Intellectually Disabled Waiver

Introduction

The Intellectually Disabled (formerly MR/DD) Waiver Program provides home and community-based care to the mentally retarded and developmentally disabled individuals who would otherwise receive such services in an Intermediate Care Facility for the Mentally Retarded (ICF/MR). The goal of this program is to reduce and prevent unnecessary institutionalization by providing home and community-based services at a cost less than or equal to institutionalization. The Department of Human Services will assess the cost of care to determine recipient eligibility to participate in the program. In some cases, the recipient is required to pay a part of the cost of the special Waiver services.

The following services are available to qualified Categorically Needy and Medically Needy recipients: case management, homemaker, personal care, homemaker/personal care, Licensed Practical Nurse, homemaker specialized, minor assistive devices, minor home modifications, supported living arrangements, respite and respite specialized services, residential habilitation, day habilitation and supported employment.

Reimbursement Guidelines

The following table lists all services for the Intellectually Disabled Waiver Program that are reimbursable through the Medical Assistance Program. A separate section will give allowed amounts. The table shows the procedure code, service description, whether or not the service requires prior authorization (Y-yes or N-no). Refer to Covered Services in this section for a description of the services included in each procedure code.

Covered Services

Case Management

The array of home and community-based services available under this Waiver are coordinated by Case Managers from the Division of Developmental Disabilities (DDD). The Case Manager is responsible for the following:

• Identifying individuals who qualify for the Waiver program. This includes the completion of a CP-1 / Eligibility Assessment form, which is reviewed by the Long Term Care (LTC) Unit at the Department of Human Services (DHS). (A sample CP-1 form is located at the end of this policy section.)
• Establishing and updating an individual plan of care
• Arranging and authorizing services
• Evaluating the cost-effectiveness of the Waiver services
• Monitoring and adjusting the service mix
• Reassessing the recipient’s need for services and ICF/MR level of care

Homemaker Services

Homemaker Services include household duties, such as cleaning, meal preparation and laundry. These services are performed and covered when the regular provider of these services, usually a relative with whom the recipient lives, is unavailable.

Personal Care Services

Hands-on care, of both a medical and non-medical supportive nature, specific to the needs of a medically stable, developmentally disabled, and/or physically handicapped individual. This service may include skilled medical care to the extent permitted by State law. Housekeeping activities which are incidental to the performance of the client-based care may also be furnished as part of this activity.

Combined Homemaker/Personal Care Services 

These services may consist of any combination of  Homemaker and Personal Care services as defined by the Case Manager in the Case Plan.

LPN Services

Licensed Practical Nurses provide nursing care to include promotion, maintainence, and restoration of health. The LPN utilizes standard nursing procedures leading to predetermined outcomes which are in accord with the professional nurse regimen under the supervisor or registered nurse.

Homemaker/LPN services require prior authorization. Before prior authorization is granted, administrative approval is needed. Approval must be granted by a Long Term Care (LTC) supervisor or an administrator equal to or above the Coordinator of Community Planning and Development at the Division of Developmental Disabilities (DDD). The Case Worker will obtain the necessary approval at DDD and forward it to the provider. Prior authorization guidelines can found on the Claims Processing page.

Homemaker Specialized Services 

Homemaker Specialized Services consist of household management and personal services provided by a licensed D/D agency to individuals who are unable to perform these functions for themselves because of the limitation of mental retardation and/or other developmental disability. Without the service, the individuals would require admission to an ICF/MR.

Minor Assistive Devices

Devices such as, but not limited to, grooming, cooking and eating aides, etc., provided as part of a total case plan.

Minor Home Modification

Minor modifications to the home (e.g., ramps, grab bars, toilet modifications) that enable the recipient to use toilet facilities and be mobile are covered services. No major construction or reconstruction of the home is covered.

Supported Living Arrangement

Supported Living Arrangements will be provided to adults as an alternative to the far more costly ICF/MR placement. Payment will not include room and board; SSI benefits will be used for that purpose. Foster parents will be trained to collaborate effectively with the case manager and achieve full implementation of the service plan for the individual. The foster parent will participate in the design of the individual care plan and be trained to carry out those aspects of client training that are more appropriately implemented within the home than in the facility providing the day program. Recruitment, training and monitoring of foster parents will be the responsibility of the social service staff of the Division of Retardation.

Respite Services

Respite services are respite care given to individuals unable to care for themselves which is provided on a short term basis to the individual because of the absence or need for relief of those persons normally providing the care. Respite care services can be provided in the individual’s home or in a facility approved by the State, such as hospital, nursing home, foster home, or community residential facility. There is a broad range of the types of individuals providing the respite service, including registered nurses, licensed practical nurses and non-professional individuals with the competency to provide care to the retarded individual.

Respite Specialized Services

Temporary care-giving services (described below) offered in the absence of the care giver or relatives for a minimum of a week.

Residential Habilitation  

Assistance with the acquisition, retention, or improvement in skills related to activities of daily living, such as personal grooming and cleanliness, and the social and adaptive skills necessary to enable the individual to reside in a non-institutional setting.

Day Habilitation

Assistance with acquisition, retention or improvement in self-help, socialization and adaptive skills which take place in a non-residential setting, separate from the home or facility in which the individual resides.

Supported  Employment

Paid employment services for persons for whom competitive employment at or above minimum wage is unlikely, and who need intensive ongoing support to perform in a work setting.

Limitations/ Special Requirements

Unlisted procedure codes require prior authorization. When requesting authorization, medical justification must be documented. Prior authorization guidelines can be found on the Claims Processing page.

All services rendered out-of-state, with the exception of those provided by border community providers require prior authorization.

Specific services provided to an individual under the Waiver program are recommended by the Case Manager and are defined in the Case Plan. For services that require prior authorization, the performing provider is responsible for obtaining the authorization.

Retroactive Authorization

Procedures normally requiring prior authorization that were performed on an emergency basis may receive retroactive authorization if the procedure was medically necessary and meets all other requirements that would have been required for normal authorization.

Procedures billed retroactively for recipients who have retroactive eligibility are valid if all other conditions for billing are met.