403 Neb. Admin. Code, ch. 4, § 004

Current through September 17, 2024

Section 403-4-004 - AVAILABLE SERVICES, LIMITATIONS, AND PROVIDER TYPES

004.01ADULT DAY SERVICES. Adult Day Services provide active supports that foster independence, encompassing both health and social services needed to ensure the optimal functioning of the participant. Adult Day Services includes assistance with activities of daily living (ADL), health maintenance, and supervision. Participants receiving Adult Day Services are integrated into the community to the greatest extent possible. The Adult Day Services provider must be within immediate proximity of the participant to allow staff to provide support, supervision, safety, security, and activities to keep participants engaged in their environment.

004.01(A)LIMITATIONS. The following limitations apply to Adult Day Services:

(i) Adult Day Services are paid at an hourly rate;

(ii) Transportation to and from the Adult Day Services are not included; and

(iii) Services must not be provided in a residential setting.

004.01(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified Providers.

004.02ASSISTIVE TECHNOLOGY. The use of assistive technology enables participants who reside in their own homes to increase their abilities to perform activities of daily living (ADL) in their home or to perceive, control, or communicate with the environment they live in, thereby decreasing their need for assistance from others as a result of limitations due to disability. Providers must provide and maintain Assistive Technology in accordance with applicable building codes or applicable standards of manufacturing, design, and installation. Providers must provide appropriate training to the participant in the use of the Assistive Technology.

004.02(A)LIMITATIONS. The following limitations apply to Assistive Technology.

(i) Each participant has an annual budget cap of $2,500 for Assistive Technology. A request to exceed the cap may be approved by the Department based on critical health or safety concerns, available Waiver funding, and other relevant factors;

(ii) The Department may require an on-site assessment of the environmental concern including an evaluation of functional necessity with appropriate Medicaid enrolled professional providers. The cost of the Environmental Modification Assessment is not included in the $2,500 cap on Assistive Technology;

(iii) For items over $500, proof of insurance or an extended warranty must be provided; and

(iv) Damaged, stolen, or lost items not covered by insurance or warranty may only be replaced once every two years.

004.02(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.03COMMUNITY INTEGRATION. Services for Community Integration may include, but are not limited to:

(A) An opportunity for the participant to practice skills taught in therapies, counseling sessions, or other settings to plan and participate in regularly scheduled community activities;

(B) Supports furnished in the community;

(C) A portion of this service received virtually if the participant chooses; and

(D) Assistance with activities of daily living (ADL), health maintenance, and supervision.

004.03(i)LIMITATIONS. The following limitations apply to Community Integration:

(1) Participants may not perform paid work activities or unpaid activities in which others are typically paid, but may perform hobbies in which minimal money is received or volunteer activities;

(2) Participants receiving Community Integration cannot receive Child Day Habilitation;

(3) Community Integration is reimbursed at an hourly rate. The Community Integration provider is in the community providing a combination of habilitation supports, protective oversight, and supervision to bill in hourly units;

(4) The rate tier for Community Integration is determined based on needs identified in the Objective Assessment Process (OAP);

(5) Transportation required in the provision of Community Integration is included in the rate. The provider is responsible for all non-medical transports, to and from services. When the provider transports participants, the provider must ensure that all participants are transported in a safe and comfortable manner that meets the needs of each participant; and

(6) This service cannot be provided during school hours set by the local school district for the participant. This limitation includes any and all public education programs funded under the Individuals with Disabilities Education Act (IDEA).

