Section 210-RICR-50-10-2.4 - DefinitionsA. The following terms, which are listed alphabetically, are referenced in this Regulation. 1. "Activities of daily living" or "ADLs" means everyday routines generally involving functional mobility and personal care, including but not limited to, bathing, dressing, eating, toileting, mobility, and transfer.2. "Applicant" means new applicants to be determined for Medicaid eligibility.3. "Assessment" means a meeting with the participant and their representative (if applicable) to evaluate ADLs and IADLs to determine the amount and scope of services needed. Assessments also help to identify services, equipment, home modifications, and other supports in the community that may help the participant to increase their independence within the community.4. "Budget" means the amount of Medicaid funds set aside each month for the participant's personal care and homemaker services. The budget is based on the amount of assistance the participant requires to meet their personal care needs as determined by the functional assessment. The budget is based on what EOHHS would normally spend to purchase services from a Home Health Agency for the services necessary to allow a participant to live at home.5. "Case management services" means services that assist participants in gaining access to needed supports through the coordination of a person-centered service plan. Such programs shall be provided in the person's home or in the home of a responsible relative or other responsible adult, but not provided in a skilled nursing facility and/or an intermediate care facility.6. "Case manager" means an individual employed by a conflict-free case management agency that assesses service needs, assists with planning what services are needed and how to receive them, performs check-ins and evaluations, and is an additional resource to the participant, representative, and/or family to promote safety and quality of care. The case manager conducts quarterly home visits, one of which is unannounced, and makes phone contact with the participant in the months where there is not a home visit. The case manager guides and supports, rather than directs and manages, the participant through the service planning and delivery process.7. "Conflict-free" means that the entity providing case management services must be different than the entity providing the direct services a participant is referred to.8. "Conflict-free case management agency" means an agency certified by EOHHS that provides conflict-free case management services for participants receiving home and community-based services, including participants in the Personal Choice program.9. "Critical incident" means any actual or alleged event or situation that creates a significant risk of substantial or serious harm to the physical or mental health, safety, or well-being of a participant. This includes but is not limited to physical abuse; verbal abuse; psychological or emotional abuse; sexual abuse; financial abuse; use of physical, chemical or mechanical restraint; self-neglect; neglect by another member of the home; exploitation; and unexplained death.10. "Electronic Visit Verification" or "EVV" is a method used to verify that home healthcare visits occur by collecting data electronically about the visit.11. "Environmental modifications" or "home modifications" are defined as those physical adaptations to the home of the participant or the participant's family as required by the participant's person-centered service plan, that are necessary to ensure the health, welfare and safety of the participant or that enable the participant to attain or retain capability for independence or self-care in the home and to avoid institutionalization, and are not covered or available under any other funding source. A completed home assessment by a specially trained and certified rehabilitation professional is also required. Such adaptations may include the installation of modular ramps, grab-bars, vertical platform lifts and interior stair lifts. Excluded are those adaptations that are of general utility, are not of direct medical or remedial benefit to the participant. Excluded are any re-modeling, construction, or structural changes to the home (i.e., changes in load bearing walls or structures) that would require a structural engineer, architect and/or certification by a building inspector. a. Adaptations that add to the total square footage of the home are excluded from this benefit. All adaptations shall be provided in accordance with applicable state or local building codes, and prior approval on an individual basis by EOHHS, Office of Durable Medical Equipment, is required.b. Items should be of a nature that they are transferable if a participant moves from their place of residence.12. "Fiscal intermediary services" or "FI services" means financial management services delivered to Personal Choice participants by an EOHHS certified Fiscal Intermediary. FI services are designed to assist participants in allocating funds as outlined in the Individual Service and Spending Plan and to facilitate employment of PCAs by the participant. Personal Choice financial matters are maintained by the fiscal agency and a portion of the participant's monthly budget is set aside for the services it provides.13. "Home delivered meals" means the delivery of hot meals, frozen meals, cultural/therapeutic meals and/or shelf staples to the participant's residence. Meals