Rhode Island Code of Regulations › Title 210 - Executive Office of Health and Human Services › Chapter 50 - Medicaid Long-Term Services and Supports › Subchapter 10 - Home and Community Based LTSS › Part 1 - "Medicaid Long-Term Services and Supports: Home and Community-Based Services (HCBS)" (210-RICR-50-10-1) › Section 210-RICR-50-10-1.6 - Medicaid Home and Community-based Long-term Services and Supports

Current through June 14, 2024
A. The HCBS options a LTSS beneficiary is
				  authorized to receive depends on the determination of needs level and the
				  person-centered care planning process (PCPP) involving the beneficiary,
				  provider and family members or authorized representatives. The following are
				  the Medicaid HCBS authorized under the Medicaid State Plan and Section 1115
				  demonstration waiver available based on need to beneficiaries:
1. Adult Companion Services -- Non-medical
				  care, supervision, and socialization, provided to a functionally impaired
				  adult. Companions may assist or supervise the beneficiary with such tasks as
				  meal preparation, laundry and shopping. The provision of companion services
				  does not entail hands-on nursing care. Providers may also perform light
				  housekeeping tasks that are incidental to the care and supervision of the
				  beneficiary. This service is provided in accordance with a therapeutic goal in
				  the service plan.
2. Assisted
				  Living Services -- Personal care and supportive services (homemaker, chore,
				  attendant services, meal preparation) that are furnished to HCBS beneficiaries
				  who reside in a setting that meets the HCBS setting requirements and includes
				  24-hour on-site response capability to meet scheduled or unpredictable resident
				  needs and to provide supervision, safety and security. Nursing and skilled
				  therapy services are incidental rather than integral to the provision of
				  assisted living services. Medicaid covered assisted living services also
				  include social and recreational programming, and medication assistance. In
				  addition, the assisted living residence must be Medicaid certified provider
				  and, as such, adhere to the following:
a.
				  Medicaid covered services that are provided by third parties must be
				  coordinated with the assisted living provider.
b. Services must be furnished in a manner
				  that meets a beneficiary's LTSS needs in a manner that promotes self-reliance,
				  dignity and independence. The beneficiary has a right to privacy and has the
				  freedom to move about unless a health practitioner has certified in writing
				  that the beneficiary has a cognitive impairment or similar condition as to be a
				  danger to self or others if given the opportunity to lock the door.
c. Assisted living residences with the
				  appropriate State licensure and Medicaid certification may provide an enhanced
				  or specialized package of services, such as dementia care, when necessary to
				  meet a beneficiary's acuity needs. Prior authorization by the State or a
				  Medicaid managed care plan is required.
d. Personalized services must be provided to
				  a beneficiary residing is a single or double living unit, when both occupants
				  consent to the arrangement, that contains sleeping and toilet facilities. Each
				  living unit is separate and distinct from each other unit. The residence must
				  have a central dining room, living room, or parlor, and common activity
				  center(s) (which may also serve as living room or dining room).
e. The beneficiary must retain the right to
				  assume risk, tempered only by his or her ability to assume responsibility for
				  that risk.
3. Case
				  Management -- Medicaid coverage is available for case management services that
				  assist beneficiaries in gaining access to needed HCBS and other State plan
				  services, as well as medical, social, educational and other services,
				  regardless of the funding source for those services.
4. Community-Based Supported Living
				  Arrangements (CSLA) -- Enhanced and specialized HCBS for persons with more
				  intensive LTSS needs provided through Medicaid certified community-based
				  providers [DOT] including certain assisted living residences, group homes for
				  persons with developmental or behavioral health disabilities, and other adult
				  supportive care homes. These providers are authorized by the State to address
				  high level functional/clinical needs that otherwise would require care in an
				  institutional- setting. To participate in the program, HCBS providers must meet
				  standards set by the State related to minimum licensure and certification and
				  establish and maintain an acuity-based, tiered service and payment system that
				  ties reimbursements to: beneficiary's clinical/functional level of need; the
				  scope of HCBS authorized and provided; and specific quality and outcome
				  measures. Occupancy limits on the number of residents allowed in such
				  arrangements may apply in accordance with State licensure and/or certification
				  requirements.
5. Community
				  Transition Services - Community transitions services are non-recurring set-up
				  expenses for applicants and beneficiaries who are transitioning from an
				  institutional or another provider-operated setting to a living arrangement in a
				  private residence where the person is directly responsible for his or her own
				  living expenses. Allowable expenses are those necessary to enable a person to
				  establish a basic household that do not constitute room and board.
a. Allowable expenses include, but are not
				  limited to: security deposits that are required to obtain a lease on an
				  apartment or home; essential household furnishings and moving expense required
				  to occupy and use a community domicile, including furniture, window coverings,
				  food preparation items, and bed/bath linens; set-up fees or deposits for
				  utility or service access, including telephone, electricity, heating and water;
				  services necessary for the person's health and safety such as pest eradication
				  and one-time cleaning prior to occupancy; moving expenses; necessary home
				  accessibility adaptations; and activities to assess need, arrange for and
				  procure needed resources; storage fees; weather appropriate clothing;
				  assistance with obtaining needed documentations for housing agreements.
b. Allowable expenses for
				  community transitions are only covered to the extent that they are reasonable
				  and necessary as determined through the PCPP, are clearly identified in the
				  person-centered service plan, and the person is unable to afford paying for the
				  transition services, or the services cannot be obtained from other
				  sources.
