reglab/statecodes huggingface dataset:
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.307 - PERSONAL CARE SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
01.
Reimbursement Rate
. Personal assistance providers will be paid a
				uniform reimbursement rate for service as established by the Department.
				Provider claims for payment will be submitted on claim forms provided or
				approved by the Department. Billing instructions will be provided by the
				Department. (3-17-22)
02.
Calculated Fee
. The fee calculated for personal care provider
				reimbursement includes a basic rate for services and mileage. No separate
				charges for mileage will be paid by the Department for non-medical
				transportation, unless approved by the Department or its contractor under a
				Home and Community-Based Services (HCBS) waiver, or provider transportation to
				and from the participant's home. Fees will be calculated as provided in
				Subsections 307.03 through
				307.08 of this rule.
				(3-17-22)
03.
Weighted
				Average Hourly Rate Methodology
. Annually Medicaid will conduct a poll
				of all Idaho nursing facilities and ICFs/IID, and establish the weighted
				average hourly rates (WAHR) for nursing facility industry employees in
				comparable positions (i.e. RN, certified and non-certified nurse's aides) in
				Idaho to be used in calculating the reimbursement rate to be effective on July
				1st of that year. (3-17-22)
04.
Payment for Personal Assistance Agency
. Payment for personal
				assistance agency services will be paid according to rates established by the
				Department. (3-17-22)
a. The Department will
				establish Personal Assistance Agency rates for personal assistance services
				based on the WAHR.
Personal Assistance Agencies
WAHR x supplemental component
= $ amount/hour
(3-17-22)
b. The Department will calculate a
				supplemental component using costs reported for travel, administration,
				training, and all payroll taxes and fringe benefits. The survey data is the
				cost information collected during the prior State Fiscal Year.
				(3-17-22)
c. The Department will
				survey one hundred percent (100%) of PCS providers. Cost surveys are unaudited,
				but a provider that refuses or fails to respond to the periodic state surveys
				may be disenrolled as a Medicaid provider. The Department will derive
				reimbursement rates using direct care staff costs, employment related
				expenditures, program related costs, and indirect general and administrative
				costs in the reimbursement methodology, when these costs are incurred by a
				provider. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: LONG-TERM CARE › Section 16.03.10.308 - PERSONAL CARE SERVICES (PCS): QUALITY ASSURANCE

Current through August 31, 2023
01.
Responsibility for Quality
. Personal Assistance Agencies, RALFs,
				and CFHs furnishing PCS are responsible for assuring that they provide quality
				services in compliance with applicable rules. (3-17-22)
02.
Review Results
. Results of
				quality assurance reviews conducted by the Department must be transmitted to
				the provider within forty-five (45) days after the review is completed.
				(3-17-22)
03.
Quality
				Improvement Plan
. The provider must respond within forty-five (45) days
				after the results are received. If problems are identified, the provider must
				implement a quality improvement plan and report the results to the Department
				upon request. (3-17-22)
04.
HCBS Compliance
. Personal Assistance Agencies are responsible for
				ensuring they meet the setting requirements described in Section
				313 of these rules. RALFs, and CFHs
				are responsible for ensuring that they meet the setting requirements described
				in Sections 313 and
				314 of these rules. All providers
				furnishing PCS are responsible for ensuring they meet the person-centered
				planning requirements described in Sections
				316 through
				317 of these rules. PCS providers
				must comply with associated Department quality assurance activities. The
				Department may take enforcement actions as described in IDAPA 16.03.09,
				"Medicaid Basic Plan Benefits," Section
				205, if the provider fails to
				comply with any term or provision of the provider agreement, or any applicable
				state or federal regulation. (3-17-22)
05.
COVID-19
. The sections of
				this rule may be subject to amendment by the BLTC for the duration of the
				COVID-19 state of emergency. Please consult Medicaid Information Release
				MA20-15 for additional guidance. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.310 - HOME AND COMMUNITY-BASED SERVICES

