Medicaid ID Number: TABS ID Number: Date of Birth: Marital Status: Please Specify

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1 Individual's Information Last Name: First Name: Middle Initial: Sex: Street Address (Line 1): Street Address (Line 2) : City: State: New York Zip Code: County: Phone Number: Version: 8/22/2014 Please Specify Please Specify Medicaid ID Number: TABS ID Number: Date of Birth: Marital Status: Please Specify Start-Up Broker Services Requesting Start-up Broker Services? Please Specify Personal Resource Account DDP Adaptive: 0.00 DDP Health: 0.00 DDP Behavior: 0.00 Is the individual: 1) less than 22 years old and 2) residing with parents or legal guardian and 3) eligible to receive or receiving services through the school district? Select "Yes" ONLY if all three criteria are met. Please Specify PRA Residential: $ - PRA OTR: $ - Both PRA: $ - Initial Plan or Amendment? DDSO: DDSO Contact: Please Specify Please Specify Template Funding Approved? Please Specify Type of Template Funding? Regional Office: DDSO Contact Phone: Please Specify DDSO Contact What type of budget is described in this document? Please Specify CSS Participant Prior to 10/01/14 Please Specify Services Requested (Select "Yes" if the service is being requested and "No" if the service is not being requested.) Provide a response for each service. Medicaid Funded Self-Hired Services Agency Supported Self-Directed Services Self-Hired Community Habilitation NA Self-Directed Community Habilitation NA Self-Hired Respite NA Self-Directed Respite NA Self-Hired Supported Employment (SEMP) NA Supported Employment (SEMP) Corp ID: NA Employment Outcome Payment Phase 1 NA Outcome Payment Phase 1 Yes Extended Employment Supports Phase 2 NA Extended Employment Supports Phase 2 Yes Support Brokerage Individual Directed Goods & Services Live-In Caregiver NA NA NA 100% State Funded Self Directed Services Housing Subsidy NA Number of Live-In Caregivers 1 Family Reimbursed Respite NA Other Than Personal Service Items NA Direct Provider Purchased Services Community Habilitation Day Habilitation NA NA Family Support Services Pathway to Employment Pre-Vocational Services Respite Supported Employment (SEMP) Employment Outcome Payment Phase 1 Extended Employment Supports Phase 2 NA NA NA NA NA NA NA Fiscal Intermediary Agency Name: Contact Name: Contact Contact Phone: Broker Broker Name: Address: Contact Contact Phone: Medicaid Service Coordinator Name: Address: Contact Contact Phone: City/State/Zip: Corp ID: City/State/Zip: Agency Affiliation City/State/Zip: Agency Affiliation Designations Documents CSS Monthly Summary Note Employee Time Sheets/Daily Service Records Invoices/Service Records for Contracted/Vendor Services Individualized Services Plan & Budget Reviews & Amendments Mileage Logs Other Designee(s) Budget Effective Date (DDRO Completes) Individuals Signature (Optional): Broker Signature (Optional): 3/23/2015Self Direction Budget Template xlsx

2 Self Directed Employment Supports This document is meant to define how employment supports can be purchased by an individual who is self directing their plan of support. Employment supports include both the direct and indirect activities associated with helping a person get a job and helping them gain skills and then retain the job. Purchase of Agency Provided SEMP: If an individual chooses to purchase all or some of an agency provided SEMP service that service cost is subtracted from the individual s PRA and the available balance can be used for the person s self directed plan. Use of Self Hired staff to provide employment supports: A person can use self hired staff to provide both job development and job coaching with a self directed plan. The duties of the job developer and job coach are contained within the service description for Supported Employment. CMS is very clear that within self direction, a person can hire their own staff to deliver Supported Employment but the payment cannot exceed the rate a provider would be paid for the service. Hence: A person can have an independent job developer, they cannot be paid more than the provider rate that would be paid to a Supported Employment provider agency. A traditional SEMP provider is not required, If a Job Developer is a licensed clinician and is providing a clinical consultation service (i.e., the job developer is evaluating an individual s habilitation plan, training self-hired staff & evaluation of the effectiveness of the self-hired staff in carrying out the services). If this is what the job developer is doing and he/she is a licensed clinician then it could be an IDGS-funded consultantship. The hourly limit for self-directed SEMP is under review, and may go up somewhat. Currently the proxy rate that will be utilized as plans are converted is the Regional Community Habilitation (CH) rate. Template: The total budget of the self hired employment supports should be reflected in the SD template. The costs associated with the budgeted resource can be identified using the attached worksheet. While this worksheet is not programmed to load the information into the template it is a tool for brokers to use to identify the component parts of the person s employment supports. August 19, 2014

3 Introduction This document describes the policy guidance regarding the conversion of Consolidated Supports and Services (CSS) plans to the new methodology for self-direction beginning on October 1, This document provides: Over-view of Self Direction Options Service Options for Self Direction Self-Direction Policy Guidance The following additional guidance is available under separate cover: Fiscal Intermediary Administrative Memorandum and Fiscal Intermediary Billing Guidance. 1) Overview of Self-Direction Options a) Participant Options for Exercising Self Direction Authority i) Self Direction Using Self Hired Staff (Budget and Employer Authority): Individuals who choose to use both budget and employer authority develop a plan of support with the help of a broker and service coordinator and others of the individuals choosing. The plan defines the services desired and is defined in the person s ISP and the Habilitation Plan; the associated cost of the services are identified on the Self Direction Budget Template. A Fiscal Intermediary works with the individual to implement the Human Resource (HR) activities and to complete billing and payment of the services identified in the budget template. The person who is self directing must work within a personal Resource Account (PRA) established based on need. If services are purchased directly from a provider agency the PRA is reduced by the cost of those services ii) Agency Supported Self Direction (Employer Authority): The services of Community Habilitation, Supported Employment (SEMP) and Respite can either currently or will be able to be self directed using employer authority by the individual who is self directing. The person uses the authority in a co-employment model to hire staff, train staff regarding their interests, monitor and provide feedback to staff, and end the employees services if they are not consistent with their expectations. The person does not have the authority to set the staff salary in this model and the provider is paid at a rate for the service that is their service rate and which includes the administrative and clinical components of the service. If the Individual Directed Goods and Services (IDGS) service is desired the person must develop all their services within their needs based PRA. 1 Self Direction Guidance September 1, 2014

4 iii) Self Direction Using Purchased Agency Services (Budget Authority): A person can choose to self direct a blend of agency purchased and other goods and services. The person has budget authority as they must operate within a PRA and identify their services on the Self Direction (SD) Budget Template. Utilizing budget authority and planning within the defined PRA will allow the person to access the IDGS service. The purchased agency services can be both agency supported where the person maintains elements of the employer authority or agency purchased where the provider is responsible for all elements of service delivery. b) Service Options in Self Direction i) Self-Hired Staffing A person can choose to hire a person to deliver the following types of HCBS waiver services: Community Habilitation Supported Employment, and Respite The worker s wage and benefits are determined by the person and the Fiscal Intermediary. The amount that is billed to emedny for self-hired Community Habilitation, Supported Employment and Respite cannot exceed the amount a provider would be paid for the same service. These payment limits are in 15-minute units and are described below: Rate Setting Region 1 New York City Rate Setting Region 2 Putnam, Rockland, Westchester, Suffolk and Nassau Counties Rate Setting Region 3 - Rest of State Respite $5.23/ Quarter Hour $5.58/ Quarter Hour $5.08/ Quarter Hour Community Habilitation $9.26/ Quarter Hour $9.60/ Quarter Hour $9.38/ Quarter Hour 1-to-1 Community Habilitation $5.79/ Quarter Hour $6.00/Quarter Hour $5.86/Quarter Hour Group Supported Employment* $9.26/ Quarter Hour $9.60/ Quarter Hour $9.38/ Quarter Hour * Hourly Support Employment Fees are under development, and this guidance will be updated once new fees are approved. ii) Agency Supported Self Directed Services As described on Page 1, Community Habilitation, Supported Employment (SEMP) and Respite can either currently or will be able to be self directed using employer authority by the individual who is self directing. The person and agency have a Memorandum of Understanding (MOU) that describes the person s authority to hire staff, train staff regarding their interests, monitor and provide feedback to staff, and end the employees services if they are not consistent with their expectations. The person does not have the authority to set the staff salary in this model and the provider is paid at a rate for the service that is their service rate and which includes the administrative and clinical components of 2 Self Direction Guidance September 1, 2014

5 the service. The agency bills emedny directly, and the cost of these services are included in the Self Direction Budget Template and count against the PRA. iii) Brokerage Services Brokerage services help the person-centered planning process, by assisting the person to develop a circle of support and complete an approvable individualized plan and budget for services. The broker may also provide training and support to the person to help him/her gain the skills and competencies he/she needs to manage self-directed services. The hourly fees paid to brokers appear below: Support Broker who has completed the necessary training but has had no experience as a Support Broker $20 and may require mentoring Support Broker with limited experience and has brokered one approved OPWDD CSS Plan/Budget for at $25 least six months. Support Broker who has brokered two approved $30. OPWDD CSS Plan/Budgets for at least six months Support Broker who has brokered three or more approved CSS Plan/Budgets for at least six months $35 Agency provided Support Broker services $40 Agency providing Support Broker services and also provides FMS services $35 iv) Live-in Caregiver Live-in Caregiver is an unrelated care provider who resides in the same household as the waiver participant and provides as needed supports to address the participant's physical, social, or emotional needs in order for the participant to live safely and successfully in his or her own home. The Live-in Caregiver must be unrelated to the participant by blood or marriage to any degree. Payment for this service will cover the additional costs of room and board incurred by the waiver participant that can be reasonably attributed to the Live-in Caregiver. Room and board includes rent, utilities and food. The participant must reside in his/her own home or leased residence. Payment will not be made when the participant lives in the caregiver's home, in a residence that is owned or leased by the provider of Medicaid services, in a Family Care home, or any other residential arrangement where the participant is not directly responsible for the residence. 3 Self Direction Guidance September 1, 2014

6 The maximum Live-in Caregiver reimbursement levels are as follows: Rate Setting Region 1 New York City Rent - $17,676 annually Food - $5,000 annually Utilities - $ 3,500 annually Annual Total - $26,176 Monthly Max - $2,181 Rate Setting Region 2 Putnam, Rockland, Westchester, Suffolk and Nassau Counties Rent - $19,200 annually Food - $5,000 annually Utilities - $ 3,500 annually Annual Total - $27,700 Monthly Max - $2,308 Rate Setting Region 3 - Rest of State Rent - $13,872 annually Food - $5,000 annually Utilities - $ 3,000 annually Annual Total - $21,872 Monthly Max - $1,823 v) Individual Directed Goods and Services (IDGS) IDGS are services, equipment or supplies not otherwise provided through OPWDD s HCBS waiver or through the Medicaid State Plan that addresses an identified need in a participant s service plan, which includes improving and maintaining the participant s opportunities for full membership in the community. Participants who choose to self-direct their services may receive IDGS as a waiver service. Participants may manage their IDGS budget, as described in their individualized service plan, to fully purchase or put funds towards their personal fiscal resources to purchase items or services which meet the following criteria: 1) Are related to a need or goal identified in the person-centered care plan/individualized Service Plan; 2) Are for the purpose of increasing independence or substituting for human assistance, to the extent the expenditures would otherwise be made for that human assistance; 3) Promote opportunities for community living and inclusion; 4) Are able to be accommodated without compromising the participant s health or safety; and, 5) Are provided to, or directed exclusively toward, the benefit of the participant. Total IDGS expenditure is limited to $32,000 annually or the person s PRA. Further detail is included in Appendix One. vi) Other Than Personal Services (OTPS) Individuals that are self-directing services with budget authority may elect to use up to $3,000 in 100% state funding. This budget category is called, Other Than Personal Service or OTPS and is used to fund items that are not Medicaid-fundable. Other generic and community resources should be explored and exhausted prior to utilizing state OTPS funds for the purchase of such items. For example, cell phones are often made available to people who have Social Security eligibility. The following supports may be included in the OTPS section of the budget includes, but are not limited to: 4 Self Direction Guidance September 1, 2014

7 phone service cell and/or land line staff activity fees to cover meals, admissions, fees, transportation or other costs incurred by staff when providing support to the self-directing individual in activities in support of a valued outcome staff recruitment costs software related to the individual s disability Cost associated with staff time for planning or training meetings where such costs exceed the hourly limits of the service. OTPS cannot be used to pay for certain excluded items. Examples of excluded items include, but are not limited to: medical visit co-pays, any expenses related to hospitalization or nursing home stays (including staff or respite supports or family expenses), expenses related to or to support the purchase of Medicaid services, such as therapies or other waiver services, any illegal item or activity, and Any expenses otherwise prohibited in a SD Plan for services and budget. Therapies that are experimental in nature are not appropriate for purchase using OTPS funds. Repairs, like a broken step or railing, may not be included since they should be covered under the lease or are the responsibility of the home owner. OTPS cannot be used to be applied against housing costs in excess of housing subsidies. If a person s rent is in excess of allowable housing subsidies, this will have to be reimbursed with the person s or family s own resources. OTPS & Continuity of Care For plans in existence prior to 10/1/2014, OTPS may be used for clinical consulting and additional living expenses not covered by a lease. This is on a time-limited basis and OTPS cannot be used for those purposes any plan implemented after October 1, Continuity of care will not apply to experimental treatments or non-evidenced practices or for direct provision of clinical services. Additional Information regarding continuity of care is in section 2-f. 2) Self Direction Policy Guidance a) Guidance on Budget Template On August 22, 2014 a new Self Direction Template was shared with SD Liaisons to share with Brokers and other stakeholders. This template will be the final template for purposes of the conversion and will need to be used to identify the plans being transitioned from CSS. This version replaces all prior budget templates that have been issued to date. Please use this template for all budgets submitted to Central Office. This is the only budget template that will be accepted for processing. 5 Self Direction Guidance September 1, 2014

8 Because we recognize that some plans were already completed using prior template versions that will now need to be changed, we will allow broker payment up to 8 hours for the plan conversion activities without any prior authorization. Requests for broker hours above 8 hours will need to be approved through the DDRO and will need clear justification for the extended work tasks. Individual s services should in no way be affected by the required conversions. The cost of the conversions should be displayed on the provided price sheet and will be paid outside of the individual s budget. If a person has unused broker hours that could more readily be applied to the conversion and which will not impact their ongoing plans of support or negatively impact their budget - those hours may be used. b) Self-Directed Fringe Benefit Budgeting and Billing This section provides guidance on claiming self-hired services to Medicaid. Topics discussed include: (a) distinctions between work hours and billable hours and wage rates and reimbursement rates, (b) types of self-hired staff, (c) accounting for indirect costs associated with self-hired employees, and (d) issues related to the self processing logic in Medicaid for selfhired services. 1) Terms. Understanding the distinctions between these terms is essential to ensure correct budgeting and claiming for self-hired services. a) Work Hours: The actual hours worked by the employee. Per federal and state labor law, employees must be paid for all hours they are "suffered or permitted to work." b) Wage Rate: The standard rate of pay per hour worked as negotiated by individual/ family and the self-hired employee. Nonstandard wage rates may apply in special circumstances (e.g., "overtime" pay). c) Billable Hours: The subset of work hours spent by the employee on billable service activities, as described and defined in OPWDD regulation and administrative memoranda. d) Indirect Employment Cost: Indirect employment costs are expenses of employment other than wage costs, including the employer-paid portions of employee benefits, payroll taxes, etc. e) Total Employment Cost: Employee wages for hours worked plus indirect expenses related to the employment of the self-hired worker. f) Effective Reimbursement Rate: Total employment costs for the service period claimed divided by the billable service hours delivered and documented during the same service period. 6 Self Direction Guidance September 1, 2014

