To be eligible to receive HCBS/P waiver services, a consumer must meet all of the following requirements:

1. The consumer must be atleast 16 years of age but less thatn 65* years of age.
   (* Consumers turning age 65 on July 1, 2002 or after this day may remain on the HCBS/PD waiver if they so choose as long as they continue to meet the eligibility criteria.)
2. The consumer must be financially eligible for Medicaid as determined by SRS Economic Employment Support Specialists.
3. The consumer must be determined physically disabled by Social Security Administration standards.
4. The consumer must meet the Medicaid long term care threshold based on an assessment completed with the Uniform Assessment Instrument (UAI) by a certified Independent Living Counselor AND have a determined need for personal assistance to accomplish the "normal rhythms of the day."
5. As of November 1, 1999, the Long Term Care (LTC) Services Threshold Guide score used to determine eligibility for the HCBS/PD waiver is 26 or greater. Therefore, any consumer who is assessed for the HCBS/PD waiver on or after November 1, 1999, and has a score below 26 will not be eligible for waiver services. Consumers who began receiving waiver services before November 1, 1999, and had a score equal to or greater than 15 will remain eligible for services after reassessment if they continue to have a score equal to or greater than 15. When an HCBS case is closed, however, and the consumer reapplies, requiring a new assessment, a LTC Services Threshold Guide score of 26 or greater will be required for eligibility.
6. If 20 years of age or younger, the consumer must receive a KAN Be Healthy screening on a yearly basis.
7. Community Developmental Disability Organizations (CDDOs) are required to assess all persons with developmental disabilities for the MR/DD waiver. If the individual does not meet the level of care necessary for services on the MR/DD waiver and the consumer also has a physical disability, the CDDO may provide a "denail of services" letter so the PD waiver provider agency can then assess the individual for the appropriateness of PD waiver services.
8. For any consumer to be eligibile for HCBS, they must be eligible for Medicaid. If a consumer fails to provide the necessary information to determine and verify Medicaid eligibility, and subsequently their Medicaid case is denied or closed, thy are not eligible for HCBS services. In this instance, 10 days notice is not required for the closure of an HCBS case, as Medicaid will no longer pay for services. Services will not be reimbursed if the consumer does not have Medicaid eligibility.
9. If an individual with ongoing services fails to submit their annual financial eligibility paperwork to SRS by the due date, the EES Specialist will notify the individual and the ILC of the potential termination of Medicaid. Services will be suspended until eligibility is reinstated. The EES Specialist has the authority to reinstante services if all necessary paperwork is received within the month of closure or the following month. Should eligibility be reinstated during this tiem, the individual will have continued eligibility and will not be placed on the PD waiver waiting list. If the required paperwork is not returned in the time alloted, they will no longer be eligible to receive services.

Regular Medical Services

1. Pharmacy
   Most prescribed medications and supplies are covered. Some medications need prior authorization. Over-the-counter medications or supplies may also be covered when prescribed.
2. Home Health / Skills Nursing
   Skilled nursing care; home health aid care and some medical suppllies; and therapies may be covered. Home health aide services require prior authorization if the consumer is receiving HCBS. When ordered by a medical provider therapies such as physical occupational, and speech, must be rehabilitative, restorative, and receive within six months of an accident or illness. A maximum of six months is covered for therapies under Medicaid State Plan services.
3. Durable Medical Equipment
   Consumer must need service for school, employment, life support, or to avoid other more costly care. Rental and purchase of medical equipment/devices must be medically necessary.
4. Transportation
   1. Ambulance - Emergency situations where lack of immediate medical attention places the consumer's health in jeopardy, seriously impairs bodily functions, or results in serious dysfunction of a body organ or part. Also non-emergency situations when a car or van cannot be used. Medical necessity must be documented.
   2. Commercial and Non-Commercial Non-Ambulance Medical Transportation (NAMT) - Transportation to and from medically necessary services only Consumers must meet Medicaid guidelines. As of January 1, 2002, HCBS/PD consumers will no longer be eligible for transporation reimbursement for trips to medical services under 100 miles round trip, except for prenatal services, renal dialysis, cancer therapy, rehabilitation services, medication monitoring, and some psychotherapy.
      1. Non-Commercial NAMT - provided by family members, friends, etc. require prior authorization before providing the trip.
      2. Commercial transportation (cab, van, etc.) - may be obtained by calling Medicaid commercial providers directly. Consumers must meet Medicaid guidelines.