Current through August 31, 2023
Home and Community-Based Services (HCBS) are those services
				  and supports that assist eligible participants to remain in their home and
				  community. The federal authorities under
				  42 CFR
				  441.301,
				  42 CFR
				  441.710, and
				  42 CFR
				  441.725 require the state to deliver HCBS in
				  accordance with the rules described in Sections
				  310 through
				  319 of these rules. HCBS include
				  the following: (3-17-22)
01.
Children's Developmental Disability Services
. Children's developmental
				disability services as defined in Sections
				663 and
				683 of these rules.
				(3-17-22)
02.
Adult
				Developmental Disability Services
. Adult developmental disability
				services as defined in Sections
				645 through
				659,
				703, and
				705 of these rules.
				(3-17-22)
03.
Consumer-Directed Services
. Consumer-directed services as defined in
				IDAPA 16.03.13, "Consumer-Directed Services." (3-17-22)
04.
Aged and Disabled Waiver
				Services
. Aged and disabled waiver services as defined in Section
				326 of these rules.
				(3-17-22)
05.
Personal Care
				Services
. Personal care services as defined in Section
				303 of these rules.
				(3-17-22)
06.
Services for
				Children with Serious Emotional Disturbance (SED)
. SED services, as
				defined in Section 368 of these
				rules, for children who are enrolled in the Medicaid SED program in support of
				Youth Empowerment Services (YES). (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.311 - HCBS REQUIREMENTS AND DECISION-MAKING AUTHORITY

Current through August 31, 2023
HCBS requirements, contained in Sections
				  312 through Sections
				  317 of these rules, do not
				  supersede decisionmaking authority legally assigned to another individual or
				  entity on the participant's behalf. This includes: (3-17-22)
01.
Payee
. A representative
				payee appointed by the Social Security Administration; (3-17-22)
02.
Restrictions (Probation or
				Parole)
. Court-imposed restrictions related to probation or parole;
				(3-17-22)
03.
Restrictions
				(When Committed)
. Court-imposed restrictions when committed to the
				Director of Health and Welfare; and (3-17-22)
04.
Legal Guardians Who Retain Full
				Decision-making Authority
. It is presumed that the parent or parents of
				participants birth through seventeen (17) years of age have full
				decision-making authority unless the minor child has another legally assigned
				decision-making authority. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.312 - HOME AND COMMUNITY-BASED SETTINGS

Current through August 31, 2023
Home and community-based settings include all locations where
				  participants who receive HCBS live or receive their services. (3-17-22)
01.
Home and Community-Based Settings
				Not Included
. Home and community-based settings do not include the
				following: (3-17-22)
a. A nursing facility;
				(3-17-22)
b. An institution for
				mental diseases; (3-17-22)
c. An
				intermediate care facility for Individuals with intellectual disabilities
				(ICF/IID); (3-17-22)
d. A hospital;
				or (3-17-22)
e. Any other location
				that has the qualities of an institutional setting. These institutional
				qualities include: (3-17-22)
i. Any setting
				that is located in a building that is also a publicly or privately operated
				facility that provides inpatient institutional treatment; or
				(3-17-22)
ii. A building on the
				grounds of, or immediately adjacent to, a state or federally operated inpatient
				treatment facility; or (3-17-22)
iii. Any setting that has the effect of
				isolating participants receiving Medicaid HCBS from the broader community of
				individuals not receiving Medicaid HCBS.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.313 - REQUIRED HOME AND COMMUNITY-BASED QUALITIES

Current through August 31, 2023
Home and community-based settings must support eligible
				  participants to have the same opportunities for integration, independence,
				  choice, and rights as individuals who do not require supports or services to
				  remain in their home or community. If a setting requirement described in this
				  rule presents a health or safety risk to the participant or those around the
				  participant, goals must be identified with strategies to mitigate the risk.
				  These goals and strategies must be documented in the person-centered plan.
				  Providers must develop and implement policies and procedures to address the
				  following HCBS setting requirements. (3-17-22)
01.
Required Home and Community-Based
				Qualities
. Home and community-based settings are required to have the
				following qualities: (3-17-22)
a. Integration
				and Access. The setting is integrated in and supports full access to the
				greater community for participants receiving HCBS. Typical, age-appropriate
				activities include opportunities to seek employment and work in competitive
				integrated settings, engage in community life, control personal resources, and
				receive services in the community in the same manner as individuals who do not
				require supports or services to remain in their home or community.
				(3-17-22)
b. Selection of Setting.
				Home and community-based settings are selected by the participant or the
				participant's decision-making authority from among disability-specific and
				non-disability-specific settings, and are based on the participant's needs and
				preferences including consideration of the participant's safety and the safety
				of those around the participant. (3-17-22)
c. Participant Rights. The setting ensures a
				participant's rights of privacy, dignity, and respect, and freedom from
				coercion and unauthorized restraint are honored. (3-17-22)
d. Autonomy and Independence. The setting
				optimizes, but does not regiment, an individual's initiative, autonomy, and
				independence in making life choices, including daily activities, physical
				environment, and with whom to interact. (3-17-22)
e. Choice. The setting promotes opportunities
				for participant choice regarding the services and supports provided in the
				setting. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.314 - RESIDENTIAL PROVIDER-OWNED OR CONTROLLED SETTING QUALITIES

