403 Neb. Admin. Code, ch. 5, § 004

Current through September 17, 2024

Section 403-5-004 - 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 include assistance with activities of daily living (ADL), health maintenance and supervision. Participants receiving Adult Day Services must be 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 is paid at an hourly rate;

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

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

(iv) Available to adult participants aged 21 years and older.

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 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

(iii) professional providers. The cost of the Environmental Modification Assessment is not included in the $2,500 cap on Assistive Technology;

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

(v) 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.

004.03BEHAVIORAL IN-HOME HABILITATION. Behavioral In-Home Habilitation is a short-term habilitative service provided to Waiver participants who have a chronic or severe mental health condition that prevents them from fully participating in community activities or employment opportunities. Services are based on the current needs and capabilities of the participant and under the direction of ongoing clinical oversight provided by the Developmental Disabilities provider.

004.03(A)LIMITATIONS. The following limitations apply to Behavioral In-Home Habilitation:

(i) Must be provided in the participant's residence. The provider must be in the residence with the participant, providing service during daytime hours, as documented in the service plan;

(ii) May be authorized in combination with any, or all, of the following services in the same service plan, but the services may not be provided and billed for concurrently: Adult Day, Small Group Vocational Support, Community Integration, Day Support, Medical In-Home Habilitation, Prevocational, Supported Employment - Follow-Along, and Supported Employment - Individual. The total combined hours for these services may not exceed a weekly amount of 35 hours. Educational school hours and Vocational Rehabilitation milestone hours are included within the weekly 35 hours;

(iii) Behavioral In-Home Habilitation is limited to 90 calendar days per occurrence. Additional occurrences must be approved by the Division of Developmental Disabilities (DDD) Central Office administration;

(iv) Behavioral In-Home Habilitation is not available to participants receiving Therapeutic Residential Habilitation, Independent Living, or Supported Family Living; and

(v) Behavioral In-Home Habilitation is reimbursed at an hourly unit and the provider must use Electronic Visit Verification.

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

004.04CHILD DAY HABILITATION. Child Day Habilitation is a habilitative service that provides teaching and staff supports to meet the age-appropriate needs of a child due to a disability or special health conditions. Child Day Habilitation activities and environments are designed to teach adaptive skills and build positive social behavior while meeting the child's additional needs related to a disability or special health conditions.

004.04(A)LIMITATIONS. The following limitations apply to Child Day Habilitation:

(i) Child Day Habilitation is available for participants living in their private family residence who are under 21 years of age;

(ii) Child Day Habilitation is not available to participants receiving Community Integration, Residential Habilitation, or Therapeutic Residential Habilitation;

(iii) Child Day Habilitation only covers necessary services and supports associated with the child's physical, medical, personal care, or behavioral needs not included in regular childcare;

(iv) Child Day Habilitation cannot exceed a weekly amount of 70 hours for participants living in their private family residence; and

(v) Child Day Habilitation is reimbursed at an hourly rate.

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

004.05COMMUNITY INTEGRATION. Services for Community Integration may include, but are not limited to:

(1) 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;

(2) Supports furnished in the community;

(3) A participant can choose to receive a portion of this service virtually; and

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

004.05(A)LIMITATIONS. The following limitations apply to Community Integration:

(i) 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;

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

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

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

(v) 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

(vi) 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).

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

004.06CONSULTATIVE 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, 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 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.

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

(i) Consultative Assessment Services is billed at an hourly rate for up to 5 hours per month;

(ii) Consultative Assessment Services may only be provided by a Licensed Independent Mental Health Practitioner (LIMHP), Licensed Clinical Psychologist or Advanced Practice Registered Nurse (APRN);

(iii) Functional Behavioral Assessments (FBA) may only be provided by a Licensed Independent Mental Health Practitioner (LIMHP), Licensed Clinical Psychologist or Advanced Practice Registered Nurse (APRN);

(iv) 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

(v) 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).

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

004.07DAY SUPPORT. Day Support services provide regularly scheduled activities, such as:

(1) Self-help;

(2) Behavioral skills;

(3) Adaptive skills;

(4) Social development;

(5) Activities of daily living; and

(6) Community living.

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

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

(ii) The rate 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;

(vi) 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

(vii) 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.

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

004.08ENVIRONMENTAL MODIFICATION 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

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

(i) 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.

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

004.09HOME MODIFICATIONS. Home Modifications are provided within the current footprint of the participant's 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.

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

(i) Home Modification has a budget cap of $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 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, unless the risk is corrected by the approved Home Modifications.

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

004.10HOMEMAKER SERVICE. Includes the performance of general household activities. This service does not include direct care or supervision of the participant.

004.10(A)LIMITATIONS. The following limitations apply to Homemaker Service.