004.03(ii)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.04CONSULTATIVE ASSESSMENT SERVICE. Consultative Assessment Service is completed in collaboration with the support planning team and includes a Functional Behavior Assessment (FBA) including risk levels, the development of a Behavior Support Plan (BSP), the development of other habilitative plans, training, and technical assistance to carry out the plan, and treatment integrity support to the participant and the provider in the ongoing implementation of the plan. Providers may conduct observations in person or remotely using video conferencing. Consultative Assessment Service is necessary to improve the independence and inclusion of participants in their community. Consultative Assessment Services may include, but are not limited to:

(1) Performing a Functional Behavioral Assessment (FBA) including the level of risk necessary to address problematic behaviors in functioning that are attributed to developmental, cognitive, or communication impairments;

(2) Evaluating whether current interventions are correctly administered and effective;

(3) Recommending any new interventions; and

(4) Recommending best practices in intervention strategies, medical and psychological conditions, or environmental impact to service delivery to the participant's team.

004.04(A)LIMITATIONS. The following limitations apply to Consultative Assessment Service:

(i) Consultative Assessment Services is billed at an hourly rate;

(ii) Consultative Assessment Services may only be provided by a Licensed Independent Mental Health Practitioner (LIMHP), Licensed Clinical Psychologist (PhD), Advanced Practice Registered Nurse (APRN), or Board-Certified Behavior Analyst (BCBA or BCBA-D) supervised under an LIMHP, licensed psychologist or APRN;

(iii) Providers of this service must attend a minimum of two Individual Support Plan (ISP) meetings per ISP year. More frequent attendance may be necessary based on the frequency of High General Event Record (GER) reporting; and

(iv) For a participant under the age of 21 years, this service is available under the Medicaid State Plan under Early and Periodic Screening, Diagnosis, and Treatment (EPSDT).

004.04(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.05ENVIRONMENTAL MODIFICATION ASSESSMENT. This assessment is used to ensure the health, welfare, and safety of the participant and to enable the participant to integrate more fully into the community.

004.05(A)LIMITATIONS. The following limitations apply to Environmental Modification Assessment:

(i) A participant's annual budget cap for Environmental Modification Assessment is $1,000. A request to exceed the cap may be approved by the Department based on critical health or safety concerns, available Waiver funding, and other relevant factors;

(ii) Environmental Modification Assessment is reimbursed at a flat rate per completed assessment not to exceed the amount charged to the general public; and

(iii) Environmental Modification Assessments must not evaluate a modification that is not allowed under this chapter.

004.05(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.06DAY SUPPORT. Day Support services provide person-centered activities. This service includes the provision of personal care, health maintenance, and supervision. Day Support services are regularly scheduled activities, formalized training, and staff supports for the acquisition, retention, or improvement in:

(1) Self-help;

(2) Behavioral skills;

(3) Adaptive skills;

(4) Social development;

(5) Activities of daily living (ADL); and

(6) Community living.

004.06(A)LIMITATIONS. The following limitations apply to Day Support:

(i) Day Support is reimbursed at an hourly rate; and

(ii) The amount of prior authorized services is based on the participant's need as documented in the service plan and within the participant's approved annual budget. If the service has a tiered rate, the rate tier for this service is determined based upon needs identified in the Objective Assessment Process (OAP);

(iii) Transportation to and from the participant's private residence, or other provider setting, to a Day Support setting is not included in the reimbursement rate;

(iv) Transportation to and from the Day Support setting to integrated community activities during the Day Support service hours is included in the reimbursement rate. When the provider transports participants, the provider must ensure that all participants are transported in a safe and comfortable manner that meets the needs of each participant; and

(v) This service must be provided in a provider-operated or controlled non-residential setting, separate from the participant's private residence or other residential living arrangement.

004.06(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified Providers.

004.07HOME MODIFICATIONS. Home Modifications are provided within the current footprint of the residence. Such modifications include, but are not limited to:

(1) Installation of ramps;

(2) Widening of doorways;

(3) Modification of bathroom facilities; and

(4) Installation of specialized electric and plumbing systems that are necessary to accommodate the medical equipment and supplies that are necessary for the welfare of the participant.

