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August 30, 2005
 
MEDICAID INFORMATION RELEASE 2005-31
 
TO:                 Residential Habilitation Providers
 
FROM:           Leslie M. Clement, Deputy Administrator
 
SUBJECT:     SUPPORTED LIVING (RESIDENTIAL HABILITATION)                                                                     REIMBURSEMENT/SERVICE CHANGES EFFECTIVE SEPTEMBER 1, 2005
 
Intense Support
 
We have removed the requirement of 1:1 support 24 hours/day for Intense Support when the provider can provide a safety plan to ensure the safety of the participant when receiving less than 1:1 support. Intense Support will still require 24 hour support.
 
To receive authorization to provide less than 24 hour/day 1:1 support for those participants currently in Intense Support:
 
For participants that will remain in Intense Support:
 
  • Submit an addendum with an Extenuating Circumstances form containing a safety plan to Regional Medicaid Service (RMS) from September 1 through September 30 only. After that, addendums will be authorized by the Independent Assessment Provider (IAP) using the current business model.
  • The RMS will review the safety plan and if the safety plan is complete and adequately ensures the safety of the participant at less than 1:1 support 24 hours/ day, the RMS will approve the addendum using the Individual Support Plan Notice.
  • The RMS will send a notice of denial if the safety plan is not approved.
  • Submit plans to the IAP for new applicants or addendums for current waiver participants requesting Intense Support for the first time. They will be processed using the current business model. The current Intense Support Criteria must be met to receive approval for this support level.
 
For participants that will transition to High Support:
 
Participants no longer requiring the level of support in Intense Support may transition into High Support, even if they do not meet the High Support criteria.  Initially, the participant will remain in Intense Support but will receive less than 24 hours per day of 1:1 support.  Providers will submit a transition plan that identifies how they will ensure the safety of the participant at less than 24 hours/day of 1:1 support and how they will transition the participant to High Support. High Support still requires 24 hours/day of support. This transition plan may be authorized for up to one year. 
 
 
To receive authorization to provide less than 24 hour/day 1:1 support for those participants that will transition to High Support:
  • Submit an addendum with an Extenuating Circumstances form, including a transition plan, to the RMS from September 1 through September 30 only. After that, addendums will be authorized by the IAP using the current business model.
  • The RMS will review the transition plan and if the plan is complete and adequately ensures the safety of the participant at less than 1:1 support 24 hours/ day, the RMS will approve the addendum using the Individual Support Plan Notice, continuing the participant in Intense Support for up to1 year. 
  • The RMS will send a notice of denial if the transition plan does not include the required information identified on the revised Extenuating Circumstances Form or does not adequately show an effective and safe transition plan to less than 1:1 support.   
  • Once the transition plan has been successfully implemented, an addendum with an Extenuating Circumstances form, including a safety plan, is submitted to the IAP to move the participant to High Support. This will require a new prior authorization.
  • A safety plan must continue to be submitted annually for those participants that would not otherwise qualify for High Support. In addition, documentation to support the need for the participant to remain at High Support must also be submitted, evaluated, and authorized on an annual basis for these participants.
  • If a participant is not successful in transitioning to High Support after one year, the team should consider keeping them in Intense Support. 
 
High Support
High Support will now be available for participants with a SIB-R support level of “Frequent”. The Department will evaluate the plans of participants that are “Frequent” to determine the cost effectiveness of moving them to the daily rate reimbursement. If the hourly plan is more cost effective than a daily plan, they will not be moved to High Support at this time. For those participants that will move into High Support, this will require a change in prior authorization.
 
Moving participants with a SIB-R support level of “Frequent” into High Support:
Initially, only those participants receiving support services from the same provider at a cost of $221.12 or higher will be moved into High Support. This will require a change in prior authorization. All others will be changed at the time of their annual plan date. At that time, they may choose to move into High Support or continue to use hourly services subject to the limitation described below.
 
Hourly Support
For participants with a SIB-R support level of Limited, Intermittent, and Infrequent, new applications for supported living services received on or after September 1, 2005, and annual plans due on or after January, 2006, will be authorized at a maximum of $190.00 per day for hourly supported living in combination with developmental therapy, community supported employment, and adult day care. 
 
Participants with a SIB-R support level of Extensive, Pervasive, or Frequent, may elect to receive hourly services, however, they will be subject to the same limitation.
 
LMC/as
 
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