Developmental Disabilities Administration HCBS Waivers Overview for The ARC of Howard County, Howard County Autism Society, and Humanim

MARYLAND DEPARTMENT OF HEALTH Developmental Disabilities Administration HCBS Waivers Overview for The ARC of Howard County, Howard County Autism Society, and Humanim February 1, 2018

Agenda 1. New Opportunities 2. Person-Centered Plans 3. DDA Waivers and Service Overview 4. Self-Direction 5. Workflow Process 6. DDA Waivers Service Meaningful Day Services Support Services Residential Services 7. Questions 2

New Opportunities to Support Individuals and Families Unprecedented opportunities to offer funding to eligible individuals and families for waivers service to support their trajectory toward their self-defined good life Waiver services funding opportunities including: Family Supports Waiver 400 children from the Waiting List Community Supports Wavier 400 individuals of any age from the Waiting List Community Pathways Waiver 300 individuals of any age from the Waiting List Transitioning Youth ~700 youth Waiver Re-Enrollment & State Funded Conversions 3

4 Person-Centered Plans

Person-Centered Plans Build on current plan Charting the LifeCourse Framework Review Important To and Important For Explore needs with new PCP discovery areas 5

Charting the LifeCourse Framework 6 Created by families (UMKC Family 2 Family) to assists individuals and families develop a vision for a good life, think about what they need to know and do, identify how to find and develop supports, and discover what it take to live the lives they want to live

Life Stages & Trajectory The Good Life 7 For more information and training: Contact DDA RO Family Support Lead http://supportstofamilies.org/

Integrated Star All people need support to lead good lives. Using a combination of many different kinds of support helps to plot a trajectory toward an inclusive, quality, community life. This tool will help families and individuals brainstorm the supports that they already have or might need in order to work in partnership to make their vision for a good life possible For more information and training: Contact DDA RO Family Support Lead http://www.lifecoursetools.com/planning/ 8

9 Integrated Star

Discovery and Exploration Explore needs with new PCP discovery areas Discovery and exploration means finding out who and what is important to the person with whom you are planning Exploring relationships, such as family and friends, community connections, faith-based associations, areas of interest, and talents can also help to identify additional potential support for desired outcomes Completed using one of the many person-centered planning tools available to help you better understand the preferences, interests, and needs of people you serve Designed to summarize a breadth of information relevant to the person, support development of a concise plan that accurately represents the individual in a person-centered manner, and help the team to support individual choice and control in all aspects of planning Information should be revisited and revised to reflect changing preferences and interests as they develop 10

DDA HCBS Waivers Overview Family Supports Waiver Children birth to 21 years Various Support Services Service Cap of $12,000 annually Community Supports Waiver Children and adults Meaningful Day and Support Services Service Cap of $25,000 annually Community Pathways Waiver Children and adults Meaningful Day, Support, and Residential Services Notes: 1. All DDA Waivers will have option of self-direction or traditional services delivery models 2. Community Pathways waiver will also be referred to as DDA s Comprehensive Waiver 3. Family Supports Waiver and Community Supports Waivers will also be referred to as DDA s Capped Supports Waivers 11

DDA Waivers Services Overview Meaningful Day Services FSW CSW CP Supported Employment (Transitioning to the new Employment Services in 2019) X X Employment Discovery and Customization Services (Transitioning to the new Employment Services in 2019) X X Career Exploration (Previously titled Transitional Employment Services) X X* Facility Based Supports X X* Small Group Supports X X* Large Group Supports X X* Community Development Services X X Day Habilitation X X Medical Day Care X X Note: * New service proposal for 7/1/18 implementation 12

DDA Waivers Services Overview Meaningful Day Services FSW CSW CP Employment Services Discovery Job Development Follow Along On-going Job Supports Co-Worker Employment Supports Customized Self-Employment Phase in July 2019 Phase in July 2019 13

DDA Waivers Services Overview 14 Support Services FSW CSW CP Assisted Technology and Services X X X Behavioral Support Services X X X Behavioral Assessment X X X Behavioral Plan X X X Behavioral Consultation X X X Brief Support Implementation Services X X X Environmental Assessment X X X Environmental Modifications X X X Family and Peer Mentoring Supports X X X* Family Caregiver Training and Empowerment Services X X X* Individual and Family Directed Goods and Services (Self-Direction Only) X X X* Goods and Services (up to $5000) X X X* Staff Recruitment and Advertisement (up to $500) X X X* Housing Support Services X X X* Note: * New service proposal for 7/1/18 implementation Support Services FSW CSW CP Live-In Caregiver Supports X Nursing Consultation X X* Nursing Case Management and Delegation Services X X* Nursing Health Case Management X X* Participant Education, Training and Advocacy Supports X X X* Personal Supports X X X Remote Electronic Monitoring X* Respite Care Services X X X Daily Rate X X X Hourly Rate (up to 8 hrs) X X X Camp X X X Support Broker Services X X X Transition Services X Transportation X X X Vehicle Modifications X X X

DDA Waivers Services Overview Residential Services FSW CSW CP Community Living--Enhanced Supports Service Trial Experience Retainer Fee Phase in July 2019 Community Living --Group Home (Currently titled Residential Habilitation) X Service X Trial Experience X Retainer Fee X Shared Living X Matching Service X Host Home Stipend X Supported Living X* Independent Model X* Shared Model X* 15 Note: * New service proposal for 7/1/18 implementation

Appropriate Supports for Needs Family Support Waiver Family Support Waiver Family Support Waiver Person Centered Plan and Budget Community Support Waiver Community Support Waiver Community Support Waiver Comprehensive Waiver Comprehensive Waiver Comprehensive Waiver 16