004.07(A)LIMITATIONS. The following limitations apply to Home Modification:

(i) Home Modification has a budget shall be capped at $10,000 per five-year period. A request to exceed the cap may be approved by the Department based on critical health or safety concerns, available Waiver funding, and other relevant factors;

(ii) Home modifications shall not be authorized for a residence that is provider-owned, provider-operated, or provider-controlled. Home modifications may be authorized for a home owned by a participant's family or guardian in which the participant resides;

(iii) The Department may require an on-site environmental assessment, including an evaluation of functional necessity with an appropriate Medicaid-enrolled professional provider. The cost of the Environmental Modification Assessment is not included in the $10,000 budget cap for Home Modification;

(iv) Renter's insurance or homeowner's insurance is required and proof shall be provided to the Department on request;

(v) Adaptations that add to the total square footage of the home are not allowed except when necessary to complete an adaptation (for example, in order to improve entry to a residence or to configure a bathroom to accommodate a wheelchair);

(vi) Adaptations or improvements to the home that are of general utility, and are not of direct medical or remedial benefit to the participant are not allowed; and

(vii) Adaptations will not be allowed if the home presents a health and safety risk to the participant, other than that corrected by the approved Home Modifications.

004.07(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.08INDEPENDENT LIVING. Independent Living is a habilitative service that provides individually tailored intermittent supports for a Waiver participant that assists with the acquisition, retention, or improvement in skills related to living in the community. Independent Living includes adaptive skill development of daily living activities necessary to enable the participant to live in the most integrated setting appropriate to their needs. Providers of Independent Living generally do not perform these activities for the participant, except when not performing the activities pose a risk to the participant's health and safety. Independent Living shall be provided to the participant in their private home and the community, not a provider-owner or leased, operated, or controlled residence. A participant may choose to receive a portion of this service virtually.

004.08(A)LIMITATIONS. The following limitations apply to Independent Living:

(i) The total combined hours for virtual supports may not exceed a weekly amount of 10 hours and are included as part of the currently existing limit of 70 hours per week of services provided during the day;

(ii) Independent Living is reimbursed at an hourly rate and the provider must use Electronic Visit Verification (EVV). Independent Living cannot exceed a weekly amount of 70 hours;

(iii) Personal care activities that only require verbal cueing may be performed remotely, but cannot be performed in lieu of the provision of habilitation and needed supervision;

(iv) Participants receiving Independent Living cannot receive Supported Family Living;

(v) Participants receiving Independent Living cannot have an active service authorization for Respite; and

(vi) This service must not overlap with, supplant, or duplicate other comparable services provided through Medicaid State Plan or Medicaid Home and Community-Based Services (HCBS) Waiver.

004.08(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.09PERSONAL EMERGENCY RESPONSE SYSTEM (PERS). The provider of the Personal Emergency Response System (PERS) is responsible for:

(1) Instruction to the participant about how to use the Personal Emergency Response System (PERS) device;

(2) Obtaining the participant's or authorized representative's signature verifying receipt of the Personal Emergency Response System (PERS) device;

(3) Ensuring that response to device signals (where appropriate to the device) will be provided 24 hours per day, 7 days per week;

(4) Ensuring that the participant has a functioning Personal Emergency Response System (PERS) device within 24 hours of notification of malfunction of the device;

(5) Updating a list of responders and contact names, at least semi-annually, to ensure accurate and correct information;

(6) Ensuring monthly testing of the Personal Emergency Response System (PERS) device; and

(7) Furnishing ongoing assistance relating to instruction, use, and maintenance of the device.

004.09(A)LIMITATIONS. The following limitations apply to Personal Emergency Response System (PERS):

(i) Personal Emergency Response System (PERS) shall not be authorized for a participant who resides in a residence that is provider-owned, provider-operated, or provider-controlled;

(ii) Personal Emergency Response System (PERS) is reimbursed as a monthly rental fee or as a one-time installation fee, as applicable; and

(iii) Personal Emergency Response System (PERS) is limited to participants who live alone or who are alone for significant parts of the day and do not have a regular unpaid caregiver or provider for extended periods of time.

004.09(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified Providers.

