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DAY HABILITATION

5/17/2005 12:00:00 AM

UNITS OF SERVICE: DAY HABILITATION (Memo e-mailed & mailed to Executive Directors regarding the final parameters for the new units of service for Day Habilitation.)

M e m o r a n d u m

TO:              Executive Directors

FROM:         Joanne Genovese, Director of Affiliate Services

                  

DATE:                   May 17, 2005

RE:             Units of Service:  Day Habilitation

Attached are the final parameters for the new units of service for Day Habilitation.

As per Jim Moran’s memorandum, OMRDD will be providing training during the next few months.  As Task Force members, we will continue to monitor the unit conversion process.

If you have any questions, please feel free to call.

Enclosures

cc:        Susan Constantino

            Mike Alvaro


MEMORANDUM

TO:                  Unit of Service Taskforce Members

FROM:            James F. Moran, Deputy Commissioner

                        Administration and Revenue Support

DATE:                        May 12, 2005

SUBJECT:     Unit of Service Documents for Day Habilitation and Prevocational Services

Enclosed are the final "blueprints" that govern the January 1, 2006 conversion of Day Habilitation and Prevocational Services.

OMRDD staff are now preparing for the January implementation date. 

A letter will be sent shortly to Executive Directors, explaining the upcoming changes and asking them to identify staff contacts who will address these unit of service issues.  In the next few months, we will begin to survey Day Habilitation and Prevocational Services providers to identify the pattern of service delivery associated with current prices.  We are also drafting proposed regulatory language based on the attached Day Habilitation and Prevocational Services write-ups.

As we have discussed, the successful change to the new units of service will require extensive outreach and training for the voluntary provider community.  Our outreach will begin this Spring and will culminate with a state-wide training campaign in the Fall of 2005.  We look forward to working cooperatively with provider associations and voluntary agencies to ensure a successful and smooth transition and thank you for all your help.  If you have any questions regarding transition activities, please contact Kate Marlay of Training and Medicaid Standards at (518) 408 2096. 

Enclosure


Group Day Habilitation, Supplemental Group Day Habilitation and Prevocational Services

OVERVIEW

This document outlines the proposed Unit of Service changes for Group Day Habilitation, “Supplemental Group Day Habilitation,” and Prevocational Services.  Individual Day Habilitation is addressed in a separate document. 

For Group Day Habilitation, “Supplemental Group Day Habilitation,” and Prevocational Services, the services and supports delivered will be based on a consumer’s ISP and Habilitation Plan.  These services are individualized and “person-centered” and offer opportunities for community inclusion.

Group Day Habilitation:  is a day service/program provided to two or more enrolled consumers.  The unit of service for Group Day Habilitation is a “Full Unit” or a “Half Unit” billed for each day of service.   Group Day Habilitation is provided on weekdays and the “program day” starts prior to 3:00 p.m.

Supplemental Group Day Habilitation: is a day service/program designed for people living at home, or in Supportive IRAs or Supportive CRs, or in family care homes.  Supplemental Group Day Habilitation services are provided to two or more enrolled consumers on weekday evenings or anytime on Saturdays or Sundays.  For weekday services, a program is considered "Supplemental Group Day Habilitation" if the program start time is 3 p.m. or later.  The unit of service for Supplemental Group Day Habilitation is a Half Unit and a Full Unit.  Medicaid payment for Supplemental Group Day Habilitation services is allowable for consumers who live at home, in family care homes or in Supportive IRAs or Supportive CRs.

 

Prevocational Services: is a day service/program that addresses individuals’ vocational interests.  The unit of service for Prevocational Services is a “Full Unit” or a “Half Unit” billed for each day of service.

GROUP DAY HABILITATION

Enrollment:

The DDSO/NYCRO authorizes the consumer’s receipt of Group Day Habilitation from the provider and enters the consumer’s enrollment in OMRDD’s Tracking and Billing System (TABS).  The DDSO/NYCRO provides the Group Day Habilitation provider with standardized written documentation of the authorization.

Unit of Service Rules:

Group Day Habilitation is provided on weekdays and the “program day” starts prior to 3:00 p.m.   The program day for Group Day Habilitation is six hours of service.   A minimum of four hours, excluding lunchtime, must be delivered to bill a Full Unit.  Where the Group Day Habilitation provider delivers from four to six hours of service to a consumer in a day, the provider may bill no more than a Full Unit of service for that day. 

A Half Unit of Group Day Habilitation is billed when the Group Day Habilitation provider delivers from two hours of billable service time up to four hours of billable service time to the consumer in a day.  Lunchtime cannot be counted toward the minimum “billable service time” requirement for a Half Unit of Group Day Habilitation.

For both a Full and a Half Unit, “billable service time” or time that “counts” involves face-to-face or in-person service provision by the Group Day Habilitation provider’s staff or its paid contract personnel.  Where a staff person accompanies a consumer to another separately billed Medicaid service, the time spent in transit cannot be counted as Group Day Habilitation.  The time the consumer spends actually receiving the other Medicaid service cannot be “counted” as billable Group Day Habilitation service time either.