Self-Direction Overview A service delivery model established by the DDA in which a participant (or their authorized representative) may self-direct his or her own services Self-Direction promotes personal choice and control over the delivery of DDA Waiver and State plan services Provides for: Employer Authority Accepts the rights and obligations of an employer (as outlined in federal, state and local law and regulation) as the employer of record Budget Authority Accepts responsibility and authority to manage his/her approved budget 17

Self-Direction Individuals have opportunities to: Identify goals to support a trajectory for the good life (LifeCourse); Choose and Schedule workers; Train, manage and discharge workers; Identify needed supports and services to support their PCP (in accordance with their approved annual budget); Control and manage a budget annually for the purchase of services and supports as specified in their PCP; and Use the services of an FMS to assist with budget and payment responsibilities, and access the optional use of a Support Broker as a human resource support Services available for Self-Direction vary by Waiver Every available service has Employer Authority, but not all have Budget Authority Participant have choice of self-directing services or using the traditional model 18

Self-Direction Services Employer and Budget Authority Employer and Budget Authority FSW CSW CP Community Development Services X X Personal Supports X X X Respite Care Services Daily Rate Hourly Rate (up to 8 hrs) Camp X X X Support Broker Services* X X X Supported Employment X X Note: *Support Broker Service under the CP will be an administrative service. Under the FSW and CSW, it is a waiver service and must be included in the budget cost. 19

Self-Direction Services Budget Authority Only Budget Authority FSW CSW CW Assisted Technology and Services X X X X X X Behavioral Support Services Employment Services 7/2019 Employment Discovery & Customization¹ X X Environmental Assessment X X X Environmental Modifications X X X Family and Peer Mentoring Supports X X X² Family Caregiver Training and Empowerment Services X X X² Housing Support Services X X X² Individual and Family Directed Goods and Services (Self-Direction Only) X X X² Live-In Caregiver Supports X Budget Authority FSW CSW CW Nursing Consultation X X² Nursing Case Management and Delegation Services X X² Nursing Health Case Management X X² Participant Education, Training and Advocacy Supports X X X² Personal Supports X X X Remote Electronic Monitoring Respite Care Services X X X Support Broker Services* X X X Supported Living X Transition Services X Transportation X X X Vehicle Modifications X X X 20 Note: 1. Budget Authority until July 2018 2. New service proposal for 7/1/18 implementation

Self-Direction Key Requirements Individuals (or their authorized representative) must: 1. Be capable of making informed decisions regarding how services are provided such that there is: No lapse or decline in the quality of care; No increased risk to the health or safety of the participant 2. Understand and accept the risks and responsibilities of being the Employer of Record Costs for services must not exceed the cost cap for the Family Supports or Community Supports Wavier, or must be cost neutral for the Comprehensive (Community Pathways) Waiver 21

Self-Direction Responsibilities Responsibilities as the Employer of Record include: Obtain FEIN for employees, and pay all legally required federal, state and local taxes Recruit and hire staff Verify staff qualifications Obtain a criminal history and/or background investigation of staff Specify additional staff qualifications Determine staff duties consistent with the service specifications Determine staff wages and benefits subject to State limits Schedule staff Orient and instruct staff in duties Supervise staff Evaluate staff performance Verify time worked by staff and approve time sheets Discharge staff 22

Self-Direction Responsibilities Responsibilities of Budget Authority include: Reallocate funds among services already approved and included in the budget Determine the amount paid for services within the established Reasonable and Customary rates Schedule the provision of services Specify any additional provider qualifications Specify how services are provided Identify service providers and refer for provider enrollment Authorize payment for waiver goods and services Review and approve provider invoices for services rendered Consider this authority as being a steward of federal monies! 23

Fiscal Management Services Financial Management Services (FMS) Supports the management and disbursement of funds contained in the participant directed budget Facilitates employment of staff by verifying provider qualifications, verifying support worker citizenship status, processing payroll, withholding Federal, State and local tax, making tax payments as appropriate Prepares and distributes Budget expenditure tracking Current FMS Services provided by: The ARC/Central Chesapeake Region and MedSource A Request for Proposal (RFP) for FMS Services will be released in early 2018 to procure the services of a new FMS vendor to service all DDA Waivers 24

Support Broker Support Broker Independent providers available to assist with human resources related employer functions Act as a coach and mentor to the Employer of Record to ensure successful day to day management of selfdirection activities Assist with: Developing recruitment interviewing and hiring skills; Developing staffing schedules; Oversight/review of budget expenses and service utilization Quality check for timesheets, vendor invoices, etc. Review FMS statements and make recommendations to adjust budget if necessary Recognizing and reporting incidents Currently provided as a Waiver service but will transition to an optional administrative service Mentor 25

Overall Process DDA provides candidate list to CCS Agencies CCS contacts person and family to schedule meeting CCS conducts faceto-face meeting to complete Waiver Packet CCS sends the Waiver packet to Regional Office for review DDA Regional Office reviews Waiver packet DDA Headquarters Waiver Team reviews Packet DDA sends Waiver Packet to EDD for review 26

DDA Waivers Service Details Meaningful Day Services Support Services Residential Services 27

Meaningful Day Services Overview: Services and systems are realigning to support competitive integrated employment and community participation outcomes Services are designed to provide a flow of services that can lead to outcomes of competitive integrated employment and/or meaningful community participation Designed to provide opportunities for individuals to: Seek employment, Work in competitive integrated employment, Develop skills, Engage in community life, and Control personal resources 28

Meaningful Day Services Employment and Day Services Current Service Name CSW and Comprehensive Waiver Only 1 Supported Employment* 1 Supported Employment* 2 Career Exploration Services 2 Employment Discovery and Customization* 4 Employment Discovery and Customization* 3 Community Learning Services 5 Community Development Services 4 Day Habilitation Services 6 Day Habilitation Services 5 Medical Day Care 7 Medical Day Care Note: *Services available through June 30, 2019 29 Slide #29