004.10PREVOCATIONAL SERVICE. Prevocational Services may include career planning to prepare the participant to obtain, maintain or advance employment. Prevocational Services with a focus on career planning includes development of self-awareness and assessment of skills, abilities, and needs for self-identifying career goals and direction, including resume or business plan development for customized home businesses. Prevocational Services may involve assisting the participant in accessing an Employment Network, the Nebraska Work Incentive Network (WIN), Ticket to Work services, Work Incentive Planning and Assistance (WIPA) services, or other qualified service programs that provide benefits planning. Prevocational Services may include job searching designed to assist the participant (or in limited situations on behalf of the participant), to locate a job, or develop a work experience. Job searching with the participant will be provided on a one-to-one basis. Prevocational Services also includes the provision of personal care and protective oversight and supervision (when applicable) to the participant. Participation in Prevocational Services is not a required pre-requisite for Supported Employment - Individual or Small Group Vocational Support.

004.010(A)LIMITATIONS. The following limitations apply to Prevocational Service:

(i) Prevocational Services shall not exceed 12 consecutive months. Up to an additional 12 months may be approved by the Department with submission of an approved employment plan (through vocational rehabilitation, school district, or the Waiver) and showing active progress on finding employment opportunities, increasing work skills, time on tasks, or other job preparedness objectives;

(ii) Prevocational Service is reimbursed at an hourly rate; and

(iii) Transportation to and from the Prevocational Service is not included in the reimbursement rate for this service.

004.10(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.11RESPITE. Respite includes assistance with activities of daily living (ADL), health maintenance, and supervision.

004.11(A)LIMITATIONS. The following limitations apply to Respite:

(i) Respite service in an institutional setting requires prior approval by the Department and is not authorized unless no other option is available. Respite service in an institutional setting shall be paid at a per diem daily rate;

(ii) Respite service, other than in an institutional setting, is reimbursed at an hourly rate . Any use of Respite over 8 hours within a 24-hour period is not reimbursable;

(iii) The maximum number of hours for participants is 240 hours per annual budget year. Unused Respite cannot be carried over into the next annual budget year. Respite provided at the daily rate counts as 8 hours towards the 240 hour annual maximum;

(iv) Transportation to and from the Respite service is not included in the reimbursement rate for this service;

(v) Respite services may not be provided during the same time period as other program services;

(vi) Respite services may not be provided by any Independent Provider living in the same private residence as the participant;

(vii) A Respite service provider or provider staff shall not provide respite services to persons 18 years and older and persons under 18 years of age at the same time and in the same location; and

(viii) An Independent Provider must have training in the following areas and provide evidence of a current certificate of completion from a source approved by the Department:

(1) State law reporting requirements and prevention of abuse, neglect, and exploitation;

(2) Cardiopulmonary Resuscitation (CPR); and

(3) Basic first aid.

004.11(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.12SMALL GROUP VOCATIONAL SUPPORT. The habilitative teaching, supervision, and ongoing supports are provided by a specially trained on-site supervisor, who is an employee of the Developmental Disabilities Certified provider. Small Group Vocational Support includes the acquisition of work skills, appropriate work behavior, and the behavioral and adaptive skills necessary to enable the participant to attain or maintain his or her maximum inclusion and personal accomplishment in the working community. Small Group Vocational Support may include services not specifically related to job skill training that enables the participant to be successful in integrating into the job setting. The provider must obtain authorization to pay subminimum wage through the Nebraska Department of Labor.

004.12(A)LIMITATIONS. The following limitations apply to Small Group Vocational Support:

(i) The participant must first be referred to Vocational Rehabilitation and determined ineligible for Vocational Rehabilitation before this service can be authorized. Another referral can be made to Vocational Rehabilitation at any time;

(ii) This service must be discontinued upon the participant obtaining competitive integrated employment;

(iii) Small Group Vocational Support is billed at an hourly rate;

(iv) Small Group Vocational Support must be provided in a manner that promotes integration into the workplace and interaction between participants and individuals without disabilities in those workplaces;

(v) This service cannot be provided in a setting or location controlled or operated by the provider; and

(vi) Waiver funds cannot be used to compensate or supplement a participant's wages.