(i) Homemaker Services have an annual cap of 520 hours;

(ii) Homemaker Services are available only to participants age 18 and younger, residing in their family homes;

(iii) Homemaker Services must not duplicate or replace other supports available to the participant such as natural supports;

(iv) Homemaker Services are reimbursed at an hourly rate;

(v) Transportation is not included in the reimbursement rate for this service;

(vi) Homemaker Services cannot be provided by a person who lives in the same private residence as the participant; and

(vii) Homemaker service is only available when the individual 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.

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

004.11HOSPITAL SUPPORT. Hospital Support services are non-waiver, non-habilitative, individually-tailored, short-term supports that are available only during a participant's in-patient, acute care hospitalization for the optimal functioning and safety of the participant. These supports include strategies to maintain learned skills, address inappropriate behaviors, and provide assistance with activities of daily living (ADL) to support the participant's optimal treatment and recovery. Providers are not allowed to engage in any health maintenance activities, treatments, procedures, medication administration, or practices that must be furnished by hospital staff. The provider must be within immediate proximity of the participant and the participant must be awake and alert.

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

(i) Hospital Support is reimbursed at an hourly rate;

(ii) Hospital Support is limited to 6 hours per day, for not more than 5 days per hospital stay;

(iii) The amount of authorized services does not come out of the participant's annual budget; and

(iv) Hospital Support services may be approved by the Department based on critical health or safety concerns, proof that all other resources, including natural supports, have been exhausted, availability of funding and other relevant factors.

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

004.12INDEPENDENT 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 is 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.

004.12(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 is 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. 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 Waiver Services.

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

004.13MEDICAL IN-HOME HABILITATION. Medical In-Home Habilitation is a short-term habilitative service provided to Waiver participants who have a chronic or severe medical condition that prevents them from fully participating in community activities or employment opportunities, or have recently been hospitalized and are continuing to recover in their residence, and their medical needs prevent them from participating in community activities or employment opportunities. This service is provided to meet needs of the participant that are not met through the provision of acute care hospital services.

004.13(A)LIMITATIONS. The following limitations apply to Medical In-home Habilitation:

(i) Medical In-Home Habilitation must be provided in the participant's residence. The provider must be in the residence with the participant, providing service during daytime hours, as documented in the service plan;

(ii) Medical In-Home Habilitation may be authorized in combination with any, or all, of the following services in the same service plan, but the services may not be provided and billed for concurrently: Adult Day, Behavioral In-Home Habilitation, Community Integration, Day Support, Prevocational, Small Group Vocational Support, Supported Employment - Follow-Along, and Supported Employment - Individual. Educational school hours and Vocational Rehabilitation milestone hours are included within the weekly 35 hours. The total combined hours for these services may not exceed a weekly amount of 35 hours;

(iii) Medical In-Home Habilitation is limited to 90 calendar days per occurrence. Additional occurrences must be approved by the Division of Developmental Disabilities (DDD) Central Office administration. Participants receiving Independent Living cannot receive Supported Family Living;

(iv) Medical In-Home Habilitation is only available to participants receiving Residential Habilitation;.

(v) Medical In-Home Habilitation is not available to participants receiving Therapeutic Residential Habilitation, Independent Living, or Supported Family Living; and

(vi) Medical In-Home Habilitation is reimbursed at an hourly unit and the provider must use Electronic Visit Verification (EVV).

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

004.14PERSONAL 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 responder 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.

004.14(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.

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

004.15PREVOCATIONAL 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 include the 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 development of 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 Small Group Vocational Support.

004.15(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.

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

004.16RESIDENTIAL HABILITATION. Residential Habilitation is a habilitative service that has three service delivery options - Continuous Home, Host Home, and Shared Living. Participants may only choose one option. Residential Habilitation supports include:

(1) Adaptive skill development;

(2) Assistance with activities of daily living (ADL); Community Integration;

(3) Transportation;

(4) Opportunities for practicing skills taught in therapies, counseling sessions, or other settings; and

(5) Social and leisure skill development.

004.16(A)LIMITATIONS. The following limitations apply to Residential Habilitation:

(i) Continuous home service shall only be authorized for a residence that is provider-owned, provider-operated, or provider-controlled;

(ii) Developmental Disability Certified Providers cannot own or lease the home in which Host Home or Shared Living is provided;

(iii) Particiants receiving a Residential Habilitation daily rate cannot receive Independent Living or Supported Family Living on the same day ;

(iv) The provider is responsible for transporting the participant to and from the residential setting at no additional charge. Reimbursement for transportation is included in the rate for Residential Habilitation. 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

(v) The provider must be in the residence with the participant providing services for a minimum of 10 hours in a 24 hour period 12:00 am - 11:59 pm. Services provided for less than 10 hrs in in a 24-hour period 12:00am - 11:59pm will be paid at one half of the daily rate.

