210 R.I. Code R. 210-RICR-50-00-5.7

Current through December 3, 2024

Section 210-RICR-50-00-5.7 - ICF/ID Needs-based Level of Care Determinations for Adults with Intellectual/Developmental Disabilities (IDD)

5.7.1Overview

A. In Rhode Island, the Medicaid ICF/I-DD level of care is reserved for persons with developmental disabilities who meet the criteria established in Part 40-00-1 of this Title. Although there are licensed ICF/I-DD health institutions operating in Rhode Island, they are limited in number and open only to new applicants who require intensive and continuous skilled services in a highly restricted setting. Since the 1980s, the State has implemented a "community first" approach for adults with developmental disabilities who, were it not for access to HCBS, would require the level of care typically provided in an ICF/I-DD.

B. In accordance with the principles established in the Olmstead decision (Olmstead v. L.C., 527 U.S. 581), BHDDH has developed service options that encourage independence and self-direction, facilitate supportive employment, and provide the appropriate level of care. The service classifications established by BHDDH are designed to ensure that the service options available to beneficiaries meet their needs in the least restrictive setting.

5.7.2Assessments and Application of Needs-based Criteria

A. The BHDDH Division of Developmental Disabilities (DDD) is responsible for determining whether an applicant for Medicaid LTSS meets the level of care for DD services under the terms of an interagency agreement with the EOHHS. In determining level of care, DDD eligibility specialists consider whether an applicant meets the criteria established in State law with respect to developmental/intellectual disabilities. The needs of applicants who meet this definition are then assessed using a Supports Intensity Scale [DOT] Adult Version (SIS-A), the nationally recognized instrument of choice for assessing the scope of ID/DD level of need. In addition, BHDDH uses the Situational Assessment of Need (SAN) tool to evaluate the scope of supervision a beneficiary requires as well as any other associated risk factors relevant in and across service settings.

B. The SIS-A and SAN assessment instruments focus on different aspects of need:

1. The Supports Intensity Scale -- Adult Version (SIS-A) -- The SIS measures support requirements in 57 life activities and 28 behavioral and medical areas including, but not limited to, home living, community living, lifelong learning, employment, health and safety, social activities, and protection and advocacy. The assessment is conducted through an interview with the applicant and other persons who know the applicant well.

a. Life activities. The SIS ranks each activity according to the frequency (refers to how often support is needed), amount (refers to how much time in one day another person is needed to provide support), and? type of support (refers to what kind of support should be provided).

b. Behavioral and medical health. The behavioral and medical section of the SIS-A rates exceptional medical and behavioral support needs.

c. Supports Intensity Level (SIL). The SIL is determined based on the Total Support Needs Index, which is a standard score generated from scores on all the items tested by the Scale. These results are organized into service classifications -- "tiers" -- that correspond to level of need and the available service options.

2. Situational Assessment of Need (SAN) -- The SAN is used to determine if a person with high needs levels requires the 24-hour supervision of a group home or shared living settings by evaluating behavioral health and legal risk factors. If the results of the SAN demonstrate that the person requires 24-hour supervision, then the beneficiary may be offered the option of placement in a community group home or shared living setting. The service options available do not change with the new placement, however.

5.7.3Service Classifications

A. The service classifications for Medicaid for LTSS for adults with disabilities are the tiers generated by the SIS assessment of needs levels.

1. Needs levels and associated tiers --The SIS assessment results are categorized as follows:

a. Tier A (High)- Qualifying Disability with mild support needs

b. Tier B (High)- Qualifying Disability with moderate support needs

c. Tier C (Highest)- Qualifying Disability with identified medical/behavioral needs requiring significant supports

d. Tier D (Highest)- Qualifying Disability with extraordinary medical issues requiring significant medical supports

e. Tier E (Highest)- Qualifying Disability with extraordinary behavioral issues requiring significant behavioral supports

2. Service classifications -- The State has established service classifications based on the SIS tiers:

a. Highest level of need. Tiers E, D and C:

(1) Tier E (extraordinary needs) -- Adults at this tier have extraordinary behavioral issues requiring significant behavioral supports including one-to-one supervision for at least a significant portion of each day. Many persons at this tier have a mental health condition in addition to a developmental disability and may pose a safety risk to themselves and/or the community without continuous on-site support.