004.12(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified Providers.

004.13SUPPORTED EMPLOYMENT - FOLLOW ALONG. This service is provided through intermittent and occasional job support, and communication with the participant's employer. The provider must observe and supervise the participant, teaching job tasks and monitoring at the work site a minimum of twice a month. The provider must facilitate natural support at the work site and advocate for the participant, but only for purposes directly related to employment.

004.13(A)LIMITATIONS. The following limitations apply to Supported Employment - Follow Along:

(i) Supported Employment - Follow Along is billed at an hourly rate not to exceed 25 hours annually;

(ii) Supported Employment - Follow Along must be provided in an integrated community work environment where more than half the employees who work around the participant do not have a disability;

(iii) A provider of Supported Employment - Follow-Along cannot be the employer of the participant to whom they provide Supported Employment - Follow-Along; and

(iv) Waiver funds cannot be used to compensate or supplement a participant's wages.

004.13(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.14SUPPORTED EMPLOYMENT - INDIVIDUAL. Supported Employment - Individual includes adaptations, supervision, and training required by participants as a result of their disabilities but does not include supervisory activities rendered as a normal part of the business setting. The employer is still responsible for all routine and ordinary employment matters. This service is provided through formalized training and supports. The provider shall provide help to the participant in accessing the following services:

(A) Employment Network;

(B) The Nebraska Work Incentive Network (WIN);

(C) Ticket to Work services;

(D) Work Incentive Planning and Assistance (WIPA) services; or

(E) Other qualified service programs that provide benefits planning.

004.14(A)LIMITATIONS. The following limitations apply to Supported Employment - Individual.

(i) Participants are required to receive at least the applicable minimum wage, except for self-employment;

(ii) Supported Employment - Individual service is reimbursed at an hourly rate; and

(iii) Transportation to and from the Supported Employment - Individual service is not included in the reimbursement rate for this service.

004.14(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.15SUPPORTED FAMILY LIVING. Supported Family Living is a habilitative service that provides individually tailored intermittent teaching and supports to assist with the acquisition, retention, or improvement in skills related to living in the community. Supported Family Living includes adaptive skill development necessary to enable the participant to live in the most integrated setting appropriate to their needs. Providers of Supported Family Living generally do not perform these activities for the participant, except when not performing the activities pose a risk to the participant's health and safety. Supported Family Living is provided to the participant in the participant's family home, not a provider-owned or leased, operated, or controlled setting. A participant can choose to receive a portion of this service virtually. The participant must reside with relatives in their private family home.

004.15(A)LIMITATIONS. The following limitations apply to Supported Family Living:

(i) The total combined hours for virtual supports may not exceed a weekly amount of 10 hours and are included as part of the currently existing limit of 70 hours per week of services provided during the day;

(ii) The use of virtual supports must be a person-centered decision and facilitate community integration and not risk leading to the isolation of the participant from the community or from interacting with other people;

(iii) The amount of prior authorized services is based on the participant's need as documented in the service plan, and within the participant's approved annual budget;

(iv) Supported Family Living is reimbursed at an hourly rate and the provider must use Electronic Visit Verification (EVV);

(v) Supported Family Living cannot exceed a weekly amount of 70 hours; and

(vi) This service must not overlap with, supplant, or duplicate other comparable services provided through the Medicaid State Plan or Home and Community-Based Services (HCBS) Waiver.

004.15(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.16TRANSITIONAL SERVICES. Transitional Services may be approved when a need remains and all other economic assistance resources are exhausted. Transitional Services include items, such as furniture, furnishings, household items, basic utility fees or deposits, or professional moving expenses.