Current through August 31, 2023
In addition to the setting requirements described in Section
				  313 of these rules, provider-owned
				  or controlled settings, including Residential Assisted Living Facilities and
				  Certified Family Homes that provide services to HCBS participants, must also
				  meet the following conditions: (3-17-22)
01.
Written Agreement
. A lease,
				residency agreement, admission agreement, or other form of written agreement
				will be in place for each HCBS participant at the time of occupancy. The lease
				or residency agreement must provide protections that address eviction processes
				and appeals comparable to those provided under Idaho landlord tenant law.
				(3-17-22)
02.
Privacy
.
				Participants have the right to privacy within their residence. Each participant
				must have privacy in their sleeping or living unit to include the following:
				(3-17-22)
a. The right to entrance doors that
				are lockable by the individual, with only appropriate staff having keys to
				doors. (3-17-22)
b. Participants
				sharing units have a choice of roommates in that setting.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.315 - EXCEPTIONS TO RESIDENTIAL PROVIDER-OWNED OR CONTROLLED SETTING QUALITIES

Current through August 31, 2023
Exceptions to residential setting requirements outlined in
				  Section 314 of these
				  rules must be made based on the needs of the participant that are identified
				  through person-centered planning. Service plans with exceptions to residential
				  setting requirements must be submitted to the Department or its designee for
				  review and approval. When an exception is made, the following information must
				  be documented in the person-centered service plan: (3-17-22)
01.
Assessed Needs
. Specific and
				individualized assessed needs that are related to the exception.
				(3-17-22)
02.
Interventions
				and Supports
. Positive interventions and supports used prior to any
				exceptions to the person-centered service plan. (3-17-22)
03.
Prior Methods
. List less
				intrusive methods previously implemented that were unsuccessful in addressing
				the needs of the participant. (3-17-22)
04.
Description of Intervention
.
				A clear description of the intervention for the exception that is directly
				proportionate to the specific assessed needs. (3-17-22)
05.
Data Collection
. Regular
				collection and review of data to measure the ongoing effectiveness of the
				exception. (3-17-22)
06.
Time
				Limits
. Established time limits for periodic reviews to determine if the
				exception is still necessary, if a transition plan can be developed, or if the
				exception can be terminated. (3-17-22)
07.
Informed Consent
. Informed
				consent of the participant or legal guardian for the exception.
				(3-17-22)
08.
Assurance of No
				Harm
. An assurance that interventions and supports will cause no harm to
				the participant. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.316 - HOME AND COMMUNITY-BASED PERSON-CENTERED PLANNING REQUIREMENTS

Current through August 31, 2023
All participants or their decision-making authority must
				  direct the development of their service plan through a person-centered planning
				  process. Information and support must be given to the HCBS participant to
				  maximize their ability to make informed choices and decisions. Individuals
				  invited to participate in the person-centered planning process should be
				  identified by the participant or the participant's decision-making authority.
				  Legal guardians who do not have full decision-making authority as described in
				  Section 311 of these
				  rules will have a participatory role as needed and defined by the participant.
				  The person-centered planning process must: (3-17-22)
01.
Timely and Convenient
. Be
				conducted timely and occur at convenient times and locations to the participant
				and the participant's decision-making authority in accordance with program
				requirements. (3-17-22)
02.
Cultural Considerations
. Reflect cultural considerations of the
				participant. (3-17-22)
03.
In Plain Language and Accessible
. Be conducted by providing information
				in plain language and in a manner that is accessible to participants with
				disabilities and persons who are limited English proficient as defined in
				42 CFR
				435.905(b).
				(3-17-22)
04.
Conflict
				Resolution
. Utilize strategies for solving conflict or disagreement
				within the process, and follow clear conflict-of-interest guidelines for all
				planning participants. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.318 - HCBS TRANSITION PLAN

Current through August 31, 2023
As required by the Department, all current providers of HCBS
				  must complete a Department-approved self assessment form related to the setting
				  requirements and qualities described in Sections
				  311 through
				  314 of these rules.
				  (3-17-22)
01.
Provider
				Transition Plan
. As part of the self-assessment process, providers not
				in compliance with any portion of the new requirements and qualities must
				develop a plan for coming into compliance. Self-assessment forms are subject to
				review and validation by the Department via quality assurance activities.
				(3-17-22)
02.
New HCBS
				Providers or Service Settings
. New HCBS providers or service settings
				are expected to fully comply with the HCBS requirements and qualities as a
				condition of becoming a Medicaid provider. (3-17-22)
03.
Quality Assurance
. The
				Department will begin enforcement of quality assurance compliance with Sections
				311 through
				314 of these rules on January 1,
				2017. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.319 - HCBS - TERMINATION OF PARTICIPANT ENROLLMENT