Meaningful Day Services Employment and Day Services FY 2020 Service Transition 1 2 Supported Employment* Employment Discovery and Customization* 1 Employment Services Discovery (3 milestones) Job Development (90 hours) Ongoing Job Supports (hourly billable) Follow Along Supports (monthly billable) Self Employment Development Supports (milestone) Co-worker Employment Supports (time limited) Note: 1.*Services available through June 30, 2019 2. Employment Services begin July 1, 2019 30 Slide #30

Supported Employment (Transitioning to Employment Services FY20) A variety of supports to help an individual identify career and employment interests, as well as to find and keep a competitive integrated job Activities can include: individualized job development and placement, on the job training, facilitation of natural supports in the workplace, ongoing job supports and monitoring in order to retain employment and selfemployment supports These services can happen in a variety of community settings, but do not include volunteering, internships or apprenticeships, unless it is part of the discovery process is time limited Key Requirements: Support to find and keep competitive integrated employment Staffing based on level of service need Can be mixed with other meaningful day services in same week 31

Employment Discovery and Customization (Transitioning to Employment Services FY20) Time limited services (6 months) to identify and develop customized employment options for individuals working toward competitive integrated employment including: Discovery Customization Discovery includes: Assessment of the community surrounding an individual's home Work skills and discovery activities to help identify the ideal conditions for employment, including selfemployment Customization includes: Use of person s social network and relationships, American Job Centers contacts to identify employers Flexible strategies: job development, job carving, job sharing, self-employment Key Requirements: Provided in a variety of community-based settings Staffing based on level of service needed Personal care may not comprise entire service Can be mixed with other Meaningful Day services within the same we 32

Community Development Services (Previously Community Learning Services) Overview: Facilitate the development of community membership and the opportunities to develop skills and increase independence related to community integration with mostly people without disabilities and paid staff Possible activities: Identifying the path to employment, Travel training, Self advocacy, Local community events and volunteering, based on the person's interests, skills and abilities Key Requirements: Provided in a variety of community-based settings Staffing based on level of service needed Personal care may not comprise entire service Can be mixed with other Meaningful Day services within the same week Provided in groups of no more than 4 individuals with similar interest and goals Flexible individualized schedule 33

Day Habilitation Services Overview: Intended to support an individual to develop and maintain skills related to activities of daily living, vocation and socialization, while utilizing formal teaching methods and participation in meaningful activities Designed to promote greater independence and personal choice and can include things like: *learning skills for employment *social skills *effective communication *safety skills *self advocacy, problem solving, and self care classes *volunteering Key Requirements: Provided in a variety of settings in the community or a facility Staffing based on level of service needed Personal care may not comprise entire service Can be mixed with other Meaningful Day services within the same week Flexible, individualized schedule 34

Career Exploration Overview: Time limited services to help people learn skills to work toward competitive integrated employment by utilizing teaching practices based on best practices People accessing these services have an employment plan in their PCP Career Exploration services include: Facility-Based Supports (provided at a fixed site that is owned, operated, or controlled by a licensed provider) Small Group Supports Large Group Supports 35

Career Exploration Small Group Supports: Groups of two (2) and eight (8) individuals (including the participant) where the group completes work tasks on a contract-basis This work must be conducted at another site in the community not owned, operated, or controlled by the licensed provider Includes enclaves, mobile work crews, and work tasks on a contract-basis The licensed provider is the employer of record and enters into the contract on behalf of the group Large Group Supports: Groups of between nine (9) and sixteen (16) individuals (including the participant) where the group completes work tasks on a contract-basis Work must be conducted at another site in the community not owned, operated, or controlled by the licensed provider The licensed provider is the employer of record and enters into the contract on behalf of the group Key Requirements: Participants accessing this service must have an employment goal in their PCP that outlines how they will transition to community integrated employment 36

Medical Day Care Overview: Medically supervised day program that includes: Health care services Nursing services Physical therapy services Occupation therapy Assistance with ADLs Nutrition services Social work Activity programming Transportation Key Requirements: Services occur in non-institutional, community-based settings Only for individuals 21 and over 37

DDA Support Services 38 Support Services FSW CSW CP Assisted Technology and Services X X X Behavioral Support Services X X X Behavioral Assessment X X X Behavioral Plan X X X Behavioral Consultation X X X Brief Support Implementation Services X X X Environmental Assessment X X X Environmental Modifications X X X Family and Peer Mentoring Supports X X X* Family Caregiver Training and Empowerment Services X X X* Individual and Family Directed Goods and Services (Self-Direction Only) X X X* Goods and Services (up to $5000) X X X* Staff Recruitment and Advertisement (up to $500) X X X* Housing Support Services X X X* Note: * New service proposal for 7/1/18 implementation Support Services FSW CSW CP Live-In Caregiver Supports X Nursing Consultation X X* Nursing Case Management and Delegation Services X X* Nursing Health Case Management X X* Participant Education, Training and Advocacy Supports X X X* Personal Supports X X X Remote Electronic Monitoring X* Respite Care Services X X X Daily Rate X X X Hourly Rate (up to 8 hrs) X X X Camp X X X Support Broker Services X X X Transition Services X Transportation X X X Vehicle Modifications X X X

Assistive Technology and Services Overview Maintain or improve functional abilities, enhance interactions, support meaningful relationships, promote ability to live independently, and meaningfully participate in their community Assistive technology means an item, piece of equipment, or product system Assistive technology service means a service that directly assists an individual in the selection, acquisition, use, or maintenance of an assistive technology device Key Requirements: Costs up to $1000 per item does not require a formal assessment More than $1000 must be recommended by an independent evaluation of the participant s AT needs Evaluation includes list of all devices, supplies, software, equipment, product systems and/or waiver services that would be most effective to meet the need Least expensive option unless explanation why the chosen option is the most cost effective Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization 39