Where a person receives another Medicaid service during his or her Group Day Habilitation program day, the Group Day Habilitation provider must document the time the person leaves Group Day Habilitation to receive the other Medicaid service, and the time the person returns to Group Day Habilitation. 

Examples:

·           A consumer arrives at the Group Day Habilitation program at 9:00 a.m. and leaves to board his bus at 3:00 p.m.  The Group Day Habilitation provider bills a Full Unit on that day of service since, with one-hour off for lunch; five hours of service were delivered on that day.

·           A consumer is regularly scheduled to attend the Group Day Habilitation program from 9:00 a.m. to 3:00 p.m., though, on this particular day, the consumer’s van is late and arrives at 10:00 a.m. at the community center where the first Group Day Habilitation activity takes place.  The consumer eats lunch from noon to 1:00 p.m.  The Group Day Habilitation provider bills a Full Unit on that day of service since the daily billing “threshold” of four hours of service was delivered on that day.

·           A consumer is regularly scheduled to attend Group Day Habilitation from 9:00 a.m. to 3:00 p.m., except on Wednesdays when he receives an hour of physical therapy from a clinic that separately bills Medicaid.  On Wednesday, the consumer arrives at Group Day Habilitation at 9:00 a.m. and eats lunch from noon to 1:00 p.m.   At 1:00 p.m. the consumer receives physical therapy from a clinic located at the Group Day Habilitation site.  The clinic service lasts one hour and the consumer returns to the Group Day Habilitation program at 2:00 p.m.  The consumer leaves the Group Day Habilitation program at 3:00 p.m. and returns home.  The Group Day Habilitation provider bills a Full Unit on Wednesday since four hours of service were delivered and the daily “threshold” of four hours of service was met.  In this example, the provider must document the person’s time in/out for the clinic service because the person received another Medicaid service during the Group Day Habilitation program day.

·           A consumer participates in Group Day Habilitation from 9:00 a.m. to noon - leaves the service site and then goes to her job at a supermarket.  The Group Day Habilitation provider bills a Half Unit on that day of service since the daily billing threshold of two hours for a Half Unit of Group Day Habilitation has been achieved.

Pricing

Each voluntary agency has a single blended Group Day Habilitation price.  All Group Day Habilitation prices are subject to Division of Budget approval, either through the streamlined or outlier review process.  Prices are subject to adjustments in accordance with OMRDD adjustment policy and procedures. 

Billing and Payment

The Group Day Habilitation Provider bills either MMIS (for services provided to Waiver-enrolled individuals) or the OMRDD Voucher Processing Unit (for services provided to non-Waiver enrolled individuals).  Any Group Day Habilitation Land and Development costs are paid automatically in 1/12 increments each month.

Documentation Requirements

Each Group Day Habilitation program enrollee must have an ISP which identifies the provider of the Group Day Habilitation service and a Group Day Habilitation Plan, which is reviewed (and revised as necessary) at least once every six months. 

1.         For each day a Full Unit of Service is delivered, the consumer record must contain:

a.      Documentation that at least four hours of Group Day Habilitation Service was delivered during the course of the day.  In an audit, the agency must provide documentation that the four hour minimum program day duration requirement was met.  The program day duration may be documented by recording the program start time and stop time on that day (e.g., John’s program started at 8:30 a.m. and program ended at 3:30 p.m. on April 5, 2005).  This requirement may also be met with a statement that the minimum program day duration for billing a full unit was met on that day (e.g., “John’s  program day duration met the 4 hour minimum on August 9, 2005”).  This statement regarding the program day duration may be documented in a narrative note or a checklist format.  Note, that the total program day duration excludes time spent at lunch, at another Medicaid service or time spent being transported to the Group Day Habilitation service at the start of the program day and return transportation at the end of the program day. 

Note, where the consumer participates in other Medicaid services during the Group Day Habilitation program day (e.g., a clinic visit), the Group Day Habilitation provider’s documentation must show “time in/time out” of the Group Day Habilitation Service.  For example, “May 20, 2004, John Doe participated in Group Day Habilitation Services from 9:00 a.m. to noon.  He left the program at 1:00 p.m. to receive other Medicaid Services.  Group Day Habilitation services were also provided from 2:00 p.m. to 3:00 p.m., signed, Sally Smith – Day Habilitation Worker, 5/20/04.”

      The Group Day Habilitation provider may document this time in/time out information in a chart form accompanied by a staff signature and date of signing for each day of service.

b.      Contemporaneous documentation of at least two individualized day habilitation services provided by staff during the day.  Services may be documented using a narrative note or checklist format.  These services must reflect the supports and services described in the consumer’s Group Day Habilitation Plan.  The service description must be expressed as a staff action.  For example: one of the two services required for a Full Unit of billing could be documented as “On our outing, I taught John how to use the public telephone, signed Sally Smith, Day Habilitation Worker, 5/20/04.”

c.      A record of the consumer’s response to the Group Day Habilitation services with the response described daily or in a monthly narrative note.

2.         For each day a Half Unit of Service is delivered, the consumer record must contain:

a.      Documentation that at least two hours of Group Day Habilitation Service was delivered during the course of the day.  See 1a above for additional documentation instructions.

b.      Contemporaneous documentation of at least one individualized Day Habilitation service provided by staff during the day.  See 1b above for additional documentation instructions.

c.      A record of the consumer’s response to the Group Day Habilitation services with the response described daily or in a monthly note.