Current through August 31, 2023
01.
Federal and State Eligibility
				Requirements
. To be enrolled in an HCBS waiver or State Plan option
				program as provided in 42
				CFR 441 and Section
				1915 of the Social Security Act, a
				participant must meet the following eligibility requirements that include:
				(3-17-22)
a. An independent assessment;
				(3-17-22)
b. A state-approved
				person-centered plan; (3-17-22)
c.
				At least an annual redetermination of eligibility; and (3-17-22)
d. Other state-established criteria for
				determining eligibility under the State Plan for medical assistance.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.320 - AGED AND DISABLED WAIVER SERVICES

Current through August 31, 2023
01.
Description of Aged and Disabled Services
. Idaho's elderly and
				physically disabled citizens should be able to maintain self-sufficiency,
				individuality, independence, dignity, choice, and privacy in a cost-effective
				home-like setting. When possible, services should be available in the
				participant's own home and community regardless of their age, income, or
				ability and should encourage the involvement of natural supports, such as
				family, friends, neighbors, volunteers, church, and others. (3-17-22)
02.
Temporary Changes to Aged and
				Disabled Rules During Declared State of Emergency Related to Novel Coronavirus
				Disease (COVID-19)
. In response to Idaho's declaration on 3/13/20 of a
				state of emergency related to COVID-19, the Department reserves the right to
				temporarily alter requirements and processes related to Aged and Disabled
				waiver services, currently and through the duration of the emergency state, in
				order to mitigate spread of disease and to ensure the health and safety of our
				participants under the guidance and authority of the provisions in a
				CMS-approved 1135 waiver or HCBS Attachment K amendment to the existing Aged
				and Disabled waiver. Guidance for approved flexibilities is posted at
https://healthandwelfare.idaho.gov/providers/idaho-medicaid-providers/information-medicaid-providers
.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.321 - AGED AND DISABLED WAIVER SERVICES: DEFINITIONS

Current through August 31, 2023
The following definitions apply to Sections
				  320 through
				  330 of these rules:
				  (3-17-22)
01.
Uniform
				Assessment Instrument (UAI)
. A set of standardized criteria adopted by
				the Department to assess functional and cognitive abilities.
				(3-17-22)
02.
Individual
				Service Plan
. A document that outlines all services including activities
				of daily living (ADL) and instrumental activities of daily living (IADL),
				required to maintain the individual in their home and community. The plan is
				initially developed by the Department or its contractor for services provided
				under the Home and Community-Based Services Waiver. This plan must be approved
				by the Department or its contractor, and all Medicaid reimbursable services
				must be contained in the plan. (3-17-22)
03.
Personal Assistance Agency or
				Agency
. An entity that recruits, hires, fires, trains, supervises,
				schedules, oversees quality of work, takes responsibility for the care given,
				and provides payroll, including all required withholding for federal and state
				tax purposes, and benefits for care providers working for them. They also bill
				Medicaid for services provided by employees, and collect participant
				contribution. (3-17-22)
04.
Employer of Record
. An entity that bills for services, withholds
				required taxes, and conducts other administrative activities for a waiver
				program participant. Such an entity is also called a personal assistance agency
				functioning as a fiscal intermediary agency. (3-17-22)
05.
Employer of Fact
. A
				participant or representative of a participant who hires, fires, and directs
				the services delivered by a waiver program provider. This individual may be a
				family member. (3-17-22)
06.
Participant
. An aged or disabled individual who requires and receives
				services under the Home and Community-based Waiver program. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.322 - AGED AND DISABLED WAIVER SERVICES: ELIGIBILITY

Current through August 31, 2023
The Department provides waiver services to eligible
				  participants: to prevent unnecessary institutional placement; to provide for
				  the greatest degree of independence possible; to enhance the quality of life;
				  to encourage individual choice; and to achieve and maintain community
				  integration. For a participant to be eligible, the Department must find that
				  the participant: (3-17-22)
01.
Has a Disabling Condition
. Requires services due to a disabling
				condition that impairs their mental or physical function or independence; and
				(3-17-22)
02.
Safe in a
				Non-Institutional Setting
. Be capable of being maintained safely and
				effectively in a non-institutional setting; and (3-17-22)
03.
Requires Such Services
.
				Would, in the absence of such services, require the level of care provided in a
				Nursing Facility. (3-17-22)
04.
Functional Level for Adults
. Based on the results of the
				assessment, the level of impairment of the individual will be established by
				the Department or its contractor. In determining need for nursing facility care
				an adult must require the level of assistance listed in Subsections
				322.04 through
				322.07 of this rule, according
				to the formula described in Subsection
				322.08 of this rule.
				(3-17-22)
05.
Critical
				Indicator - 12 Points Each
. (3-17-22)
a. Total assistance with preparing or eating
				meals. (3-17-22)
b. Total or
				extensive assistance in toileting. (3-17-22)
c. Total or extensive assistance with
				medications that require decision making prior to taking, or assessment of
				efficacy after taking. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.323 - AGED AND DISABLED WAIVER SERVICES: PARTICIPANT ELIGIBILITY DETERMINATION