Assistive Technology and Services Assistive technology devices include : Speech and communication devices also known as augmentative and alternative communication devices (AAC) such as speech generating devices, text-to-speech devices and voice amplification devices; Blind and low vision devices such as video magnifiers, devices with optical character recognizer (OCR) and Braille note takers; Deaf and hard of hearing devices such as alerting devices, alarms, and assistive listening devices; Devices for computers and telephone use such as alternative mice and keyboards or hands-free phones; Environmental control devices such as voice activated lights, lights, fans, and door openers; Aides for daily living such as weighted utensils, adapted writing implements, dressing aids; Cognitive support devices and items such as task analysis applications or reminder systems; Remote support devices such as remote health monitoring and personal emergency response systems; and Adapted toys and specialized equipment such as specialized car seats and adapted bikes 40

Assistive Technology and Services Assistive technology services include: Assistive Technology needs assessment; Programs, materials, and assistance in the development of adaptive materials; Training or technical assistance for the individual and their support network including family members; Repair and maintenance of devices and equipment; Programming and configuration of devices and equipment; Coordination and use of assistive technology devices and equipment with other necessary therapies, interventions, or services ; and Services consisting of purchasing or leasing devices 41

Behavioral Support Services Overview Assist participants who, without such supports, are experiencing, or are likely to experience difficulty at home or in the community as a result of behavioral, social, or emotional issues Help to understand a participant s challenging behavior, its function, and to develop a behavior plan with the primary aim of enhancing the participant s independence and inclusion in their community Behavioral Support Services includes: Behavioral Assessment - identifies a participant s challenging behaviors by collecting and reviewing relevant data, discussing the information with the participant s support team, and developing a Behavior Plan, that best addresses the function of the behavior, if needed; Behavioral Consultation - services that oversee, monitor, and modify the Behavior Plan; and Brief Support Implementation Services - time limited service to provide direct assistance and modeling to families, agency staff, and caregivers so they can independently implement the Behavior Plan 42

Behavioral Support Services Key Requirements: Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization BSS may not be provided at the same time as the direct provision of Community Living Enhanced Supports or Respite Care Services Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid s EPSDT services to help meet children s health and developmental needs. This includes age appropriate medical, dental, vision, and hearing screening services and diagnostic and treatment services to correct or ameliorate identified conditions. Supports provided by this waiver service is to improve and maintain the ability of the child to remain in and engage in community activities 43

Environmental Assessment Overview On-site assessment with the participant at residence to determine if environmental modifications or assistive technology may be necessary in the participant s home An environmental assessment includes an evaluation of the: 1) Participant, 2) Environmental factors in the participant s home, 3) Participant's ability to perform activities of daily living, 4) Participant's strength, range of motion, and endurance, 5) Participant's need for assistive technology and/or modifications, and 6)Participant's support network including family members capacity to support his or her independence Key Requirements: Environmental Assessment Service Report will provide recommendations Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization 44

Environmental Modification Overview Service includes: Physical modifications to a participant s home based on the environmental assessment Training on use of modification; and Service and maintenance of the modification Key Requirements: An environmental modification must be completed as per the environmental assessment requirements Environmental Modifications recommended by the team that cost up to $2,000 does not require a formal assessment If the modification is estimated to cost over $2,000 over a 12-month period, at least three bids are required (unless otherwise approved by DDA) Environmental modifications services provided by a family member or relative are not covered All restrictive adaptive measures such as locked windows, doors, and fences must be included in the participants approved behavior plan as per DDA s policy on positive behaviors supports 45

Environmental Modification Key Requirements: Pre-approved by the property manager or owner of the home with agreement to remain in the residence at least one year Excluded are adaptations or improvements that are of no direct medical or remedial benefit to the participant Generator only to support medical and health devices Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization 46

Family and Peer Mentoring Services Overview Supports from experienced mentors (parent, or other family member to a peer, another parent or family caregiver) who share experiences. Mentors explain community services, programs, and strategies they have used to achieve goals including beyond those offered through the DDA s waivers Key Requirements: Available to parent or family caregiver who is the primary unpaid support to the participant Include supports to siblings from others with shared experiences Include facilitation of parent or family member "matches" and follow-up support to assure the matched relationship meets peer expectations Additional support needs are identified in the PCP Mentors cannot mentor their own family members Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file 47

Family Caregiver Training & Empowerment Services Overview Education and support (based on the unpaid family/caregiver s unique needs) to preserve the family unit and increase confidence, stamina and empowerment Includes educational materials, training programs, workshops and conferences, that help the family caregiver to: Understand the disability of the person supported; Achieve greater competence and confidence in providing supports; Develop and access community and other resources and supports; Develop or enhance key parenting strategies; Develop advocacy skills; and Support the person in developing self-advocacy skills Key Requirements: Offered only for a family caregiver who is providing unpaid support training, companionship, or supervision Does not include the cost of travel, meals, or overnight lodging as per federal requirement Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization 48

Housing Support Services Overview Time-limited supports to help navigate housing opportunities; address or overcome barriers to housing; and secure and retain their own home including: Housing Information and Assistance to obtain and retain independent housing; Housing Transition Services to assessing housing needs and develop individualized housing support plan; and Housing Tenancy Sustaining Services which assist the individual to maintain living in their rented or leased home Housing Information and Assistance including: Assistance with searching for housing; Housing application processes; Assessing the living environment and requesting reasonable accommodations Reviewing the lease and other documents, including property rules, prior to signing; Developing, reviewing and revising a monthly budget, including a rent and utility payment plan; Identifying and addressing housing challenges such as credit and rental history, criminal background, and behaviors; and Assistance with resolving disputes 49

