Chapter 513 Intellectual and developmental disabilities ...

1 Chapter 513 Intellectual AND developmental disabilities W AIVER (IDDW ) BMS Provider Manual Page 1 Chapter 513 Intellectual and developmental disabilities Waiver (IDDW) Effective 12/1/2015 DISCLAIMER: This Chapter does not address all the complexities of Medicaid policies and procedures, and must be supplemented with all State and Federal Laws and Regulation. Contact BMS Fiscal Agent for coverage, prior authorization requirements, service limitations and other practitioner information. TABLE OF CONTENTS SECTION PAGE NUMBER Background .. 7 Program Description .. 7 Provider Enrollment and Participation Requirements .. 8 Bureau for Medical Services (BMS) Contractual Relationships.

2 8 Provider Enrollment and Responsibilities .. 9 Criminal Background Checks .. 12 Pre-Screening .. 12 Fingerprinting .. 13 Employment Fitness Determination .. 13 Provisional Employees .. 13 Variance .. 14 Appeals .. 14 Responsibility of the Hiring Entity .. 15 Record Retention .. 15 Change in Employment .. 15 Office Criteria .. 16 Quality Improvement System (QIS) .. 16 Centers for Medicare and Medicaid Services (CMS) Quality Assurances .. 17 Quality Improvement and Advisory (QIA) Council .. 17 IDDW Provider Reviews .. 18 Plan of Correction .. 19 Training and Technical Assistance .. 19 Self-Reviews .. 19 Chapter 513 Intellectual AND developmental disabilities W AIVER (IDDW ) BMS Provider Manual Page 2 Chapter 513 Intellectual and developmental disabilities Waiver (IDDW) Effective 12/1/2015 DISCLAIMER: This Chapter does not address all the complexities of Medicaid policies and procedures, and must be supplemented with all State and Federal Laws and Regulation.

3 Contact BMS Fiscal Agent for coverage, prior authorization requirements, service limitations and other practitioner information. Utilization Guidelines for IDDW .. 20 Staff Qualifications and Training Requirements .. 21 Behavior Support Professional (BSP) Agency Staff Qualifications .. 21 Behavior Support Professional I (BSP I) Agency Staff Qualifications .. 21 Behavior Support Professional II (BSP II) Agency Staff Qualifications .. 21 Crisis Services Agency Staff Qualifications .. 22 Dietary Therapist Agency Staff Qualifications .. 22 Facility-Based Day Habilitation Agency Staff Qualifications .. 22 Job Development Agency Staff Qualifications .. 22 Occupational Therapist Agency Staff Qualifications .. 22 Person-Centered Support Agency Staff Qualifications .. 22 Physical Therapist Agency Staff Qualifications .. 23 Pre-Vocational Agency Staff Qualifications .. 23 Qualified Support Workers (QSW) Qualifications (Personal Options Only).

4 23 Respite Agency Staff Qualifications .. 24 Service Coordination Agency Staff Qualifications .. 24 Skilled Nursing Agency Staff Qualifications .. 24 Speech Therapist Agency Staff Qualifications .. 25 Stand-By Intervention Agency Staff Qualifications .. 25 Supported Employment Agency Staff Qualifications .. 25 Transportation Agency Staff Qualifications .. 25 Reporting Requirements .. 25 Documentation and Record Retention Requirements .. 27 Eligibility and Enrollment .. 28 Applicant Eligibility and Enrollment Process .. 28 Chapter 513 Intellectual AND developmental disabilities W AIVER (IDDW ) BMS Provider Manual Page 3 Chapter 513 Intellectual and developmental disabilities Waiver (IDDW) Effective 12/1/2015 DISCLAIMER: This Chapter does not address all the complexities of Medicaid policies and procedures, and must be supplemented with all State and Federal Laws and Regulation.

5 Contact BMS Fiscal Agent for coverage, prior authorization requirements, service limitations and other practitioner information. Application Process .. 29 Initial Eligibility Determination Process .. 29 Initial Medical Eligibility .. 31 Diagnosis .. 32 32 Active Treatment .. 33 Initial Financial Eligibility .. 33 Determination of Initial Financial Eligibility .. 33 Slot Allocation Referral and Selection Process .. 34 Eligibility Effective Date .. 35 Annual Re-Determination of Eligibility Process .. 35 Annual Re-Determination of Medical Eligibility .. 35 Annual Re-Determination of Financial Eligibility .. 36 Policy .. 36 Individual Program Plan (IPP) .. 36 The Interdisciplinary Team (IDT) .. 39 Seven Day IDT Meeting .. 40 Thirty Day IDT Meeting .. 40 Transfer/Discharge IDT Meeting .. 41 Critical Juncture IDT Meeting .. 41 Annual, Quarterly and Six-Month IDT Meetings .. 42 Description of Service Options .. 42 Traditional Service Option.

