remain in effect for one hundred and twenty (120) days or until December 9, 2013, unless superseded by publication of a Notice of Final Rulemaking in the D.C. Register. 

 

The Director of DHCF also gives notice of the intent to take final rulemaking action to adopt these proposed rules in not less than thirty (30) days after the date of publication of this notice in the D.C. Register.

 

A new Section 1925 (Individualized Day Supports) is added to Chapter 19 (Home and Community Based Services for Individuals with Intellectual and Developmental Disabilities) of Title 29 (Public Welfare) of the DCMR, to read as follows:

 

1925                INDIVIDUALIZED DAY SUPPORTS

1925.1             This section establishes standards governing Medicaid eligibility for individualized day supports services for persons enrolled in the Home and Community-Based Services Waiver for Persons with Intellectual and Developmental Disabilities (Waiver) and shall establish conditions of participation for providers of individualized day supports services seeking Medicaid reimbursement.

1925.2             The following rules pertain only to Medicaid reimbursable individualized day supports services to be received by an individual enrolled in the Waiver, hereinafter referred to as “person” or “persons”.         

 1925.3            In order to receive Medicaid reimbursement for individualized day supports services, a provider  must document that the need for the service is consistent with the person’s Individual Support Plan (ISP) and Plan of Care, and show at least one of the following:

(a)                That the person chooses to participate in habilitation services;

 

(b)               That the person chooses to continue habilitation services in a non-traditional community-based setting;

 

(c)                That the person is transitioning into retirement and chooses to continue habilitation services;

 

(d)               That the person’s social development would be greatly enhanced by individualized day support services;

 

(e)                That the person’s performance of activities of daily living would improve; or

 

(f)                That the person has a documented need for individualized day supports due to medical or safety issues that are consistent with the Health Care Management Plan (HCMP) and Behavioral Support Plan.       

 

1925.4             Medicaid reimbursable individualized day supports services shall:

 

(a)                Be habilitative in nature;

 

(b)               Be delivered in a community setting; and

 

(c)                Be provided in a group consisting of no more than two (2) persons.

1925.5             Medicaid reimbursable individualized day supports services shall provide:

(a)                Highly individualized, structured activities that emphasize social skills development, vocational exploration, and life skills training, within an inclusive community setting;

 

(b)               Activities that maximize the person’s functional levels;

 

(c)                Activities that support the person’s choice in identifying his or her own areas of interest and preferences;

(d)               Activities that provide opportunities for socialization including leisure activities that enhance adult skill development in the community;

(e)                Training in the safe and effective use of one or more modes of accessible public transportation; and

(f)                Coordination and provision of transportation to participate in community activities consistent with this service.   

1925.6                          In order to be eligible for Medicaid reimbursement, each individualized day supports provider entity shall:

 

(a)                Comply with Section 1904 (Provider Qualifications) and Section 1905 (Provider Enrollment Process) of Chapter 19, Title 29 of the DCMR;

 

(b)        Have a minimum of five (5) years of experience providing day services to

persons with intellectual disabilities and/or developmental  disabilities;

 

(c)        Provide verification of passing the Department on Disability Services (DDS) provider certification review for at least three (3) years;

 

(d)       Provide oversight, supervision and training of all Direct Service Personnel (DSP) providing individualized day supports; and

 

(e)        Maintain a staff-to-person ratio as indicated in the ISP and Plan of Care up to a maximum ratio of one to two (1:2), ensuring that services meet the person’s needs and are provided appropriately and safely.

 

1925.7             Services shall only be authorized for Medicaid reimbursement if the following conditions are met:

(a)                DDS provides a written service authorization before beginning service delivery;

(b)               The individualized day support service name, enrolled provider and DSP rendering service are identified in the ISP, Plan of Care and Summary of Support Services;

(c)                The amount and frequency of services to be received is documented in the ISP, Plan of Care and Summary of Support Services;

(d)               Services shall not conflict with the service limitations described under Section 1925.11;  

(e)                The staffing plan, and individualized activity plan described under Section 1925.8 are submitted upon commencement of services; and

(f)                The quarterly reports shall be submitted within thirty (30) days after the commencement of the first quarter and each subsequent quarter.  