Waiver Services

1. Personal Services
   1. Personal Services means one or more persons assisting a person who has a disability with tasks which the disabled individual would typically do for themselves in the absence of their disability. Such services may include assisting consumers in accomplishing an Activity of Daily Living (ADL) or an Instrumental Activity of Daily Living (IADL) associated with the consumer's normal rhythms of the day.
   2. Providers
      Consumers have the right to choose any enrolled provider of services who operates in their area
      1. Spouses or parents of minor children as providers
         Certain family members cannot be reimbursed for providing assistance with ADLs and / or IADLs. Federal Medicaid regulation 42 CFR 440.167 states that legally responsible family member (spouses or parents of minor children) cannot provide personal care services unless they eet the specific, approved criteria. Exceptions to the family reimbursement restrictions are set out in K.A.R. 30-5-307 (See Section B-3, a).
      2. Legal respresentatives
         1. Guardians and / or conservators are not allowed to benefi financially from their interactions with the ward and / or conservatee they represent (See K.A.R. 30-5-302).
         2. As of January 1, 2000, the HCBS/PD waiver, as approved by CMS, states that "persons directing a consumer's care through the self-directed care option may not be a provider of this service."
            Those providing the service prior to this date have been "grandfathered" under this standard.
      3. Time Sheets & signatures
         The consumer file shall be legible and stand on its own. Documentation for the HCBS program shall include at a minimum the use of a timesheet to validate services were provided. Each visit should include the date, time started/stopped, caregiver’s name and signature, and the consumer’s or their legal respresentative’s signature or individual “mark.” A traditional “check mark” (T) or signature stamp will not be accepted.
   3. The installation of personal emergency response systems (such as “Lifeline”) may be covered under Personal Services more than once due to telephone disconnection or the relocation of the consumer.
2. Independent Living Counseling
   1. Independent Living Counseling is required for all HCBS/PD consumers and must be provided by an Independent Living Counselor (ILC) who has met the qualifications set out in the waiver. The goal of the ILC is to foster and maximize a consumer’s independence through his/her individual strengths by providing accurate information regarding the available choices.
      Responsibilities of the ILC include but are not limited to:
      1. Serve as a point of access for Medicaid services;
         • Making necessary referrals.
         • Providing information on Medicaid covered services.
         • Assist the consumer with the completion of the Medicaid application if necessary.
      2. Determined functional eligibility by completing the assessmen process;
         • Conducting in-home visits and completing the UAI which included completion of the LTC Services Threshold Guide.
         • Initial assessments are to be done within 5 working days from the date of the referral, unless otherwise requested by the oconsumer. Annual assessments should be completed within 30 days before or 30 days following the date of the assessment due date.
         • Assessments are to be completed as needed when there is a change in the consumers' condition or living arrangement that leads to POC changes.
         • Assure that assessments contain accurate information. This may mean using other resources to verify information.
         • Conduct assessments in a manner by which the consumer will understand the questions and understand the importance of accurate information.
         • Ask questions to clarify any information given.
      3. Develop the consumers' Plan of Care and update as needed.
         • Enter the Plan of Care into the electronic Prior Authorization system (MMIS).
         • Assure that all other options have been considered before the waiver becomes the payer. This included unpaid family members or others living in the residence.
         • Assure that the consumers' choice of providers is considered at all times.
         • Educate the consumer regarding the difference between needed and wanted services.
         • Follow up with the consumer when there has been an increase in services due to an acute episode, or a decrease in services due to a positive change in health status or other matters that increase the consumer's level of independence.
      4. Ensure that the consumers' Plans of Care are cost effective and meet their basic health and welfare needs.
         • Educate the consumer regarding wants and needs.
         • Tell the consumer when the program cannot provide what they are wanting.
         • Evaluate what other members of the household can do as opposed to the waiver being the provider.
         • Assure that the waiver is not reimbursing for tasks completed on behalf of the other household member.
         • Look at attendanta performing more than one task at a time (e.g. laundry and housekeeping).