(2) Tier D (extraordinary needs) -- Adults at this tier include persons with the most extensive/complex medical support needs that require nurse management to minimize medical risk factors. Maximum assistance with activities of daily living is required to meet their extensive physical support needs and personal hygiene; including lifting/transferring and positioning. Feeding tubes and other feeding supports (e.g., aspiration risk management), oxygen therapy or breathing treatments, suctioning, and seizure management are common as well. Persons at this needs level may be medically unstable or receiving hospice services.

(3) Tier C (significant needs) -- Adults at this tier have profound medical/behavioral needs requiring significant supports. Some time may be spent alone, engaging independently in certain community activities and/or with natural supports.

b. High level of needs. Tiers B and A:

(1) Tier B (moderate needs) -- Adults at this level require more hours of daily support than those with needs at Tier A. Even though members of this tier have a broader scope of personal needs than those in Tier A, 24/7 supports are not required as their needs are still considered minimal in a significant number of life areas.

(2) Tier A (mild needs) -- Adults at this level are assessed as having mild support needs. Persons at this tier are capable of managing many aspects of their lives with limited supports and services. They do not require 24/7 paid supports as they are able to spend a significant amount of time on their own and/or engaging in the community with limited supports and services.

5.7.4Service Options

A. Services in an ICF/I-DD health institution are reserved for beneficiaries determined to have the highest level of "extraordinary need" (Tier E) on the SIS who require intensive 24/7 care and, due to extenuating circumstances, may only be served in a highly restricted setting. Generally, medical conditions requiring continuous on-site skilled, rather than custodial care, prohibit applicants at this level from obtaining care in an HCBS setting. Persons with this level of need are served in an NF or LTH offering the same or a more robust service array.

B. The HCBS service options available to beneficiaries with the needs levels at each service classification provide the appropriate care and supports in the least restrictive setting. A summary of the service options available at each tier is as follows:

DD/ID Needs-Based Service Tier Classifications and Options
Tier	Service Options	Available Supports
Tier D and E (Highest): Extraordinary Needs	Living with family/caregiver Independent Living Shared Living Group Home/Specialized Group Home Community Supported Living Services	Community Residential Support or access to overnight support services Integrated Employment Supports Integrated Community and/or Day supports Transportation
Tier C (Highest): Significant Needs	Living with family/caregiver Independent Living Shared Living Group Home Community Supported Living Services	Community Residential Support or Access to overnight support services Integrated Employment Supports Integrated Community and/or Day supports Transportation
Tier B (High): Moderate Needs	Living with family/ caregiver Independent Living Shared Living Community Supported Living Services Group Home (Only an available service option when the conditions set forth below in §5.7.4 D are met).	Integrated Employment supports Integrated Community and/or Day supports Access to overnight support services Transportation
Tier A (High): Mild Needs	Living with Family/Caregiver Independent Living Community Supported Living Services Group Home (Only an available service option when the conditions set forth below in §5.7.4 D are met). Shared Living (Tier A will have access to Shared Living services if they meet at least one defined exception).	Integrated Employment supports Integrated Community and/or Day Supports Access to overnight support services Transportation

C. Otherwise eligible persons who do not meet the needs-based criteria set forth above for the highest tier -- D and E -- may be placed in an alternative, more intensive care setting if certain special circumstances apply. In these situations, the scope of authorized supports remains tied to the tier associated with needs even though the setting has changed. Such circumstances include:

1. Loss of primary caregiver, such as hospitalization, debilitating illness, or death of spouse, caretaker sibling or adult child;

2. Loss of living situation, such as fire, flood, foreclosure, or sale of principal residence due to inability to maintain housing expenses;

3. A principal treating health care provider, or prior to ending an acute care hospital stay, a discharge planner indicates, based on a functional/clinical assessment, that the health and welfare of the applicant/beneficiary is at imminent risk if services are not provided or if services are discontinued;

4. The applicant/beneficiary met the highest level of care criteria on or before June 30, 2015 and chose to receive Medicaid LTSS at home or in a community-setting and the beneficiary reports he or she has experienced a failed placement that, if continued, may pose risks to the beneficiary's health and safety;

5. The beneficiary was admitted to a hospital or NF and is being discharged back to the original setting within any given forty (40) day period; or

6. There is a court order or other legal action requiring the provision of intensive supports or supervision that is only available in a residential supportive care setting.

5.7.5Reassessments of the ICF/I-DD Level of Need

The BHDDH conducts reassessments of clinical and functional status at least annually and on an "as needed" basis. Unless these assessments warrant further review, redeterminations of clinical/functional eligibility and the level of need occur at five (5) year intervals.

210 R.I. Code R. 210-RICR-50-00-5.7