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 2 - Self-Directed Care › Section 210-RICR-50-10-2.4 - Definitions

Current through June 14, 2024
A. The following terms, which are listed
				  alphabetically, are referenced in this Regulation.
1. "Activities of daily living" or "ADLs"
				  means everyday routines generally involving functional mobility and personal
				  care, including but not limited to, bathing, dressing, eating, toileting,
				  mobility, and transfer.
2.
				  "Applicant" means new applicants to be determined for Medicaid
				  eligibility.
3. "Assessment" means
				  a meeting with the participant and their representative (if applicable) to
				  evaluate ADLs and IADLs to determine the amount and scope of services needed.
				  Assessments also help to identify services, equipment, home modifications, and
				  other supports in the community that may help the participant to increase their
				  independence within the community.
4. "Budget" means the amount of Medicaid
				  funds set aside each month for the participant's personal care and homemaker
				  services. The budget is based on the amount of assistance the participant
				  requires to meet their personal care needs as determined by the functional
				  assessment. The budget is based on what EOHHS would normally spend to purchase
				  services from a Home Health Agency for the services necessary to allow a
				  participant to live at home.
5.
				  "Case management services" means services that assist participants in gaining
				  access to needed supports through the coordination of a person-centered service
				  plan. Such programs shall be provided in the person's home or in the home of a
				  responsible relative or other responsible adult, but not provided in a skilled
				  nursing facility and/or an intermediate care facility.
6. "Case manager" means an individual
				  employed by a conflict-free case management agency that assesses service needs,
				  assists with planning what services are needed and how to receive them,
				  performs check-ins and evaluations, and is an additional resource to the
				  participant, representative, and/or family to promote safety and quality of
				  care. The case manager conducts quarterly home visits, one of which is
				  unannounced, and makes phone contact with the participant in the months where
				  there is not a home visit. The case manager guides and supports, rather than
				  directs and manages, the participant through the service planning and delivery
				  process.
7. "Conflict-free" means
				  that the entity providing case management services must be different than the
				  entity providing the direct services a participant is referred to.
8. "Conflict-free case management agency"
				  means an agency certified by EOHHS that provides conflict-free case management
				  services for participants receiving home and community-based services,
				  including participants in the Personal Choice program.
9. "Critical incident" means any actual or
				  alleged event or situation that creates a significant risk of substantial or
				  serious harm to the physical or mental health, safety, or well-being of a
				  participant. This includes but is not limited to physical abuse; verbal abuse;
				  psychological or emotional abuse; sexual abuse; financial abuse; use of
				  physical, chemical or mechanical restraint; self-neglect; neglect by another
				  member of the home; exploitation; and unexplained death.
10. "Electronic Visit Verification" or "EVV"
				  is a method used to verify that home healthcare visits occur by collecting data
				  electronically about the visit.
11.
				  "Environmental modifications" or "home modifications" are defined as those
				  physical adaptations to the home of the participant or the participant's family
				  as required by the participant's person-centered service plan, that are
				  necessary to ensure the health, welfare and safety of the participant or that
				  enable the participant to attain or retain capability for independence or
				  self-care in the home and to avoid institutionalization, and are not covered or
				  available under any other funding source. A completed home assessment by a
				  specially trained and certified rehabilitation professional is also required.
				  Such adaptations may include the installation of modular ramps, grab-bars,
				  vertical platform lifts and interior stair lifts. Excluded are those
				  adaptations that are of general utility, are not of direct medical or remedial
				  benefit to the participant. Excluded are any re-modeling, construction, or
				  structural changes to the home (i.e., changes in load bearing walls or
				  structures) that would require a structural engineer, architect and/or
				  certification by a building inspector.
a.
				  Adaptations that add to the total square footage of the home are excluded from
				  this benefit. All adaptations shall be provided in accordance with applicable
				  state or local building codes, and prior approval on an individual basis by
				  EOHHS, Office of Durable Medical Equipment, is required.
b. Items should be of a nature that they are
				  transferable if a participant moves from their place of residence.
12. "Fiscal intermediary services"
				  or "FI services" means financial management services delivered to Personal
				  Choice participants by an EOHHS certified Fiscal Intermediary. FI services are
				  designed to assist participants in allocating funds as outlined in the
				  Individual Service and Spending Plan and to facilitate employment of PCAs by
				  the participant. Personal Choice financial matters are maintained by the fiscal
				  agency and a portion of the participant's monthly budget is set aside for the
				  services it provides.
13. "Home
				  delivered meals" means the delivery of hot meals, frozen meals,
				  cultural/therapeutic meals and/or shelf staples to the participant's residence.