Current through August 31, 2023
Waiver eligibility will be determined by the Department or
				  its contractor. The participant must be eligible for Medicaid as described in
				  IDAPA 16.03.05, "Eligibility for Aid to the Aged, Blind, and Disabled (AABD)."
				  In addition, waiver participants must meet the following requirements.
				  (3-17-22)
01.
Requirements for
				Determining Participant Eligibility
. The Department or its contractor
				must determine that: (3-17-22)
a. The
				participant would qualify for nursing facility level of care under Sections
				222 and
				223 of these rules
,
if
				the waiver services listed in Section
				326 of these rules were not made
				available; and (3-17-22)
b. The
				participant could be safely and effectively maintained in the requested or
				chosen community residence with appropriate waiver services. Prior to any
				denial of services on this basis, the Department or its contractor must verify
				that services to correct the concerns of the team are not available.
				(3-17-22)
c. The average daily cost
				of waiver services and other medical services to the participant would not
				exceed the average daily cost to Medicaid of nursing facility care.
				(3-17-22)
d. Following the approval
				by the Department or its contractor for services under the waiver, the
				participant must receive and continue to receive a waiver service as described
				in these rules. A participant who does not use a waiver service for thirty (30)
				consecutive days will be terminated from the waiver program.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.324 - AGED AND DISABLED WAIVER SERVICES: TARGET GROUP

Current through August 31, 2023
Persons who would be Medicaid eligible if residing in a
				  nursing facility, require the level of care provided in a nursing facility, are
				  over the age of eighteen (18), demonstrate significant disability on the UAI,
				  and have deficits that affect their ability to function independently.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.325 - HOME AND COMMUNITY-BASED SERVICES (HCBS) WAIVER: PARTICIPANT LIMITATIONS

Current through August 31, 2023
The number of Medicaid participants to receive waiver
				  services under the HCBS waiver for the aged and disabled will be limited to the
				  projected number of users identified in the Department's approved waiver. If
				  necessary, participants who apply for waiver services after the waiver maximum
				  has been reached will be placed on a waiting list and will have their
				  applications processed after September 30th of each new waiver year. The
				  earliest effective date of waiver service delivery for these participants will
				  be October 1st of each new waiver year. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.326 - AGED AND DISABLED WAIVER SERVICES: COVERAGE AND LIMITATIONS

Current through August 31, 2023
01.
Adult Day Health
. Adult day
				health is a supervised, structured service generally furnished four (4) or more
				hours per day on a regularly scheduled basis, for one (1) or more days per
				week. It is provided outside the home of the participant in a
				non-institutional, community-based setting, and it encompasses health services,
				social services, recreation, supervision for safety, and assistance with
				activities of daily living needed to ensure the optimal functioning of the
				participant. Adult day health services provided under this waiver will not
				include room and board payments. (3-17-22)
02.
Adult Residential Care
				Services
. Adult residential care services consist of a range of services
				provided in a homelike, non-institutional setting that include RALFs and CFHs.
				Payment is not made for the cost of room and board, including the cost of
				building maintenance, upkeep and improvement. (3-17-22)
a. Adult residential care services consist of a range of services
				provided in a congregate setting licensed under IDAPA 16.03.22, "Residential
				Assisted Living Facilities," that include: (3-17-22)
i. Medication assistance, to the extent
				permitted under State law; (3-17-22)
ii. Assistance with activities of daily
				living; (3-17-22)
iii. Meals,
				including special diets; (3-17-22)
iv. Housekeeping; (3-17-22)
v. Laundry; (3-17-22)
vi. Transportation; (3-17-22)
vii. Opportunities for socialization;
				(3-17-22)
viii. Recreation; and
				(3-17-22)
ix. Assistance with
				personal finances. (3-17-22)
x.
				Administrative oversight must be provided for all services provided or
				available in this setting. (3-17-22)
xi. A documented individual service plan must
				be negotiated between the participant or their legal representative, and a
				facility representative. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.327 - AGED AND DISABLED WAIVER SERVICES: PLACE OF SERVICE DELIVERY

