Planned Respite also includes skill development activities. Planned Respite Services:. Assistance with acquisition, retention or improvement in self-help, socialization and adaptive skills including communication, and travel that regularly takes place in a non- residential setting, separate from the person's private residence or other residential arrangement.
Activities and environments are designed to foster the acquisition of skills, appropriate behavior, greater independence, community inclusion, relationship building, self-advocacy and informed choice.
Individual Day Habilitation a one-to-one, individual-to-worker provided service with an hourly unit of service and Group Day Habilitation services are on a regularly scheduled basis for 1 or more days per week or less frequently as specified in the participant's Plan of Care POC. Meals provided as part of these services shall not constitute a "full nutritional regimen" 3 meals per day.
All Day Habilitation services Group and individual have the same service description and focus on enabling the participant to attain or maintain his or her maximum functional level and shall be coordinated with any physical, occupational or speech therapies in the POC. In addition, Day Habilitation services may serve to reinforce skills, behaviors or lessons taught in other settings. Group and individual Day Habilitation cannot be billed as overlapping services.
Supplemental services are not available to individuals residing in certified residential settings, because the residence is paid for staffing on weekday evenings and anytime on weekends. Any child receiving HCBS under this waiver may receive this service. Children have a maximum daily amount of services that are available to individuals based upon their residence. Individuals residing in certified settings are limited to a maximum of six hours of non-residential services or its equivalent which must commence no later than 3 pm on weekdays.
Day Habilitation services will not include funding for direct, hands-on physical therapy, occupational therapy, speech therapy, nutrition, or psychology services.
Habilitation is divided into individual and group services. Acquisition, maintenance and enhancement are defined as:. Acquisition is described as the service available to a physically and mentally capable individual who is thought to be capable of achieving greater independence by potentially learning to perform the task for him or herself. There should be a reasonable expectation that the individual will acquire the skills necessary to perform that task within the authorization period.
These identified services will be used as a means to maximize personal independence and integration in the community, preserve functioning and prevent the likelihood of future institutional placement. For this reason, skill acquisition, maintenance and enhancement services are appropriate for persons who have the capacity to learn to live in the community, with or without support.
Community Habilitation may be delivered in individual or group modality. ADL, IADL Skill Acquisition, Maintenance and Enhancement is related to assistance with functional skills training and may help a person accomplish specific tasks who has difficulties with skills related to:. Services may not be duplicative of any services that may be available under Community First Choice Option:.
Teaching health-related tasks is defined as specific tasks related to the needs of a person, which can be delegated or assigned by licensed health-care professionals under State law to be performed by a certified home health aide or a direct service professional. Health related tasks also include tasks that home health aides or direct service professionals can perform under applicable exemptions from the Nurse Practice Act.
Some specific health-related tasks available for assistance include, but are not limited to: Teaching the individual to perform simple measurements and tests; assisting with the preparation of complex modified diets; assisting with a prescribed exercise program; pouring, administering and recording medications; assisting with the use of medical equipment, supplies and devices; assisting with special skin care; assisting with a dressing change; and assisting with ostomy care.
These services can be delivered at any home or community setting. Approved settings do not include an OPWDD certified residence or day program, a social day care or health care setting in which employees of the particular setting care for or oversee the enrollee. Foster care children meeting LOC may receive these services in a home or community-based setting where they reside that is not an institution.
Children living in community residences with professional staffing may only receive this service on weekdays with a start time prior to 3 pm. For school-age children, this service cannot be provided during the school day. Time spent receiving another Medicaid service cannot be counted toward the Habilitation billable service time. If a child requires medically necessary services that are best delivered in the school setting by a community provider, the service must be detailed on the POC.
Excluded are those adaptations or improvements to the home that are of general utility and are not of direct medical or remedial benefit to the child. Adaptations that add to the total square footage of the home's footprint are excluded from this benefit except when necessary to complete an adaptation e. Also excluded are pools and hot tubs and associated modifications for entering or exiting the pool or hot tub. However, in reasonable circumstances determined and approved by the State, a second modification may be considered for funding as follows: if a person moves to another home; if the current modifications are in need of repair, worn- out or unsafe; or if a participant wishes to spend considerable time with a non-cohabitating parent in their home and such modifications are required to ensure health and safety during these periods.
Services that began prior to April 1, should not be stopped or delayed due to this transition. In instances where SPV funding and prior approval are requested for the same service, the requests should be submitted for processing together. If either request is not approved, the LDSS will be so notified. If additional information is needed, the disbursement may be delayed pending submission of the additional information.