Housing Support Services Housing Transition Services including: Tenant screening and housing assessment including barriers and identification of potential housing retention challenges; Developing an individualized housing support plan with goals, strategies and natural supports, resources, community providers, and other services to support goals and strategies Housing Tenancy Sustaining Services (to maintain living in their rented or leased home) including: Education and training on the role, rights and responsibilities of the tenant and landlord; how to be a good tenant; and lease compliance; Coaching to develop and maintain key relationships with landlord/property manager and neighbors; Assistance with housing recertification process; Early identification and intervention for behaviors that jeopardize tenancy and resolving disputes; Advocacy and linkage with community resources to prevent eviction; and Review, update and modify the housing support plan 50

Individual and Family Directed Goods & Services Overview Helps purchase services, equipment or supplies that: Relate to a need or goal identified in the PCP; Maintain or increase independence; Promote opportunities for community living and inclusion; and Not available under a waiver service or State Plan services Individual and Family Directed Goods and Services: Decrease the need for Medicaid services, Increase community integration, Increase the participant s safety in the home, or Support the family in the continued provision of care to the participant Includes dedicated funding up to $500 to support staff recruitment and advertisement efforts such as developing and printing flyers and using staffing registries Goods and services include nutritional supplements, therapeutic swimming or horseback riding recommended by a professional licensed in the relevant field 51

Individual and Family Directed Goods & Services Overview Individual and Family Directed Goods and Services do not include services, goods, or items including: Experimental or prohibited goods and treatments; That have no benefit to the participant; Otherwise covered by the waiver or the Medicaid State Plan Services; Additional units or costs beyond the maximum allowable for any waiver service or Medicaid State Plan, with the exception of a second wheelchair; Co-payment for medical services, over-the-counter medications, or homeopathic services; Items used solely for entertainment or recreational purposes, such as televisions, video recorders, game stations, DVD player, and monthly cable fees; Monthly telephone fees; Room & board, including deposits, rent, and mortgage expenses and payments; Vacation expenses; Tickets and related cost to attend recreational events; Personal trainers; spa treatments; Staff bonuses and housing subsidies; Costs of travel, meals, and overnight lodging for staff, families and natural support network members to attend a training event or conference 52

Individual and Family Directed Goods & Services Key Requirements: Individual and Family Directed Goods and Services must: Be purchased from the participant s self-directed budget without compromising their health and safety; Clearly linked to an assessed need; Provide or direct an exclusive benefit to the participant; Be cost effective; and Cost should be reasonable, customary, and necessary Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization 53

Live-In Caregiver Supports Overview Purpose is to pay the additional cost of rent and food that can be reasonably attributed to an unrelated live in personal caregiver who is residing in the same household with an individual A caregiver is defined as someone that is providing supports and services in the individual's home Explicit agreements, including detailed service expectations, arrangement termination procedures, recourse for unfulfilled obligations, and monetary considerations must be executed and signed. This agreement will be forwarded to DDA as part of the service request authorization, and a copy will be maintained by the CCS Service Limits: Rental rates must fall within Fair Market Rent (FMR) for the jurisdiction as determined by the Department of Housing and Urban Development (HUD) Within a single-family dwelling unit, the difference in rental costs between a 1 and 2-bedroom (or 2 and 3- bedroom, etc.) unit based on the FMR Live-in Caregiver Food is limited to the USDA Monthly Food Plan Cost at the 2 person moderate plan level 54

Nurse Consultation Services Overview Provides recommendations to the participant, and his or her caregivers, for accessing health services to have needs met that are available in the community and other community resources In collaboration with person, develops care protocols for the person to use when they train their staff Nursing Consultation services includes: Review information about the person s health Performance of a comprehensive nursing assessment Completion of the Medication Administration Screening Tool Review of the Health Risk Screening Tool (HRST) at Level 3 or above Review and development of communication systems for person to effectively share health information among various entities Development of emergency protocols Health and Wellness Note: Service does not include delegation of nursing tasks 55

Nurse Consultation Services Key Requirements: Adults age 22 and older only Must live in own home or family home Receives gratuitous (unpaid) care or assessed to be able to perform and train on treatments of a routine nature and self-medicate Support for participants self-directing or receiving Supported Living Services May be provided before the effective date of the participant s eligibility for waiver services for participants interested in the self-directed services model based on preauthorization from the DDA and paid as an administrative service Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid s EPSDT services to help meet children s health and developmental needs. 56

Nurse Health Case Management Overview Licensed Registered Nurse (RN) services when direct support staff are employed by a DDA provider agency to perform health services other than medication and treatment administration Nursing Health Case Management services as part of a collaborative process includes: Review the participant s health services and supports; Develop health care plans and protocols that direct DDA provider staff in the provision of ADLs, emergency interventions, and other health monitoring Comprehensive nursing assessment Completion of the Medication Administration Screening Tool Review of the Health Risk Screening Tool (HRST) at Level 3 or above Monitors health data and reviews person s health services and supports from DDA provider agency staff 57

Nurse Health Case Management Key Requirements Person may qualify if he or she is: Able to perform self-medication and treatments; Medication and treatments are provided as gratuitous care; or Direct support staff are employed by a DDA provider for residential, meaningful day service, or personal supports Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid s EPSDT services to help meet children s health and developmental needs 58