9 2) Types of Self-Hired Staff. a) Contractors. Staff members who perform services at a negotiated payment per hour of service rendered as outlined in a formal service contract. Self-hired contractors may be self-employed (i.e., an "independent contractor") or may be the formal employees of a staffing agency. In either case, the legal relationship between the individual and the self-hired contractor is "purchaser-contractor," not "employer-employee." The negotiated service rate is considered "paymentin-full" for services rendered and there are no indirect costs to be reimbursed. At present, there are significant impediments that prevent most direct care workers from delivering services as contracted staff. OPWDD is studying ways to remove these impediments. Nevertheless, there may be instances where this option can be used to hire staff that perform community habilitation, respite, and supported employment services. b) Employees. Self hired staff may also be hired as employees. The individual and the fiscal intermediary (FI) share responsibilities as "co-employer" of self-hired employees. FI's should permit the self-hiring individual broad leeway to negotiate the wage rates of self-hired staff, subject to the reimbursement restrictions described below. But because the FI is the legal "employer of record," benefit packages and other terms of employment typically must follow the FI's policies and may not be negotiated by the individual. Nearly all true employees drive indirect costs in addition to their wage payments. These indirect costs, in addition to the direct wage costs, must be appropriately accounted and billed to Medicaid. 3) Accounting Indirect Employment Costs. In addition to wage expenses, there are "indirect" costs associated with self-hired employees. Indirect costs include mandated expenses such as the employer portion of payroll taxes, costs associated with workers compensation and unemployment insurance, and the employer's cost of providing health insurance to full time employees. FI agencies often elect to provide additional employee benefits including life insurance, pension/retirement plan, and paid time off. Indirect employment costs are part of the total cost of delivering a service and must be properly charged on the service claim in order to be reimbursed by Medicaid. There are two basic methods for calculating and charging indirect employment costs to Medicaid: a) Direct accounting method. The FI may elect to record and charge indirect employment costs in the precise month in which they are incurred for the specific self-hired employees of each self-directed plan. This method is most feasible when the employee benefit package is sparse and the FI submits reimbursement claims on a monthly billing cycle. 7 Self Direction Guidance September 1, 2014

10 b) Fringe rate method. As an alternative, the FI may create a separate pooled account to cover indirect employment expenses across all of the self-direction plans it administers. Such pooled account/fund should be funded by fixed percentage surcharges on the wages of self-hired employees, so that each payment of employee wages yields a corresponding and proportionate payment into the FI's pooled fringe account. FIs have freedom to establish and administer their own fringe benefits programs and it is expected that these programs may differ substantially from FI to FI. However, the following principles should be adhered to: i) Uniformity. The fringe program administered by the FI should be uniform across all self-direction plans participating within it. At their option, FIs may offer single or multiple fringe packages. When multiple packages are offered, the FI may charge differing fringe assessment rates reflecting the cost differences among the various packages offered. All benefits packages must be potentially available to all self direction plans administered by the FI and the assessment rate charged for each benefit package offered should be the same for all participants. ii) Disclosure. The individual should understand what he/she is "buying" for employees through the fringe assessment. The FI should provide individuals with a clear, concise, and complete outline of all indirect employment costs and employee benefits funded under each fringe package(s) offered and the assessment rate associated with each package. iii) Impact on permissible wage ranges. The impact of fringe assessment rates on the permissible wage rates that may be negotiated with self-hired employees should be explained to individuals and their brokers. iv) Advance notice of benefit package and fringe assessment rate changes. FI agencies shall give individuals with self-hired employees at least two months prior notice before adjusting benefit packages and/or fringe assessment rates. The implications of an assessment rate change on the approved budget plan should be reviewed with the individual. Assessment rates shall not be adjusted retroactively. v) No administration charge. Costs associated with the FI's administration of the fringe benefits pool are included in the FI's monthly fee for FI services. Fringe assessment rates shall not include any component reimbursing the FI for its administrative cost and effort in managing the fringe pool account. vi) Management fringe account balances. The FI is responsible for setting assessment rates that fully fund all fringe program obligations and permit timely payment of such obligations. (1) Separate Account. A separate, dedicated account or fund must be established for the self-hired fringe program. Once assessed and transferred, funds in the pooled fringe account may only be used to 8 Self Direction Guidance September 1, 2014

11 cover indirect employment outlined in the description provided to participating individuals. (2) Surpluses. Surplus funds in the fringe account should not be transferred or skimmed to cover other costs, losses, or obligations of the FI agency. When account balances become excessive, surplus funds should be used to reduce the fringe assessment percentage. (3) Deficits. If the fringe account is temporarily in deficit, the FI will be expected to honor any financial obligations on behalf of participating plans using its own operational funds until such time it implements an increase in fringe assessment rate. (4) Monitoring by OPWDD. OPWDD may develop procedures and protocol to monitor pooled fringe accounts for compliance with the above principles. This may include new reporting requirements within Consolidated Fiscal Reporting (CFR) process and new auditing protocols. 4) Preparing Claims to Medicaid for Self-Hired Services. Self-hired services billed to Medicaid will be processed using special logic. Ordinarily, the charge amount submitted by providers is ignored by emedny when paying HCBS waiver services. Instead, emedny itself calculates the amount due to the provider by multiplying the submitted units times the official rate on file for the provider for the rate code billed. Under self-direction, however, when they successfully make arrangements to reduce the total cost of community habilitation, respite, or supported employment services through the use of self-hired staff, individuals free up PRA resources that can be used to fund additional or different services. Because of this, emedny must be able to pay claims for self-hired services at reimbursement rates that are at or below, but not above, the official rate for the equivalent agencydirected service. This has the following implications for claims submission and adjudication: a) Service Unit Claiming. Just as with equivalent agency-directed services, FI agencies will submit the total billable service units provided on each date services were rendered. If multiple self-hired employees rendered services to the individual on a service date, the sum of billable service units delivered by all staff should be entered for that date. It is important to note that wage hours and billable time may differ. FI agencies must ensure only billable time, as described in OPWDD regulations and administrative memoranda, is entered on the claim form. b) Amount Charged. The total employment cost paid out by the FI for self-hired services rendered to the individual on the service date should be entered into the amount charged field on the claim. Total employment cost includes both the wage payment to the employee plus indirect costs paid out (typically, the 9 Self Direction Guidance September 1, 2014

12 fringe assessment taken as percentage of wages and transferred the FI's pooled account for that purpose). If multiple self-hired staff rendered services to the individual on the service date, the sum of total employment cost for all employees should be entered. For any contracted self-hired staff, the amount charged should be equivalent to the contractor's service rate multiplied by the service hours rendered. There should be no indirect costs for self-hired staff who work as contractors. c) Multi-day versus Single-day Claiming. The emedny system permits providers to submit claims covering multiple dates of service in a single claim transaction. For a variety of reasons, OPWDD recommends against such bundling for most HCBS services. For self-hired services, however, this bundling technique may be advantageous. The effective reimbursement rate, which is later compared to the fee for the equivalent agency-directed service (see below), is calculated at the claim document level. This means emedny will calculate the effective reimbursement rate as an average over multiple service dates. In situations where an individual's effective reimbursement rate is occasionally over the agency directed rate on some days but under on other days, FI agencies will want to submit multi-day claims. Claims for OPWDD service may not span calendar months, however. All such "averaging," therefore, must take place within the course of a single calendar month. d) Reimbursement Rate Cap Logic. The State may not pay self-directed services at reimbursement rates that exceed the rate paid for equivalent agencydirected services. Payment processing logic enforces this rule as follows: i) Medicaid calculates the effective reimbursement rate claimed for the selfdirected services submitted on the claim, total charges / total service units. ii) Medicaid retrieves the fee rate for the equivalent agency-directed service. iii) If the effective reimbursement rate on the claim for self-directed services is less than or equal to the equivalent agency-directed fee rate, emedny pays the precise amount charged by the FI agency. iv) If the effective reimbursement rate on the claim for self-directed services is greater than the equivalent agency-directed fee rate, emedny pays the submitted units times the equivalent agency-directed fee rate. C) Guidance on Overnight supports People may need supports during the overnight hours when they spend some or most of the time sleeping. These supports could include monitoring for events that will require hands-on assistance or ongoing activities that are needed for the person s safety or to learn skills. As plans are converted from the CSS service they should be reviewed to determine the appropriate approach to night time supports if they are needed for the person. It is always helpful to review the supports that have been used to determine if they are still needed upon the conversion. 10 Self Direction Guidance September 1, 2014

13 Perhaps the person has demonstrated independent living skills and does not need the continued level of night time support. If night time supports continue to be needed the following areas should be considered for appropriate plan and budget development. Paid Neighbor funded via IDGS: A paid neighbor may be able to be available to the person so that if they have a need that person can respond and provide the appropriate support. A paid neighbor provides as needed support. See the IDGS chart for paid neighbor specifics. Personal Care funded via State Plan Medicaid: If the need for support relates to the provision of personal care it may be appropriate to obtain supports from a personal care assistant through a community based program where those supports are delivered. Community Habilitation: Community Habilitation (CH) requires that a face to face service be delivered during the course of the continuous time period where the service is provided. A review of the hours that the CH staff person works recognizing the need for a service should be part of the service planning. Respite: If an individual lives in a setting with an unpaid support giver respite may be an appropriate option for overnight supports. D) Guidance on Inclusive Community Settings in IDGS Self Directed supports offer great opportunity for people with developmental disabilities to purchase community based classes that result in active engagement and participation in typical community settings. This guidance is meant to define the elements of a setting or a class that are consistent with an inclusive definition. The setting and class is open to broad members of the community. The setting is not a certified OPWDD setting. The class is not taught by a paid employee of an OPWDD operated or funded provider. The setting results in typical interactions with other participants who do not have an intellectual or developmental disability. It is appropriate for participation in specialized classes that take special needs, such as physical limitations or beginner level learning; into consideration as long as those special classes are open to the broader public. E) Self Directed Employment Supports This document is meant to define how employment supports can be purchased by an individual who is self directing their plan of support. Employment supports include both the direct and indirect activities associated with helping a person get a job and helping them gain skills and then retain the job. 11 Self Direction Guidance September 1, 2014

14 Purchase of Agency Provided SEMP: If an individual chooses to purchase all or some of an agency provided SEMP service the cost of those services are included in the Self Direction Budget Template and count against the PRA. Use of Self Hired staff to provide employment supports: A person can use self hired staff to provide both job development and job coaching with a self directed plan. The duties of the job developer and job coach are contained within the service description for Supported Employment. CMS is very clear that within self direction, a person can hire their own staff to deliver Supported Employment but the payment cannot exceed the rate a provider would be paid for the service. Hence: A person can have an independent job developer; they cannot be paid more than the provider rate that would be paid to a Supported Employment provider agency. A traditional SEMP provider is not required, A person can have an independent job developer but they cannot be paid more than the provider rate that would be paid to a Supported Employment provider agency. A traditional SEMP provider is not required. If a Job Developer is a licensed clinician and is providing a clinical consultation service (i.e., the job developer is evaluating an individual s habilitation plan, training self-hired staff & evaluation of the effectiveness of the self-hired staff in carrying out the services) then it could be an IDGS-funded consultantship. The hourly limit for self-directed SEMP is under review, and may go up somewhat. Currently the proxy rate that will be utilized as plans are converted is the Regional Community Habilitation (CH) rate. F) Template The total budget of the self hired employment supports should be reflected in the SD template. The costs associated with the budgeted resource can be identified using the supplemental worksheet. While this worksheet is not programmed to load the information into the template it is a tool for brokers to use to identify the component parts of the person s employment supports. G) Policy on Funding Clinical Services in Self Direction There are two ways that clinicians support can be funded in self directed plan using IDGS: 1. Clinical Consultation may be purchased and, 2. certain therapies may be purchased. 12 Self Direction Guidance September 1, 2014

15 1) Clinical Consultation may be funded through Individual Directed Goods and Services (IDGS). This is an indirect service not available through the state plan and allows a clinician to assist the person s self directed planning and service delivery in the following ways: Evaluate an individual s habilitation plan Train self-hired staff in delivering the self directed plan Evaluation of the effectiveness of the self-hired staff in carrying out the services in the self-directed plan The clinician must meet the following requirements: The Consultant/contractor must be a member of a discipline authorized under Article 16 clinic regulations (Psychology, OT, PT, SLP, social work, nursing, nutrition/ dietetics, rehabilitation counseling ) Consultants/contractors services cannot replicate any service available through a thirdparty insurer, the Medicaid State Plan or the HCBS Waiver Service. Consultants must provide a written outline of services to be delivered prior to approval; consultants must provide an annual update of progress/provision of service and need to continue. 2) Therapies In IDGS the following categories of therapy may be funded: Hippo therapy, Aquatic Therapy, Art Therapy, Massage Therapy, Music Therapy, and Play Therapy. The therapist must be a professional identified in the NYSED Office of the Professions website ( Therapeutic riding must be provided by a currently certified PATH instructor. The hourly payment limit effective 10/1/14 is based on the Bureau of Labor Statistics data for the 90 th percentile hourly wage (see attached chart). 3) Purchase of Direct Service provision (Clinical) is not allowed Self directed funds (IDGS) cannot be used to purchase a service that is available under the state plan. For information regarding continuity of care provisions, see below section. For additional information on IDGS see Appendix One. H) Guidance on Continuity of Care Provisions OPWDD recognizes that continuity of effective supports is critical to the well being and the quality of life experienced by people who are receiving supports and services. During the transition from the CSS service to a new methodology for self direction OPWDD will work with individuals, brokers and service coordinators to ensure that the effective supports in place, which are consistent with the defined rules for self directed supports, continue for the person. i) General Continuity of Care Provisions - In order to ensure continuity the following guidelines should be followed: For plans that are converting from CSS to the new methodology PRA levels can be exceeded to meet the person s needs with state paid resources. In some 13 Self Direction Guidance September 1, 2014

16 instances the new PRA levels are not able to accommodate the service budgets that are currently within the PRA; this option for state fund payment will address the over PRA issue in those instances. The state paid option for over PRA is only available to the people who are transitioning from the CSS model and is temporary. OPWDD has not established a firm end date for state funding of costs over PRA. Plans that include supports that are not allowed within the new methodology such as experimental therapy and direct provision of clinical supports that are available in the state plan will not be covered with state funding and must be removed from the plan and transitioned to state plan supports. Supports for Community Habilitation, Supported Employment and Respite must utilize the defined methodology and support must be provided within the defined costs of those services. State funds are not to be used to augment the rate paid for the self hired staff costs of those services. See detailed guidance for Employment supports. ii) Continuity of Care provisions for Clinician and Certain Therapy Services effective 10/1/14 (Note: These are continuity of care provisions only. New self-direction plans must fully comport with the IGDS requirements; 100% state funding through OPTS (or any other source) is not available to substitute for or supplement IGDS funding in the case of new self-direction plans.) (1) Clinical Consultation To ensure continuity of care, an individual self-directing their services may augment the hourly rate paid to a consulting clinician with 100% state funds. This is allowed when the individual s CSS budget prior to 10/1/14 included the consulting clinician s services, and the hourly rate paid to the consulting clinician exceeds the hourly rate paid through IDGS. OPWDD will evaluate the timeframe that this continuity of care provision will be allowed. (2) Clinician - Direct Service provision - No use of state funds is allowed. (3) Therapies To ensure continuity of care, an individual self-directing their services may augment with 100% state funds the hourly rate paid for Hippo therapy, Therapeutic Riding, Aquatic Therapy, Art Therapy, Massage Therapy, Music Therapy, and Play Therapy. This is allowed when the individual s CSS budget prior to 10/1/14 included the therapy, and the hourly rate paid to the consulting clinician exceeds the hourly rate paid through IDGS. OPWDD will evaluate the timeframe that this continuity of care provision will be allowed. iii) Continuity of Care and Vehicle Lease Guidance: Vehicle leases will only be allowed in a Self Directed plan for those with current leases or those who submitted final plans for approval prior to June 1, The leases will only be funded for the life of the lease. No new plans with leased vehicles will be approved in the new Self Direction model. 14 Self Direction Guidance September 1, 2014

17 Impact on Individual Budget/PRA: The cost of the lease will be subtracted from the total budget of the person and identified for payment with state funds. The remaining budget balance is available to the person to use for self directed supports. If the budget is under the PRA no additional approvals are needed and the plan can be submitted. If the remaining budget is over the PRA, augmentation to the plan with state funds can only be approved if the justification is related to health and safety. (This is the case for all plans that are over PRA) If the subtraction of the vehicle costs results in additional room within the PRA, the person can only access additional funding for health and safety reasons. It is expected that the plan will be cost neutral with the exception of health and safety needs. 15 Self Direction Guidance September 1, 2014

18 TABLE 1: Allowable IDGS Expenses Individual Directed Goods and Services (IDGS) Category Available To Individuals in Certified Residences? Description Qualifications Pricing Parameters Camp No Funding may be requested for the cost of summer camp in a self-directed plan for a camp that is able to provide the needed safeguarding supports and supports to achieve the person s valued outcomes. Camps can be either focused on supporting individuals with disabilities or camps that are available to the general public. Directly related to a valued outcome. For a children s camp, a state, city, or county health department permit to operate legally and must operate in compliance with Subpart 7-2 of the State Sanitary Code requirements. A permit is issued only when the camp is in compliance with the state's health regulations. Not to exceed published fees Annual cap $4000/year. Community Classes & Publicly Available Training/Coach ing Yes Classes available to the general public in any subject area that relates to a person s valued outcomes (Art, Dance, Exercise, Cooking, Computer Training, Etc.) Sessions with a private trainer (physical education/exercise) may be covered as long as the service relates to a valued outcome). Classes must be related to a habilitative need in the individual s person-centered plan and not just for recreational purposes. N/A Not to exceed the published fees as outlined in the entity s published course fees. 16 Self Direction Guidance September 1, 2014

