11110.1In order to receive Medicaid reimbursement, individual-directed goods and services shall only be provided to IFS Waiver participants who are enrolled in the My Life, My Way program and are purchased from the participants PDS budget.
11110.2Individual-directed goods and services are services, equipment or supplies not otherwise provided through the IFS Waiver or the Medicaid State Plan that address an identified need in the participant's ISP, including improving and maintaining the participant's opportunities for full membership in the community.
11110.3Individual-directed goods and services shall meet the following requirements:
(a) The requested item or service would decrease the participant's need for other Medicaid services;(b) The requested item or service would promote the participant's inclusion in the community; or(c) The requested item or service would increase the participant's safety in the home environment.11110.4Allowable individual directed goods and services shall include, but not be limited to, the following:
(b) Fitness items that can be purchased at most retail stores;(c) Toothbrushes or electric toothbrushes;(d) Weight loss program services (other than food);(e) Dental services recommended by a licensed dentist and not covered by health insurance;(f) Nutritional supplements recommended by a professional licensed in the relevant field;(g) Therapeutic swimming or horseback riding with recommendation from licensed professional;(h) Fees for activities that promote community integration;(i) Fingerprinting, drug testing costs needed for the participant to be considered for a job but not otherwise covered;(j) Non-post-secondary educational classes that are open to the general public and that offer the opportunity for community integration and engagement while the participant is engaged in skill building or a hobby (for example, cooking class; fitness class; money management; art);(k) Durable medical equipment prescribed by a physician but not otherwise covered through health insurance;(l) Cleaning service from firms or individuals to clean the waiver participant's personal areas including bedroom, bathroom, kitchen, etc.;(m) Food preparation service and delivery of prepared foods (does not provide payment for the food);(n) Small electric appliances which allow the participants to safely prepare meals;(o) Laundry service from a Laundromat or other provider; and(p) Funding up to five hundred dollars ($500) that participants may choose to support staff recruitment and advertisement efforts such as developing and printing flyers and using staffing registries.11110.5Non-allowable individual directed goods and services shall include, but not be limited to, the following:
(a) Experimental or prohibited treatments;(b) Items used solely for entertainment or recreational purposes, such as televisions, video recorders, DVD players, monthly cable fees; monthly telephone fees; vacation expenses, lottery tickets, alcoholic beverages, tobacco/nicotine products, illegal drugs (including cannabis), movies tickets, spa treatments;(c) Goods or services with costs that significantly exceed community norms for the same or similar good or service;(d) Expenses related to routine daily living, including groceries, rent or mortgage payments, utility payments, home maintenance, gifts, pets (excluding service animals), and other items as determined by the DDS;(e) Items and services that are excluded from receiving Federal Financial Participation (FFP), including but not limited to services provided while a participant is an inpatient of a hospital, nursing facility, or ICF/ID;(f) Services or goods or items provided to or benefiting participants other than the participant;(g) Services or goods that are otherwise covered by the IFS Waiver or the Medicaid State Plan; additional units or costs beyond the maximum allowable for any waiver good service or Medicaid State Plan good or service, with the exception of a second wheelchair; co-payment for medical services; over-the-counter medications; homeopathic services; and(h) Tuition for educational services otherwise available through a program funded under the Individuals with Disabilities Education Act (IDEA), including private tuition.11110.6Participants in the My Life, My Way program may purchase individual-directed goods and services that are included in their ISP, meet the requirements of §§ 11110.3 and 11110.4 and are within their PDS budget to purchase, and not exceed the cost of twenty-five hundred dollars ($2,500).
11110.7Goods and services may not be purchased from a waiver participant's spouse, legally responsible person, or relative.
11110.8These services shall be reimbursed only if approved in the participant's ISP based on recommendations from the support team and where appropriate, assessment and professional recommendations; and when not otherwise available under the participant's private health insurance (if applicable), the IFS waiver; the Medicaid State plan or through other resources, including services available to an individual under a program funded through section 110 of the Rehabilitation Act of 1973.
11110.9Individual-directed goods and services shall be documented in the participant's PDS budget and ISP. The participant's support broker shall assist participants to revise their PDS budgets, as necessary, to account for new, appropriate individual-directed goods and services they would like to purchase. All revisions to a participant's PDS budget to account for new, appropriate individual-directed goods and services shall be accompanied by justification supporting the revision.
11110.10Upon revising a PDS budget to reflect a new individual-directed good or service, the support broker shall submit the revised PDS budget and justification to DDS for approval.
11110.11DDS shall review all requested individual-directed goods and services.
11110.12The VF/EA FMS-Support Broker entity shall only authorize payment of invoices submitted for individual-directed goods and services that are included in the participant's ISP and PDS budget and that have been approved by DDS.
D.C. Mun. Regs. tit. 29, r. 29-11110
Final Rulemaking published at 70 DCR 8909 (6/23/2023)