Transportation to/from Group Day Habilitation

Where Funding for Transportation to the first site of group day habilitation and home from the last is included in a provider’s current Day Habilitation prices, this funding will continue to be included in the provider’s new Group Day Habilitation price.  Both the Full and Half Unit price will include funding for round-trip “to/from” transportation.  The time a person spends in “to/from transit” (i.e., on the van or bus) cannot be counted toward the Group Day Habilitation “billable service time” for that person. 


SUPPLEMENTAL GROUP DAY HABILITATION

Enrollment:

The DDSO/NYCRO authorizes the consumer’s receipt of Supplemental Group Day Habilitation by the provider and enters the consumer’s enrollment in the TABS system.  During the review, the DDSO will confirm that the consumer lives at home, in a Supportive CR, in a Supportive IRA or in a Family Care Home. The DDSO/NYCRO will provide the Supplemental Group Day Habilitation provider with standardized written documentation of the authorization. 

            If the consumer lives in a certified residential setting with 24-hour staffing other than Family Care (i.e., Supervised CR or Supervised IRA), the residential provider will be required to pay for the Supplemental Group Day Habilitation service since the Supplemental Group Day Habilitation service cannot be separately billed to Medicaid or the OMRDD Voucher Processing Unit.

            In cases where consumers receive both Supplemental Group Day Habilitation and Supportive CR or Supportive IRA services from the same agency, the provider must maintain documentation that clearly documents the provision of the two distinct services; that is, residential habilitation services are clearly documented as separate and distinct from services that are delivered as part of Supplemental Group Day Habilitation.   In no case can services delivered as part of Supplemental Group Day Habilitation be counted toward the Supportive CR or Supportive IRA billing requirements.

Unit of Service Rules:

The unit of service for Supplemental Group Day Habilitation is a Half Unit or Full Unit.  Supplemental Group Day Habilitation services are those services which are provided on weekday evenings or anytime on Saturday or Sunday, with special arrangements to accommodate religious calendars.  For weekday services, a program is considered "Supplemental Group Day Habilitation" if the program start time is 3 p.m. or later.   In order to bill a Half Unit, the provider must deliver a minimum of two hours of service excluding meal time.  In order to bill a Full Unit, the provider must deliver a minimum of four hours of service excluding meal time.  Staff must document service “start time” and service “stop time.”

For both a Full and a Half Unit, “billable service time” or time that “counts” involves face-to-face service provision by the Supplemental Group Day Habilitation provider’s staff or its paid contract personnel.  Where a staff person accompanies a consumer to another separately billed Medicaid service, the time spent in transit cannot be counted as Supplemental Group Day Habilitation.  The time the consumer spends actually receiving the other Medicaid service cannot be “counted” as billable Supplemental Group Day Habilitation service time either.

 

Examples:

·           A consumer arrives at the Supplemental Group Day Habilitation program on Tuesday at 7:00 p.m. and leaves to board his bus at 9:00 p.m.  The Supplemental Group Day Habilitation provider bills a Half Unit since two hours of service were delivered on that evening.

·           On Wednesday, a consumer attends Supplemental Group Day Habilitation from 4:30 p.m. to 7:30 p.m.  The consumer eats dinner from 5:30 to 6:00 p.m.  The Supplemental Group Day Habilitation provider bills a Half Unit on Wednesday since the daily “threshold” of two hours of service was delivered. 

Pricing

Each voluntary agency providing Supplemental Group Day Habilitation has a single blended Supplemental Group Day Habilitation price.  All Supplemental Group Day Habilitation prices are subject to Division of Budget approval, either through the streamlined or outlier review process.  Prices are subject to adjustments in accordance with OMRDD adjustment policy and procedures.

Billing and Payment

The Supplemental Group Day Habilitation Provider will bill either MMIS (for services provided to Waiver enrolled individuals) or the OMRDD Voucher Processing Unit (for services provided to non-Waiver enrolled individuals).  Consumers residing in Supervised Community Residences or Supervised IRAs may participate in a Supplemental Group Day Habilitation service, though, as is true for any after hours activities in which the resident participates, the Supervised IRA or Supervised CR provider is responsible for the cost.  Supplemental Group Day Habilitation provided to a Supervised IRA or Supervised CR resident cannot be separately billed to Medicaid or to OMRDD’s Voucher Processing Unit. Any Supplemental Group Day Habilitation Land and Development costs will be paid automatically in 1/12 increments each month.

Documentation Requirements

Each Supplemental Group Day Habilitation program enrollee must have an ISP and a Supplemental Group Day Habilitation Plan, which is reviewed (and revised as necessary) at least once every six months. 

1.         For each day a Full Unit of Supplemental Group Day Habilitation Service is delivered, the consumer record must contain:

A contemporaneous record of the “start and stop times” of the face-to-face provision of Supplemental Group Day Habilitation services by staff demonstrating at least 4 hours of service.    For example, where the Supplemental Group Day Habilitation provider bills a Full Unit on May 2, 2005, the consumer’s record must show, on that day, that the consumer started Supplemental Group Day Habilitation services at 3:00 p.m. and concluded at 8:00 p.m. on May 2, 2005.”  The Supplemental Day Habilitation provider may document this time in/time out information in a chart form accompanied by a staff signature and date of signing for each day of service.