19 TABLE 1: Allowable IDGS Expenses Individual Directed Goods and Services (IDGS) Category Available To Individuals in Certified Residences? Description Qualifications Pricing Parameters Coaching/ education for parent(s), spouse and advocates involved in the person s selfdirected services No Classes must be non-credit bearing; IDGS funding is for nonmatriculating students. IDGS funding is for Parent/Spouse/Advocate to attend/participate in educational opportunities (not covered by other public programs) that assist participants and those close to them to achieve goals established in the individual s service plan. Self-directing individual is over age 18 (Under 18 is through FET). May Include registration, and conference fees. Annual cap $500/year based on Family Education & Training (FET) pricing parameters in 1915(c) HCBS waiver. Reimbursement is only up to FET reimbursement levels; overnight lodging or travel not allowable. Clinician Consultants, Independent Contractors (Non-Direct Service Provision -- Clinical Consultation Yes, but only related to self-directed services Consultants/contractors are clinical specialists who are hired for the following purpose: Evaluate an individual s habilitation plan Training self-hired staff in delivering the self directed plan (NOTE: State Plan clinic services may not be used to train and consult with paid caregivers. To the extent that IDGS Consultation services are being used to train self-hired staff, who might otherwise not have such resources available to them, it will not duplicate State Plan services) Evaluation of the effectiveness of the self-hired staff in A consultant/ contractor who is a member of a profession that is under the jurisdiction of the NYSED Office of the Professions, must meet all licensure or registration requirements as verified at the following site:: The hourly amount paid to the therapist cannot exceed the 90th percentile for the hourly wage for the therapeutic or consultant s professional discipline (i.e., the standard occupational code) published by the Bureau of Labor Statistics (BLS) 17 Self Direction Guidance September 1, 2014

20 TABLE 1: Allowable IDGS Expenses Individual Directed Goods and Services (IDGS) Category Available To Individuals in Certified Residences? Description Qualifications Pricing Parameters Specialties ) carrying out the services in the self-directed plan Consultants/contractors services cannot replicate any service available through a third-party insurer, the Medicaid State Plan or the HCBS Waiver Service. Consultants must provide a written outline of services to be delivered prior to approval; consultants must provide an annual update of progress/provision of service and need to continue. v/opsearches.htm Discipline authorized under Article 16 clinic regulations (Psychology, OT, PT, SLP, social work, nursing, nutrition/ dietetics, rehabilitation counseling) and is identified in the table below Clinician (Direct- Provision of Therapies/ Therapeutic Activities Not Otherwise Funded in the State Plan) Yes Hippo Therapy: A treatment strategy by physical therapists, occupational therapists, and speech language pathologists that is incorporated into the professional s plan of care to achieve functional outcomes. Hippo therapy is a medical treatment, not a recreational program of teaching a progressive riding and horsemanship skill. Funding may be requested for hippo therapy in a selfdirected plan by Individuals with cerebral palsy and other neurological disorders that permanently affect body movement and muscle coordination. Funding may be requested for hippo therapy in a self- Hippo Therapy An individual providing hippo therapy must be a NYS licensed Occupational, Physical or Speech Therapist; if he/she is an Assistant in one of those categories (OTA, PTA) then he/she must be working under an OT or PT. Therapeutic Riding & The hourly amount paid to the therapist cannot exceed the 90th percentile for the hourly wage for the therapeutic or consultant s professional discipline (i.e., the standard occupational code) published by the Bureau of Labor Statistics (BLS) and is identified in the table below. 18 Self Direction Guidance September 1, 2014

21 directed plan by Individuals with cerebral palsy and other neurological disorders that permanently affect body movement and muscle coordination. Therapeutic Riding & Equine-assisted Activities Therapeutic Riding and equine-assisted activities address and contribute positively to the cognitive, physical, emotional and social well-being of individuals with special needs. Therapeutic riding and equine-assisted activities are taught by a PATH International Instructor to individuals five (5) years old and older. The PATH instructor will provide written policies on the eligibility and discharge of individual, written documentation of the initial evaluation of the individual and written progress notes for the individual. The initial evaluation of abilities establishes the appropriate goals and objectives for the individual and the progress notes document the achievements and problem areas. The discharge should be supported by appropriate documentation that shows a baseline for goals and objectives and a recommended course of action when continued participation is no longer appropriate. Instructors communicate with the individual/parents/guardians at the start and at the end of the session (6-8 weeks) to discuss the goals, objectives, accomplishments and the next steps, and best practice includes mid-session meetings and informal discussions each time the individual rode. Equine Assisted Activities PATH International Instructor must carry a certification business card with an annual expiration date, and must requalify each year to be certified Aquatic, Art, Massage, Music, Play Therapy: A consultant/ contractor who is a member of a profession that is under the jurisdiction of the NYSED Office of the Professions, must meet all licensure or registration requirements as verified at the following site: v/opsearches.htm Aquatic, Art, Massage, Music, Play Therapy: Funding for massage therapy may be included in a selfdirected plan when the service has been prescribed by the 19 Self Direction Guidance September 1, 2014

22 individual s medical doctor to ameliorate a specific medical diagnosis/condition for which massage therapy has recognized efficacy. Funding is not available to support vague goals such as "promote well-being," "reduce stress, or promote relaxation." There must be a corresponding valued outcome in the individual's plan. Funding for music therapy may be included in a selfdirected plan only if there is a specific communication or audiological requirement for the service as stated in the plan and justified by the individual s medical doctor or licensed clinician, and a corresponding valued outcome. All Services Ordering, Treatment Plan & Documentation Requirements The request for funding must be accompanied by a written prescription from the individual s medical doctor with a goal of treating a specific medical diagnosis/ condition and shall support a specific valued outcome. The therapist shall conduct an initial assessment, report findings, and propose a treatment plan. The treatment plan shall outline treatment goals, proposed therapeutic activities, and their anticipated frequency and duration. The treatment plan shall acknowledge the individual's personal goals and support a specific valued outcome(s) described in the ISP. The treatment plan becomes active upon the referring/prescribing medical doctor's review and written approval. On-going treatment services shall be delivered only in accordance with the approved treatment plan. Each session shall be documented with a brief treatment note outlining the therapeutic services/activities performed, duration, and response to treatment. The therapist shall provide periodic (at least semi-annual) 20 Self Direction Guidance September 1, 2014

23 progress reports to the referring/ prescribing medical doctor. Such report shall review the individual's progress toward goals and the efficacy of services to date; it shall propose any necessary updates/ revisions to the treatment plan. The medical doctor shall review the individual's progress and, if warranted, approve the updated treatment plan and continuation of services in writing. Health Club/ Organizational Memberships/ Community Participation Yes Health club memberships; Community membership dues -- Funding for a gym, health club or other community organization membership may be included in the selfdirected plan for reasons of health and fitness or community integration in accordance with the participant s valued outcomes. Membership is for individual only; no family memberships allowed with IDGS funding. The club/organization must offer open enrollment to the public, and cannot be a private club with a closed membership where membership is available by invitation only. An individual may have multiple memberships to health clubs. Payment not to exceed the entity s published membership dues/fees specified. Annual cap $1500/year. Household- Related Items and Services No Item cannot be funded through any other funded program and may include Appliances that assist a person to live more independently (i.e., a microwave oven for someone who cannot safely use a stove or oven) Appliance must benefit the individual and be related to a valued outcome as well as be related to health and safety. Household support (cleaning, minor maintenance, snow removal, lawn mowing) only for individuals not living in the N/A Annual cap $1500/year. 21 Self Direction Guidance September 1, 2014

24 family home. Note: The Community Transition Services (CTS) waiver service and funding cap remains separate from IDGS funding in this category. Paid Neighbor No Stipend paid to neighbor to be on-call to assist a person who lives independently. If the paid neighbor is called upon to provide direct services, he/she is paid an hourly wage for the delivery of self-hired community habilitation. The specific duties are defined in a contract signed by the paid neighbor and the Fiscal Intermediary. Self-Directed Staffing Support Transition Programs for Individuals with IDD Yes, but only related to selfdirected services No Assistance with scheduling self-hired staff and with assisting the person to complete staffing related paperwork. Not to duplicate FI employer responsibilities or Broker services related to development of the person s self directed plan. The self-hired staff person providing this support is not a staff person of a NFP agency and is not a person who is active in assisting the person with decision-making regarding his/her self directed services (not a family-member or a member of the person s freely chosen planning team). Tuition for non-credit bearing transition programs for individuals with IDD who have already completed their educational program (i.e. aged out ). The coursework must address a person s valued outcomes and address skill building and employment outcomes. Programs may be provided in non-site based settings, on college campuses, but not in locations certified by OPWDD. Coursework may include training on personal care skills, and socialization skills, but this training is provided to support vocational outcomes for the person. 22 Self Direction Guidance September 1, 2014 The paid neighbor staff person cannot be a family member of the person. Must meet all requirements for background check, and training that would be required of a self-hired staff person. All staff, volunteers and trainers are screened for criminal background and excluded provider status All staff, volunteers and trainers are screened for criminal background and excluded provider status Monthly cap $800 Not to exceed payment of $20/hour Published fees cannot be exceeded. Per class limit for tuition is $350/course. Where tuition is on a monthly basis, not to exceed $800/month

25 To be funded via a person s self direction budget, the program cannot be funded by ACCESS-VR, IDEA or other funding sources. Services are time-limited and cannot exceed a two year timeframe. No room and board costs are fundable. Transportation Yes, only related to selfdirected services Funding may be requested for the cost of service related transportation that is directly related to valued outcomes, safeguards and services identified and approved in the selfdirected plan. In order to make the determination whether transportation is service related, and costs may be reimbursed, the questions to be answered are: 1. What valued outcome/safeguard is this activity in support of? 2. What service was this transportation related to? 3. What service was actually provided? 4. Who provided the service? Transportation costs are not reimbursed through the selfdirected plan for transportation to and from OPWDD funded services for which transportation costs are included in the price developed and paid for the service. Mileage may not be reimbursed for medical appointments as this duplicates a State Plan service. Transportation reimbursement takes several forms: 1. Reimbursement for service related miles may be made to: a. Staff person who drove his/her personal vehicle to a service related activity, b. Participant who drove or was driven in his/her personal vehicle to a service related activity, or c. Friend or family member who drove his/her personal vehicle to a service related activity. Service related mileage may be paid from IDGS for Vehicle must be operated by a licensed driver. Mileage reimbursement not to exceed standard federal mileage rate: Standard-Mileage-Ratesfor-Business,-Medicaland-Moving-Announced Reimbursement of public transportation and paratransport limited to published rates. Discounts for disabled individuals shall be requested, where available. Vendor transportation limited to published fees. 23 Self Direction Guidance September 1, 2014

26 transportation costs required for the individual to access a generic service in the community that is Medicaid reimbursable within the self-directed plan (directly related to a valued outcome or safeguard) regardless of whether or not there is a paid staff person present. Mileage reimbursement covers all operating costs related to the vehicle and included in the IRS standard mileage rate standards, i.e., gas, registration, vehicle inspection, insurance, repairs & maintenance. Reimbursement for the cost of public transportation or paratransit, such as bus passes, bus, taxi and train fares that is directly related to valued outcomes, safeguards and services identified and approved in the self-directed plan. TABLE 2: The Following items cannot be funded through IDGS Academic Tutoring Automatic pill dispenser/ medication system Cell Phones/Telephones Computer Hardware Academic tutoring is not funded through the IDGS. This service should be pursued through the school district or college setting. Academic tutoring/homework assistance is not an appropriate task for self-hired staff. Available through Assistive Technology, outside the person s self-directed budget Funding for cell phones is not an allowable IDGS expense. The SafeLink Wireless program is available to eligible individuals in New York State who receive Supplemental Security Income (SSI). The SafeLink service in New York State allows for a cell phone and limited free minutes for a person who has a diagnosed developmental disability and receives social security benefits under SSI. Not allowable in IDGS 24 Self Direction Guidance September 1, 2014

27 Computer Programs/Software Computer Software is available through Assistive Technology, outside the person s self-directed budget. Leased Vehicles Leased Vehicles are not an allowable expense under IDGS. Health-Related Services, Equipment and Supplies Parents Activity Fees, Expenses, and Meals Participants Activity Fees, Expenses, and Meals Personal Monitoring Systems Staff Activity Fees, Expenses, and Meals Direct Clinician service delivery and Therapies: Physical Therapy, Occupational Therapy, Speech Therapy, Psychology (Medicaid state funded) Experimental Therapies Health related supplies such as food and beverage thickeners, trachea collars, disposable bed pads, wipes, incontinence products, and supplemental medications are funded through the State Plan only; not through IDGS funding. Activity fees, expenses, and meals incurred by parents of individuals are not reimbursed with IDGS funds and must be paid by the parents when they accompany an individual to an activity supported by the his/her self-directed plan. Activity fees, expenses, and meals incurred by individuals are not reimbursed with IDGS funds and must be paid by the individual or his/her family. Available through State Plan Activity fees, expenses, and meals incurred by self-hired staff supporting individuals are not reimbursed with IDGS funds, but may be funded through OTPS. On-going therapies that are provided directly to the person are funded through the individual s State Plan Medicaid Card or, if the individual is school-aged, through the local school district, and are not funded under IDGS. Experimental therapies are not reimbursable in any clinical category within IDGS and are not a permitted expense in the OTPS payment category. 25 Self Direction Guidance September 1, 2014

28 Table 3: Clinician & Therapy Payment Capitation Levels Area: New York Period: May 2013 Based on 90 th Percentile Wages from BLS July 31, 2014 Occupation (SOC code) Hourly 90th percentile wage Social Workers, All Other(211029) $ Dietitians and Nutritionists(291031) $ Occupational Therapists(291122) $ Physical Therapists(291123)**includes Equine, Aquatic Therapy $ Recreational Therapists(291125) $ Speech-Language Pathologists(291127) $ Therapists All Other(291129) $ Registered Nurses(291141) $ Nurse Practitioners(291171) $ Hearing Aid Specialists(292092) $ Occupational Therapy Assistants(312011) $ Occupational Therapy Aides(312012) $ Physical Therapist Assistants(312021) $ Physical Therapist Aides(312022) $ Psychologists, All Other(193039) Footnotes: (1) Annual wages have been calculated by multiplying the hourly mean wage by 2080 hours; where an hourly mean wage is not published the annual wage has been directly calculated from the reported survey data. SOC code: Standard Occupational Classification code -- see Data extracted on July Self Direction Guidance September 1, 2014

29 Introduction This document describes the policy guidance regarding the conversion of Consolidated Supports and Services (CSS) plans to the new methodology for self direction beginning on October 1, This document provides: Over view of Self Direction Options Service Options for Self Direction Self Direction Policy Guidance The following additional guidance is available under separate cover: Fiscal Intermediary Administrative Memorandum and Fiscal Intermediary Billing Guidance. 1) Overview of Self Direction Options a) Participant Options for Exercising Self Direction Authority i) Self Direction Using Self Hired Staff (Budget and Employer Authority): Individuals who choose to use both budget and employer authority develop a plan of support with the help of a broker and service coordinator and others of the individuals choosing. The plan defines the services desired and is defined in the person s ISP and the Habilitation Plan; the associated cost of the services are identified on the Self Direction Budget Template. A Fiscal Intermediary works with the individual to implement the Human Resource (HR) activities and to complete billing and payment of the services identified in the budget template. The person who is self directing must work within a personal Resource Account (PRA) established based on need. If services are purchased directly from a provider agency the PRA is reduced by the cost of those services ii) Agency Supported Self Direction (Employer Authority): The services of Community Habilitation, Supported Employment (SEMP) and Respite can either currently or will be able to be self directed using employer authority by the individual who is self directing. The person uses the authority in a co employment model to hire staff, train staff regarding their interests, monitor and provide feedback to staff, and end the employees services if they are not consistent with their expectations. The person does not have the authority to set the staff salary in this model and the provider is paid at a rate for the service that is their service rate and which includes the administrative and clinical components of the service. If the Individual Directed Goods and Services (IDGS) service is desired the person must develop all their services within their needs based PRA. 1 Self Direction Guidance September 1, 2014