Standard provisions of the NYS Finance Law and procurement policies must be followed to ensure that contractors are qualified, and that State required bidding procedures have been followed. Services are only billed to Medicaid or the MCO once the contract work is verified as complete and the amount billed is equal to the contract value. Vehicle Modifications are limited to the primary means of transportation for the child. The vehicle may be owned by the child or by a family member or non-relative who provides primary, consistent and ongoing transportation for the child.
All equipment and technology used for entertainment is prohibited. Costs may not exceed current market value of vehicle. However, in reasonable circumstances determined and approved by the State, a second modification may be considered for funding if the current modifications are in need of repair, worn-out or unsafe. Replacements, repairs, upgrades, or enhancements made to existing equipment will be paid if documented as a necessity. In addition, when the modification must be replaced or repaired, a depreciation schedule will be used to determine the limit of the amount to be applied to the cost.
Such devices cannot be used for the purpose of surveillance, but to support the person to live with greater independence, Devices to assist with medication administration, including tele-care devices that prompt, teach or otherwise assist the participant, Portable generators necessary to support equipment or devices needed for the health or safety of the person, and stretcher stations.
Adaptive and Assistive Equipment Services include: A. Adaptive Devices are expected to be a one-time only purchase. Replacements, repairs, upgrades, or enhancements made to existing equipment will be paid if documented as a necessity and approved by the State or its designee. Ongoing monitoring associated with telecare support services or other approved systems authorized under this definition may be provided if necessary, for health and safety and documented to the satisfaction of the State or designee.
Warranties, repairs or maintenance on assistive technology may be reimbursed only when they are the most cost effective and efficient means to meet the need and are not available through the Medicaid state plan at a , CFCO or third-party resources.
Services are only billed to Medicaid once the equipment is procured and the amount billed is equal to the purchased value. Standard provisions of the NYS Finance Law and procurement policies must be followed to ensure that vendors are qualified, and that State required bidding procedures have been followed.
Services are only billed to Medicaid or the MCO once the equipment is verified as received and the amount billed is equal to the contract value. Billing guidance for Health Home services can be found here.
Health Home Care Management provides person-centered, child and family-driven care planning and management. Health Homes deliver person-centered planning through six core services, including comprehensive care management, care coordination, health promotion, comprehensive transitional care, child and family support, referral to community and social supports and service linkages using health information technology. Requests for these services will be managed directly with the Managed Care Plan for those children enrolled in a plan.
Service limits are as follows:. In all cases, service limits are soft limits that may be exceeded due to medical necessity. This justification must be submitted to NYSDOH along with the request for service packet in order to obtain approval of the request. Environmental and Vehicle modifications are non-medical services and will need to be billed from provider to plan using invoices.
Plans will need to convert these invoices into claims. EPSDT is the key to ensuring that children and adolescents receive appropriate preventive, dental, mental health, developmental, and specialty services. In instances where such combinations are discovered, NYS will make the appropriate recoveries and referrals for judicial action. Subject to additions 6 7. Subject to additions 7 8. Subject to additions 8.
Navigation menu. A Medicaid Managed Care Plan has discretion to deny a claim from an out of network provider. Exception: For any of the newly carved-in services, if a provider is delivering a service to the enrollee prior to the implementation date and does not contract with the MMCP, the MMCP must allow a provider to continue to treat an enrollee on an out of network basis for up to 24 months following the implementation date.
Medicaid Managed Care Plans must execute SCAs with non-participating providers to meet clinical needs of children when in- network services are not available.
Providers should always verify that claims are submitted to the correct MMCP. Multiple Services Provided on the Same Date to the Same Individual In some cases, an individual can receive multiple services on the same day. Services Provided While in Transit Services that are delivered in transit are allowable and may be billed within the daily limits of the service.
Submitting Claims for Non-Sequential Time for the Same Service, on the Same Day If the same service is delivered to the same individual on the same day but at non- sequential times, the total time spent on the service may be submitted as a combined claim.
Timed Units per Encounter of Service Range of minutes per face-to-face encounter Billable minutes Billable units 15 minutes per unit Under 8 minutes minutes Not billable minutes 15 minutes 1 unit minutes 30 minutes 2 units minutes 45 minutes 3 units minutes 60 minutes 4 units minutes 75 minutes 5 units minutes 90 minutes 6 units minutes minutes 7 units minutes minutes 8 units Submitting Claims for Daily Billed Services Services that are billed on a daily basis should be submitted on separate claims.
Please refer to UM Guidance for details on annual and daily limits. Claims for OLP initial evaluation are defined using a distinct rate code. See Appendix A. Off-site services will be billed with one claim for the service rate code and a second claim for the off-site rate code. These would both have the same procedure code and different modifiers as described in Appendix A. By continuing beyond this notice, users consent to being monitored, recorded, and audited by company personnel.
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