Home and Community-Based Services (HCBS) under the Home and Community-Based Living at Home (LAH) Waiver for persons with Intellectual Disabilities are defined as Title XIX Medicaid-funded services provided to Revised 5\15\22 52-2individuals with intellectual disabilities who, without these services, would require services in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID). These HCBS under the LAH Waiver will provide health, social, and related support needed to ensure optimal functioning of individuals with intellectual disabilities within a community setting. The operating agency may provide or subcontract for any services provided in this waiver. To qualify for Medicaid reimbursement each individual HCBS must be necessary to prevent institutionalization. Each provider of services must have a signed provider contract, meet provider qualifications and comply with all applicable state and federal laws and regulations. Services that are reimbursable through Medicaid's EPSDT Program shall not be reimbursed as HCBS under the LAH Waiver. The following are specific HCBS available under the LAH Waiver:

1. (1) Day Habilitation Services

   1. (a) Day Habilitation Services are services which involve the provision of regularly scheduled activities in non-residential settings, separate from the member’s residence or other residential living arrangement. This service can be provided in a Day Habilitation Facility or in the Community. Activities focus on assistance with acquisition, retention, or improvement in self-help, socialization and adaptive skills that enhance social integration and outcomes. Activities are designed to foster the acquisition of positive social skills and interpersonal competence, greater independence and ability to exercise and communicate personal choices and preferences. Day Habilitation Services also provide assistance that supports community participation including achievement of valued social roles that reflect a member’s individualized interests and desires with regard to type(s) of community involvement and community contributions the member prefers.
   2. (b) Day Habilitation Services focus on enabling the member to attain and maintain his or her maximum potential and shall be coordinated with any needed therapies in the member’s person-centered services and support plan, such as physical, occupational, or speech therapy. Day Habilitation services shall support and enhance, rather than supplant, an individual’s involvement in public education, post-secondary education/training and competitive integrated employment (or services designed to lead to competitive integrated employment).
   3. (c) Day Habilitation Services are expected to be furnished in a variety of settings in the community, except for the member’s residence, that may utilize a provider-owned or controlled setting as a hub or base. Day Habilitation settings must comply fully with the HCBS Settings Rule, therefore ensuring each member’s Day Habilitation service plan includes opportunities to participate in a variety of community-based activities that are consistent with the purpose and intended outcome of the service and that facilitate the member’s interactions with people from the broader community.
   4. (d) The provider for Day Habilitation Services can be reimbursed based on four levels of Day/Community Habilitation and four levels of Day/Community Habilitation Transportation. Reimbursement rates are associated with each level, based on the associated minimum staffing ratios needed to support persons with different ICAP scores and whether the service is delivered in a facility-based (provider controlled) setting or an integrated community setting, taking account of the more intensive staffing ratios and different costs that are applicable for services delivered in integrated community settings.
   5. (e) Day Habilitation Services cannot exceed five hours per day. Day Habilitation Services may not be used to provide activities involving paid work, including any situation where work done by a member is required to be paid under state and federal labor laws.
   6. (f) Transportation between the Day Habilitation facility and one or more integrated community sites for integrated service delivery time is always included in the service and accounted for in the rate for the service. Transportation between the member’s place of residence and the Day Habilitation facility, or site where the member starts and ends Day Habilitation services each day, shall either be, included as a component part of Day Habilitation or arranged for the member in another way. If this transportation is provided by the Day Habilitation provider, the cost of this transportation shall be included and accounted for in the rate paid to the provider. All providers of transportation shall ensure that the provider qualifications for specialized (community) transportation are met.

2. (2) Prevocational Services

   1. (a) Prevocational services are designed to create a path to competitive integrated employment, which includes competitive integrated self-employment and customized employment or customized self-employment that otherwise meets the criteria for being competitive and integrated. Competitive integrated employment is employment that meets all of the following criteria:

      1. 1. Ensures compensation is at least the locally established minimum wage where the member works.
      2. 2. Occurs in a location typically found in the community.
      3. 3. Enables the member to interact with co-workers and customers to the same extent as a person without a disability filling a similar position.
      4. 4. For wage employment, ensures the employer of record is the business or organization benefitting from the work done by the member.
      5. 5. Offers the member an individualized position.
   2. (b) Prevocational services involve the provision of learning and skill-building experiences, including community-based volunteering for an organization other than the service provider, where a member can develop general, non-job-task-specific strengths and skills that contribute to employability in competitive integrated employment. Services are intended to develop and teach general skills for competitive integrated employment, including but not limited to: ability to communicate effectively with supervisors, coworkers and customers; generally accepted community workplace conduct and dress; ability to follow directions; ability to attend to tasks; workplace problem solving skills and strategies; and general workplace safety and mobility training.
   3. (c) Prevocational services are expected to be furnished in a variety of settings in the community, except for the member’s residence or other waiver-funded residential settings. While a provider may utilize a provider-owned or controlled setting as a hub or base for service delivery, and that setting may include individuals without disabilities who are not receiving HCBS, prevocational services must be delivered consistent with all of the requirements of the HCBS Setting Rule, therefore ensuring each individual’s Prevocational service plan includes opportunities to participate in a variety of community-based activities that are consistent with the purpose and intended outcome of the service and that facilitate the individual’s access to the broader community and interactions, in the broader community, with people not receiving HCBS.
   4. (d) Reimbursement rates are associated with the minimum staffing ratios needed to support persons based on whether the service is delivered in a facility-based (provider controlled) setting or an integrated community setting, taking into account the different staffing ratios and different costs that are applicable for services delivered in integrated community settings.
   5. (e) Transportation between the individual’s place of residence and the provider facility, or site where the individual starts and ends Prevocational services each day, is included as a component part of the service or arranged for the individual in another way. Transportation during the service is always a component part of the service.
   6. (f) Prevocational services are not otherwise available to the member, in a timeframe that is otherwise typical, through a program funded by ADRS under the section 110 of the Rehabilitation Act of 1973 or, for individuals ages 18-22, through a program funded under the Individuals with Disabilities Education Act (IDEA) (20 U.S.C.1401 et seq).