Current through August 31, 2023
01.
Place of Service Delivery
.
				Waiver services may be provided in the participant's: (3-17-22)
a. Personal residence; (3-17-22)
b. Employment program; or (3-17-22)
c. Community. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.328 - AGED AND DISABLED WAIVER SERVICES: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Role of the Department
. The
				Department or its contractor will provide for the administration of the UAI,
				and the development of the initial individual service plan. This will be done
				either by Department staff or a contractor. The Department or its contractor
				will review and approve all individual service plans, and will authorize
				Medicaid payment by type, scope, and amount. (3-17-22)
a. Services that are not in the individual
				service plan approved by the Department or its contractor are not eligible for
				Medicaid payment. (3-17-22)
b.
				Services in excess of those in the approved individual service plan are not
				eligible for Medicaid payment. (3-17-22)
c. The earliest date that services may be
				approved by the Department or its contractor for Medicaid payment is the date
				that the participant's individual service plan is signed by the participant or
				their designee. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.329 - AGED AND DISABLED WAIVER SERVICES: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
Each provider must have a signed provider agreement with the
				  Department for each of the services it provides. (3-17-22)
01.
Employment Status
. Unless
				otherwise specified by the Department, each individual service provider must be
				an employee of record or fact of an agency. The Department may enter into
				provider agreements with individuals in situations in which no agency exists,
				or no fiscal intermediary agency is willing to provide services. Such
				agreements will be reviewed annually to verify whether coverage by a personal
				assistance agency or fiscal intermediary agency is still not available.
				(3-17-22)
02.
Fiscal
				Intermediary Services
. An agency that has responsibility for the
				following: (3-17-22)
a. To directly assure
				compliance with legal requirements related to employment of waiver service
				providers; (3-17-22)
b. To offer
				supportive services to enable participants or their families to perform the
				required employer tasks themselves; (3-17-22)
c. To bill the Medicaid program for services
				approved and authorized by the Department; (3-17-22)
d. To collect any participant participation
				due; (3-17-22)
e. To pay personal
				assistants and other waiver service providers for service; (3-17-22)
f. To perform all necessary withholding as
				required by state and federal labor and tax laws, rules and regulations;
				(3-17-22)
g. To assure that
				personal assistants providing services meet the standards and qualifications
				under in this rule; (3-17-22)
h. To
				maintain liability insurance coverage; (3-17-22)
i. To conduct, at least annually, participant
				satisfaction or quality control reviews that are available to the Department
				and the general public; (3-17-22)
j. To obtain such criminal background checks
				and health screens on new and existing employees of record and fact as
				required. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.330 - AGED AND DISABLED WAIVER SERVICES: PROVIDER REIMBURSEMENT

Current through August 31, 2023
The criteria used in reimbursing providers for waiver
				  services are listed in Subsections
				  330.01 through
				  330.03 of these rules.
				  (3-17-22)
01.
Fee for
				Services
. Waiver service providers will be paid on a fee for service
				basis as established by the Department, or as agreed upon by the Department's
				contractor and the provider, depending on the type of service provided. Adult
				residential care will be paid on a per diem basis, based on the number of hours
				and types of assistance required by the participant as identified in the UAI.
				(3-17-22)
02.
Provider
				Claims
. Provider claims for payment will be submitted on claim forms
				provided or approved by the Department or its contractor. Billing instructions
				will be provided by the Department's payment system contractor.
				(3-17-22)
03.
Calculation of
				Fees
. The fees calculated for waiver services include both services and
				mileage. No separate charges for mileage will be paid by the Department for
				provider transportation to and from the participant's home or other service
				delivery location when the participant is not being provided waiver or state
				plan transportation. (3-17-22)
04.
EVV Compliance
. Provider claims for the following Aged and
				Disabled Waiver Services require EVV compliance as described in Section
				041 of these rules in order to be
				eligible for payment: (3-17-22)
a. Attendant
				Care; (3-17-22)
b. Homemaker; and
				(3-17-22)
c. Respite.
				(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOME AND COMMUNITY-BASED SERVICES › Section 16.03.10.350 - TRANSITION MANAGEMENT