30 iii) Self Direction Using Purchased Agency Services (Budget Authority): A person can choose to self direct a blend of agency purchased and other goods and services. The person has budget authority as they must operate within a PRA and identify their services on the Self Direction (SD) Budget Template. Utilizing budget authority and planning within the defined PRA will allow the person to access the IDGS service. The purchased agency services can be both agency supported where the person maintains elements of the employer authority or agency purchased where the provider is responsible for all elements of service delivery. b) Service Options in Self Direction i) Self Hired Staffing A person can choose to hire a person to deliver the following types of HCBS waiver services: Community Habilitation Supported Employment, and Respite The worker s wage and benefits are determined by the person and the Fiscal Intermediary. The amount that is billed to emedny for self hired Community Habilitation, Supported Employment and Respite cannot exceed the amount a provider would be paid for the same service. These payment limits are in 15 minute units and are described below: Rate Setting Region 1 New York City Rate Setting Region 2 Putnam, Rockland, Westchester, Suffolk and Nassau Counties Rate Setting Region 3 Rest of State Respite $5.23/ Quarter Hour $5.58/ Quarter Hour $5.08/ Quarter Hour Community Habilitation $9.26/ Quarter Hour $9.60/ Quarter Hour $9.38/ Quarter Hour 1 to 1 Community Habilitation $5.79/ Quarter Hour $6.00/Quarter Hour $5.86/Quarter Hour Group Supported Employment* $9.26/ Quarter Hour $9.60/ Quarter Hour $9.38/ Quarter Hour * Hourly Support Employment Fees are under development, and this guidance will be updated once new fees are approved. ii) Agency Supported Self Directed Services As described on Page 1, Community Habilitation, Supported Employment (SEMP) and Respite can either currently or will be able to be self directed using employer authority by the individual who is self directing. The person and agency have a Memorandum of Understanding (MOU) that describes the person s authority to hire staff, train staff regarding their interests, monitor and provide feedback to staff, and end the employees services if they are not consistent with their expectations. The person does not have the authority to set the staff salary in this model and the provider is paid at a rate for the service that is their service rate and which includes the administrative and clinical components of 2 Self Direction Guidance September 1, 2014

31 the service. The agency bills emedny directly, and the cost of these services are included in the Self Direction Budget Template and count against the PRA. iii) Brokerage Services Brokerage services help the person centered planning process, by assisting the person to develop a circle of support and complete an approvable individualized plan and budget for services. The broker may also provide training and support to the person to help him/her gain the skills and competencies he/she needs to manage self directed services. The hourly fees paid to brokers appear below: Support Broker who has completed the necessary training but has had no experience as a Support Broker $20 and may require mentoring Support Broker with limited experience and has brokered one approved OPWDD CSS Plan/Budget for at $25 least six months. Support Broker who has brokered two approved $30. OPWDD CSS Plan/Budgets for at least six months Support Broker who has brokered three or more approved CSS Plan/Budgets for at least six months $35 Agency provided Support Broker services $40 Agency providing Support Broker services and also provides FMS services $35 iv) Live in Caregiver Live in Caregiver is an unrelated care provider who resides in the same household as the waiver participant and provides as needed supports to address the participant's physical, social, or emotional needs in order for the participant to live safely and successfully in his or her own home. The Live in Caregiver must be unrelated to the participant by blood or marriage to any degree. Payment for this service will cover the additional costs of room and board incurred by the waiver participant that can be reasonably attributed to the Live in Caregiver. Room and board includes rent, utilities and food. The participant must reside in his/her own home or leased residence. Payment will not be made when the participant lives in the caregiver's home, in a residence that is owned or leased by the provider of Medicaid services, in a Family Care home, or any other residential arrangement where the participant is not directly responsible for the residence. 3 Self Direction Guidance September 1, 2014

32 The maximum Live in Caregiver reimbursement levels are as follows: Rate Setting Region 1 New York City Rent $17,676 annually Food $5,000 annually Utilities $ 3,500 annually Annual Total $26,176 Monthly Max $2,181 Rate Setting Region 2 Putnam, Rockland, Westchester, Suffolk and Nassau Counties Rent $19,200 annually Food $5,000 annually Utilities $ 3,500 annually Annual Total $27,700 Monthly Max $2,308 Rate Setting Region 3 Rest of State Rent $13,872 annually Food $5,000 annually Utilities $ 3,000 annually Annual Total $21,872 Monthly Max $1,823 v) Individual Directed Goods and Services (IDGS) IDGS are services, equipment or supplies not otherwise provided through OPWDD s HCBS waiver or through the Medicaid State Plan that addresses an identified need in a participant s service plan, which includes improving and maintaining the participant s opportunities for full membership in the community. Participants who choose to self direct their services may receive IDGS as a waiver service. Participants may manage their IDGS budget, as described in their individualized service plan, to fully purchase or put funds towards their personal fiscal resources to purchase items or services which meet the following criteria: 1) Are related to a need or goal identified in the person centered care plan/individualized Service Plan; 2) Are for the purpose of increasing independence or substituting for human assistance, to the extent the expenditures would otherwise be made for that human assistance; 3) Promote opportunities for community living and inclusion; 4) Are able to be accommodated without compromising the participant s health or safety; and, 5) Are provided to, or directed exclusively toward, the benefit of the participant. Total IDGS expenditure is limited to $32,000 annually or the person s PRA. Further detail is included in Appendix One. vi) Other Than Personal Services (OTPS) Individuals that are self directing services with budget authority may elect to use up to $3,000 in 100% state funding. This budget category is called, Other Than Personal Service or OTPS and is used to fund items that are not Medicaid fundable. Other generic and community resources should be explored and exhausted prior to utilizing state OTPS funds for the purchase of such items. For example, cell phones are often made available to people who have Social Security eligibility. The following supports may be included in the OTPS section of the budget includes, but are not limited to: 4 Self Direction Guidance September 1, 2014

33 phone service cell and/or land line staff activity fees to cover meals, admissions, fees, transportation or other costs incurred by staff when providing support to the self directing individual in activities in support of a valued outcome staff recruitment costs software related to the individual s disability Cost associated with staff time for planning or training meetings where such costs exceed the hourly limits of the service. OTPS cannot be used to pay for certain excluded items. Examples of excluded items include, but are not limited to: medical visit co pays, any expenses related to hospitalization or nursing home stays (including staff or respite supports or family expenses), expenses related to or to support the purchase of Medicaid services, such as therapies or other waiver services, any illegal item or activity, and Any expenses otherwise prohibited in a SD Plan for services and budget. Therapies that are experimental in nature are not appropriate for purchase using OTPS funds. Repairs, like a broken step or railing, may not be included since they should be covered under the lease or are the responsibility of the home owner. OTPS cannot be used to be applied against housing costs in excess of housing subsidies. If a person s rent is in excess of allowable housing subsidies, this will have to be reimbursed with the person s or family s own resources. OTPS & Continuity of Care For plans in existence prior to 10/1/2014, OTPS may be used for clinical consulting and additional living expenses not covered by a lease. This is on a time limited basis and OTPS cannot be used for those purposes any plan implemented after October 1, Continuity of care will not apply to experimental treatments or non evidenced practices or for direct provision of clinical services. Additional Information regarding continuity of care is in section 2 f. 2) Self Direction Policy Guidance a) Guidance on Budget Template On August 22, 2014 a new Self Direction Template was shared with SD Liaisons to share with Brokers and other stakeholders. This template will be the final template for purposes of the conversion and will need to be used to identify the plans being transitioned from CSS. This version replaces all prior budget templates that have been issued to date. Please use this template for all budgets submitted to Central Office. This is the only budget template that will be accepted for processing. 5 Self Direction Guidance September 1, 2014

34 Because we recognize that some plans were already completed using prior template versions that will now need to be changed, we will allow broker payment up to 8 hours for the plan conversion activities without any prior authorization. Requests for broker hours above 8 hours will need to be approved through the DDRO and will need clear justification for the extended work tasks. Individual s services should in no way be affected by the required conversions. The cost of the conversions should be displayed on the provided price sheet and will be paid outside of the individual s budget. If a person has unused broker hours that could more readily be applied to the conversion and which will not impact their ongoing plans of support or negatively impact their budget those hours may be used. b) Self Directed Fringe Benefit Budgeting and Billing This section provides guidance on claiming self hired services to Medicaid. Topics discussed include: (a) distinctions between work hours and billable hours and wage rates and reimbursement rates, (b) types of self hired staff, (c) accounting for indirect costs associated with self hired employees, and (d) issues related to the self processing logic in Medicaid for selfhired services. 1) Terms. Understanding the distinctions between these terms is essential to ensure correct budgeting and claiming for self hired services. a) Work Hours: The actual hours worked by the employee. Per federal and state labor law, employees must be paid for all hours they are "suffered or permitted to work." b) Wage Rate: The standard rate of pay per hour worked as negotiated by individual/ family and the self hired employee. Nonstandard wage rates may apply in special circumstances (e.g., "overtime" pay). c) Billable Hours: The subset of work hours spent by the employee on billable service activities, as described and defined in OPWDD regulation and administrative memoranda. d) Indirect Employment Cost: Indirect employment costs are expenses of employment other than wage costs, including the employer paid portions of employee benefits, payroll taxes, etc. e) Total Employment Cost: Employee wages for hours worked plus indirect expenses related to the employment of the self hired worker. f) Effective Reimbursement Rate: Total employment costs for the service period claimed divided by the billable service hours delivered and documented during the same service period. 6 Self Direction Guidance September 1, 2014

35 2) Types of Self Hired Staff. a) Contractors. Staff members who perform services at a negotiated payment per hour of service rendered as outlined in a formal service contract. Self hired contractors may be self employed (i.e., an "independent contractor") or may be the formal employees of a staffing agency. In either case, the legal relationship between the individual and the self hired contractor is "purchaser contractor," not "employer employee." The negotiated service rate is considered "paymentin full" for services rendered and there are no indirect costs to be reimbursed. At present, there are significant impediments that prevent most direct care workers from delivering services as contracted staff. OPWDD is studying ways to remove these impediments. Nevertheless, there may be instances where this option can be used to hire staff that perform community habilitation, respite, and supported employment services. b) Employees. Self hired staff may also be hired as employees. The individual and the fiscal intermediary (FI) share responsibilities as "co employer" of self hired employees. FI's should permit the self hiring individual broad leeway to negotiate the wage rates of self hired staff, subject to the reimbursement restrictions described below. But because the FI is the legal "employer of record," benefit packages and other terms of employment typically must follow the FI's policies and may not be negotiated by the individual. Nearly all true employees drive indirect costs in addition to their wage payments. These indirect costs, in addition to the direct wage costs, must be appropriately accounted and billed to Medicaid. 3) Accounting Indirect Employment Costs. In addition to wage expenses, there are "indirect" costs associated with self hired employees. Indirect costs include mandated expenses such as the employer portion of payroll taxes, costs associated with workers compensation and unemployment insurance, and the employer's cost of providing health insurance to full time employees. FI agencies often elect to provide additional employee benefits including life insurance, pension/retirement plan, and paid time off. Indirect employment costs are part of the total cost of delivering a service and must be properly charged on the service claim in order to be reimbursed by Medicaid. There are two basic methods for calculating and charging indirect employment costs to Medicaid: a) Direct accounting method. The FI may elect to record and charge indirect employment costs in the precise month in which they are incurred for the specific self hired employees of each self directed plan. This method is most feasible when the employee benefit package is sparse and the FI submits reimbursement claims on a monthly billing cycle. 7 Self Direction Guidance September 1, 2014

36 b) Fringe rate method. As an alternative, the FI may create a separate pooled account to cover indirect employment expenses across all of the self direction plans it administers. Such pooled account/fund should be funded by fixed percentage surcharges on the wages of self hired employees, so that each payment of employee wages yields a corresponding and proportionate payment into the FI's pooled fringe account. FIs have freedom to establish and administer their own fringe benefits programs and it is expected that these programs may differ substantially from FI to FI. However, the following principles should be adhered to: i) Uniformity. The fringe program administered by the FI should be uniform across all self direction plans participating within it. At their option, FIs may offer single or multiple fringe packages. When multiple packages are offered, the FI may charge differing fringe assessment rates reflecting the cost differences among the various packages offered. All benefits packages must be potentially available to all self direction plans administered by the FI and the assessment rate charged for each benefit package offered should be the same for all participants. ii) Disclosure. The individual should understand what he/she is "buying" for employees through the fringe assessment. The FI should provide individuals with a clear, concise, and complete outline of all indirect employment costs and employee benefits funded under each fringe package(s) offered and the assessment rate associated with each package. iii) Impact on permissible wage ranges. The impact of fringe assessment rates on the permissible wage rates that may be negotiated with self hired employees should be explained to individuals and their brokers. iv) Advance notice of benefit package and fringe assessment rate changes. FI agencies shall give individuals with self hired employees at least two months prior notice before adjusting benefit packages and/or fringe assessment rates. The implications of an assessment rate change on the approved budget plan should be reviewed with the individual. Assessment rates shall not be adjusted retroactively. v) No administration charge. Costs associated with the FI's administration of the fringe benefits pool are included in the FI's monthly fee for FI services. Fringe assessment rates shall not include any component reimbursing the FI for its administrative cost and effort in managing the fringe pool account. vi) Management fringe account balances. The FI is responsible for setting assessment rates that fully fund all fringe program obligations and permit timely payment of such obligations. (1) Separate Account. A separate, dedicated account or fund must be established for the self hired fringe program. Once assessed and transferred, funds in the pooled fringe account may only be used to 8 Self Direction Guidance September 1, 2014

37 cover indirect employment outlined in the description provided to participating individuals. (2) Surpluses. Surplus funds in the fringe account should not be transferred or skimmed to cover other costs, losses, or obligations of the FI agency. When account balances become excessive, surplus funds should be used to reduce the fringe assessment percentage. (3) Deficits. If the fringe account is temporarily in deficit, the FI will be expected to honor any financial obligations on behalf of participating plans using its own operational funds until such time it implements an increase in fringe assessment rate. (4) Monitoring by OPWDD. OPWDD may develop procedures and protocol to monitor pooled fringe accounts for compliance with the above principles. This may include new reporting requirements within Consolidated Fiscal Reporting (CFR) process and new auditing protocols. 4) Preparing Claims to Medicaid for Self Hired Services. Self hired services billed to Medicaid will be processed using special logic. Ordinarily, the charge amount submitted by providers is ignored by emedny when paying HCBS waiver services. Instead, emedny itself calculates the amount due to the provider by multiplying the submitted units times the official rate on file for the provider for the rate code billed. Under self direction, however, when they successfully make arrangements to reduce the total cost of community habilitation, respite, or supported employment services through the use of self hired staff, individuals free up PRA resources that can be used to fund additional or different services. Because of this, emedny must be able to pay claims for self hired services at reimbursement rates that are at or below, but not above, the official rate for the equivalent agencydirected service. This has the following implications for claims submission and adjudication: a) Service Unit Claiming. Just as with equivalent agency directed services, FI agencies will submit the total billable service units provided on each date services were rendered. If multiple self hired employees rendered services to the individual on a service date, the sum of billable service units delivered by all staff should be entered for that date. It is important to note that wage hours and billable time may differ. FI agencies must ensure only billable time, as described in OPWDD regulations and administrative memoranda, is entered on the claim form. b) Amount Charged. The total employment cost paid out by the FI for self hired services rendered to the individual on the service date should be entered into the amount charged field on the claim. Total employment cost includes both the wage payment to the employee plus indirect costs paid out (typically, the 9 Self Direction Guidance September 1, 2014

38 fringe assessment taken as percentage of wages and transferred the FI's pooled account for that purpose). If multiple self hired staff rendered services to the individual on the service date, the sum of total employment cost for all employees should be entered. For any contracted self hired staff, the amount charged should be equivalent to the contractor's service rate multiplied by the service hours rendered. There should be no indirect costs for self hired staff who work as contractors. c) Multi day versus Single day Claiming. The emedny system permits providers to submit claims covering multiple dates of service in a single claim transaction. For a variety of reasons, OPWDD recommends against such bundling for most HCBS services. For self hired services, however, this bundling technique may be advantageous. The effective reimbursement rate, which is later compared to the fee for the equivalent agency directed service (see below), is calculated at the claim document level. This means emedny will calculate the effective reimbursement rate as an average over multiple service dates. In situations where an individual's effective reimbursement rate is occasionally over the agency directed rate on some days but under on other days, FI agencies will want to submit multi day claims. Claims for OPWDD service may not span calendar months, however. All such "averaging," therefore, must take place within the course of a single calendar month. d) Reimbursement Rate Cap Logic. The State may not pay self directed services at reimbursement rates that exceed the rate paid for equivalent agencydirected services. Payment processing logic enforces this rule as follows: i) Medicaid calculates the effective reimbursement rate claimed for the selfdirected services submitted on the claim, total charges / total service units. ii) Medicaid retrieves the fee rate for the equivalent agency directed service. iii) If the effective reimbursement rate on the claim for self directed services is less than or equal to the equivalent agency directed fee rate, emedny pays the precise amount charged by the FI agency. iv) If the effective reimbursement rate on the claim for self directed services is greater than the equivalent agency directed fee rate, emedny pays the submitted units times the equivalent agency directed fee rate. C) Guidance on Overnight supports People may need supports during the overnight hours when they spend some or most of the time sleeping. These supports could include monitoring for events that will require hands on assistance or ongoing activities that are needed for the person s safety or to learn skills. As plans are converted from the CSS service they should be reviewed to determine the appropriate approach to night time supports if they are needed for the person. It is always helpful to review the supports that have been used to determine if they are still needed upon the conversion. 10 Self Direction Guidance September 1, 2014