Nurse Case Management & Delegation Services Overview Licensed Registered Nurse (RN) services including: Health case management services, and Delegates nursing tasks as appropriate and in accordance with applicable regulations Nursing Health Case Management services includes: Develop health care plans and protocols that direct paid staff in the provision of medications, performance of medical and nursing treatments, ADLs, and emergency interventions Performance of a comprehensive nursing assessment Completion of the Medication Administration Screening Tool Review of the Health Risk Screening Tool (HRST) at Level 3 or above Monitors health data and reviews person s health services and supports from paid staff Delegation of Nursing Services includes: Assessment of (a) need and abilities of participant; (b) direct care staff performance of delegated tasks; and (c) the environment Delegation of tasks to unlicensed direct care staff that may be CMTs, CNAs, or other unlicensed assistive personnel in accordance with MD Board of Nursing regulations Training, supervision, and remediation of unlicensed direct care staff On-call service, to paid direct care staff that are performing delegated nursing tasks (24/7, 365 days per year) 59

Nurse Case Management & Delegation Services Key Requirements: Person may qualify if he or she is: Receiving residential, personal supports, or meaningful day services under the traditional services delivery model Receiving services under the self-directed service delivery model In order to access, all of the following criteria must be met: Health condition must be determined to be chronic, stable, routine, predictable, and uncomplicated and nursing tasks that can be delegated Participant is assessed to be unable to perform own care Tasks, skills required, and interval support the participant s health and safety Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid s EPSDT services to help meet children s health and developmental needs 60

Participant Education, Training & Advocacy Supports Overview Training programs, workshops and conferences which help the participant develop self-advocacy skills, exercise his or her civil rights, and acquire skills needed to exercise control and responsibility over other support services Covered expenses include: Enrollment fees Books and other educational materials, and Transportation related to participation in training courses, conferences and other similar events Key Requirements: Supports needed to participate in the training should be identified in the PCP Does not include tuition, air fare, meals, or overnight lodging Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization 61

Personal Supports Overview Individualized supports, delivered in a personalized manner to support independence in a participant s own home or community in which they wish to be involved based on their personal resources Service includes: In-home skills development such as budgeting and money management; completing homework; maintaining a bedroom for a child or home for an adult; being a good tenant; cooking; house cleaning/chores; and laundry Community integration and engagement skills development to facilitate the process by which participants integrate, engage and navigate their lives at home and in the community Personal care assistance services incidental to in-home skills or community integration/engagement skills development and may not compromise the entirety of the services 62

Personal Supports Key Requirements: Staffing is based on level of service need. Effective July1, 2018, the following criteria applies: Person needs support for community engagement (outside of meaningful day services) or home skills development; and Service is most cost-effective to meet the person s needs For children, includes supports to meet the child s exceptional care needs due to the disability that are above and beyond the typical, basis care for a child that all families may experience Service can be provided: Before and after school Any time when school is not in session Before and after meaningful day services On nights and weekends 63

Personal Supports Key Requirements: Under the self-directed services delivery model, this service includes funding for staff benefits and leave time subject to the following requirements: The benefits and leave time are: (a) within applicable reasonable and customary standards as established by DDA policy; or (b) required for the participant s compliance, as the employer of record, with applicable federal, State, or local laws; Any benefit and leave time offered by the participant must comply with any and all applicable federal, State, or local laws; and All funded benefits and leave time shall be included in and be part of the participant s annual budget There is no restriction on the participant funding additional benefits or leave time (or both) from the participant's personal funds. However, such additional funds will not be included in the participant's annual budget and will not be paid in any way by the DDA. The participant shall be responsible for ensuring any additional benefits or leave time that the participant personally funds comply with any and all applicable laws 64

Personal Supports Key Requirements Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization Children have access to any medically necessary preventive, diagnostic, and treatment services under Medicaid s EPSDT services to help meet children s health and developmental needs. 65 Service transitions from July 1, 2018 through June 1, 2019: Transportation costs associated with the provision of personal supports outside the participant s home will be covered under the stand alone transportation services and billed separately. Beginning July 2019, transportation costs associated with the provision of services outside the participant s home will be covered within the new rate For people currently utilizing this service: It may include professional services (i.e. nursing services) not otherwise available under the individual's private health insurance (if applicable), the Medicaid State Plan, or through other resources These services will transition to the new stand alone nursing services and behavioral support services

Remote Monitoring Overview Provide oversight and monitoring within the participant s home through an off-site electronic support system in order to reduce or replace the amount of staffing a participant needs Service includes: Electronic support system installation, repair, maintenance, and back-up system; Training and technical assistance for the participant and his or her support network; Off-site system monitoring staff; and Stand-by intervention staff for notifying emergency personnel such as police, fire, and back-up support staff 66

Remote Monitoring Key Requirements: Service designed and implemented to ensure the need for independence and privacy of the participant who receives services in their own home Team must conduct a preliminarily assessment for appropriateness in ensuring the health and welfare of the all individuals in the residence. The preliminary assessment must be documented in the participant s PCP Each individual residing in the residence, his or her legal guardians, and teams must be made aware of both the benefits and risks of the Remote Electronic Monitoring service Informed consent must be obtained for all individuals in the residence Only available for individuals aged 18 or older Use of the system may be restricted to certain hours as indicated in the participant s PCP Time-limited direct supports from the existing services are available during transition to remote monitoring Service not available for participants in Community Living Enhanced Supports or Shared Living services 67

Respite Care Services Overview Short-term care intended to provide both the participant and his or her family with a break from their daily routines. Can be provided in: The participant s own home, The home of a respite care provider, A licensed residential site, A state-certified overnight or youth camp and, Other settings and camps as approved by DDA Key Requirements: Someone who lives with the participant may be the respite provider, as long as she or he is not the person who normally provides care for the participant and is not contracted or paid to provide any other DDA funded service to the participant A relative (who is not a spouse or legally responsible person) of a participant in Self-Directed Services may be paid to provide this service A neighbor or friend may provide services 68