Note, where the consumer participates in other Medicaid services during the Supplemental Group Day Habilitation program day (e.g., a clinic visit), the Supplemental Group Day Habilitation provider’s documentation must show both the time the consumer left the Supplemental Group Day Habilitation program to receive the other Medicaid service, and the time the consumer returned to the Supplemental Group Day Habilitation program after receiving the other Medicaid service.  For example, “August 15, 2005, Jane Doe left Supplemental Group Day Habilitation at 5:00 p.m. for a clinic visit and returned at 6:00 p.m., signed, Sally Smith – Day Habilitation Worker, 8/15/05.”

Contemporaneous documentation of at least two Supplemental Group Day Habilitation services provided by staff during the evening or Saturday or Sunday.  Services may be documented using a narrative note or checklist format.  This service must reflect the supports and services described in the Supplemental Group Day Habilitation Plan.  The service description must be expressed as a staff action.  For example: one of the required services for Supplemental Group Day Habilitation could be documented as “On our outing, I taught Susan how to purchase an item of clothing, signed John Smith, Supplemental Group Day Habilitation Worker, 5/20/04.”

A record of the consumer’s response to the Supplemental Group Day Habilitation services with the response described daily or in a monthly note.

2. For each day a Half Unit of Service is delivered, the consumer record must contain:

A contemporaneous record of the “start and stop times” of the face-to-face provision of Supplemental Group Day Habilitation services by staff.    The rules described in 1.a above apply for documenting time in/time out.

Contemporaneous documentation of at least one Supplemental Group Day Habilitation service provided by staff during the evening or Saturday or Sunday.  The rules described in 1.b above apply.

A record of the consumer’s response to the Supplemental Group Day Habilitation services with the response described daily or in a monthly note.

Transportation to/from Supplemental Group Day Habilitation

The to/from transportation funding in a provider’s current Day Habilitation prices, will continue to be included in the provider’s Supplemental Group Day Habilitation price.  The time a person spends “in transit” (i.e., on the van or bus) cannot be counted toward the Supplemental Group Day Habilitation “billable service time” for that person. 

PREVOCATIONAL SERVICES

Enrollment:

The DDSO/NYCRO authorizes the consumer’s receipt of Prevocational Services by the provider and enters the consumer’s enrollment in the TABS system.  The DDSO/NYCRO provides the Prevocational Services provider with standardized written documentation of the authorization.

           

Unit of Service Rules:

The program day for Prevocational Services is six hours.  A Full Unit of Prevocational Services can be billed when:

·        A person attends the provider’s “vocational/work program” for a minimum of four hours during the day  (excluding lunchtime), and

·        The provider delivers a minimum of two documented, individualized prevocational habilitative services in accordance with the person’s ISP and Prevocational Services Plan.

A Half Unit of Prevocational Services can be billed when:

·        A person attends the provider’s “vocational/work program” for two to four hours during the day  (excluding lunch), and

·        The provider delivers a minimum of one documented, individualized prevocational habilitative service in accordance with the person’s ISP and Prevocational Services Plan.

Note: the above reference to “vocational/work program” does not include a provider’s HCBS Waiver Supported Employment (SEMP) services.

For both a Full and a Half Unit, “billable service time” or time that “counts” is the time that the person is present at the provider’s “vocational/work program” where prevocational services are provided.  Time spent at lunch and time spent in “to/from” transportation cannot be “counted” toward the Prevocational Services program day.  To/from transportation is the transportation from the consumer’s home to Prevocational Services and the return trip home at the end of the day. 

For both a Full and a Half Unit, “billable service time” or time that “counts” involves face-to-face service provision by the Prevocational Services provider’s staff or its paid contract personnel.  Where a staff person accompanies a consumer to another separately billed Medicaid service, the time spent in transit cannot be counted as Prevocational Services.  The time the consumer spends actually receiving the other Medicaid service cannot be “counted” as billable service time either.

Examples:

·           A consumer arrives at the Prevocational Services Program at 9:00 a.m. and leaves to board his bus at 3:00 p.m.  The Prevocational Services provider bills a Full Unit on that day of service since, with one-hour off for lunch; five hours of service were delivered on that day.

·           A consumer is regularly scheduled to attend the Prevocational Services Program from 9:00 a.m. to 3:00 p.m., though, on this particular day, the consumer’s bus is late getting to the program and the consumer arrives at 10:00 a.m.  The consumer eats lunch from noon to 1:00 p.m.  The Prevocational Services provider bills a Full Unit on that day of service since the daily billing “threshold” of four hours of service was delivered on that day.