39 Perhaps the person has demonstrated independent living skills and does not need the continued level of night time support. If night time supports continue to be needed the following areas should be considered for appropriate plan and budget development. Paid Neighbor funded via IDGS: A paid neighbor may be able to be available to the person so that if they have a need that person can respond and provide the appropriate support. A paid neighbor provides as needed support. See the IDGS chart for paid neighbor specifics. Personal Care funded via State Plan Medicaid: If the need for support relates to the provision of personal care it may be appropriate to obtain supports from a personal care assistant through a community based program where those supports are delivered. Community Habilitation: Community Habilitation (CH) requires that a face to face service be delivered during the course of the continuous time period where the service is provided. A review of the hours that the CH staff person works recognizing the need for a service should be part of the service planning. Respite: If an individual lives in a setting with an unpaid support giver respite may be an appropriate option for overnight supports. D) Guidance on Inclusive Community Settings in IDGS Self Directed supports offer great opportunity for people with developmental disabilities to purchase community based classes that result in active engagement and participation in typical community settings. This guidance is meant to define the elements of a setting or a class that are consistent with an inclusive definition. The setting and class is open to broad members of the community. The setting is not a certified OPWDD setting. The class is not taught by a paid employee of an OPWDD operated or funded provider. The setting results in typical interactions with other participants who do not have an intellectual or developmental disability. It is appropriate for participation in specialized classes that take special needs, such as physical limitations or beginner level learning; into consideration as long as those special classes are open to the broader public. E) Self Directed Employment Supports This document is meant to define how employment supports can be purchased by an individual who is self directing their plan of support. Employment supports include both the direct and indirect activities associated with helping a person get a job and helping them gain skills and then retain the job. 11 Self Direction Guidance September 1, 2014

40 Purchase of Agency Provided SEMP: If an individual chooses to purchase all or some of an agency provided SEMP service the cost of those services are included in the Self Direction Budget Template and count against the PRA. Use of Self Hired staff to provide employment supports: A person can use self hired staff to provide both job development and job coaching with a self directed plan. The duties of the job developer and job coach are contained within the service description for Supported Employment. CMS is very clear that within self direction, a person can hire their own staff to deliver Supported Employment but the payment cannot exceed the rate a provider would be paid for the service. Hence: A person can have an independent job developer; they cannot be paid more than the provider rate that would be paid to a Supported Employment provider agency. A traditional SEMP provider is not required, A person can have an independent job developer but they cannot be paid more than the provider rate that would be paid to a Supported Employment provider agency. A traditional SEMP provider is not required. If a Job Developer is a licensed clinician and is providing a clinical consultation service (i.e., the job developer is evaluating an individual s habilitation plan, training self hired staff & evaluation of the effectiveness of the self hired staff in carrying out the services) then it could be an IDGS funded consultantship. The hourly limit for self directed SEMP is under review, and may go up somewhat. Currently the proxy rate that will be utilized as plans are converted is the Regional Community Habilitation (CH) rate. F) Template The total budget of the self hired employment supports should be reflected in the SD template. The costs associated with the budgeted resource can be identified using the supplemental worksheet. While this worksheet is not programmed to load the information into the template it is a tool for brokers to use to identify the component parts of the person s employment supports. G) Policy on Funding Clinical Services in Self Direction There are two ways that clinicians support can be funded in self directed plan using IDGS: 1. Clinical Consultation may be purchased and, 2. certain therapies may be purchased. 12 Self Direction Guidance September 1, 2014

41 1) Clinical Consultation may be funded through Individual Directed Goods and Services (IDGS). This is an indirect service not available through the state plan and allows a clinician to assist the person s self directed planning and service delivery in the following ways: Evaluate an individual s habilitation plan Train self hired staff in delivering the self directed plan Evaluation of the effectiveness of the self hired staff in carrying out the services in the self directed plan The clinician must meet the following requirements: The Consultant/contractor must be a member of a discipline authorized under Article 16 clinic regulations (Psychology, OT, PT, SLP, social work, nursing, nutrition/ dietetics, rehabilitation counseling ) Consultants/contractors services cannot replicate any service available through a thirdparty insurer, the Medicaid State Plan or the HCBS Waiver Service. Consultants must provide a written outline of services to be delivered prior to approval; consultants must provide an annual update of progress/provision of service and need to continue. 2) Therapies In IDGS the following categories of therapy may be funded: Hippo therapy, Aquatic Therapy, Art Therapy, Massage Therapy, Music Therapy, and Play Therapy. The therapist must be a professional identified in the NYSED Office of the Professions website ( Therapeutic riding must be provided by a currently certified PATH instructor. The hourly payment limit effective 10/1/14 is based on the Bureau of Labor Statistics data for the 90 th percentile hourly wage (see attached chart). 3) Purchase of Direct Service provision (Clinical) is not allowed Self directed funds (IDGS) cannot be used to purchase a service that is available under the state plan. For information regarding continuity of care provisions, see below section. For additional information on IDGS see Appendix One. H) Guidance on Continuity of Care Provisions OPWDD recognizes that continuity of effective supports is critical to the well being and the quality of life experienced by people who are receiving supports and services. During the transition from the CSS service to a new methodology for self direction OPWDD will work with individuals, brokers and service coordinators to ensure that the effective supports in place, which are consistent with the defined rules for self directed supports, continue for the person. i) General Continuity of Care Provisions In order to ensure continuity the following guidelines should be followed: For plans that are converting from CSS to the new methodology PRA levels can be exceeded to meet the person s needs with state paid resources. In some 13 Self Direction Guidance September 1, 2014

42 instances the new PRA levels are not able to accommodate the service budgets that are currently within the PRA; this option for state fund payment will address the over PRA issue in those instances. The state paid option for over PRA is only available to the people who are transitioning from the CSS model and is temporary. OPWDD has not established a firm end date for state funding of costs over PRA. Plans that include supports that are not allowed within the new methodology such as experimental therapy and direct provision of clinical supports that are available in the state plan will not be covered with state funding and must be removed from the plan and transitioned to state plan supports. Supports for Community Habilitation, Supported Employment and Respite must utilize the defined methodology and support must be provided within the defined costs of those services. State funds are not to be used to augment the rate paid for the self hired staff costs of those services. See detailed guidance for Employment supports. ii) Continuity of Care provisions for Clinician and Certain Therapy Services effective 10/1/14 (Note: These are continuity of care provisions only. New self direction plans must fully comport with the IGDS requirements; 100% state funding through OPTS (or any other source) is not available to substitute for or supplement IGDS funding in the case of new self direction plans.) (1) Clinical Consultation To ensure continuity of care, an individual self directing their services may augment the hourly rate paid to a consulting clinician with 100% state funds. This is allowed when the individual s CSS budget prior to 10/1/14 included the consulting clinician s services, and the hourly rate paid to the consulting clinician exceeds the hourly rate paid through IDGS. OPWDD will evaluate the timeframe that this continuity of care provision will be allowed. (2) Clinician Direct Service provision No use of state funds is allowed. (3) Therapies To ensure continuity of care, an individual self directing their services may augment with 100% state funds the hourly rate paid for Hippo therapy, Therapeutic Riding, Aquatic Therapy, Art Therapy, Massage Therapy, Music Therapy, and Play Therapy. This is allowed when the individual s CSS budget prior to 10/1/14 included the therapy, and the hourly rate paid to the consulting clinician exceeds the hourly rate paid through IDGS. OPWDD will evaluate the timeframe that this continuity of care provision will be allowed. iii) Continuity of Care and Vehicle Lease Guidance: Vehicle leases will only be allowed in a Self Directed plan for those with current leases or those who submitted final plans for approval prior to June 1, The leases will only be funded for the life of the lease. No new plans with leased vehicles will be approved in the new Self Direction model. 14 Self Direction Guidance September 1, 2014

43 Impact on Individual Budget/PRA: The cost of the lease will be subtracted from the total budget of the person and identified for payment with state funds. The remaining budget balance is available to the person to use for self directed supports. If the budget is under the PRA no additional approvals are needed and the plan can be submitted. If the remaining budget is over the PRA, augmentation to the plan with state funds can only be approved if the justification is related to health and safety. (This is the case for all plans that are over PRA) If the subtraction of the vehicle costs results in additional room within the PRA, the person can only access additional funding for health and safety reasons. It is expected that the plan will be cost neutral with the exception of health and safety needs. 15 Self Direction Guidance September 1, 2014

44 TABLE 1: Allowable IDGS Expenses Individual Directed Goods and Services (IDGS) Category Available To Individuals in Certified Residences? Description Qualifications Pricing Parameters Camp No Funding may be requested for the cost of summer camp in a self directed plan for a camp that is able to provide the needed safeguarding supports and supports to achieve the person s valued outcomes. Camps can be either focused on supporting individuals with disabilities or camps that are available to the general public. Directly related to a valued outcome. For a children s camp, a state, city, or county health department permit to operate legally and must operate in compliance with Subpart 7 2 of the State Sanitary Code requirements. A permit is issued only when the camp is in compliance with the state's health regulations. Not to exceed published fees Annual cap $4000/year. Community Classes & Publicly Available Training/Coach ing Yes Classes available to the general public in any subject area that relates to a person s valued outcomes (Art, Dance, Exercise, Cooking, Computer Training, Etc.) Sessions with a private trainer (physical education/exercise) may be covered as long as the service relates to a valued outcome). Classes must be related to a habilitative need in the individual s person centered plan and not just for recreational purposes. N/A Not to exceed the published fees as outlined in the entity s published course fees. 16 Self Direction Guidance September 1, 2014

45 TABLE 1: Allowable IDGS Expenses Individual Directed Goods and Services (IDGS) Category Available To Individuals in Certified Residences? Description Qualifications Pricing Parameters Coaching/ education for parent(s), spouse and advocates involved in the person s selfdirected services No Classes must be non credit bearing; IDGS funding is for nonmatriculating students. IDGS funding is for Parent/Spouse/Advocate to attend/participate in educational opportunities (not covered by other public programs) that assist participants and those close to them to achieve goals established in the individual s service plan. Self directing individual is over age 18 (Under 18 is through FET). May Include registration, and conference fees. Annual cap $500/year based on Family Education & Training (FET) pricing parameters in 1915(c) HCBS waiver. Reimbursement is only up to FET reimbursement levels; overnight lodging or travel not allowable. Clinician Consultants, Independent Contractors (Non Direct Service Provision Clinical Consultation Yes, but only related to self directed services Consultants/contractors are clinical specialists who are hired for the following purpose: Evaluate an individual s habilitation plan Training self hired staff in delivering the self directed plan (NOTE: State Plan clinic services may not be used to train and consult with paid caregivers. To the extent that IDGS Consultation services are being used to train self hired staff, who might otherwise not have such resources available to them, it will not duplicate State Plan services) Evaluation of the effectiveness of the self hired staff in A consultant/ contractor who is a member of a profession that is under the jurisdiction of the NYSED Office of the Professions, must meet all licensure or registration requirements as verified at the following site:: The hourly amount paid to the therapist cannot exceed the 90th percentile for the hourly wage for the therapeutic or consultant s professional discipline (i.e., the standard occupational code) published by the Bureau of Labor Statistics (BLS) 17 Self Direction Guidance September 1, 2014

46 TABLE 1: Allowable IDGS Expenses Individual Directed Goods and Services (IDGS) Category Available To Individuals in Certified Residences? Description Qualifications Pricing Parameters Specialties ) carrying out the services in the self directed plan Consultants/contractors services cannot replicate any service available through a third party insurer, the Medicaid State Plan or the HCBS Waiver Service. Consultants must provide a written outline of services to be delivered prior to approval; consultants must provide an annual update of progress/provision of service and need to continue. v/opsearches.htm Discipline authorized under Article 16 clinic regulations (Psychology, OT, PT, SLP, social work, nursing, nutrition/ dietetics, rehabilitation counseling) and is identified in the table below Clinician (Direct Provision of Therapies/ Therapeutic Activities Not Otherwise Funded in the State Plan) Yes Hippo Therapy: A treatment strategy by physical therapists, occupational therapists, and speech language pathologists that is incorporated into the professional s plan of care to achieve functional outcomes. Hippo therapy is a medical treatment, not a recreational program of teaching a progressive riding and horsemanship skill. Funding may be requested for hippo therapy in a selfdirected plan by Individuals with cerebral palsy and other neurological disorders that permanently affect body movement and muscle coordination. Funding may be requested for hippo therapy in a self Hippo Therapy An individual providing hippo therapy must be a NYS licensed Occupational, Physical or Speech Therapist; if he/she is an Assistant in one of those categories (OTA, PTA) then he/she must be working under an OT or PT. Therapeutic Riding & The hourly amount paid to the therapist cannot exceed the 90th percentile for the hourly wage for the therapeutic or consultant s professional discipline (i.e., the standard occupational code) published by the Bureau of Labor Statistics (BLS) and is identified in the table below. 18 Self Direction Guidance September 1, 2014

47 directed plan by Individuals with cerebral palsy and other neurological disorders that permanently affect body movement and muscle coordination. Therapeutic Riding & Equine assisted Activities Therapeutic Riding and equine assisted activities address and contribute positively to the cognitive, physical, emotional and social well being of individuals with special needs. Therapeutic riding and equine assisted activities are taught by a PATH International Instructor to individuals five (5) years old and older. The PATH instructor will provide written policies on the eligibility and discharge of individual, written documentation of the initial evaluation of the individual and written progress notes for the individual. The initial evaluation of abilities establishes the appropriate goals and objectives for the individual and the progress notes document the achievements and problem areas. The discharge should be supported by appropriate documentation that shows a baseline for goals and objectives and a recommended course of action when continued participation is no longer appropriate. Instructors communicate with the individual/parents/guardians at the start and at the end of the session (6 8 weeks) to discuss the goals, objectives, accomplishments and the next steps, and best practice includes mid session meetings and informal discussions each time the individual rode. Equine Assisted Activities PATH International Instructor must carry a certification business card with an annual expiration date, and must requalify each year to be certified Aquatic, Art, Massage, Music, Play Therapy: A consultant/ contractor who is a member of a profession that is under the jurisdiction of the NYSED Office of the Professions, must meet all licensure or registration requirements as verified at the following site: v/opsearches.htm Aquatic, Art, Massage, Music, Play Therapy: Funding for massage therapy may be included in a selfdirected plan when the service has been prescribed by the 19 Self Direction Guidance September 1, 2014

48 individual s medical doctor to ameliorate a specific medical diagnosis/condition for which massage therapy has recognized efficacy. Funding is not available to support vague goals such as "promote well being," "reduce stress, or promote relaxation." There must be a corresponding valued outcome in the individual's plan. Funding for music therapy may be included in a selfdirected plan only if there is a specific communication or audiological requirement for the service as stated in the plan and justified by the individual s medical doctor or licensed clinician, and a corresponding valued outcome. All Services Ordering, Treatment Plan & Documentation Requirements The request for funding must be accompanied by a written prescription from the individual s medical doctor with a goal of treating a specific medical diagnosis/ condition and shall support a specific valued outcome. The therapist shall conduct an initial assessment, report findings, and propose a treatment plan. The treatment plan shall outline treatment goals, proposed therapeutic activities, and their anticipated frequency and duration. The treatment plan shall acknowledge the individual's personal goals and support a specific valued outcome(s) described in the ISP. The treatment plan becomes active upon the referring/prescribing medical doctor's review and written approval. On going treatment services shall be delivered only in accordance with the approved treatment plan. Each session shall be documented with a brief treatment note outlining the therapeutic services/activities performed, duration, and response to treatment. The therapist shall provide periodic (at least semi annual) 20 Self Direction Guidance September 1, 2014