Respite Care Services Key Requirements: Hourly rate for 8 hours or less; or at a day rate for over 8 hours, daily Respite cannot replace day care while the participant s parent or guardian is at work Respite does not include funding for any fees associated with the respite care (for example, membership fees at a recreational facility, community activities, or insurance fees) Respite Care Services are not available to participants receiving support services in Community Living- Enhanced Supports, Community Living-Group Home, or Supported Living services Respite Care Services are not available at the same time as the direct provision of Career Exploration, Community Development Services, Community Living-Enhanced Supports, Community Living-Group Homes, Day Habilitation, Employment Discovery and Customization, Employment Services, Medical Day Care, Personal Supports, Shared Living, Supported Employment, Supported Living, or Transportation services Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file 69

Transition Services Overview: Provides funding for allowable expenses related to the participant moving from an institutional setting or a community residential provider to either: a private residence in the community, or another community residential provider site Allowable expenses, are defined as actual costs associated with moving and establishing a new household. Examples may include: Cost of a security deposits that is required to obtain a lease on an apartment or home; Reasonable cost, as defined by the DDA, of essential household goods, such as furniture, window coverings, and kitchen, bed, and bath items which cannot be transferred from the previous location to the new one; Fees or deposits associated with set-up of, initial access to, or installation of essential utilities and for telephone, electricity, heating and water; and Cost of services necessary for the participant s health and safety, such as pest removal services and onetime cleaning prior to moving in; Moving expenses 70

Transition Services Key Requirements: The participant must be unable to pay for, and is unable to obtain assistance from other sources or services as documented in the participant s PCP The participant will own all of the items purchased under this service Must be reasonable, necessary, and based on the participant s needs Service cannot be purchased a relative, legal guardian, or legally responsible individual Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization 71

Transition Services Service Limits: May not exceed $5,000 per participant during his or her lifetime unless otherwise authorized by DDA Transition items and goods must be procured within 60 days after moving Does not include payment for the costs of the following items: Monthly rental or mortgage expense; Food; Regular utility charges; Monthly telephone fees; Entertainment related household items or services such as televisions, video game consoles, DVD players, or monthly cable fees, and Payment for room and board 72

Transportation Overview: Designed specifically to improve the participant s and the family caregiver s ability to access community activities within their own community in response to needs identified through the participant s PCP including: Orientation services in using other senses or supports for safe movement from one place to another; Accessing Mobility and volunteer transportation services such as transportation coordination and accessing resources; Travel training such as supporting the participant and his or her family in learning how to access and use informal, generic, and public transportation for independence and community integration; Transportation services provided by different modalities, including: public and community transportation, taxi services, and non-traditional transportation providers; Mileage reimbursement for transportation provided by another individual using their own car; and Purchase of prepaid transportation vouchers and cards, such as the Charm Card and Taxi Cards 73

Transportation Key Requirements: Must be living in own home or in the participant's family home Most cost-efficient mode available that meets the needs For participants self-directing their services: Transportation budget is based on their need while considering their preferences and funds availability from their authorized PCP and budget A relative (who is not a spouse or legally responsible person) of a participant may be paid to provide services The Program will not make payment to spouses or legally responsible individuals for furnishing transportation services Transportation services are not available at the same time as the direct provision of: Meaningful Day Services, Community Living-Enhanced Supports, Community Living-Group Homes, Medical Day Care, Personal Supports (beginning July 1, 2019), Respite Care, Shared Living, or Supported Living services 74

Transportation Key Requirements: Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization Does not include transportation to medical appointments Service Limits: May not exceed $7,500 per participant (traditional services) per year 75

Vehicle Modifications Overview: Adaptations or alterations which are made to a vehicle that is the participant s primary means of transportation May include: Assessment services Assistance with modifications to be purchased and installed in a vehicle owned by the participant, or legally responsible parent of a minor or other caretaker Fund the portion of a new or used vehicle purchase that relates to the cost of accessibility adaptations. (In order to fund these types of adaptations, a clear breakdown of purchase price versus adaptation is required) Non-warranty vehicle modification repairs; and Training on use of the modification Note: Does not include the purchase of new or used vehicles, general vehicle maintenance or repair, State inspections, insurance, gasoline, fines, tickets, or the purchase of warranties 76

Vehicle Modifications Key Requirements: A vehicle modification assessment and/or a driving assessment A Vehicle Equipment and Adaptation Prescription Agreement (VEAPA) for vehicle modifications must be completed by a driver rehabilitation specialist or certified driver rehabilitation specialist The vehicle owner is responsible for: The maintenance and upkeep of the vehicle; and Purchasing insurance on vehicle modifications. The program will not correct or replace vehicle modifications provided under the program that have been damaged or destroyed in an accident Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization Service Limits: May not exceed $15,000 over a ten year period 77

DDA Residential Services Residential Services FSW CSW CP Community Living--Enhanced Supports Service Trial Experience Retainer Fee Phase in July 2019 Community Living --Group Home (Currently titled Residential Habilitation) X Service X Trial Experience X Retainer Fee X Shared Living X Matching Service X Host Home Stipend X Supported Living X* Independent Model X* Shared Model X* 78 Note: * New service proposal for 7/1/18 implementation

Supported Living Available July 2018 Overview: Individualized services to support living independently in the community and assistance to: Learn self-direction and problem-solving related to performing ADLs and IADLS; and Engage in community-based activities of the participant s choosing within their personal resources Services include Assistance and facilitation with finding an apartment or home, roommates, and shared supports based on the participant s preferences and choice; Overseeing quality management; and Monitoring compliance with program requirements once the arrangement is established Service criteria to access includes: Participant chooses to live independently or with roommates; and Most cost-effective service model to meet the participant s needs 79