6. Day treatment
				  and supports -- Services that are necessary for the diagnosis or treatment of a
				  beneficiary's behavior health condition, mental illness, or disability. The
				  purpose of this service is to maintain the beneficiary's condition and
				  functional level and to prevent relapse or hospitalization. Range of services
				  available includes the following:
a.
				  Individual and group therapy with physicians or psychologists (or other health
				  professionals to the extent authorized under State law);
b. Occupational therapy, requiring the skills
				  of a qualified occupational therapist;
c. The services of trained psychiatric
				  nurses, social workers, and other professionals and paraprofessionals trained
				  to work with individuals with psychiatric illness;
d. Drugs and biologicals furnished for
				  therapeutic purposes, that are otherwise not covered by Medicaid or
				  Medicare;
e. Individual activity
				  therapies that are not primarily recreational or diversionary;
f. Family counseling (the primary purpose of
				  which is treatment of the beneficiary's condition);
g. Training and education of the individual
				  (to the extent that training and educational activities are closely and clearly
				  related to the individual's care and treatment); and
h. Diagnostic services.
7. Habilitation services [DOT] Services
				  designed to assist beneficiaries in acquiring, retaining and improving the
				  self-help, socialization, and adaptive skills necessary to reside successfully
				  in a home or community-based setting. May be included as part of integrated day
				  services or residential habilitation services, as indicated below:
a. Day habilitation. Regularly scheduled
				  habilitative services and related activities in a setting apart from the
				  beneficiary's private residence. These day services focus on enabling a
				  beneficiary to attain or maintain his or her maximum potential and are
				  coordinated with any needed therapies in the PCP, such as physical,
				  occupational or speech therapy.
b.
				  Residential habilitation. Individually tailored habilitation services and
				  supports targeted at improving skills related to living in the community.
				  Includes adaptive skill development, assistance with the activities of daily
				  living, community inclusion, transportation, adult education, employment
				  supports, and the development of social and leisure skills that assist the
				  beneficiary in living in the most integrated setting appropriate. In addition,
				  the service covers personal care and protective oversight and
				  supervision.
8. Homemaker
				  services [DOT] The performance of general household tasks (e.g., meal
				  preparation and routine household care) provided by a qualified homemaker, when
				  the beneficiary or caretaker regularly responsible for these activities is
				  temporarily absent or unable to manage the home and care for him or herself or
				  others in the home.
9. Home
				  delivered meals -- The delivery of hot meals and shelf staples to the
				  beneficiary's residence. These services are available to a beneficiary who has
				  a functional dependency/disability that limits the ability to prepare meals and
				  who requires food preparation and delivery to live in the community. Home
				  delivered meals must provide a minimum of one-third of the current recommended
				  dietary allowance and generally do not meet the full daily nutritional
				  requirement.
10. Individual
				  directed goods and services [DOT] The services, equipment, or supplies not
				  otherwise covered by Medicaid that address an identified need in the
				  beneficiary's service plan, including improving and maintaining the
				  beneficiary's opportunities for full membership in the community. Individual
				  directed goods and services are purchased from the beneficiary-directed budget.
				  To be covered, the beneficiary must not have the funds to purchase the item or
				  service or the item or service must not be available through another source and
				  the item or service must:
a. Decrease the
				  need for other Medicaid services; AND/OR
b. Promote inclusion in the community; AND/OR
c. Increase the beneficiary's
				  safety in the home environment; AND,
d. Not be an experimental or prohibited
				  treatment.
11. Integrated
				  supported employment -- Integrated employment supports are services and
				  training activities provided in regular business and industry settings for
				  beneficiaries who have disabilities. The outcome of this service is sustained
				  paid employment and work experience leading to further career development and
				  integrated community-based employment for which the beneficiary is compensated
				  at or above the minimum wage, but 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.
a. Supports
				  may include any combination of the following services: vocational/job-related
				  discovery or assessment, person- centered employment planning, job placement,
				  job development, negotiation with prospective employers, job analysis, training
				  and systematic instruction, job coaching, benefits management, transportation
				  and career advancement services. Other workplace support services may include
				  services not specifically related to job skill training that enable the HCBS
				  beneficiary to be successful in integrating into the job setting.
b. Supported employment must be provided in a
				  manner that promotes integration into the workplace and interaction between
				  beneficiaries and people without disabilities in those workplaces.
12. Medication
				  management/administration [DOT] Pharmacologic management including review of
				  medication use, both current and historical, if indicated; evaluation of
				  symptoms being treated, side effects and effectiveness of current
				  medication(s), adjustment of medications if indicated, and prescription,
				  provided by a medical professional practicing within the scope of his or her
				  licensure.