1925.8                          Each DSP providing individualized day supports shall meet all of the requirements in Section 1906 (Requirements for Direct Support Professionals) of Chapter 19, Title 29 of the DCMR, in order to be eligible for Medicaid Reimbursement.

1925.9             In order to be eligible for Medicaid reimbursement each DSP providing individualized day supports services shall meet the following requirements:

(a)                Assist with the development of the individualized activity plan to implement the individualized day supports services;

(b)               Coordinate the scheduled activities specified under the individualized activity plan; and

(c)                Utilize positive behavioral support strategies and crisis interventions as described in the approved Behavioral Support Plan to address emergency situations.

1925.10           Each provider entity of individualized day supports services shall, in order to be eligible for Medicaid reimbursement, maintain documents for monitoring and audit reviews as described under Section 1909 (Records and Confidentiality of Information) of Chapter 19, Title 29 of the DCMR, and maintain the following additional records:

(a)                A list of the names and types of staff who will provide services when back-up staff is unavailable, if the lack of immediate care poses a serious threat to the person’s health and welfare; and

 

(b)               The individualized activity plan containing the following information:

(1)               The name of the person receiving the services;

(2)               The name of the DSP rendering services;

(3)               The schedule of activities taking place in the community, including the date, start and end time that the person receiving services will participate in;

(4)               The goals, including measurable outcomes which promote community integration, for all services identified in the ISP and Plan of Care;

(5)               The strategies that were used to execute the goals for all services that have been identified in the ISP and Plan of Care;

(6)               The teaching strategies that were implemented to achieve the goal that coincides with the date, time and response of the person receiving services  to the strategy used;

(7)               The observations made by the DSP regarding the person receiving services’ newly acquired skills that should be included in the person’s amended or annual ISP; and

(8)               The learning styles of the person.

 

1925.11           In order to be eligible for Medicaid reimbursement, each Provider shall comply with Section 1908 (Reporting Requirements) and Section 1911 (Individual Rights) of Chapter 19, Title 29 of the DCMR.

                         

1925.12           Medicaid shall only reimburse individualized day supports services for six (6) hours per day, and up to five (5) days a week.

1925.13           Medicaid does not reimburse the person’s family and other individuals who reside with the person receiving individualized day supports services to qualify as a DSP.

 

1925.14           A DSP shall not perform individualized day support services if he/she also provides the person with the following waiver services:

 

(a)        Residential Habilitation;

(b)        Supported Living;

(c)        Shared Living;

(d)       Host Home; and

(h)        In-Home Supports.

1925.15                      Individualized day supports shall be billed at the unit rate.  The reimbursement rate shall be six dollars and eleven cents ($6.11) per billable unit or twenty-four dollars and forty-four cents ($24.44) per hour. This service shall not exceed 1,560 hours per year or 6,250 units annually.  A standard unit of service is fifteen (15) minutes and the provider shall provide at least eight (8) continuous minutes of services to bill for one (1) unit of service.     

1925.16           Individualized day supports services shall not be billed concurrently with the following services:

(a)                Supported Employment;

(b)               Employment Readiness;

(c)                Day Habilitation;

(d)               Respite;

(e)                Shared Living; and

(f)                Transportation-Community Access.

 

Section 1999 (DEFINITIONS) is amended by adding the following:

Individualized Activity Plan - A plan that includes structured activities and practical experiences by incorporating goals and strategies that best meets the individual’s interests, needs and learning styles and that can be implemented within a flexible time period.

 

Person – An individual enrolled in the Home and Community Based Services Waiver for Individuals with Intellectual and Developmental Disabilities.

 

Comments on the emergency and proposed rule shall be submitted, in writing, to Linda Elam, Ph.D., MPH, Senior Deputy Director/State Medicaid Director, Department of Health Care Finance, 899 North Capitol Street, NE, Suite 6037, Washington, D.C. 20002, via telephone on [phone], via email at [e-mail], or online at www.dcregs.dc.gov, within thirty (30) days after the date of publication of this notice in the D.C. Register.  Copies of the emergency and proposed rule may be obtained from the above address.