Supported Living Available July 2018 Key Requirements: No more than four (4) individuals may share a residence; Shared bedroom with spouse, domestic partner, or significant other; Services may include up to 24 hours of support per day as specified PCP; Each person has free choice of service providers and is not required to use the same Supported Living provider; Private dwelling and not a licensed individual site of a provider; Owned or leased by at least one of the person residing in the home or family member/guardian; Residents are legally responsible for the residence in accordance lease, mortgage, or other property agreements; Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization 80

Shared Living Overview: Long-term sharing of lives, forming of caring households, and close personal relationships between a participant and the Host Home Host Home supports assure that the participant is safe and free from harm and has the support that he or she needs to take risks and to work and participate in community activities Services include Recruiting for Host Homes providers; Facilitating recruitment and matching services based on the participant s preferences and choice, Overseeing quality management and monitoring compliance with program requirements once the arrangement is established; and Compensation to Host Home for additional household cost Effective July 1, 2018, the following criteria will be used: Participant does not have family or relative supports; and Participant chooses this living option 81

Shared Living Key Requirements: From July 1, 2018 through June 1, 2019, Shared Living services may include other services that are integral to meeting the participant s daily needs and professional services (e.g. nursing and behavioral services) not otherwise available under the participant's private health insurance (if applicable), the Medicaid State Plan, or through other resources. These services will transition to the appropriate stand alone waiver services or new waiver services The couple or family who provides the host home and services and supports to the participant shall: Be chosen by the participant and reflect their preferences and desires and Be compensated for sharing a home and their lives with the participant Compensation to Host Home includes transportation costs associated with the provision of service is covered within the rate Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization 82

Community Living Group Home Overview: Provide the participant with development and maintenance of skills related to activities of daily living, instrumental activities of daily living, socialization, and safety of self and others, by providing additional observation and direction in a community residential setting Services include coordination, training, mentoring, supports, or supervision (as indicated in the PCP) related to development or maintenance of the participant s skills, particularly pertaining to remediating the participant s challenging behaviors Requires preauthorized by the DDA based on documented level of supports needed Staffing is based on level of service need 83

Community Living Group Home Effective July 1, 2018, the following criteria will be used: Critical support needs that cannot be met by other residential or in-home services and supports; Least restrictive and most cost effective model The participant meets one of the following criteria: Lives on own and unable to care for self even with services and supports, Lives on own or with family/unpaid caregivers and such living situation presents an imminent risk to health and safety or the health and safety of others, The participant is (i) homeless and living on the street; (ii) has no permanent place to live; or (ii) at immediate risk of homelessness or having no permanent place to live; Currently lives with family or other unpaid caregivers and documentation exists that in-home services available through the other waiver services would not be sufficient to meet the needs of the participant; The participant s family s or unpaid caregiver s health changes significantly where the primary caregiver is incapacitated and there is no other available caregiver. Examples of such significant health changes include a long-term illness or permanent injury There is no family or unpaid caretaker to provide needed care 84

Community Living Group Home Service criteria - continued: The participant meets one of the following criteria: Risk of abuse or neglect in current living situation as evidenced by: 1. Recurrent involvement of the CPS or APS that indicates the health and safety cannot be assured and attempts to resolve the situation are not effective with CPS or APS involvement; or 2. Removal from the home by CPS or APS With no other home or residential setting available, the participant is: 1. Ready for discharge from a hospital, nursing facility, State Residential Center, psychiatric facility, or other institution; 2. Ready for release from incarceration; 3. Residing in a temporary setting such as a shelter, hotel, or hospital emergency department 4. Transitioning from a residential school; or 5. Returning from an out of State placement 85

Community Living Group Home Key Requirements: Trial experience for people transitioning from an institutional or non-residential site on a temporary, trial basis No more than four (4) individuals (including the participant) in one home unless approved by DDA Six (6) hours a day or when the participant spends the night in the residential home From July 1, 2018 through June 1, 2019, service may include professional services (i.e. nursing services) not otherwise available under the individual's private health insurance (if applicable), the Medicaid State Plan, or through other resources. These services should be transitioned to the new stand alone nursing services Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization 86

Community Living Enhanced Supports Available July 2019 Overview: Provide the participant, who exhibits challenging behaviors or have court ordered restrictions, with development and maintenance of skills related to activities of daily living, instrumental activities of daily living, socialization, and safety of self and others, by providing additional observation and direction in a community residential setting Services include coordination, training, mentoring, supports, or supervision (as indicated in the PCP) related to development or maintenance of the participant s skills, particularly pertaining to remediating the participant s challenging behaviors Requires preauthorized by the DDA based on documented level of supports needed Staffing is based on level of service need Each participant receiving this service must have his or her own bedroom Service criteria to access includes: Critical support needs that cannot be met by other residential or in-home services and supports; and The participant meets the following criteria: Court ordered restrictions to community living; or Demonstrated history of severe behaviors requiring restrictions and the need for enhanced skills staff; and Least restrictive environment to meet needs 87

Community Living Enhanced Supports Available July 2019 Key Requirements: Trial experience for people transitioning from an institutional or non-residential site on a temporary, trial basis No more than four (4) individuals (including the participant) in one home unless approved by DDA Six (6) hours a day or when the participant spends the night in the residential home Prior to accessing DDA funding for this service, all other available and appropriate funding sources, must be explored, exhausted, and documented in the participant s file To the extent that any listed services are covered under the Medicaid State Plan, the services under the waiver would be limited to additional services not otherwise covered under the Medicaid State Plan, but consistent with waiver objectives of avoiding institutionalization 88

89 Questions