·           A consumer is regularly scheduled to attend Prevocational Services from 9:00 a.m. to 3:00 p.m., except on Wednesdays when he receives an hour of physical therapy from a clinic.  On Wednesday the consumer arrives at Prevocational Services at 9:00 a.m., eats lunch from noon to 1:00 p.m., and receives a separately billed clinic service from 1:00 p.m. to 2:00 p.m.  The consumer resumes Prevocational Services participation at 2:00 p.m. and leaves at 3:00 p.m.  The Prevocational Services provider bills a Full Unit on Wednesday since the daily “threshold” of four hours of service was delivered.  In this example, the provider documents the person’s time in/time out, because the person received another Medicaid service during the Prevocational Services program day.

·           A consumer is scheduled to participate in Prevocational Services from 9:00 a.m. to noon.  However, after one hour, the work is completed and the consumer receives Group Day Habilitation for the remainder of the day.  The Prevocational Services provider does not bill for Prevocational Services that day since the daily billing threshold of two hours for a Half Unit of Prevocational Services has not been achieved.

Pricing

Each voluntary agency has a single blended Prevocational Services price.   All Prevocational Services’ prices are subject to Division of Budget approval, either through the streamlined or outlier review process.   Prices are subject to adjustments in accordance with OMRDD adjustment policy and procedures.

Billing and Payment

The Prevocational Services Provider will bill either MMIS (for services provided to Waiver enrolled individuals) or the OMRDD Voucher Processing Unit (for services provided to non-Waiver enrolled individuals). 

 Documentation Requirements

Each Prevocational Services program enrollee must have an ISP which identifies the Prevocational Services provider and a Prevocational Services Plan, which is reviewed (and revised as necessary) at least once every six months. 

1.         For each day a Full Unit of Service is delivered, the consumer record must contain:

a          Documentation that at least four hours of Prevocational Services was delivered during the course of the day.  In an audit, the agency must provide documentation that the four hour minimum program day duration requirement was met.  The program day duration may be documented by recording the program start time and stop time on that day (e.g., John’s program started at 8:30 a.m. and program ended at 3:30 p.m. on April 5, 2005).  This requirement may also be met with a statement that the minimum program day duration was met on that day (e.g., “John’s program day duration met the 4 hour minimum on August 9, 2005”).  This statement regarding the program day duration may be documented in a narrative note or a checklist format. Note, that the total program day duration excludes time spent at lunch, time at another Medicaid service or time spent travelling to Prevocational Services at the start of the program day and return transportation at the end of the program day.

            Also, where the consumer participates in other Medicaid services (e.g., a clinic visit) during the Prevocational Services program day, the Prevocational Services provider’s documentation must show “time in/time out” for the Prevocational Services.  For example, “May 20, 2004, John Doe participated in Prevocational Services from 9:00 a.m. to noon.  He left the program at 1:00 p.m. to receive another Medicaid service.  Prevocational Services were again provided from 2:00 p.m. to 3:00 p.m., signed, Sally Smith – Prevocational Services Worker, 6/21/04.”

      The Prevocational Services provider may document this “time in/time out” information in a chart form accompanied by a staff signature and date of signing for each day of service.

b.                 Contemporaneous documentation of at least two individualized Prevocational Services provided by staff during the day.  Services may be documented using a narrative note or checklist format.  These services must reflect the supports and services described in the Prevocational Services Plan.  The service description must be expressed as a staff action.  For example: one of the two services required for a Full Unit of billing could be documented as “Worked with John to keep him focused on his assembly task, signed Sally Smith, Prevocational Services Worker, 5/20/04.”

c.                  A record of the consumer’s response to the Prevocational Services with the response described daily or in a monthly narrative note.

2.         For each day a Half Unit of Service is delivered, the consumer record must contain:

a.      Documentation that at least two hours of Prevocational Services were delivered during the course of the day.  See 1.a above for additional documentation instructions.

b.     Contemporaneous documentation of at least one Prevocational service provided by staff during the day.  See 1.b above for additional documentation instructions.

c.      A record of the consumer’s response to the Prevocational service with the response described daily or in a monthly note.

DAILY LIMIT ON PAYMENT OF GROUP DAY HABILITATION, SUPPLEMENTAL GROUP DAY HABILITATION, DAY TREATMENT AND PREVOCATIONAL SERVICES

Rule # 1: Exact Duplication System Edits

Medicaid will not pay a claim when an “exact duplicate” claim has already been processed.  A claim is an “exact duplicate” when the provider, the service (rate code), consumer and date of service are identical. 

Thus, when billing MMIS or OMRDD for Prevocational Services, a single provider cannot submit two Half Unit claims for Group Day Habilitation, or two Half Unit claims for Prevocational Services, or two Half Unit claims for Supplemental Group Day Habilitation.  Instead, all “service time” must be “added together” and a single Full Unit claim must be submitted where the four hour minimum duration is achieved.

 

Rule #2: Maximum 1½ Units Per Person Per Day for Group Day Habilitation and Prevocational Services

On a given day, providers will be paid for no more than 1½ Units of service provided to a consumer (either one Full and one Half Unit or three Half Units) of:

·        Group Day Habilitation alone,

·        Prevocational Services alone, or

·        Any combination of Group Day Habilitation or Prevocational Services.

This rule applies where a single provider or multiple providers render the service.  An edit will be developed in MMIS that will prohibit two Full Units to be paid on the same day.  Similar edits will be developed for processing “mirrored” payments for services delivered to non-HCBS enrolled consumers.  Note, a Full Unit of Supplemental Group Day Habilitation may be paid on the same day that a Full Unit of either Group Day Habilitation or Prevocational Services is paid.