      5. Ensure that consumers have full and unbiased access to a variety of services and service providers to meet their specific needs, including a list of all available Independent Living Counseling agencies which provide that service.
         • Educate the consumer about self-direction and the different choices of payroll agents. Choices are made by the consumer.
      6. Advocate for consumers by arranging for services with individuals, businesses, and agencies for the best available service within limited resources.
      7. Participate in the quality assurance process
         • Communicate with consuemrs to assure that services on the Plan of Care are being provided.
         • Monitor attendant hours to determine if changes need to be made.
         • Provide needed information to AMM staff for annual reviews.
         • Respond in writing to recommendations made by the AMM staff within 30 days of the date of the notification letter.
      8. Documentation
         • Maintain a case file on all PD waiver consumers.
         • Document all contacts with the consumer, family members, legal representatives, or services providers.
         • Documentation should validate all billable time for ILC.
         • Documentation should contain information regarding changes in service providers.
      9. Transferring file information
         • When a consumer's file is transferred from one CIL or HHA to annother, the ILC should transfer a copy of all forms and consumer logs for the previous 12 months. The party that sends the file should make a notation in it, as to where the record is transferred and the date it is transferred.
         • Both the sending and receiving ILC should notify the SRS EES Specialist of the transfer using the ES 3161 form. The receiving ILC should be reviewed and updated with the consumer, as needed.
   2. Independent Living (IL) Counseling may only be provided by enrolled CILs and HHAs.
   3. The reimbursement rate is $30.00 per hour for each approved POC hour of IL Counseling. One unit of billing equals one hour of IL Counseling. The maximum number of hours of IL Counseling any consumer can receive is 120 hours per year.
   4. KAR 30-5-302 states that a CIL shall not use any consumer as an ILC when that consumer receives services from the same IL Counseling agency.
   5. An individual who has an APS confirmed record of abuse and whose name appears on the SRS abuse registry may not provide IL Counseling services.
3. Assistive Services
   1. Assistive services are thsoe services, which meet an individuals assessed needs by modifying or improving an individuals home and through the provision of adaptive equipment. Assistive Services may include environmental changes such as ramps, lifts, and bathroom modifications or adaptive equipment and technology assistance devices, which should be substituted for a personal service when it is a cost effective alternative to the service of the POC.
      1. The maximum lifetime expenditure on Assistive Services is $7,500. Those individuals who have received a similar service previously on the HCBS/TBI or HCBS/MRDD waivers must deduct the amount of the previous assistive service from the lifetime maximum of $7,500 to determine the amount which may be available to the consumer under the PD waiver.
      2. Environmental modifications may only be purchased in rented apartments or home when the landlord agress in writing to maintain the modifications for a period of not less than three years and will give first rent priority to tenants with physical disabilities.
   2. Providers of this service include contractors and / or agencies licensed by the county or city in which they work (if required by the county or city) and perform all work according to existing building codes.
      1. Reimbursement is limited to the individuals assessed level of service and based on the annualized care plan. The consumer may choose to obtain bids from any qualified provider. A minimum of three bids must be obtained by the ILC and submited to the AMM staff with the Assistive Services Worksheet and POC. The provider with the lowest bid will be approved to provide the service.

Consumer complaints

As the consumer's advocate, the ILC should help resolve any complaints the consumer may have. If the ILC is not able to alleviate the problem or the consumer's complaint is with the ICIL or the ILC, the consumer should:

1. If the complaint is with the consumer's ILC, they should try to resolve the problem at that level. If that is not possible, the consumer needs to discuss the matter with their ILC's supervisor or the director of the CIL or HHA.
2. The consumer always has the option of filing a complaint with the consumer assistance unit of the fiscal agent. When this is done, the fiscal agent logs and tracks complaints. If a provider has three complaints lodged against them, an investigation is initiated.
3. If a consumer should contact local AMM staff with a complaint, the AMM staff should refer them back to their CIL and / o r the Consumer Assistance Unit.
4. If the consumer still feels the complaint needs resolution, they may file and appeal with the CIL or HHA. The CIL or HHA should have the necessary appeal forms or can acquire them from their local AMM personnel.
5. Consumer complaints reguarding abuse, neglect, or exploitation should be referred to Adult Protective Services.