13. Personal care -- A
				  range of services and supports that enables HCBS beneficiaries to accomplish
				  tasks that they would normally do for themselves if they did not have
				  functional and/or clinical limitations. Personal care may take the form of
				  hands-on assistance or cuing to prompt the beneficiary to perform a task. The
				  services may be provided on an episodic or on a continuing basis and may be
				  provided by a home health aide, personal care attendant, or direct service
				  worker.
14. Personal Emergency
				  Response System (PERS) -- PERS is an electronic device that enables HCBS
				  beneficiaries to secure help in an emergency. The system is connected to the
				  beneficiary's phone and programmed to signal a response center once a "help"
				  button is activated. The response center is staffed by trained professionals,
				  as specified herein.
15.
				  Prevocational Services [DOT] Services intended to develop and teach general
				  skills that lead to competitive and integrated employment including, but not
				  limited to the ability to: communicate effectively with supervisors, co-workers
				  and customers; follow directions; attend to tasks; solve workplace problems;
				  engage in appropriate work conduct and meet applicable norms related to
				  grooming and dress; and adhere to health and safety standards.
a. Participation in prevocational services is
				  not a required pre-requisite for HCBS individual or small group supported
				  employment services.
b. Includes
				  volunteer work and other non-paid work that facilitate the development of
				  general, non-job-task-specific strengths and skills that enhance a
				  beneficiary's employability.
c.
				  Services are expected to occur over a defined period of time and with specific
				  outcomes to be achieved, as determined by the beneficiary in the PCPP with the
				  assistance of the health professionals and other participants in that process.
				  Beneficiaries receiving prevocational services must have employment-related
				  goals in their person-centered service plan and their general habilitation
				  activities must be designed to support such employment goals.
16. Private duty nursing
				  -Individual and continuous care (in contrast to part time or intermittent care)
				  provided by licensed nurses within their scope of practice under State law.
				  These services are provided to a beneficiary at home.
17. Respite care -- Services provided to
				  beneficiaries, within parameters established by the State, who are unable to
				  care for themselves that are furnished on a short-term basis because of the
				  absence or need for relief of those persons who normally provide care for the
				  beneficiary.
18. Shared-living
				  [DOT] A supported living arrangement in which necessary core HCBSs (e.g.,
				  personal care, homemaker, chore, companion services and medication oversight)
				  are bundled and provided in a private residence to a beneficiary by a principal
				  caregiver who shares the home. The scope of HCBS available in share living
				  arrangements, and service agencies, varies depending whether a beneficiary
				  requires a NF or ICF/I-DD level of care and the extent of his or her acuity
				  needs. The State pays the principal caregiver through the service agency for
				  the HCBS provided to the beneficiary and for assisting in coordinating access
				  to other needed services. Separate payment is not made for homemaker or chore
				  services furnished to the beneficiary as these services are integral to and
				  inherent in the provision of the shared living arrangement.
19. Skilled nursing -- Services listed in the
				  PCP plan that are within the scope of a nurse's area of practice under State
				  law. HCBS skilled nursing is distinguished from private duty nursing in that it
				  is part time or intermittent and provided by a registered professional nurse,
				  or licensed practical or vocational nurse under the supervision of a registered
				  nurse in either the beneficiary's home or Medicaid certified community living
				  arrangement.
20. Specialized
				  medical equipment and supplies -- Specialized medical equipment and supplies
				  are devices, controls, or appliances, specified in the plan of care, that
				  enable beneficiaries to: increase their ability to perform activities of daily
				  living; perceive, control, or communicate with the environment in which they
				  live; ensure life support; or address physical conditions along with ancillary
				  supplies and equipment necessary to the proper functioning of such items. Also
				  includes:
a. Other durable and non-durable
				  medical equipment and medical supplies not covered under the State Plan that
				  are necessary to address a beneficiary's functional limitations.
b. Remote devices that enable appropriately
				  licensed health care professionals to monitor certain aspects of a
				  beneficiary's health at home or in other residential living
				  arrangements.
c. Items covered
				  under HCBS 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 beneficiary.
d. All items must meet applicable standards
				  of manufacture, design and installation.
21. Supports for consumer direction [DOT] The
				  services and supports provided by a facilitator [DOT] referred to as the
				  service advisement agency -- that empowers beneficiaries participating in
				  self-directed "personal choice" service delivery options under Part 2,
				  subchapter 10 of this Chapter to define and direct their own personal
				  assistance needs and services; guides and supports, rather than directs and
				  manages, the beneficiary through the service planning and delivery process. The
				  facilitator counsels and assists in development of the PCP which includes both
				  paid and unpaid services and supports designed to enable the beneficiary to
				  live at home and participate in the community. A back-up plan is also developed
				  to assure that the needed assistance will be provided in the event that regular
				  services identified in the PCP are temporarily unavailable.