MEDICAID INFORMATION RELEASE MA04-50

Medicaid Information Release MA04-50 supercedes Medicaid Information Release 2003-82 and Informational Letter 2004-44 (including attachment #2 Policy Clarification)

SUPPORTED LIVING ACUITY-BASED LEVELS OF SUPPORT

New applications for supported living received on or after October 1, 2004, and annual plans due on or after January 1, 2005, will be authorized using the following criteria.  Plan implementation will follow the existing timeframes under the Adult DD Care Management business model:

• Plan Development for January plans will occur during the month of November, and
• Review and Authorization of services for January plans will occur during the month of December.

High Support

H2022 Daily Rate - Blended Staff - $221.12/day – 24 hours/day supported living service

Participants must meet one of the SIB-R Support Levels of Pervasive or Extensive described below:

            SIB-R Support Score 1-24, SIB-R Support Level Pervasive – “Individuals require pervasive or highly intense levels of support and supervision.  This level of support is provided in all circumstances and requires highly intense personal supervision and related levels of support at all times.”

            SIB-R Support Score 25-39, SIB-R Support Level Extensive – “Individuals require extensive or continuous support and supervision.”

Additionally:

• Providers receiving reimbursement under High Supports are required to provide both group and one-on-one supported living services.  Plans must identify hours per day/week of group and one-on-one supported living services.
• The blended staff rate includes a combination of one-on-one and group supported living.
• No home and community-based developmental therapy services, center-based developmental therapy services, or adult day care services will be authorized for a participant receiving this service.
• Non-medical transportation is included in this daily rate and will not be authorized separately.

Intense Support

H2016 Daily Rate - 1:1 Staff - $263.36/day – 24 hours/day supported living service

The intense support level is for those exceptional individuals who require intense one-on-one support.  These individuals will be evaluated on a case-by-case basis using the following support criteria.  At the time of the participant’s annual review, functional/behavioral assessment, and status review, their records documenting habilitation interventions and progress made during the preceding year will be reviewed to determine the continuing need for this level of intense behavioral support.

Participants must meet one or more of the criteria described below to qualify for Intense Support. 

1.      Criminal/Aggressive Behaviors

A.           Participants with recent felony convictions and/or charges for offenses related to the serious injury/harm of another person or participants charged with such a felony. These participants must have been placed in a supported living setting directly from incarceration or directly after being diverted from incarceration.

B.           Participants with a history of predatory sexual offenses and that are at high risk to re-offend based on a sexual offender risk assessment completed by an appropriate professional. 

C.           Participants with a documented history of serious aggressive behavior showing a pattern of causing harm to themselves or others.  (Note: this level of service is not available for participants exhibiting episodic aggressive behavior; in these cases, crisis intervention services should be utilized.)  The participant’s serious aggressive behavior must be such that their threat or use of force on another reasonably makes that person fear bodily harm; in addition, the participant must have the capability to carry out such threats. The frequency and intensity of this type of aggressive behavior must require continuous monitoring to prevent injury to themselves or others, as identified in the Extenuating Circumstances form.

2. Complex Medical Conditions 

Participants with chronic or acute medical conditions that are so complex or unstable that one-on-one staffing is required to provide frequent interventions and constant (24 hours/day) monitoring.  Without these interventions and monitoring the participant would require placement in a nursing facility, hospital, or ICF/MR with 24 hour on-site nursing.  This requires medical documentation verifying the existence of the complex medical condition(s) and indicating the need for this level of service.

Additionally:

• Participants authorized for Intense Supports must receive one-on-one staffing at all times.
• No home and community based developmental therapy services, center-based developmental therapy services, or adult day care services will be authorized for a participant receiving this service.
• Non-medical transportation is included in this daily rate and will not be authorized separately.

Hourly Support

H2015- U8 $12.72/hour for individual supported living services, and

H2015-U8 HQ $7.48/hour for group supported living services

Participants who do not meet either the High or Intense Support criteria may receive hourly supported living services according to their assessed needs. Hourly supported living services will only be authorized when a participant is actually receiving these services.  Plans must identify the hours per day/week that a participant is engaged in other paid services, unpaid/informal supports, and time alone. 

Home and community based developmental therapy services and center-based developmental therapy services will be authorized only for individuals who require hourly supported living.  For these individuals, all developmental therapy services, in combination with OT, Adult Day Care, and IBI, is limited to 30 hours per week.

Conditions for All Supported Living Levels

• Community integration goals must be addressed in all supported living plans. Services are expected to provide for the following outcomes: maintained or enhanced independence, quality of life, and self-determination.  When possible, participants will be expected to transition to lesser supports as these outcomes are attained.
• The 21-day advance PA for higher reimbursement during the temporary absences of roommates is only available to participant’s receiving hourly supported living.
• Staffing ratios must meet the individualized needs of each participant.
• The Independent Assessment Provider (IAP) may approve plans that fall outside of their level of support budget range without pending them to the Care Manager for participants meeting the criteria for High or Intense Support. The IAP will pend plans that do not contain sufficient documentation to support the need for Intense Support.  If a participant doesn’t qualify for either High or Intense Support and the IAP cannot negotiate an hourly plan, the plan pends to the Care Manager.

We will issue another Information Release in the December MedicAide that will address reimbursement for those participants who are in school and for those participants who are receiving supported employment services.

If you have any questions concerning the information contained in this release, please contact Jean Christensen, Manager, Behavioral Health, Bureau of Care Management at (208) 364-1828.

Thank you for your continued participation in the Idaho Medicaid Program.

LC/as