If a consumer participates in Day Treatment on the same day he or she participates in Group Day Habilitation, or Prevocational Services, then a similar limit also applies.   If a Day Treatment provider bills a Full Day Unit of Day Treatment for a consumer, then no more than one Half Unit of either Group Day Habilitation, or Prevocational services may be billed on the same day.  If a Day Treatment provider bills a Half Day Unit of Day Treatment for a consumer, a consumer may also receive either one Full Unit or two Half Units of any combination of the HCBS Waiver Day services.

Example 1:

A consumer attends Group Day Habilitation on Tuesday from 10 a.m. to 4 p.m., and the provider bills a Full Unit of Group Day Habilitation.  Later in the evening, the same consumer participates in another provider’s Supplemental Group Day Habilitation service for two hours.  The second provider bills a Half Unit of Supplemental Group Day Habilitation.  MMIS will pay both the Full Unit and the Half Unit claim.  Similarly, if “mirrored” services are provided, OMRDD will pay both the Full Unit and the Half Unit claim.

Example 2:

A consumer attends Prevocational Services on Thursday from 8:30 a.m. to 1:30 p.m. with an hour break for lunch, and the provider bills a Full Unit of Prevocational Services.  Later in the day, the consumer participates in Group Day Habilitation services from 2:00 p.m. to 6:00 p.m.   MMIS will NOT pay two Full Unit claims on the same day for the same person. Similarly, if “mirrored” services are provided, OMRDD will NOT pay two Full Unit claims on the same day for the same person.


Individual Day Habilitation and

Supplemental Individual Day Habilitation

OVERVIEW

            This document describes the Unit of Service Proposal for Individual Day Habilitation and Supplemental Individual Day Habilitation.  These services are designed to provide services to a single enrolled consumer.  Services are provided by one (or more) staff person(s) to one consumer. 

            Services typically occur in a variety of community settings where the consumer engages in local community life based on his or her interests and values.  One-on-one staff support is provided during these community experiences.  The service may include planned volunteer activities with a staff person providing intermittent “one-on-one” visits to the volunteer placement. 

Supplemental Individual Day Habilitation

The two types of Individual Day Habilitation are distinguished by the schedules of service delivery.  When services are delivered on weekdays and have a service start time prior to 3:00 p.m., the service is known as “Individual Day Habilitation.”  “Supplemental Individual Day Habilitation” services are delivered on a weekday with the start time after 3:00 p.m. or anytime on weekends, with special arrangements to accommodate religious calendars.

Supplemental Individual Day Habilitation is a service designed for people living at home, in Supportive IRAs, in Supportive CRs, or in family care homes.  Payment from Medicaid or the OMRDD Voucher Payment Unit for Supplemental Individual Day Habilitation is allowable only for consumers living in these residential settings.  Consumers residing in Supervised CRs or Supervised IRAs may participate in the Supplemental Individual Day Habilitation service; although, as with any after-hours activities in which the resident participates, the Supervised IRA or Supervised CR provider is responsible for the cost.  Supplemental Individual Day Habilitation services provided to Supervised IRA or Supervised CR residents cannot be separately billed to Medicaid.

Hallmarks of Individual Day Habilitation and Supplemental Individual Day Habilitation Services

            Individual Day Habilitation and Supplemental Individual Day Habilitation are distinct “stand-alone” services, and as such, are not components of a larger Group Day Habilitation program.  For example, if participants in a Group Day Habilitation program receive one-on-one services for a portion of their Group Day Habilitation program day, these one-on-one service times are a component of the Group Day Habilitation program and not an Individual Day Habilitation service. While Group Day Habilitation offers individualized services and provides one-to-one supports intermittently, Individual Day Habilitation and Supplemental Individual Day Habilitation involves staff and a single consumer as the regular, scheduled mode of service delivery.

Consumers will be enrolled in a provider’s Individual Day Habilitation or Supplemental Individual Day Habilitation service only after a careful review by the DDSO/NYCRO of the planned services the consumer will receive.  Approval of the services will be granted only where the Habilitation Plan and proposed schedule of services identify that services are predominantly delivered with a one-on-one staff to consumer ratio.  The DDSO/NYCRO will expect that the consumer’s schedule has at least 90% of services regularly delivered with a one-on-one staff ratio.

           

Unit of Service Design for Individual Day Habilitation and Supplemental Individual Day Habilitation

Enrollment:

An agency may not provide and be paid for Individual Day Habilitation or Supplemental Individual Day Habilitation services, unless the DDSO/NYCRO first authorizes the service provision.  The DDSO/NYCRO reviews the community-based services/program planned for the consumer to confirm that at least 90% of the time, the services will be delivered with a “one-to-one” staff to consumer ratio.  The DDSO/NYCRO authorizes the provider to deliver the Individual Day Habilitation or the Supplemental Individual Day Habilitation and enters the consumer’s enrollment in the TABS system.  The DDSO/NYCRO provides the Individual Day Habilitation or Supplemental Individual Day Habilitation provider with standardized written documentation of the service authorization. 