are available to individuals unable to care for their nutritional needs because of a functional dependency/disability and who require this assistance to live in the community. Meals provided under this service will not constitute a full daily nutritional requirement. Meals must provide a minimum of one third (1/3) of the current recommended dietary allowance. Provision of home delivered meals will result in less assistance being authorized for meal preparation for individual participants, if applicable.14. "Homemaker services" means aid in grocery shopping, cooking, using the phone, looking up phone numbers, assistance with housework (cleaning, dusting, vacuuming, laundry), assistance using public transportation, assistance paying and managing bills, and reminding the participant to take their medication(s).15. "In-home training" means training directed by the participant, as opposed to mandatory orientation and training. This option empowers the participant, as the employer, to train the PCA themselves and decide how services should be delivered by the PCA to suit the participant's needs.16. "Individual service and spending plan" or "ISSP" means a written plan that shows the services that are purchased with the budget amount provided through the Personal Choice Program. The plan shows the services purchased, the rate of purchased services, and the total dollars spent on care. The ISSP provides information on the participant's goals, goods, and services, as well as taxes and fees associated with their budget. The ISSP also includes a plan for handling emergencies. The ISSP can be updated annually or as the budget or other personal circumstances change.17. "Instrumental activities of daily living" or "IADLs" means activities related to living independently in the community, including but not limited to: meal planning and preparation; managing finances; shopping for food, clothing, and other essential items; performing essential household chores; scheduling appointments; communicating by phone or other media, and traveling around and participating in the community.18. "Mandatory orientation and training" means a series of orientation and training courses required by EOHHS for all PCAs listed on the registry. Courses include program overview and structure; PCA eligibility, scope of work, and responsibilities; ethics, accountability, consumer privacy and dignity, HIPAA, and EVV; recognizing and reporting critical incidents; infection control and safety; health management; emotional support; mobility; and understanding and supporting ADLs and IADLs.19. "Medicaid fraud" means making a false statement, misrepresentation of material fact, submitting a claim or causing a submission to obtain some benefit or payment involving Medicaid money for which no entitlement would otherwise exist. This can be done for the benefit of oneself or another party and includes obtaining something of value through misrepresentation, concealment, omission, or willful blindness of a material fact.20. "Minor environmental modifications" means minor modifications to the home that may include grab bars, versa frame (toilet safety frame), handheld shower and/or diverter valve, raised toilet seats and other simple devices or appliances such as eating utensils, transfer bath bench, shower chair, aides for personal care (e.g., reachers), and standing poles to improve home accessibility adaptation, health, or safety.21. "Nonmedical" means not involving, relating to, used in, or concerned with medical care or the field of medicine.22. "Participant" means the individual, also referred to as the beneficiary, who utilizes services in the Personal Choice program.23. "Participant directed goods and services" means services, equipment or supplies not otherwise provided through Medicare or Medicaid, that address an identified need and are in the approved ISSP (including improving and maintaining the individual's opportunities for full membership in the community). Examples include a laundry service for a person unable to launder and fold clothes or a microwave for a person unable to use a stove due to their disability.24. "Person-centered" means that the assessment and service planning processes are directed and led by the participant (with assistance as needed or desired from a representative or other persons of the participant's choosing) for the purposes of identifying the strengths, capacities, preferences, needs, and desired outcomes that become the core of an individualized plan of LTSS care.25. "Person-centered options counseling" means an interactive decision-support process that helps people assess and understand their LTSS needs, goals, and preference. Person-centered options counseling emphasizes person-centered thinking to support consumers in making informed decisions about their LTSS options. The person-centered options counseling process is a multi-step approach of asking for and providing information about LTSS programs, offering decision support, and assisting in accessing services.26. "Person-centered options counselor" means an individual who is trained in person-centered options counseling.27. "Person-centered service plan" means the written document, developed in a person-centered manner, that specifies the services and supports, both formal and informal, that are furnished to meet the needs of each participant and help them remain in the community. The person-centered service plan contains the types