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

004.17RESPITE. Respite includes assistance with activities of daily living, health maintenance, and supervision.

004.17(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, and the provider must use Electronic Visit Verification. Any use of respite over eight hours within a 24-hour period is not reimbursable;

(iii) The maximum number of hours for participants is 360 hours per annual budget year. Unused Respite hours cannot be carried over into the next annual budget year. Respite provided at the daily rate counts as 9 hours towards the 360 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 Medicaid Home and Community Based Services (HCBS);

(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 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; and

(3) Basic first aid.

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

004.18SMALL GROUP VOCATIONAL SUPPORT. 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 enable the participant to be successful in integrating into a job setting. The provider must obtain authorization to pay subminimum wage through the Nebraska Department of Labor.

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

(i) Small Group Vocationl Support may be authorized in combination with any, or all, of the following services in the same service plan, but the services may not be provided and billed for concurrently; Adult Day, Behavioral In-Home Habilitation, Community Integration, Day Support, Prevocational, and Medical In-Home Habilitation. The total combined hours for these services may not exceed a weekly amount of 35 hours. A week is defined as 12:00am Monday through 11:59pm Sunday;

(ii) The participant must first be referred to Vocational Rehabilitation and be determined ineligible for Vocational Rehabilitation before this service can be authorized;

(iii) Small Group Vocational Support Supported Employment - Enclave is billed at an hourly rate;

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

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

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

004.19SUPPORTED EMPLOYMENT - FOLLOW ALONG. Providers must maintain contact with the employer and participant to reinforce and stabilize job placement. 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 supports at the work site and advocate for the participant, but only for purposes directly related to employment.

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

(i) Supported Employment- Follow Along is reimbursed at an hourly rate;

(ii) Supported Employment - Follow Along is not to exceed 25 hours annually and be a combination of communication with the employer and face-to- participant support; and

(iii) 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.

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

004.20SUPPORTED 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. The provider shall provide help to the participant in accessing the following services:

(1) Employment Network:

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

(3) Ticket to Work services;

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

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

004.20(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.

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

004.21SUPPORTED 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 live with relatives in their private family home.

004.21(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 is included as part of the currently existing limit of 70 hours per week of services provided during the day;

(ii) 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 participant's 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;

(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.

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

004.22THERAPEUTIC RESIDENTIAL HABILITATION. Therapeutic Residential Habilitation is a continuous all-inclusive habilitative service designed specifically for participants living with co-occurring disorders of Developmental Disabilities (DD) with Severe Mental Illness (SMI). The intent of Therapeutic Residential Habilitation is to assist participants in gaining the life skills needed to transition to the least restrictive settings and services in the community.

004.22(A)LIMITATIONS. The following limitations apply to Therapeutic Residential Habilitation:

(i) Therapeutic Residential Habilitation is reimbursed at a daily rate;

(ii) The provider must be with the participant, providing a combination of habilitation, supports, protective oversight, and supervision for a minimum of ten hours in a 24-hour period 12:00am - 11:59pm for the provider to bill a daily rate. When the provider is with the participant, providing a combination of habilitation, supports, protective oversight, and supervision for less than ten hours in a 24-hour period, the provider will be paid one-half of the daily rate;

(iii) Participants receiving Therapeutic Residential Habilitation cannot receive Adult Day, Behavioral In-Home Habilitation, Child Day Habilitation, Small Group Vocational Support, Community Integration, Medical In-Home Habilitation, Prevocational, Supported Employment - Follow-Along, or Supported Employment - Individual. Supported Family Living is reimbursed at an hourly rate, and the provider must use Electronic Visit Verification;

(iv) Participants receiving Therapeutic Residential Habilitation cannot receive Residential Habilitation Continuous Home, Host Home, Respite or Shared Living options; and

(v) Participants receiving Therapeutic Residential Habilitation cannot receive Independent Living or Supported Family Living on the same day.

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

004.23TRANSITIONAL SERVICES. Transitional Services may be approved when a need remains and all other economic assistance resources are exhausted. Transitional Services includes items such as furniture, furnishings, household items, basic utility fees or deposits, and professional moving expenses.

004.23(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 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.

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

004.24TRANSPORTATION 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 may 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 particpant 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 in meeting the needs of the specific participants for whom transportation is provided.

004.24(A)LIMITATIONS. The following limitations apply to Transportation Service:

(i) Provider reimbursement for transporting a participant to and from destinations must be calculated by using the most direct route;

(ii) Participant's annual budget cap for Transportation Service is $5,000. 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;

(iii) 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;

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

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

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

004.25VEHICLE 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.

004.25(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 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, 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) Regularly scheduled upkeep and maintenance of a vehicle except upkeep and maintenance of the modifications is not considered vehicle modifications.

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

403 Neb. Admin. Code, ch. 5, § 004

Amended effective 5/7/2024