Unit of Service:

The unit of service for Individual Day Habilitation and Supplemental Individual Day Habilitation is an hour.  Services are billed in 15 minute segments or “billing units.”   When determining the “billable service time,” only face-to-face or in-person service delivery by staff actively providing a habilitation service “counts.”  Staff can be “regular” payroll staff or staff under contract with the Day Habilitation provider. 

Billable Service Time

For both Individual Day Habilitation and Supplemental Individual Day Habilitation, “billable service time” or time that “counts” involves face-to-face or in-person service provision by the provider’s staff or its paid contract personnel.  


Examples:

·        The Individual Day Habilitation provider works with the Public Library to establish a volunteer experience for the consumer.  The consumer stacks books at the Library weekdays from 9:00 a.m. to noon.  Individual Day Habilitation program staff come each morning from 9:00 a.m. to 10:00 a.m. to help orient the consumer.  The Individual Day Habilitation provider bills four quarter hour billing units.  This is the time the Individual Day Habilitation staff provided face-to-face service.  Both time the staff person spends working with the Public Library personnel to establish the volunteer position and time the consumer spends at the Library on his own on weekdays from 10:00 a.m. to noon does not qualify as “billable service time.”

·        As part of his Supplemental Individual Day Habilitation service, a person volunteers at a nursing home five evenings a week.  It is only on Friday, from 4:00 p.m. to 5:00 p.m. that Supplemental Individual Day Habilitation staff visit the nursing home and provide face-to-face Supplemental Individual Day Habilitation services to the person.  In this case, the total billable service time for the week is one hour (or four, quarter hour billing units) for services delivered on Friday.  There is no billable service time on the other days of the week.

Time spent in the following activities cannot be “counted” as “billable service time,” however; the cost associated with these group activities can be included in the calculation of the Individual Day Habilitation and Supplemental Individual Day Habilitation price:

Group Activities

Up to 10% of the Individual Day Habilitation or Supplemental Individual Day Habilitation schedule may be devoted to group activities.  Although the schedule may include group activities, the time spent in the group activities cannot be counted as “billable service time.” 

Example:

·                    A consumer volunteers in a Library for 4 hours on Monday, and then travels with the Individual Day Habilitation staff person to a local gym for a game of basketball with other consumers who also participate in Individual Day Habilitation services.  The time when the group of consumers gather to play basketball cannot be “counted” as Individual Day Habilitation “billable service time.” 


Same Day Medicaid Services

Where a staff person accompanies a consumer to another separately billed Medicaid service, the time spent in transit cannot be counted as Individual Day Habilitation or Supplemental Individual Day Habilitation.  The time the consumer spends actually receiving the other Medicaid service cannot be “counted” as billable service time either.  Where a person receives another Medicaid service during his or her Individual Day Habilitation or Supplemental Individual Day Habilitation program day, the provider must document the time the person leaves Individual Day Habilitation or Supplemental Individual Day Habilitation service to receive the other Medicaid service, and the time the person returns to Individual Day Habilitation or Supplemental Individual Day Habilitation. 

Example:

·                    On Friday the consumer receives Individual Day Habilitation services from staff. Services begin at 9:00 a.m. and are provided at the Public Library.  At 1:00 p.m. the consumer and the Individual Day Habilitation staff person leave the Library to go to a doctor’s appointment and return to the Library at 2:30 p.m.  The consumer’s Individual Day Habilitation services provided by the Individual Day Habilitation staff person continue until 4:00 p.m.  In this situation, the total billable service time for the day is 5½ hours (4 hours from 9:00 a.m. – 1:00 p.m. and an additional 1½ hours from 2:30 p.m. – 4:00 p.m.).  The Individual Day Habilitation provider must document the service “stop time” when the staff person and consumer leave the Library to travel to the doctor’s office, and the “start time” when they return to the Library and Individual Day Habilitation services resume. 

Transportation to and from Home

Even when accompanied by staff, time spent in transportation to the first Individual Day Habilitation or Supplemental Individual Day Habilitation service of the day from the consumer’s home, and the return trip from the last activity of the day to the consumer’s home cannot be counted toward the Individual Day Habilitation or Supplemental Individual Day Habilitation “billable service time.” 

Example:

·                    The Individual Day Habilitation staff person picks the consumer up at her house at 9:30 a.m. and drives the consumer to the hospital where the consumer volunteers as part of her Individual Day Habilitation service.  At 10:00 a.m., the staff person and the consumer arrive at the hospital and Individual Day Habilitation services begin.  The volunteer experience with the Individual Day Habilitation staff person present lasts until 2:00 p.m., when the staff person drives the consumer back to her house.  The “billable service time” is 4 hours (10:00 a.m. – 2:00 p.m.).  The time spent driving to and from the consumer’s home is not “countable.”

There is one exception to the rule regarding transportation to and from the person’s home.  Time spent traveling to and from the home may be “counted,” if time-limited travel training services are being provided (see below for further information).

Time spent in the following activities can be “counted” as “billable service time”:

Time-Limited Travel Training

Travel training provided by Individual Day Habilitation staff or Individual Supplemental Day Habilitation staff during the consumer’s trip to and from home can be counted as billable service time. Travel training must be:

·        Provided on a time-limited basis; and

·        Specifically identified in the consumer’s Habilitation Plan.