of services to be furnished; the amount, frequency, and duration of each service; and the type of provider to furnish each service.28. "Personal care services" means the provision of direct supportive, nonmedical services provided in the home or community to individuals in performing tasks they are functionally unable to complete independently due to illness and/or disability, based on the ISSP. Personal care services do not include services that require a professional license, certification or registration by State law such as wound care, injections, oxygen application, and other services which are medical in nature. Personal care services may include but are not limited to:a. Participant assistance with activities of daily living, such as grooming, personal hygiene, toileting, bathing, and dressing;b. Assistance with monitoring health status and physical condition;c. Assistance with preparation and eating of meals (not the cost of the meals itself);d. Assistance with housekeeping activities (bed making, dusting, vacuuming, laundry, grocery shopping, cleaning);e. Assistance with transferring; ambulation; use of special mobility devices; assisting the participant by directly providing or arranging transportation.29. "Personal emergency response system" or "PERS" means an electronic device that enables certain individuals at high risk of institutionalization to secure help in an emergency. The individual may also wear a portable "help" button to allow for mobility. The system is connected to the person's phone and programmed to signal a response center once a "help" button is activated. This service includes coverage for installation and a monthly service fee. Providers are responsible to ensure the upkeep and maintenance of the devices/systems.30. "Registry" means the official list, maintained by EOHHS or its designee, of qualified PCAs who are available to provide services to participants in the Personal Choice program. Participants may utilize the registry when hiring PCAs for self-directed care.31. "Representative" means a person designated by a participant to assist the participant in managing some or all the requirements of the Personal Choice program. A representative cannot be paid to provide this assistance. The representative also cannot be paid to provide direct care or hands on care. In other words, the representative cannot be a paid PCA.32. "Self-directed" means a participant-controlled method of selecting and providing services and supports that allows the individual maximum control of their home and community-based services and supports, with the individual acting as the employer of record with necessary supports to perform that function, or the individual having a significant and meaningful role in the management of a provider of service when the agency-provider model is utilized. Individuals exercise as much control as desired to select, train, supervise, schedule, determine duties, and dismiss the PCA.33. "Service advisement team" means a team, consisting of a Case Manager, a Nurse, and a Mobility Specialist, that focuses on empowering participants to define and direct their own personal assistance needs and services.34. "Special medical equipment" or "Minor assistive devices" means the following: a. Devices, controls, or appliances, specified in the plan of care, which enable participants to increase their ability to perform activities of daily living;b. Devices, controls, or appliances that enable the participant to perceive, control, or communicate with the environment in which they live; including such other durable and non-durable medical equipment not available through the participant's medical insurance that is necessary to address participant functional limitations;c. Items reimbursed with waiver funds through the Personal Choice Program are in addition to any medical equipment and supplies furnished by Medicaid and exclude those items that are not of direct medical or remedial benefit to the participant. All items shall meet applicable standards of manufacture, design, and installation. Provision of Specialized Medical Equipment requires prior approval on an individual basis by Medicaid.35. "Supports for participant direction" or "Supports facilitation" means empowering participants to define and direct their own personal assistance needs and services by guiding and supporting, rather than directing and managing, the participant through the service planning and delivery process.36. "Taxes" means fees deducted from the participant's monthly budget that are required to be paid on behalf of employees (PCAs):a. FICA (Federal Insurance Contributions Act): Finances care for the aging, disabled, and survivors, including funding for Medicare.b. FUTA (Federal Unemployment Tax Act): Finances employment programs at the federal level.c. SUTA (State Unemployment Tax Act): Finances employment programs at the state level.d. RITDI (Rhode Island Temporary Disability Insurance): Provides income to employees who cannot work temporarily due to illness or non-job related injury.37. "Worker's Compensation Insurance" means funds that provide for monetary awards paid to individuals who are injured, disabled, or killed on the job. Worker's Compensation Insurance is a cost of employment paid by the participant from their monthly budget.210 R.I. Code R. 210-RICR-50-10-2.4
Amended effective 10/28/2019
Amended effective 12/15/2020
Amended effective 3/8/2023
Amended effective 2/12/2024