Current through August 31, 2023
Transition management provides relocation assistance and
				  intensive service coordination activities to assist nursing facility, hospital,
				  IMD and ICF/IID residents to transition to community settings of their choice.
				  Transition managers provide oversight and coordination activities for
				  participants during a transitional period up to twelve (12) months following a
				  return to the community. This provider type will function as a liaison between
				  the participant, institutional or facility discharge staff, and other
				  individuals as designated by the participant and the Department to support a
				  successful and sustainable transition to the community. A participant is
				  eligible to receive transition management when planning to discharge from a
				  qualifying institution after residing within that institution for a minimum of
				  forty-five (45) days. (3-17-22)
01.
Provider Qualifications
. Transition managers must: (3-17-22)
a. Satisfactorily complete a criminal history
				and background check in accordance with IDAPA 16.05.06, "Criminal History and
				Background Checks"; (3-17-22)
b.
				Have documented successful completion of the Department approved Transition
				Manager training prior to providing any transition management and transition
				services; (3-17-22)
c. Have a
				Bachelor's Degree in a human services field from a nationally accredited
				university or college, or three (3) years' supervised work experience with the
				population being served; and (3-17-22)
d. Be employed with a provider type approved
				by the Department. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOSPICE › Section 16.03.10.450 - HOSPICE

Current through August 31, 2023
Medical assistance will provide payment for hospice services
				  for eligible participants. Reimbursement will be based on Medicare program
				  coverage as set out in Sections
				  450 through
				  456 of these rules.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOSPICE › Section 16.03.10.451 - HOSPICE: DEFINITIONS

Current through August 31, 2023
The following definitions apply to Sections
				  450 through
				  456 of these rules.
				  (3-17-22)
01.
Attending
				Physician
. A physician who: (3-17-22)
a. Is a doctor of medicine or osteopathy; and
				(3-17-22)
b. Is identified by the
				participant, at the time they elect to receive hospice care, as having the most
				significant role in the determination and delivery of the participant's medical
				care. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOSPICE › Section 16.03.10.452 - HOSPICE: ELIGIBILITY

Current through August 31, 2023
Inherent in the Hospice program is that a participant
				  understands the nature and basis for eligibility for hospice care without an
				  inappropriate and explicit written statement about how the impending death will
				  affect care. Though only written acknowledgment of the election periods is
				  mandated, it is required that the participant or their representative be fully
				  informed by a hospice before the beginning of a participant's care about the
				  reason and nature of hospice care. The following are the eligibility
				  requirements for Hospice: (3-17-22)
01.
Certification
. A
				certification that the participant is terminally ill must have been completed
				in accordance with Section
				454.01 of these rules.
				(3-17-22)
02.
Medically
				Necessary
. Hospice services must be reasonable and necessary for the
				palliation and management of the terminal illness and related conditions.
				(3-17-22)
03.
Election of
				Services
.The participant must elect hospice care in accordance with
				Section 454.02 of
				these rules
.
(3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOSPICE › Section 16.03.10.454 - HOSPICE: PROCEDURAL REQUIREMENTS

Current through August 31, 2023
01.
Physician Certification
. The hospice must obtain the certification that
				a participant is terminally ill in accordance with the following procedures:
				(3-17-22)
a. For the first period of hospice
				coverage, the hospice must obtain, no later than two (2) calendar days after
				hospice care is initiated, written certification statements signed by the
				medical director of the hospice or the physician member of the hospice
				interdisciplinary group and the participant's attending physician (if the
				participant has one). The certification must include the statement that the
				participant's medical prognosis is that their life expectancy is six (6) months
				or less and the signature(s) of the physician(s). In the event the
				participant's medical prognosis or the appropriateness of hospice care is
				questionable, the Department has the right to obtain another physician's
				opinion to verify a participant's medical status. (3-17-22)
b. For any subsequent election period, the
				hospice must obtain, no later than two (2) calendar days after the beginning of
				that period, a written certification statement prepared by the medical director
				of the hospice or the physician member of the interdisciplinary group. The
				certification must include the statement that the participant's medical
				prognosis is that their life expectancy is six (6) months or less and the
				signature(s) of the physician(s). (3-17-22)
c. The hospice must maintain the monthly
				certification statements for review. (3-17-22)
d. The hospice will submit a physician
				listing with their provider application and update changes in the listing of
				physicians that are hospice employees, including physician volunteers, to the
				Bureau of Facility Standards. The designated hospice must also notify the
				Medicaid program when the designated attending physician of a participant in
				their care is not a hospice employee. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOSPICE › Section 16.03.10.455 - HOSPICE: PROVIDER QUALIFICATIONS AND DUTIES

Current through August 31, 2023
All services must be performed by appropriately qualified
				  personnel, but it is the nature of the service, rather than the qualification
				  of the person who provides it, that determines the category of the service.
				  (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOSPICE › Section 16.03.10.457 - HOSPICE: LIMITATION ON PAYMENTS FOR INPATIENT CARE