004.16(A)LIMITATIONS. The following limitations apply to Transitional Services:

(i) Transitional Services have a participant budget cap of $1,500. A request to exceed the cap must be based on critical health or safety concerns, based on available Waiver funding and other relevant factors, and is subject to approval by the Department;

(ii) Approved Transitional Services shall be reimbursed directly to a provider, and not the participant;

(iii) Payment for a rental deposit or rent is not allowed in this service;

(iv) Payment for personal care items, food, or clothing, is not allowed in this service; and

(v) This service cannot be provided for a residence owned or controlled by the provider.

004.16(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.17TRANSPORTATION SERVICE. This service does not include transportation to medical appointments that is available under the Medicaid State Plan or other federal and state transportation programs. Transportation Service is not intended to replace formal or informal transportation options, like the use of natural supports. Transportation providers must meet the same requirements as Medicaid Non-Emergency Transportation Providers, with the exception that the participant's household can own their own vehicle. The provider must ensure that all participants are transported in a safe and comfortable manner that meets the needs of each participant. The provider must ensure that:

(1) Vehicles are adapted to meet the needs of all participants served. Participants must not be denied Transportation Services due to the lack of adaptation of vehicles;

(2) Adequate measures are taken to provide a sufficient number of staff in the vehicle to ensure safety and to meet the needs of each participant being transported; and

(3) Each person transporting participants served:

(i) Has a valid driver's license with the appropriate class code;

(ii) Has knowledge of state and local traffic rules;

(iii) Is capable of assisting participants in and out of vehicles and to and from parking places, when required; and

(iv) Has received training in first aid, Cardiopulmonary Resuscitation (CPR), and meeting the needs of the specific participants for whom transportation is provided.

004.17(A)LIMITATIONS. The following limitations apply to Transportation Service: Provider reimbursement for transporting a participant to and from destinations must be calculated by using the most direct route;

(i) Transportation is reimbursed per mile:

(1) Certified provider mileage is reimbursed pursuant to Neb. Rev. Stat. § 81-1176 times three; and

(2) Independent Provider mileage is reimbursed pursuant to Neb. Rev. Stat. § 81-1176;

(ii) Public transit system transportation is reimbursed at the cost of a single ride pass; and

(iii) The public transportation rate shall not exceed the rates charged to the general public.

004.17(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified or Independent Providers.

004.18VEHICLE MODIFICATIONS. Vehicle Modifications are specified by the service plan as necessary to enable the participant to integrate more fully into the community and to ensure the health, welfare, and safety of the participant.

004.18(A)LIMITATIONS. The following limitations apply to Vehicle Modifications:

(i) Vehicle Modification services has a budget cap of $10,000 per five-year period. A request to exceed the cap must be based on critical health or safety concerns, based on available Waiver funding and other relevant factors, and is subject to approval by the Department;

(ii) The Department may require an on-site assessment of an environmental concern, including an evaluation of functional necessity with an appropriate Medicaid enrolled professional provider. The cost of the Environmental Modification Assessment is not included in the $10,000 budget cap for Vehicle Modification;

(iii) Motor vehicle insurance is required, and proof must be provided to the Department on request;

(iv) If the motor vehicle is leased, the proof that the modification is transferrable to the next motor vehicle must be provided before Vehicle Modification will be approved;

(v) Vehicle Modifications are limited to motor vehicles that are titled or leased in the name of the participant or a family member;

(vi) Adaptations or improvements to the vehicle that are of general utility, and are not of direct medical or remedial benefit to the participant, are not allowed;

(vii) Vehicle Modification service cannot be used to purchase or lease a vehicle;

(viii) The purchase of existing adaptations or adaptations begun without prior authorization is not allowed; and

(ix) The regularly scheduled upkeep and maintenance of a vehicle except for upkeep and maintenance of the modifications are not considered a Vehicle Modification.

004.18(B)ELIGIBLE PROVIDER TYPES. This service may be provided by Certified Providers.

403 Neb. Admin. Code, ch. 4, § 004

Amended effective 5/7/2024