				  Meals are available to individuals unable to care for their nutritional needs
				  because of a functional dependency/disability and who require this assistance
				  to live in the community. Meals provided under this service will not constitute
				  a full daily nutritional requirement. Meals must provide a minimum of one third
				  (1/3) of the current recommended dietary allowance. Provision of home delivered
				  meals will result in less assistance being authorized for meal preparation for
				  individual participants, if applicable.
14. "Homemaker services" means aid in grocery
				  shopping, cooking, using the phone, looking up phone numbers, assistance with
				  housework (cleaning, dusting, vacuuming, laundry), assistance using public
				  transportation, assistance paying and managing bills, and reminding the
				  participant to take their medication(s).
15. "In-home training" means training
				  directed by the participant, as opposed to mandatory orientation and training.
				  This option empowers the participant, as the employer, to train the PCA
				  themselves and decide how services should be delivered by the PCA to suit the
				  participant's needs.
16.
				  "Individual service and spending plan" or "ISSP" means a written plan that
				  shows the services that are purchased with the budget amount provided through
				  the Personal Choice Program. The plan shows the services purchased, the rate of
				  purchased services, and the total dollars spent on care. The ISSP provides
				  information on the participant's goals, goods, and services, as well as taxes
				  and fees associated with their budget. The ISSP also includes a plan for
				  handling emergencies. The ISSP can be updated annually or as the budget or
				  other personal circumstances change.
17. "Instrumental activities of daily living"
				  or "IADLs" means activities related to living independently in the community,
				  including but not limited to: meal planning and preparation; managing finances;
				  shopping for food, clothing, and other essential items; performing essential
				  household chores; scheduling appointments; communicating by phone or other
				  media, and traveling around and participating in the community.
18. "Mandatory orientation and training"
				  means a series of orientation and training courses required by EOHHS for all
				  PCAs listed on the registry. Courses include program overview and structure;
				  PCA eligibility, scope of work, and responsibilities; ethics, accountability,
				  consumer privacy and dignity, HIPAA, and EVV; recognizing and reporting
				  critical incidents; infection control and safety; health management; emotional
				  support; mobility; and understanding and supporting ADLs and IADLs.
19. "Medicaid fraud" means making a false
				  statement, misrepresentation of material fact, submitting a claim or causing a
				  submission to obtain some benefit or payment involving Medicaid money for which
				  no entitlement would otherwise exist. This can be done for the benefit of
				  oneself or another party and includes obtaining something of value through
				  misrepresentation, concealment, omission, or willful blindness of a material
				  fact.
20. "Minor environmental
				  modifications" means minor modifications to the home that may include grab
				  bars, versa frame (toilet safety frame), handheld shower and/or diverter valve,
				  raised toilet seats and other simple devices or appliances such as eating
				  utensils, transfer bath bench, shower chair, aides for personal care (e.g.,
				  reachers), and standing poles to improve home accessibility adaptation, health,
				  or safety.
21. "Nonmedical" means
				  not involving, relating to, used in, or concerned with medical care or the
				  field of medicine.
22.
				  "Participant" means the individual, also referred to as the beneficiary, who
				  utilizes services in the Personal Choice program.
23. "Participant directed goods and services"
				  means services, equipment or supplies not otherwise provided through Medicare
				  or Medicaid, that address an identified need and are in the approved ISSP
				  (including improving and maintaining the individual's opportunities for full
				  membership in the community). Examples include a laundry service for a person
				  unable to launder and fold clothes or a microwave for a person unable to use a
				  stove due to their disability.
24.
				  "Person-centered" means that the assessment and service planning processes are
				  directed and led by the participant (with assistance as needed or desired from
				  a representative or other persons of the participant's choosing) for the
				  purposes of identifying the strengths, capacities, preferences, needs, and
				  desired outcomes that become the core of an individualized plan of LTSS
				  care.
25. "Person-centered options
				  counseling" means an interactive decision-support process that helps people
				  assess and understand their LTSS needs, goals, and preference. Person-centered
				  options counseling emphasizes person-centered thinking to support consumers in
				  making informed decisions about their LTSS options. The person-centered options
				  counseling process is a multi-step approach of asking for and providing
				  information about LTSS programs, offering decision support, and assisting in
				  accessing services.
26.
				  "Person-centered options counselor" means an individual who is trained in
				  person-centered options counseling.
27. "Person-centered service plan" means the
				  written document, developed in a person-centered manner, that specifies the
				  services and supports, both formal and informal, that are furnished to meet the
				  needs of each participant and help them remain in the community. The
				  person-centered service plan contains the types of services to be furnished;
				  the amount, frequency, and duration of each service; and the type of provider
				  to furnish each service.