49 progress reports to the referring/ prescribing medical doctor. Such report shall review the individual's progress toward goals and the efficacy of services to date; it shall propose any necessary updates/ revisions to the treatment plan. The medical doctor shall review the individual's progress and, if warranted, approve the updated treatment plan and continuation of services in writing. Health Club/ Organizational Memberships/ Community Participation Yes Health club memberships; Community membership dues Funding for a gym, health club or other community organization membership may be included in the selfdirected plan for reasons of health and fitness or community integration in accordance with the participant s valued outcomes. Membership is for individual only; no family memberships allowed with IDGS funding. The club/organization must offer open enrollment to the public, and cannot be a private club with a closed membership where membership is available by invitation only. An individual may have multiple memberships to health clubs. Payment not to exceed the entity s published membership dues/fees specified. Annual cap $1500/year. Household Related Items and Services No Item cannot be funded through any other funded program and may include Appliances that assist a person to live more independently (i.e., a microwave oven for someone who cannot safely use a stove or oven) Appliance must benefit the individual and be related to a valued outcome as well as be related to health and safety. Household support (cleaning, minor maintenance, snow removal, lawn mowing) only for individuals not living in the N/A Annual cap $1500/year. 21 Self Direction Guidance September 1, 2014

50 family home. Note: The Community Transition Services (CTS) waiver service and funding cap remains separate from IDGS funding in this category. Paid Neighbor No Stipend paid to neighbor to be on call to assist a person who lives independently. If the paid neighbor is called upon to provide direct services, he/she is paid an hourly wage for the delivery of self hired community habilitation. The specific duties are defined in a contract signed by the paid neighbor and the Fiscal Intermediary. Self Directed Staffing Support Transition Programs for Individuals with IDD Yes, but only related to selfdirected services No Assistance with scheduling self hired staff and with assisting the person to complete staffing related paperwork. Not to duplicate FI employer responsibilities or Broker services related to development of the person s self directed plan. The self hired staff person providing this support is not a staff person of a NFP agency and is not a person who is active in assisting the person with decision making regarding his/her self directed services (not a family member or a member of the person s freely chosen planning team). Tuition for non credit bearing transition programs for individuals with IDD who have already completed their educational program (i.e. aged out ). The coursework must address a person s valued outcomes and address skill building and employment outcomes. Programs may be provided in non site based settings, on college campuses, but not in locations certified by OPWDD. Coursework may include training on personal care skills, and socialization skills, but this training is provided to support vocational outcomes for the person. 22 Self Direction Guidance September 1, 2014 The paid neighbor staff person cannot be a family member of the person. Must meet all requirements for background check, and training that would be required of a self hired staff person. All staff, volunteers and trainers are screened for criminal background and excluded provider status All staff, volunteers and trainers are screened for criminal background and excluded provider status Monthly cap $800 Not to exceed payment of $20/hour Published fees cannot be exceeded. Per class limit for tuition is $350/course. Where tuition is on a monthly basis, not to exceed $800/month

51 To be funded via a person s self direction budget, the program cannot be funded by ACCESS VR, IDEA or other funding sources. Services are time limited and cannot exceed a two year timeframe. No room and board costs are fundable. Transportation Yes, only related to selfdirected services Funding may be requested for the cost of service related transportation that is directly related to valued outcomes, safeguards and services identified and approved in the selfdirected plan. In order to make the determination whether transportation is service related, and costs may be reimbursed, the questions to be answered are: 1. What valued outcome/safeguard is this activity in support of? 2. What service was this transportation related to? 3. What service was actually provided? 4. Who provided the service? Transportation costs are not reimbursed through the selfdirected plan for transportation to and from OPWDD funded services for which transportation costs are included in the price developed and paid for the service. Mileage may not be reimbursed for medical appointments as this duplicates a State Plan service. Transportation reimbursement takes several forms: 1. Reimbursement for service related miles may be made to: a. Staff person who drove his/her personal vehicle to a service related activity, b. Participant who drove or was driven in his/her personal vehicle to a service related activity, or c. Friend or family member who drove his/her personal vehicle to a service related activity. Service related mileage may be paid from IDGS for Vehicle must be operated by a licensed driver. Mileage reimbursement not to exceed standard federal mileage rate: Standard Mileage Ratesfor Business, Medicaland Moving Announced Reimbursement of public transportation and paratransport limited to published rates. Discounts for disabled individuals shall be requested, where available. Vendor transportation limited to published fees. 23 Self Direction Guidance September 1, 2014

52 transportation costs required for the individual to access a generic service in the community that is Medicaid reimbursable within the self directed plan (directly related to a valued outcome or safeguard) regardless of whether or not there is a paid staff person present. Mileage reimbursement covers all operating costs related to the vehicle and included in the IRS standard mileage rate standards, i.e., gas, registration, vehicle inspection, insurance, repairs & maintenance. Reimbursement for the cost of public transportation or paratransit, such as bus passes, bus, taxi and train fares that is directly related to valued outcomes, safeguards and services identified and approved in the self directed plan. TABLE 2: The Following items cannot be funded through IDGS Academic Tutoring Automatic pill dispenser/ medication system Cell Phones/Telephones Computer Hardware Academic tutoring is not funded through the IDGS. This service should be pursued through the school district or college setting. Academic tutoring/homework assistance is not an appropriate task for self hired staff. Available through Assistive Technology, outside the person s self directed budget Funding for cell phones is not an allowable IDGS expense. The SafeLink Wireless program is available to eligible individuals in New York State who receive Supplemental Security Income (SSI). The SafeLink service in New York State allows for a cell phone and limited free minutes for a person who has a diagnosed developmental disability and receives social security benefits under SSI. Not allowable in IDGS 24 Self Direction Guidance September 1, 2014

53 Computer Programs/Software Computer Software is available through Assistive Technology, outside the person s self directed budget. Leased Vehicles Leased Vehicles are not an allowable expense under IDGS. Health Related Services, Equipment and Supplies Parents Activity Fees, Expenses, and Meals Participants Activity Fees, Expenses, and Meals Personal Monitoring Systems Staff Activity Fees, Expenses, and Meals Direct Clinician service delivery and Therapies: Physical Therapy, Occupational Therapy, Speech Therapy, Psychology (Medicaid state funded) Experimental Therapies Health related supplies such as food and beverage thickeners, trachea collars, disposable bed pads, wipes, incontinence products, and supplemental medications are funded through the State Plan only; not through IDGS funding. Activity fees, expenses, and meals incurred by parents of individuals are not reimbursed with IDGS funds and must be paid by the parents when they accompany an individual to an activity supported by the his/her self directed plan. Activity fees, expenses, and meals incurred by individuals are not reimbursed with IDGS funds and must be paid by the individual or his/her family. Available through State Plan Activity fees, expenses, and meals incurred by self hired staff supporting individuals are not reimbursed with IDGS funds, but may be funded through OTPS. On going therapies that are provided directly to the person are funded through the individual s State Plan Medicaid Card or, if the individual is school aged, through the local school district, and are not funded under IDGS. Experimental therapies are not reimbursable in any clinical category within IDGS and are not a permitted expense in the OTPS payment category. 25 Self Direction Guidance September 1, 2014

54 Table 3: Clinician & Therapy Payment Capitation Levels Area: New York Period: May 2013 Based on 90 th Percentile Wages from BLS July 31, 2014 Occupation (SOC code) Hourly 90th percentile wage Social Workers, All Other(211029) $ Dietitians and Nutritionists(291031) $ Occupational Therapists(291122) $ Physical Therapists(291123)**includes Equine, Aquatic Therapy $ Recreational Therapists(291125) $ Speech Language Pathologists(291127) $ Therapists All Other(291129) $ Registered Nurses(291141) $ Nurse Practitioners(291171) $ Hearing Aid Specialists(292092) $ Occupational Therapy Assistants(312011) $ Occupational Therapy Aides(312012) $ Physical Therapist Assistants(312021) $ Physical Therapist Aides(312022) $ Psychologists, All Other(193039) Footnotes: (1) Annual wages have been calculated by multiplying the hourly mean wage by 2080 hours; where an hourly mean wage is not published the annual wage has been directly calculated from the reported survey data. SOC code: Standard Occupational Classification code see Data extracted on July Self Direction Guidance September 1, 2014

55 [Insert Agency Name] [Insert Individual s Name] The Habilitation Plan with any addendums or revisions and services described remain in effect until a new Habilitation Plan is written. The following is an optional format for Habilitation Plans. Providers may, or may not, choose to use the outline as it appears here. The choice of whether or not to use the outline is an agency management decision that should be based on factors such as past success using their current plan format, review team comments about needed plan improvements and other pertinent factors. This is an optional Habilitation Plan format that may be followed by providers. The instructions under each header are provided for guidance and may be removed. Insert Agency Name Insert service(s) name(s)habilitation Plan Name of Person: Habilitation Plan Review Date: Medicaid Number (CIN#): Valued Outcome(s) The habilitation provider uses at least one of the valued outcomes stated in the Individualized Service Plan (ISP) as the starting point to develop the habilitation activities and periodic staff supports that will appear in the plan. The valued outcome does not need to be verbatim from the ISP. Example - Kevin likes to have contact with his brother and his family. Staff Services and Supports This section contains the services the individual needs to reach his or her valued outcome or those supports in which the individual has maximized his/her skills. Habilitation Activities The plan can, and often should, address priority needs that may not be directly correlated to one or more valued outcomes. A plan may contain valued outcomes or habilitation activities to support the valued outcomes or staff supports. For example, a person with a valued outcome to spend time with a special friend may have a plan that contains activities to learn how to use a telephone, how to travel safely in the community, etc. The same plan may have staff supports to ensure the person is dressed appropriately for the weather when he/she goes out with the friend. Example: Staff will teach Kevin to call his brother on the phone. Staff will teach Kevin to recognize the numbers: 0, 1, 2, 3, and 4 using verbal prompts, five days per week Periodic Staff Supports Habilitation Plan Format 3/7/2012 Page 1

56 [Insert Agency Name] [Insert Individual s Name] This section may contain the supports a person needs for which the individual has reached his or her maximum skill level or the staff supports continue to be needed by the person, but the supports have very little relationship to a valued outcome. For example, an adult may have maximized his/her tooth brushing skills. The person still needs reminders or some physical assistance by staff to adequately brush his or her teeth. Recording such staff supports in the plan gives a more accurate picture of the person s needs and also allows the agency staff to take full credit for all the work they perform to properly care for people. Safeguards This section is also known as Plan for Protective Oversight in Individual Residential Alternatives (IRAs) regulated under 14 NYCRR Part or Health and Welfare in other venues where waiver services are provided. As cited above, this section can list all the safeguard needs and the staff actions that will be taken or it can list the safeguard needs and refer the reader to other documents in the record that address each need. Required Signature: Habilitation plan author s Name: Title: Habilitation plan author s Signature: Date: Optional Signatures Person: Date: Advocate: Date: Supervisor/reviewer: Date: Habilitation Plan Format 3/7/2012 Page 2

57 INDIVIDUAL DIRECTED GOODS AND SERVICES (IDGS) DEFINITIONS ADDENDUM C Individual Directed Goods and Services (IDGS) Category Available To Individuals in Certified Residences? Description Qualifications Pricing Parameters Camp No Funding may be requested for the cost of summer camp in a self-directed plan for a camp that is able to provide the needed safeguarding supports and supports to achieve the person s valued outcomes. Camps can be either focused on supporting individuals with disabilities or camps that are available to the general public. Directly related to a valued outcome. For a children s camp, a state, city, or county health department permit to operate legally and must operate in compliance with Subpart 7-2 of the State Sanitary Code requirements. A permit is issued only when the camp is in compliance with the state's health regulations. Not to exceed published fees Annual cap $4000/year. Community Classes & Publicly Available Training/Coaching Yes Classes available to the general public in any subject area that relates to a person s valued outcomes (Art, Dance, Exercise, Cooking, Computer Training, Etc.) Sessions with a private trainer (physical education/exercise) may be covered as long as the service relates to a valued outcome). Classes must be related to a habilitative need in the individual s person-centered plan and not just for recreational purposes. Classes must be non-credit bearing; IDGS funding is for non-matriculating students. N/A Not to exceed the published fees as outlined in the entity s published course fees. Self-Directed Plan Guidance for Individual Directed Goods and Services 8/19/2014 1

58 INDIVIDUAL DIRECTED GOODS AND SERVICES (IDGS) DEFINITIONS ADDENDUM C Coaching/educati on for parent(s), spouse and advocates involved in the person s selfdirected services No IDGS funding is for Parent/Spouse/Advocate to attend/participate in educational opportunities (not covered by other public programs) that assist participants and those close to them to achieve goals established in the individual s service plan. Self-directing individual is over age 18 (Under 18 is through FET). May Include registration, and conference fees. Annual cap $500/year based on Family Education & Training (FET) pricing parameters in 1915(c) HCBS waiver. Reimbursement is only up to FET reimbursement levels; overnight lodging or travel not allowable. Clinician Consultants, Independent Contractors (Non-Direct Service Provision - - Clinical Consultation Specialties ) Yes, but only related to self-directed services Consultants/contractors are clinical specialists who are hired for the following purpose: Evaluate an individual s habilitation plan Training self-hired staff in delivering the self directed plan (NOTE: State Plan clinic services may not be used to train and consult with paid caregivers. To the extent that IDGS Consultation services are being used to train self-hired staff, who might otherwise not have such resources available to them, it will not duplicate State Plan services) Evaluation of the effectiveness of the self-hired staff in carrying out the services in the self-directed plan Consultants/contractors services cannot replicate any service available through a third-party insurer, the Medicaid State Plan or the HCBS Waiver Service. Consultants must provide a written outline of services to be delivered prior to approval; consultants must provide an annual update of progress/provision of service and need to continue. A consultant/ contractor who is a member of a profession that is under the jurisdiction of the NYSED Office of the Professions, must meet all licensure or registration requirements as verified at the following site:: gov/opsearches.htm Discipline authorized under Article 16 clinic regulations (Psychology, OT, PT, SLP, social work, nursing, nutrition/ dietetics, rehabilitation counseling) The hourly amount paid to the therapist cannot exceed the 90th percentile for the regional hourly wage for the therapeutic or consultant s professional discipline (i.e., the standard occupational code) published by the Bureau of Labor Statistics (BLS) that can be queried at the following website: Self-Directed Plan Guidance for Individual Directed Goods and Services 8/19/2014 2

59 INDIVIDUAL DIRECTED GOODS AND SERVICES (IDGS) DEFINITIONS ADDENDUM C Clinician (Direct- Provision of Therapies/ Therapeutic Activities Not Otherwise Funded in the State Plan) Yes Hippo Therapy: A treatment strategy by physical therapists, occupational therapists, and speech language pathologists that is incorporated into the professional s plan of care to achieve functional outcomes.. Hippo therapy is a medical treatment, not a recreational program of teaching a progressive riding and horsemanship skill. Funding may be requested for hippo therapy in a selfdirected plan by Individuals with cerebral palsy and other neurological disorders that permanently affect body movement and muscle coordination. Funding may be requested for hippo therapy in a selfdirected plan by Individuals with cerebral palsy and other neurological disorders that permanently affect body movement and muscle coordination. Therapeutic Riding & Equine-assisted Activities Therapeutic Riding and equine-assisted activities address and contribute positively to the cognitive, physical, emotional and social well-being of individuals with special needs. Therapeutic riding and equine-assisted activities are taught by a PATH International Instructor to individuals five (5) years old and older. The PATH instructor will provide written policies on the eligibility and discharge of individual, written documentation of the initial evaluation of the individual and written progress notes for the individual. The initial evaluation of abilities establishes the appropriate goals and objectives for the individual and the progress notes document the achievements and problem areas. The discharge should be supported by appropriate documentation that shows a baseline for goals and objectives and a recommended course of action when continued participation is no longer appropriate. Instructors communicate with the individual/parents/guardians at the start and at the end Hippo Therapy An individual providing hippo therapy must be a NYS licensed Occupational, Physical or Speech Therapist; if he/she is an Assistant in one of those categories (OTA, PTA) then he/she must be working under an OT or PT. Therapeutic Riding & Equine Assisted Activities PATH International Instructor must carry a certification business card with an annual expiration date, and must requalify each year to be certified Aquatic, Art, Massage, Music, Play Therapy: A consultant/ contractor who is a member of a profession that is under the jurisdiction of the NYSED Office of the Professions, must meet all licensure or registration requirements as verified at the following site: The hourly amount paid to the therapist cannot exceed the 90th percentile for the regional hourly wage for the therapeutic or consultant s professional discipline (i.e., the standard occupational code) published by the Bureau of Labor Statistics (BLS) that can be queried at the following website: Self-Directed Plan Guidance for Individual Directed Goods and Services 8/19/2014 3