Example:

·                    On Wednesday, the Individual Day Habilitation staff person picks the consumer up at his house at 9:00 a.m. to travel to the first Individual Day Habilitation activity.  As described in the consumer’s Habilitation Plan, the Individual Day Habilitation staff person teaches the consumer to use public transportation to get to the first Individual Day Habilitation activity which is a volunteer activity at the local park.  The staff person remains with the consumer for two hours at the park from 9:30 a.m. to 11:30 a.m.  On the return trip to the consumer’s home, the staff person again provides travel-training services.  They arrive at the consumer’s home at noon.  Because this time-limited travel training is described in the person’s Habilitation Plan, the entire period from 9:00 a.m. to noon is “countable service time.”

Internal or ‘site-to-site’ transportation is the transportation between community sites where Individual Day Habilitation or Supplemental Individual Day Habilitation services are provided by staff.  This transportation is distinct from transportation to and from the consumer’s home.  The provider may “count” the time spent in internal or site-to-site transportation, where the Individual Day Habilitation or Supplemental Individual Day Habilitation staff person accompanies the consumer.

Example:

·                    A consumer’s schedule for Individual Day Habilitation services includes planned activities at the Library and at a local art studio where the consumer participates in classes with the assistance of the Individual Day Habilitation staff person.  At 10:00 a.m., the staff person and the consumer arrive at the Library to begin Individual Day Habilitation Services.  At 1:30 p.m., the staff person drives the consumer to the art studio for the consumer’s 2:00 p.m. art class.  The class ends at 3:30 p.m., when the staff person drives the person home at the end of the day.  The “countable service time” in this situation is 5½ hours or 22 billing units (beginning when the consumer arrives at the Library, through the end of the art class).  The time spent driving from the Library to the art studio is “internal transportation” time, and is therefore part of the “countable service time” for the day.

Mealtime

Mealtime may be included in the Individual Day Habilitation or Supplemental Individual Day Habilitation “billable service time” only where staff are present and providing one-on-one services specified in the consumer’s Day Habilitation Plan.

Example:

·                    A consumer participates in Individual Day Habilitation services from 10:00 a.m. to 2:00 p.m.  On Monday, the staff person and the consumer go to a restaurant at noon.  While at the restaurant, one-on-one services are provided (teaching the consumer to select items from the menu).  The time spent at the restaurant is “countable.”

Pricing:

Each voluntary agency providing Individual Day Habilitation has a single, blended Individual Day Habilitation price. Each voluntary agency providing Supplemental Individual Day Habilitation has a single, blended Supplemental Individual Day Habilitation price.  All Day Habilitation prices are subject to Division of Budget approval, either through the streamlined or outlier review process.   Prices are subject to adjustments in accordance with OMRDD adjustment policy and procedures.

Billing and Payment:

The Individual Day Habilitation and Supplemental Individual Day Habilitation provider bills either MMIS (for services provided to Waiver-enrolled individuals) or the OMRDD Voucher Processing Unit (for services provided to non-Waiver-enrolled individuals).

Documentation Requirements:

·           Each Individual Day Habilitation and Supplemental Individual Day Habilitation program enrollee must have an ISP which identifies the Individual Day Habilitation or Supplemental Individual Day Habilitation provider and a Day Habilitation Plan, which is reviewed (and revised as necessary) at least once every six months. 

·           Additionally, for each day on which Individual Day Habilitation or Supplemental Individual Day Habilitation is billed there must be:

a.      A contemporaneous record of the actual “start and stop times” of the face-to-face provision of Individual Day Habilitation or Supplemental Individual Day Habilitation services by staff.   For example, where the Individual Day Habilitation provider bills four quarter hour billing units on May 2, 2003, the consumer’s record must show that “John Doe, Individual Day Habilitation staff member provided service from 9:00 a.m. to 10:00 a.m. on May 2, 2003.”  The notation must be signed and dated by the staff member. The Individual Day Habilitation provider may document this time in/time out information in a chart form accompanied by a staff signature and date of signing for each day of service.

b.     Contemporaneous Documentation of at least one face-to-face Individual Day Habilitation or Supplemental Individual Day Habilitation Service staff provided during any continuous service delivery period.  Services may be documented using a narrative note or checklist format.  For example:  The Individual Day Habilitation staff person orients the consumer to her volunteer job at the animal shelter from 9:00 a.m. to 11:00 a.m.  The Individual Day Habilitation provider bills eight quarter hour billing units.  For this period of service the staff person must document at least one Individual Day Habilitation service.  If on another day the staff person works with the consumer from 9:00 a.m. to 10:00 a.m., leaves the consumer on her own at the animal shelter and then returns for half hour, later in the day, to help the consumer board the bus for home, there must be documentation of at least two Individual Day Habilitation services; one service delivered during the 9:00 a.m. -10:00 a.m. period of billable service time and one service provided during the half hour of countable time later in the day.  

c.      A record of the consumer’s response to the Individual Day Habilitation or Supplemental Individual Day Habilitation services with the response described daily or in a monthly narrative note.

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