Current through August 31, 2023
Payments to a hospice for inpatient care must be limited
				  according to the number of days of inpatient care furnished to Medicaid
				  patients. During the twelve (12) month period beginning November 1st of each
				  year and ending October 31st of the next year, the aggregate number of
				  inpatient days (both general inpatient days and inpatient respite care) may not
				  exceed twenty percent (20%) of the total number of days of hospice care
				  provided to all Medicaid participants during the same period by the designated
				  hospice or its contracted agent(s). (3-17-22)
01.
For Purposes of Computation
.
				If it is determined that the inpatient rate should not be paid, any days for
				which the hospice receives payment at a home care rate will not be counted as
				inpatient days. The limitations on payment for inpatient days are as follows:
				(3-17-22)
a. The maximum number of allowable
				inpatient days will be calculated by multiplying the total number of a
				provider's Medicaid hospice days by twenty percent (20%). (3-17-22)
b. If the total number of days of inpatient
				care to Medicaid hospice patients is less than or equal to the maximum number
				of inpatient days computed in Subsection
				457.01 of these rules then no
				adjustment is made. (3-17-22)
c. If
				the total number of days of inpatient care exceeds the maximum number of
				allowable inpatient days computed in Subsection
				457.01 of these rules then the
				payment limitation will be determined by: (3-17-22)
i. Calculating the ratio of the maximum
				allowable inpatient days to the number of actual days of inpatient care, and
				multiplying this ratio by the total reimbursement for inpatient care that was
				made. (3-17-22)
ii. Multiplying
				excess inpatient care days by the routine home care rate. (3-17-22)
iii. Adding the amounts calculated in
				Subsections 457.01.c.i. and 457.01.c.ii.
				of these rules. (3-17-22)
iv.
				Comparing the amount in Subsection
				457.01.c.iii. of these
				rules with interim payments made to the hospice for inpatient care during the
				"cap period." (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOSPICE › Section 16.03.10.459 - HOSPICE: CAP ON OVERALL REIMBURSEMENT

Current through August 31, 2023
Aggregate payments to each hospice will be limited during a
				  hospice cap period per Subsection
				  451.05 of these rules. The total
				  payments made for services furnished to Medicaid participants during this
				  period will be compared to the "cap amount" for this period. Any payments in
				  excess of the cap must be refunded by the hospice. (3-17-22)
01.
Overall Cap
. The overall cap
				will be compared to reimbursement after the inpatient limitation is computed
				and subtracted from total reimbursement due the hospice. (3-17-22)
02.
Total Payment for Services
.
				Total payment made for services furnished to Medicaid participants during this
				period means all payments for services rendered during the cap year, regardless
				of when payment is actually made. (3-17-22)
03.
Calculation of Cap Amount
.
				The "cap amount" is calculated by multiplying the number of participants
				electing certified hospice care during the period by six thousand five hundred
				dollars ($6,500). This amount will be adjusted for each subsequent cap year
				beginning November 1, 1983, to reflect the percentage increase or decrease in
				the medical care expenditure category of the Consumer Price Index (CPI) for all
				urban consumers as published by the Bureau of Labor Statistics. It will also be
				adjusted as per Subsection
				459.07 of these rules.
				(3-17-22)
04.
Computation and
				Application of Cap Amount
. The computation and application of the "cap
				amount" is made by the Department after the end of the cap period.
				(3-17-22)
05.
Report Number
				of Medicaid Participants
. The hospice must report the number of Medicaid
				participants electing hospice care during the period to the Department.
				(3-17-22)
a. This must be done within thirty
				(30) days after the end of the cap period: and (3-17-22)
b. If the participant is transferred to a
				non-certified hospice no payment to the non-certified hospice will be made and
				the certified hospice may count a complete participant benefit period in their
				cap amount. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB AREA: HOSPICE › Section 16.03.10.460 - HOSPICE: POST-ELIGIBILITY TREATMENT OF INCOME

Current through August 31, 2023
Where a participant is determined eligible for medical
				  assistance participation in the cost of long term care, the Department will
				  reduce its payments for all costs of the hospice benefit, including the
				  supplementary amounts for room and board, by an amount determined according to
				  Section 227 of these
				  rules. (3-17-22)
Idaho Administrative Code › Title IDAPA 16 - Health and Welfare, Department of › Rule 16.03.10 - MEDICAID ENHANCED PLAN BENEFITS › SUB PART: ENHANCED DEVELOPMENTAL DISABILITY SERVICES › Section 16.03.10.500 - DEVELOPMENTAL DISABILITY DETERMINATION STANDARDS

Current through August 31, 2023
Prior to receiving developmental disability services as
				  provided in Sections 507 through
				  719 of these rules, the participant
				  must be determined to have a developmental disability. (3-17-22)