6 43 Participant-Directed Service Option .. 44 Behavior Support Professional Services .. 48 Chapter 513 Intellectual AND developmental disabilities W AIVER (IDDW ) BMS Provider Manual Page 4 Chapter 513 Intellectual and developmental disabilities Waiver (IDDW) Effective 12/1/2015 DISCLAIMER: This Chapter does not address all the complexities of Medicaid policies and procedures, and must be supplemented with all State and Federal Laws and Regulation. Contact BMS Fiscal Agent for coverage, prior authorization requirements, service limitations and other practitioner information. Behavior Support Professional I and II (Traditional Option) .. 48 Behavior Support Professional I and II, Individual Program Planning (Traditional Option) .. 51 Crisis Services .. 52 Crisis Services (Traditional Option).

7 52 Extended Professional 53 Dietary Therapy (Traditional Option) .. 53 Occupational Therapy (Traditional Option) .. 54 Physical Therapy (Traditional Option) .. 56 Speech Therapy (Traditional Option) .. 57 Electronic Monitoring .. 58 Electronic Monitoring (Traditional Option) .. 58 Environmental Accessibility Adaptations .. 61 Environmental Accessibility Adaptations Home (Traditional Option) .. 61 Environmental Accessibility Adaptations Vehicle (Traditional Option) .. 62 Day 63 Facility-Based Day Habilitation (Traditional Option) .. 63 Pre-Vocational (Traditional Option) .. 65 Job Development (Traditional Option) .. 67 Supported Employment (Traditional Option) .. 69 Goods and Services .. 71 Goods and Services (Participant-Directed Option, Personal Options Model) .. 71 Person-Centered Support .. 74 Family Person-Centered Support .. 74 Family Person-Centered Support (Traditional Option) .. 74 Family Person-Centered Support (Personal Options Model).

8 76 Chapter 513 Intellectual AND developmental disabilities W AIVER (IDDW ) BMS Provider Manual Page 5 Chapter 513 Intellectual and developmental disabilities Waiver (IDDW) Effective 12/1/2015 DISCLAIMER: This Chapter does not address all the complexities of Medicaid policies and procedures, and must be supplemented with all State and Federal Laws and Regulation. Contact BMS Fiscal Agent for coverage, prior authorization requirements, service limitations and other practitioner information. Home-Based Person-Centered Support (Traditional Option) .. 78 Licensed Group Home Person-Centered Support (Traditional Option) .. 81 Unlicensed Residential Person-Centered Support .. 83 Unlicensed Residential Person-Centered Support (Traditional Option) .. 83 Unlicensed Residential Person-Centered Support (Personal Options Model).

9 86 Crisis Site Person-Centered Support (Traditional Option) .. 88 Respite .. 90 In-Home Respite .. 90 In-Home Respite (Traditional Option) .. 90 In-Home Respite (Personal Options Model) .. 92 Out-of-Home Respite .. 94 Out-of-Home Respite (Traditional Option) .. 94 Out-of-Home Respite (Personal Options Model).. 96 Service Coordination .. 98 Service Coordination (Traditional Option) .. 98 Skilled Nursing .. 103 Skilled Nursing Licensed Practical Nurse (Traditional Option) .. 103 Skilled Nursing Licensed Registered Nurse (Traditional Option) .. 105 Skilled Nursing Licensed Registered Nurse, Individual Program Planning (Traditional Option) .. 107 108 Transportation Miles (Traditional Option) .. 108 Transportation Miles (Participant-Directed Option, Personal Options Model) .. 109 Transportation Trips (Traditional Option) .. 110 Prior Authorizations .. 111 Chapter 513 Intellectual AND developmental disabilities W AIVER (IDDW ) BMS Provider Manual Page 6 Chapter 513 Intellectual and developmental disabilities Waiver (IDDW) Effective 12/1/2015 DISCLAIMER: This Chapter does not address all the complexities of Medicaid policies and procedures, and must be supplemented with all State and Federal Laws and Regulation.

10 Contact BMS Fiscal Agent for coverage, prior authorization requirements, service limitations and other practitioner information. Billing Procedures .. 111 Payments and Payment Limitations .. 112 Rights and Responsibilities of Persons Receiving Services/Legal Representatives .. 112 Rights .. 112 Responsibilities .. 113 Grievances/Complaints .. 114 Appeals and Service Authorizations .. 114 Medical Re-Determination Eligibility Appeals .. 114 Service Authorization 115 Discharge .. 116 Transfer .. 118 Service Limitations and Service Exclusions .. 118 How to Obtain Information .. 119 Glossary .. 119 Change Log .. 126 Chapter 513 Intellectual AND developmental disabilities W AIVER (IDDW ) BMS Provider Manual Page 7 Chapter 513 Intellectual and developmental disabilities Waiver (IDDW) Effective 12/1/2015 DISCLAIMER: This Chapter does not address all the complexities of Medicaid policies and procedures, and must be supplemented with all State and Federal Laws and Regulation.