60 INDIVIDUAL DIRECTED GOODS AND SERVICES (IDGS) DEFINITIONS ADDENDUM C of the session (6-8 weeks) to discuss the goals, objectives, accomplishments and the next steps, and best practice includes mid-session meetings and informal discussions each time the individual rode. gov/opsearches.htm Aquatic, Art, Massage, Music, Play Therapy: Funding for massage therapy may be included in a selfdirected plan when the service has been prescribed by the individual s medical doctor to ameliorate a specific medical diagnosis/condition for which massage therapy has recognized efficacy. Funding is not available to support vague goals such as "promote well-being," "reduce stress, or promote relaxation." There must be a corresponding valued outcome in the individual's plan. Funding for music therapy may be included in a selfdirected plan only if there is a specific communication or audiological requirement for the service as stated in the plan and justified by the individual s medical doctor or licensed clinician, and a corresponding valued outcome. All Services Ordering, Treatment Plan & Documentation Requirements The request for funding must be accompanied by a written prescription from the individual s medical doctor with a goal of treating a specific medical diagnosis/ condition and shall support a specific valued outcome. The therapist shall conduct an initial assessment, report findings, and propose a treatment plan. The treatment plan shall outline treatment goals, proposed therapeutic activities, and their anticipated frequency and duration. The treatment plan shall acknowledge the individual's personal goals and support a specific valued outcome(s) described in the ISP. The treatment plan becomes active upon the referring/prescribing medical doctor's review and written approval. Self-Directed Plan Guidance for Individual Directed Goods and Services 8/19/2014 4

61 INDIVIDUAL DIRECTED GOODS AND SERVICES (IDGS) DEFINITIONS ADDENDUM C On-going treatment services shall be delivered only in accordance with the approved treatment plan. Each session shall be documented with a brief treatment note outlining the therapeutic services/activities performed, duration, and response to treatment. The therapist shall provide periodic (at least semi-annual) progress reports to the referring/ prescribing medical doctor. Such report shall review the individual's progress toward goals and the efficacy of services to date; it shall propose any necessary updates/ revisions to the treatment plan. The medical doctor shall review the individual's progress and, if warranted, approve the updated treatment plan and continuation of services in writing. Health Club/ Organizational Memberships/ Community Participation Yes Health club memberships; Community membership dues -- Funding for a gym, health club or other community organization membership may be included in the selfdirected plan for reasons of health and fitness or community integration in accordance with the participant s valued outcomes. Membership is for individual only; no family memberships allowed with IDGS funding. The club/organization must offer open enrollment to the public, and cannot be a private club with a closed membership where membership is available by invitation only. An individual may have multiple memberships to health clubs. Payment not to exceed the entity s published membership dues/fees specified. Annual cap $1500/year. Household- Related Items and Services No Item cannot be funded through any other funded program and may include Appliances that assist a person to live more independently (i.e., a microwave oven for someone who cannot safely use a stove or oven) N/A Annual cap $1500/year. Self-Directed Plan Guidance for Individual Directed Goods and Services 8/19/2014 5

62 INDIVIDUAL DIRECTED GOODS AND SERVICES (IDGS) DEFINITIONS ADDENDUM C Appliance must benefit the individual and be related to a valued outcome as well as be related to health and safety. Household support (cleaning, minor maintenance, snow removal, lawn mowing) only for individuals not living in the family home. Note: The Community Transition Services (CTS) waiver service and funding cap remains separate from IDGS funding in this category. Paid Neighbor No Stipend paid to neighbor to be on-call to assist a person who lives independently. If the paid neighbor is called upon to provide direct services, he/she is paid an hourly wage for the delivery of self-hired community habilitation. The specific duties are defined in a contract signed by the paid neighbor and the Fiscal Intermediary. Self-Directed Staffing Support Yes, but only related to selfdirected services Assistance with scheduling self-hired staff and with assisting the person to complete staffing related paperwork. Not to duplicate FI employer responsibilities or Broker services related to development of the person s self directed plan. The self-hired staff person providing this support is not a staff person of a NFP agency and is not a person who is active in assisting the person with decision-making regarding his/her self directed services (not a familymember or a member of the person s freely chosen planning team). The paid neighbor staff person cannot be a family member of the person. Must meet all requirements for background check, and training that would be required of a self-hired staff person. All staff, volunteers and trainers are screened for criminal background and excluded provider status Monthly cap $800 Not to exceed payment of $20/hour Self-Directed Plan Guidance for Individual Directed Goods and Services 8/19/2014 6

63 INDIVIDUAL DIRECTED GOODS AND SERVICES (IDGS) DEFINITIONS ADDENDUM C Transition Programs for Individuals with IDD No Tuition for non-credit bearing transition programs for individuals with IDD who have already completed their educational program (i.e. aged out ). The coursework must address a person s valued outcomes and address skill building and employment outcomes. Programs may be provided in non-site based settings, on college campuses, but not in locations certified by OPWDD. Coursework may include training on personal care skills, and socialization skills, but this training is provided to support vocational outcomes for the person. To be funded via a person s self direction budget, the program cannot be funded by ACCESS-VR, IDEA or other funding sources. Services are time-limited and cannot exceed a two year timeframe. No room and board costs are fundable. All staff, volunteers and trainers are screened for criminal background and excluded provider status Published fees cannot be exceeded. Per class limit for tuition is $350/course. Where tuition is on a monthly basis, not to exceed $800/month Transportation Yes, only related to self-directed services Funding may be requested for the cost of service related transportation that is directly related to valued outcomes, safeguards and services identified and approved in the self-directed plan. In order to make the determination whether transportation is service related, and costs may be reimbursed, the questions to be answered are: 1. What valued outcome/safeguard is this activity in support of? 2. What service was this transportation related to? 3. What service was actually provided? 4. Who provided the service? Transportation costs are not reimbursed through the selfdirected plan for transportation to and from OPWDD funded services for which transportation costs are included in the price developed and paid for the service. Mileage may not be reimbursed for medical Vehicle must be operated by a licensed driver. Mileage reimbursement not to exceed standard federal mileage rate: Standard-Mileage-Rates- for-business,-medical-and- Moving-Announced Reimbursement of public transportation and paratransport limited to published rates. Discounts for disabled individuals shall be requested, where available. Vendor transportation limited to published fees. Self-Directed Plan Guidance for Individual Directed Goods and Services 8/19/2014 7

64 INDIVIDUAL DIRECTED GOODS AND SERVICES (IDGS) DEFINITIONS ADDENDUM C appointments as this duplicates a State Plan service. Transportation reimbursement takes several forms: 1. Reimbursement for service related miles may be made to: a. Staff person who drove his/her personal vehicle to a service related activity, b. Participant who drove or was driven in his/her personal vehicle to a service related activity, or c. Friend or family member who drove his/her personal vehicle to a service related activity. Service related mileage may be paid from IDGS for transportation costs required for the individual to access a generic service in the community that is Medicaid reimbursable within the self-directed plan (directly related to a valued outcome or safeguard) regardless of whether or not there is a paid staff person present. Mileage reimbursement covers all operating costs related to the vehicle and included in the IRS standard mileage rate standards, i.e., gas, registration, vehicle inspection, insurance, repairs & maintenance. Reimbursement for the cost of public transportation or paratransit, such as bus passes, bus, taxi and train fares that is directly related to valued outcomes, safeguards and services identified and approved in the self-directed plan. Service Categories Not Allowable Under IDGS: Academic Tutoring Automatic pill dispenser/ medication system Academic tutoring is not funded through the IDGS. This service should be pursued through the school district or college setting. Academic tutoring/homework assistance is not an appropriate task for self-hired staff. Available through Assistive Technology, outside the person s self-directed budget Self-Directed Plan Guidance for Individual Directed Goods and Services 8/19/2014 8

65 INDIVIDUAL DIRECTED GOODS AND SERVICES (IDGS) DEFINITIONS ADDENDUM C Cell Phones/Telephones Computer Hardware Funding for cell phones is not an allowable IDGS expense. The SafeLink Wireless program is available to eligible individuals in New York State who receive Supplemental Security Income (SSI). The SafeLink service in New York State allows allows for a cell phone and limited free minutes for a person who has a diagnosed developmental disability and receives social security benefits under SSI. Not allowable in IDGS Computer Programs/Software Computer Software is available through Assistive Technology, outside the person s self-directed budget. Leased Vehicles Health-Related Services, Equipment and Supplies Parents Activity Fees, Expenses, and Meals Participants Activity Fees, Expenses, and Meals Personal Monitoring Systems Staff Activity Fees, Expenses, and Meals Direct Clinician service delivery and Therapies: Physical Therapy, Occupational Therapy, Speech Therapy, Psychology (Medicaid state funded) Experimental Therapies Leased Vehicles are not an allowable expense under IDGS. Health related supplies such as food and beverage thickeners, trachea collars, disposable bed pads, wipes, incontinence products, and supplemental medications are funded through the State Plan only; not through IDGS funding. Activity fees, expenses, and meals incurred by parents of individuals are not reimbursed with IDGS funds and must be paid by the parents when they accompany an individual to an activity supported by the his/her self-directed plan. Activity fees, expenses, and meals incurred by individuals are not reimbursed with IDGS funds and must be paid by the individual or his/her family. Available through State Plan Activity fees, expenses, and meals incurred by self-hired staff supporting individuals are not reimbursed with IDGS funds, but may be funded through OTPS. On-going therapies that are provided directly to the person are funded through the individual s State Plan Medicaid Card or, if the individual is school-aged, through the local school district, and are not funded under IDGS. Experimental therapies are not reimburseable in any clinical category within IDGS and are not a permitted expense in the OTPS payment category. Self-Directed Plan Guidance for Individual Directed Goods and Services 8/19/2014 9

66 Last Name: 0 First Name: Self-Hired Supported Employment Staff Supports Works Position Title Total Annual Cost Hourly Wage Hours/ Week Weeks/ Year Annual Staff Hours Annual Billable 1/4 Hour Units Total Staff Salary Fringe Benefit 0 0 $ $ $ - $ $ 0.00%

67 0 Middle Initial: 0 sheet (SEMP) Total Staff Salary and Fringe Total Annual Staff Cost Unit Cost Hourly Unit Cost $0 $0 #DIV/0! #DIV/0! $0 $0 #DIV/0! #DIV/0! $0 $0 #DIV/0! #DIV/0! $0 $0 #DIV/0! #DIV/0!

68 Last Name: 0 First N Self-Hired Supported Employment Staff Support Position Title Hourly Wage Hours/ Week Weeks/ Year Annual Staff Hours Annual Billable 1/4 Hour Units Amounts for Self Determination Template #DIV/0! 0 #DIV/0! 0 0

69 Name: 0 Middle Initial: 0 ts Worksheet (SEMP) Total Staff Salary Fringe Benefit Total Staff Salary and Fringe Total Annual Staff Cost Unit Cost Hourly Unit Cost $ - $0 $0 #DIV/0! #DIV/0! $ - $0 $0 #DIV/0! #DIV/0! $ - $0 $0 #DIV/0! #DIV/0! $ - #DIV/0! $ - $0 #DIV/0! #DIV/0!

70

71 OPWDD FEES for VOLUNTARY PROVIDERS IN EFFECT HOURLY COMMUNITY HABILITATION EFFECTIVE OCTOBER 1, 2012 HOURLY COMMUNITY HABILITATION REIMBURSEMENT PER OPWDD INDIVIDUAL REGION SERVING 1 GROUP SERVING 2 GROUP SERVING 3 GROUP SERVING 4 1 $37.05 $23.16 $18.53 $ $38.39 $23.99 $19.20 $ $37.51 $23.44 $18.76 $16.41 HOURLY COMMUNITY HABILITATION CONVERTED TO QUARTER HOUR REIMBURSEMENT PER DEPARTMENT OF HEALTH INDIVIDUAL GROUP GROUP GROUP REGION SERVING 1 SERVING 2 SERVING 3 SERVING 4 1 $9.26 $5.79 $4.63 $ $9.60 $6.00 $4.80 $ $9.38 $5.86 $4.69 $4.10 INTENSIVE BEHAVIORAL FEES EFFECTIVE OCTOBER 1, 2013 PRODUCT FEE (ONE TIME ONLY) REGION FEE DDRO 1 WESTERN & FINGER LAKES $1, DDRO 2 CENTRAL,BROOME & SUNMOUNT $1, DDRO 3 CAPITAL DISTRICT $1, DDRO 3 HUDSON VALLEY & TACONIC $1, DDRO 4 METRO, BROOKLYN, STATEN ISLAND & FINESON $1, DDRO 5 LONG ISLAND $1, INTENSIVE BEHAVIORAL HOURLY FEE REGION 1/4 hr. billing unit DDRO 1 WESTERN & FINGER LAKES $16.25 DDRO 2 CENTRAL,BROOME & SUNMOUNT $16.25 DDRO 3 CAPITAL DISTRICT $16.25 DDRO 3 HUDSON VALLEY & TACONIC $17.50 DDRO 4 METRO, BROOKLYN, STATEN ISLAND & FINESON $18.75 DDRO 5 LONG ISLAND $17.50 page 1 of 2

72 OPWDD FEES for VOLUNTARY PROVIDERS IN EFFECT MSC FEES EFFECTIVE NOVEMBER 1, 2011 RATE CODE DEFINITION LOCATOR CODE 11/1/2011 FEES 5211 Regular - Basic 03 $ Regular - Willowbrook 03 $ Transition - Basic 04 $ Transition - Willowbrook 04 $1, Plan of Care Support Services (PCSS) Family Education and Training (FET) EFFECTIVE APRIL 1, 2010 SERVICE TYPE PCSS FEE $ FET Individual $ Group $55.84 SUPPORTED EMPLOYMENT FEES EFFECTIVE JULY 1, 2011 LEVEL OF SUPPORT NYC FEES REST OF THE STATE 1 $538 $386 2 $720 $515 3 $812 $581 page 2 of 2

73 ADMINISTRATIVE MEMORANDUM - # TO: Executive Directors of Voluntary Provider Agencies Executive Directors of MSC Vendors DDSO Directors FROM: SUBJECT: Gerald Huber, Deputy Commissioner Division of Person-Centered Supports Habilitation Plan Requirements DATE: March 7, 2012 EFFECTIVE DATE: April 1, 2012 Suggested Distribution: Habilitation Program/Service Staff Quality/Compliance Staff Billing Department Staff MSC Service Coordinators and Service Coordinator Supervisors Applicability: This information is applicable for all individuals currently receiving, or seeking to receive habilitation services through the OPWDD service system. The information in the attached materials is effective April 1, Purpose: Effective April 1, 2012, this Administrative Memorandum (ADM) issued by the Office for People With Developmental Disabilities (OPWDD) describes the Habilitation Plan and the program standards and payment standards of the Habilitation Plan. This ADM also serves to bring Habilitation Plan review processes in line with ISP review processes changed in ADM # Program Standards: Individualized Service Plan (ISP) Format and Timeframes for Review and We help people with developmental disabilities live richer lives.