28.
				  "Personal care services" means the provision of direct supportive, nonmedical
				  services provided in the home or community to individuals in performing tasks
				  they are functionally unable to complete independently due to illness and/or
				  disability, based on the ISSP. Personal care services do not include services
				  that require a professional license, certification or registration by State law
				  such as wound care, injections, oxygen application, and other services which
				  are medical in nature. Personal care services may include but are not limited
				  to:
a. Participant assistance with activities
				  of daily living, such as grooming, personal hygiene, toileting, bathing, and
				  dressing;
b. Assistance with
				  monitoring health status and physical condition;
c. Assistance with preparation and eating of
				  meals (not the cost of the meals itself);
d. Assistance with housekeeping activities
				  (bed making, dusting, vacuuming, laundry, grocery shopping,
				  cleaning);
e. Assistance with
				  transferring; ambulation; use of special mobility devices; assisting the
				  participant by directly providing or arranging transportation.
29. "Personal emergency response
				  system" or "PERS" means an electronic device that enables certain individuals
				  at high risk of institutionalization to secure help in an emergency. The
				  individual may also wear a portable "help" button to allow for mobility. The
				  system is connected to the person's phone and programmed to signal a response
				  center once a "help" button is activated. This service includes coverage for
				  installation and a monthly service fee. Providers are responsible to ensure the
				  upkeep and maintenance of the devices/systems.
30. "Registry" means the official list,
				  maintained by EOHHS or its designee, of qualified PCAs who are available to
				  provide services to participants in the Personal Choice program. Participants
				  may utilize the registry when hiring PCAs for self-directed care.
31. "Representative" means a person
				  designated by a participant to assist the participant in managing some or all
				  the requirements of the Personal Choice program. A representative cannot be
				  paid to provide this assistance. The representative also cannot be paid to
				  provide direct care or hands on care. In other words, the representative cannot
				  be a paid PCA.
32. "Self-directed"
				  means a participant-controlled method of selecting and providing services and
				  supports that allows the individual maximum control of their home and
				  community-based services and supports, with the individual acting as the
				  employer of record with necessary supports to perform that function, or the
				  individual having a significant and meaningful role in the management of a
				  provider of service when the agency-provider model is utilized. Individuals
				  exercise as much control as desired to select, train, supervise, schedule,
				  determine duties, and dismiss the PCA.
33. "Service advisement team" means a team,
				  consisting of a Case Manager, a Nurse, and a Mobility Specialist, that focuses
				  on empowering participants to define and direct their own personal assistance
				  needs and services.
34. "Special
				  medical equipment" or "Minor assistive devices" means the following:
a. Devices, controls, or appliances,
				  specified in the plan of care, which enable participants to increase their
				  ability to perform activities of daily living;
b. Devices, controls, or appliances that
				  enable the participant to perceive, control, or communicate with the
				  environment in which they live; including such other durable and non-durable
				  medical equipment not available through the participant's medical insurance
				  that is necessary to address participant functional limitations;
c. Items reimbursed with waiver funds through
				  the Personal Choice Program are in addition to any medical equipment and
				  supplies furnished by Medicaid and exclude those items that are not of direct
				  medical or remedial benefit to the participant. All items shall meet applicable
				  standards of manufacture, design, and installation. Provision of Specialized
				  Medical Equipment requires prior approval on an individual basis by
				  Medicaid.
35. "Supports
				  for participant direction" or "Supports facilitation" means empowering
				  participants to define and direct their own personal assistance needs and
				  services by guiding and supporting, rather than directing and managing, the
				  participant through the service planning and delivery process.
36. "Taxes" means fees deducted from the
				  participant's monthly budget that are required to be paid on behalf of
				  employees (PCAs):
a. FICA (Federal Insurance
				  Contributions Act): Finances care for the aging, disabled, and survivors,
				  including funding for Medicare.
b.
				  FUTA (Federal Unemployment Tax Act): Finances employment programs at the
				  federal level.
c. SUTA (State
				  Unemployment Tax Act): Finances employment programs at the state
				  level.
d. RITDI (Rhode Island
				  Temporary Disability Insurance): Provides income to employees who cannot work
				  temporarily due to illness or non-job related injury.
37. "Worker's Compensation Insurance" means
				  funds that provide for monetary awards paid to individuals who are injured,
				  disabled, or killed on the job. Worker's Compensation Insurance is a cost of
				  employment paid by the participant from their monthly budget.