74 ADMINISTRATIVE MEMORANDUM # Habilitation Plan Requirements Effective April 1, 2012 Distribution. The requirements in this ADM apply to habilitation plans written or reviewed on or after April 1, 2012, and to the services delivered in accordance with those habilitation plans, whether the services are delivered to individuals who are enrolled in the Home and Community Based Services (HCBS) waiver or to non-waiver enrolled individuals. Requirements set forth in this Administrative Memorandum supersede OPWDD ADM # and provisions of the Key to Individualized Services (OPWDD, 1997) related to Habilitation Plans. Habilitation services include: (a) Residential Habilitation in certified sites: Individualized Residential Alternative (IRA), Community Residence (CR) and Family Care; (b) Day Habilitation; (c) Community Habilitation; (d) Prevocational Services; and (e) Supported Employment (SEMP). This ADM also provides guidelines about the monthly summary note documentation. Defining the Habilitation Service and Habilitation Plan: Habilitation services are designed to assist participants in acquiring, retaining and improving the self-help, socialization and adaptive skills necessary to reside successfully in home and communitybased settings. Habilitation Plans describe what staff (this term includes family care providers) will do to help the person reach his/her valued outcome(s) that have been identified in the Individualized Service Plan (ISP). Habilitation services involve staff teaching a skill, providing supports and exploring new experiences. The regulations that govern habilitation services are 14 NYCRR Parts 624, 633, 635, 671, and 686. Habilitation Plan Program Standards: The Habilitation Plan Program Standards are designed to provide guidance to service providers regarding the expected level of a quality habilitation service. These standards will be reviewed by OPWDD s Division of Quality Improvement and may be subject to corrective actions, however, they are not considered to be a specific requirement to justify billing, unless there is a separate standard identified in the Habilitation Plan Payment Standards section below. Initial Habilitation Plan The initial Habilitation Plan must be written by the habilitation service provider and should be developed in collaboration with the person, their advocate and service coordinator. The initial 2

75 ADMINISTRATIVE MEMORANDUM # Habilitation Plan Requirements Effective April 1, 2012 Habilitation Plan must be written and forwarded to the service coordinator within 60 days of the start of the habilitation service. General Guidance for Developing the Habilitation Plan The Individual s Individualized Service Plan (ISP) describes who the person is, what he/she wants to accomplish and who or what will help the individual to accomplish these things. The details on how this will be accomplished are described in the Habilitation Plan. Therefore, Habilitation Plans are not developed merely by copying information directly from the ISP. It is expected that the ISP and the valued outcomes are the starting point to developing the Habilitation Plan The next step to developing the Habilitation Plan is in listening, discovering and understanding the individual. The Habilitation Plan should be a collaborative process between habilitation staff and the individual. When getting to know the individual, habilitation staff should look at the individual s background, health, lifestyle, habits, relationships, abilities and skills, preferences, accomplishments, challenges, culture, places he or she goes, beliefs, and hopes and dreams. Staff should also ensure that the individual has opportunities for choice, community inclusion, and decision making. After getting to know the individual and looking at what the individual needs and wants from the habilitation service, the agency should assess an individual s current skill level by observing the individual and collecting baseline data. After the assessment, the agency determines the methodology for the service(s) and/or support(s) that the agency provides. It is through this process that the Habilitation provider is able to help the individual reach his/her outcomes and does not just simply continue repeating the past. Habilitation Plan Reviews Once the Habilitation Plan has been implemented, the Habilitation Plan must be reviewed at least twice annually. This review is the agency s and the individual s opportunity to reassess the plan and its services. During this review the habilitation provider should also consider an individual s progress and the prevention of regression. The Habilitation Plan review should include discussion on the services and supports that have been provided up to this point and what the challenges have been and what new strategies or methodologies may need to be used. Those reviewing the Habilitation Plan should establish objectives to be met before the next periodic review and establish agreement on those objectives. Finally the review should include recognition of the accomplishments that the individual has achieved since the last review. Revised Habilitation Plans, which are also written by the habilitation service provider, must be sent to the person s service coordinator no more than 30 days after either: (a) an ISP review date, or (b) 3

76 ADMINISTRATIVE MEMORANDUM # Habilitation Plan Requirements Effective April 1, 2012 the date on which the habilitation service provider makes a significant change in the Habilitation Plan. If the habilitation provider fails to send the Habilitation Plan within the 30 day time frame, the habilitation provider is then responsible for distributing the Habilitation Plan to the service coordinator and all other required parties including other Waiver Service Providers, the individual being served and/or his/her advocate. Each Habilitation Plan must be reviewed and revised as necessary when there is a significant change in the habilitation service. At a minimum, the Habilitation Plan must be reviewed (and revised as necessary) at least twice annually and should be coordinated with the ISP reviews. It is recommended that these occur at six month intervals. At least annually, one of the Habilitation Plan reviews must be conducted at the time of the ISP meeting arranged by the person s service coordinator. This meeting should include the individual, the advocate, and all other major service providers. Four Required Sections of the Habilitation Plan Every Habilitation Plan must include the following sections: 1) Identifying information. This must include the individual s name, the individual s Medicaid ID number, the name of the habilitation provider, identification of the habilitation service, the review date, and any other information that the agency deems useful. 2) Valued Outcomes. The person s valued outcome(s) are derived from the ISP. The habilitation service must relate to at least one of the individual s valued outcomes. Using these valued outcomes as a starting point, the Habilitation Plan describes the actions that will enable the person to reach the particular valued outcome(s). A single Habilitation Plan may address one or more valued outcomes. 3) Staff Services and Supports. A Habilitation Plan is individualized by using the person s valued outcomes as a starting point. The Habilitation Plan must address one or more of the following strategies for service delivery: skill acquisition/retention, staff support, or exploration of new experiences. The strategies are discussed below. The habilitation service provider should use its best judgment, and in consultation with the person and his/her service coordinator, decide which service strategies are to be addressed in the Habilitation Plan. The Habilitation Plan must be specific enough to enable new habilitation service staff to know what they must do to implement the person s Habilitation Plan. a. Skill Acquisition/retention describes the services staff will carry out to make a person more independent in some aspect of life. Staff assess the person s current skill level, identify a method by which the skill will be taught and measure progress 4

77 ADMINISTRATIVE MEMORANDUM # Habilitation Plan Requirements Effective April 1, 2012 periodically. The assessment and progress may be measured by observation, interviewing staff or others who know the person well, and/or by data collection. Skill acquisition/retention activities should be considered in developing the Habilitation Plan. Further advancement of some skills may not be reasonably expected for certain people due to a medical condition, advancing age or the determination that the particular skill has been maximized due to substantial past efforts. In such instances, based on an appropriate assessment by members of the habilitation service delivery team, activities specified in the Habilitation Plan can be directed to skill retention. b. Staff Supports are those actions that are provided by the habilitation staff when the person is not expected to independently perform a task without supervision and are essential to preserve the person s health or welfare, or to reach a valued outcome. Examples are assistance with personal hygiene or activities of daily living. Staff oversight of the person s health and welfare is also a part of the habilitation service (e.g., when staff accompanies people in the community or provides first aid). c. Exploration of new experiences is an acceptable component of the Habilitation Plan when based on an appropriate review by the habilitation service provider. Learning about the community and forming relationships often require a person to try new experiences to determine life directions. This trial and error process eventually enables the person to make informed choices and, consequently, to identify new valued outcomes that then become part of the ISP and the Habilitation Plan. 4) Safeguards. The safeguards delineated in Section 1 of the ISP are used as the starting point for the habilitation service provider. Safeguards are necessary to provide for the person s health and safety while participating in the habilitation service. All habilitation staff supporting the person must have knowledge of the person s safeguards. Either including the safeguards in the Habilitation Plan or referencing the safeguards in an attached document is acceptable. For additional information on safeguards, see the memorandum Supporting Individuals to Achieve Personal Safety and Wellbeing issued on 10/17/2011 and is available on the OPWDD website at a. Safeguards for persons receiving IRA Residential Habilitation must be addressed in the individual s Plan for Protective Oversight in accordance with 14 NYCRR Section The individual s Plan for Protective Oversight must be attached to the IRA Residential Habilitation Plan. b. For all other habilitation services (Residential Habilitation in Family Care and Community Residences, Community Habilitation, Day Habilitation, Prevocational Services, Consolidated Supports and Services, and Supported Employment) 5

78 ADMINISTRATIVE MEMORANDUM # Habilitation Plan Requirements Effective April 1, 2012 safeguards must be included in the Habilitation Plan or the plan must reference other documentation that specifies the safeguards. Information on the safeguards must be readily available to the habilitation service provider staff. For example: i. A safeguard included in the Habilitation Plan for a person with exercise-induced asthma might state that he or she must use an inhaler prior to any physical activity. ii. The Habilitation Plan might reference the nutritional plan notebook located in the program office, which contains information on the individual s food allergies. c. As required in 14 NYCRR Part 633, the medication records are distinct and separate from the Habilitation Plan. The Habilitation Plan references the medication records as containing important health related information when applicable. If the habilitation service provider is teaching the person to self-administer medication, that activity and methodology should appear in the Habilitation Plan. d. Providers of residential habilitation must have written procedures for providing back-up supports to individuals when the absence of the provider s regularly scheduled staff would pose a threat to the person s health or safety. For IRAs, this information must be included in site-specific Plans for Protective Oversight and in Individual Plans for Protective Oversight as appropriate. Habilitation Plan Format An optional Habilitation Plan Format has been issued with this Memorandum. Providers may use this format or create their own; however, the Habilitation Plan must include the minimum information as described in this ADM. Habilitation providers are expected to write plans that not only include the information required by this memorandum, but also clearly communicate information to the habilitation staff and illustrate the steps staff are taking to address an individual s needs. Habilitation Plan Payment Standards: The following standards define the documentation which must be retained to support a service claim by the provider. 6

79 ADMINISTRATIVE MEMORANDUM # Habilitation Plan Requirements Effective April 1, 2012 For every habilitation service, an individual must have a Habilitation Plan that contains the following elements: 1) The individual s name. 2) The individual s Medicaid Identification Number (CIN), if the person is a Medicaid enrollee. 3) The habilitation service provider s agency name. 4) Identification of the habilitation service(s) provided. 5) The date on which the Habilitation Plan was reviewed. 6) Identification of at least one valued outcome that is derived from the individual s ISP (valued outcomes do not need to be verbatim from the ISP). 7) Description of the services and supports the habilitation staff will provide to the person. 8) The safeguards (health and welfare) that will be provided by the habilitation service provider. 9) The printed name, signature and title of the staff who wrote the Habilitation Plan. 10) The date that staff signed the Habilitation Plan. In addition, there must be evidence that the Habilitation Plan was reviewed within 12 months prior to the month in which the service occurs. Evidence of a review may include but is not limited to a review sign-in sheet, a service note indicating a review, or a revised/updated Habilitation Plan. Evidence of reviews must include: 1) The individual s name. 2) The habilitation service(s) under review. 3) The staff s signature(s) from the habilitation service. 4) The date of the staff s signature. 5) Date of the review. Service Claim Documentation As noted, the initial Habilitation Plan must be in place within 60 days of the start of the habilitation service. Therefore, services that are provided within the first 60 days of the start of the habilitation service may not necessarily have a Habilitation Plan in place. Habilitation Plans with Multiple Services Habilitation Plans may include multiple habilitation services (such as residential habilitation, day habilitation, prevocational services, and SEMP), if the services are all provided by the same agency. 7

80 ADMINISTRATIVE MEMORANDUM # Habilitation Plan Requirements Effective April 1, 2012 For Habilitation Plans that incorporate multiple habilitation services, the Habilitation Plan must have a separate section that describes the supports and services associated with each service. When the same support/service is delivered in multiple habilitation services, the service/staff action must be identified in each supports and services section of the Habilitation Plan. For each habilitation service described on the Habilitation Plan, one staff from each habilitation service should assist with writing the plan and include his/her name, title, signature, and signature date on the Habilitation Plan. Evidence of a habilitation review must include a staff signature from each habilitation service. Documentation Retention 18 NYCRR Section 504.3(a) states that by enrolling in the Medicaid program, the provider agrees to prepare and to maintain contemporaneous records demonstrating its right to receive payment under the medical assistance program and to keep for a period of six years from the date the care, services or supplies were furnished, all records necessary to disclose the nature and extent of services furnished and all information regarding claims for payment submitted by, or on behalf of, the provider and to furnish such records and information, upon request, to the Secretary of the United States Department of Health and Human Services, the Deputy Attorney General for Medicaid Fraud Control and the New York State Department of Health. In addition, 18 NYCRR Section 517.3(b)(2) states that All information regarding claims for payment submitted by or on behalf of the provider is subject to audit for a period of six years from the date the care, services or supplies were furnished or billed, whichever is later.... It should be noted that there are other entities with rights to audit Medicaid waiver claims as well, including OPWDD. Additional Information For additional information about the Habilitation Plan, please contact OPWDD Division of Person- Centered Supports at (518) cc: Provider Associations Jill Gentile Eric Pasternak Eugenia Haneman Maryellen Moeser Tricia Downes Lisa Kennedy Attachments: Habilitation Plan Template 8

81 IDGS clinician wages at the 90 percentile Area: New York Period: May 2013 Occupation (SOC code) Hourly 90th percentile wage Annual 90th percentile wage(1) Social Workers, All Other(211029) $ $ 79, Dietitians and Nutritionists(291031) $ $ 83, Occupational Therapists(291122) $ $ 107, Physical Therapists(291123)**includes Equine, Aquatic Therapy $ $ 111, Recreational Therapists(291125) $ $ 71, Speech Language Pathologists(291127) $ $ 127, Therapists All Other(291129) $ $ 89, Registered Nurses(291141) $ $ 106, Nurse Practitioners(291171) $ $ 135, Hearing Aid Specialists(292092) $ $ 63, Occupational Therapy Assistants(312011) $ $ 70, Occupational Therapy Aides(312012) $ $ 52, Physical Therapist Assistants(312021) $ $ 70, Physical Therapist Aides(312022) $ $ 37, Psychologists, All Other(193039) Footnotes: (1) Annual wages have been calculated by multiplying the hourly mean wage by 2080 hours; where an hourly mean wage is not published the annual wage has been directly calculated from the reported survey data. SOC code: Standard Occupational Classification code see Data extracted on July

82 Live-In Caregiver Maximums Rate Setting Region 1 New York City Rent - $17,676 annually Food - $5,000 annually Utilities - $ 3,500 annually Annual Total - $26,176 Monthly Max - $2,181 Rate Setting Region 2 Putnam, Rockland, Westchester, Suffolk and Nassau Counties Rent - $19,200 annually Food - $5,000 annually Utilities - $ 3,500 annually Annual Total - $27,700 Monthly Max - $2,308 Rate Setting Region 3 - Rest of State Rent - $13,872 annually Food - $5,000 annually Utilities - $ 3,000 annually Annual Total - $21,872 Monthly Max - $1,823

83 OPWDD: Putting People First OPWDD Guidance on Overnight Asleep Supports October 23, 2014 Many individuals need supports during the night to ensure their safety, but do not need direct observation during sleep hours. These individuals may need available support staff who can provide direct service if a specific need arises during the night. The Community Habilitation (CH) service is meant to support individuals to live as independently as possible, and a portion of the CH service includes implementing individualspecific safeguards that are foundational to ensuring an individual s health and safety. A CH plan of support can include the identification of indirect service time for a portion of the CH service that is integral to the overall plan, but is not delivered in a face to face manner. Components of indirect service time for the CH service can include: Staff training time (hours worked to attend training) Planning time (hours worked as part of person centered planning team) Documentation time (time spent completing pertinent and required notes and service documentation) Staff coordination and scheduling On-call time (hours spent on site by staff who are available as needed to implement the Habilitation Plan) Asleep overnight staff The following parameters must be met if asleep overnight staff time is built into the indirect cost: 1) The total hourly cost cannot exceed the regional rate for CH; and 2) There are enough billable hours to ensure that the indirect costs cover sleep time; and 3) The CH plan provides justification that asleep staff are able to provide adequate oversight of the individual; and 4) CH staff who are also Live-In Caregivers or Paid Neighbors for the person must not be paid for time spent asleep or in "on call" status. Note: Under no circumstances does asleep staff support count as billable CH service time. Page 1 of 2

84 OPWDD: Putting People First Indirect service time must be documented as indirect service time in support of the CH service, and must be tracked and paid as hours worked. However, indirect service time cannot be billed as CH service hours. The indirect service time is paid as part of the rate provided to agencies for the CH service, or as a component of the self hired staff wage established by the individual or designee. All revenue and payments for both direct and indirect service time for staff must be reported on the Consolidated Fiscal Report (CFR). Page 2 of 2

85 Safeguards Does Not Apply I do not need support in this area I need support in this area Supports and services needed to address this Safeguard Who is responsible for training staff on this Safeguard? Guardianship I know who my legal guardian is and how to contact him/her. Informed Consent for General Non Emergency Medical Procedures I give consent for general non emergency medical procedures. Informed Consent for Psychotropic Medication I give consent for psychotropic medication. Reporting Incidents I know how to correctly identify an incident and report the incident to my FMS agency and/or MSC. Budgeting I manage my money and my budget. Transportation I travel independently within my community. Transportation I travel independently outside my community.

86 Back up Plan for Daily Needs I have and can use a backup plan when my regular schedule changes, e.g., staff cancellation, staff is tardy, or staff leaves employment unexpectedly. Medication Administration I am able to correctly self administer medications. Medical/Health Concerns/Reactions I am aware of my medical/ health issues and needs and manage them by making and keeping appointments as needed, communicating concerns and symptoms, and being mindful of potential risks. Potential health problems could include asthma, allergies, risk of aspiration, ingestion or swallowing difficulties, potential sensitivity to medication, dairy, peanuts, etc. Nutrition I maintain an adequate diet that meets my nutritional needs, e.g., preventing choking, avoiding food allergies. Protective Oversight/Level of Supervision I maintain my personal safety and am free from self Injury; I do not threaten the safety or property of others. Fire Safety I respond safely in a fire including evacuating promptly and calling for help once out of the building. Personal Safety 1. I respond appropriately in emergencies including following direction from law enforcement or community supports (EMS, fire departments, etc.)

87 Personal Safety 2. I am aware of my surroundings and do not put myself in situations where I do not know where I am or how to return to my home. Emergency Preparedness I have and can carry out emergency plans for sheltering in place and for identifying a plan and location if I need to relocate. I also know situations, such as severe weather, when I need to evacuate. Communication Connections I can communicate with others, such as make phone calls to advocates, contact members of my circle of support, or file complaints/grievances. I can also call others to set up appointments if needed, such as a doctor s appointment. (Need for a cell phone or land line telephone is included here.)