3. (3) Supported Employment Services

   1. (a) There are three variations of Supported Employment Services: (1) Individual Assessment/Discovery (2) Small Group and (3) Individual.

      1. 1. Individual Assessment/Discovery is a one-time, time-1imited target service designed to help a waiver recipient who wishes to pursue individualized, integrated employment or self-employment. Discovery may involve a comprehensive analysis of the waiver recipient’s history; interviews with family, friends and support staff; observing the waiver recipient performing work skills; and career research in order to determine the waiver recipient’s career interests, talents, skills, support needs and choice; and the writing of a Profile, which may be paid for through waiver funds in order to provide a valid assessment for Vocational Rehabilitation (VR) services, which will begin with the development of an employment plan through VR.
      2. 2. Employment Small Group often consists of groups of waiver recipients being supported in enclave or mobile work crew activities. Employment Small Group are services and training activities provided in regular business, industry, and community settings for groups of two to eight workers with disabilities.

      3. 3. Employment Individual services are the ongoing support to waiver recipients obtain and maintain an individual job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce for which a waiver recipient is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities. Employment Individual includes two distinct services: Job Developer and Job Coach.

         1. (i) The Job Developer duties include, but are not limited to, marketing the Supported Employment Service and the waiver recipient’s skills; negotiating hours or location to meet the abilities of the waiver recipient; and job placement.
         2. (ii) The Job Coach enters once placement has been arranged. The Job Coach duties include, but are not limited to, assisting with training of waiver recipients in supported work to perform specific jobs consistent with their abilities; teaching waiver recipients associated work skills, responsibilities and behaviors not related to the specific job being performed; and providing continued ongoing support to waiver recipients in supported work.
   2. (b) Supported Employment Services are conducted in a variety of settings, particularly, work sites in which persons without disabilities are employed. Supported employment includes activities needed to sustain paid work by waiver recipients, including supervision and training.
   3. (c) When Supported Employment Services are provided at a work site in which persons without disabilities are employed, payment will be made only for the adaptations, supervision and training required by individuals receiving waiver services as a result of their disabilities. Payment for the supervisory activities rendered as a normal part of the business setting will not be made.
   4. (d) Supported Employment Services are not available to waiver recipients eligible for benefits under a program funded by either Section 110 of the Rehabilitation Act of 1973, or Section 602 (16) and (17) of the Education of the Handicapped Act.

   5. (e) Medicaid reimbursement shall not be claimed for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

      1. 1. Incentive payments made to an employer to encourage or subsidize the employer's participation in a supported employment program;
      2. 2. Payments that are passed through to users of supported employment programs; or
      3. 3. Payments for vocational training that is not directly related to an individual’s supported employment program.
   6. (f) Transportation will be provided between the waiver recipient’s place of residence and the site of the habilitation services or between habilitation sites (in cases where the waiver recipient receives habilitation services in more than one place) as a component part of habilitation services. The cost of this transportation is included in the rate paid to providers of the appropriate type of habilitation services.
   7. (g) Supported Employment Transportation Services can be authorized, under special circumstances, intended to be limited in scope, duration, and not to exceed the annual cap.
   8. (h) Providers of supported employment must be certified by the Department of Mental Health.
   9. (i) Supported Employment Services also include activities needed to sustain paid employment by waiver recipients, including supervision and training.

4. (4) Occupational Therapy Services

   1. (a) Occupational Therapy Services are the application of occupation-oriented or goal-oriented activity to achieve optimum functioning, to prevent dysfunction, and to promote health. Occupational Therapy Services include assisting in the evaluation of a waiver recipient to determine level of functioning by applying diagnostic and prognostic tasks and guiding and treating waiver recipients in the prescribed therapy to secure and/or obtain necessary functioning.
   2. (b) Therapists may also provide consultation and training to staff or caregivers (such as waiver recipient’s family and/or foster family). Consultation/Training Services to direct caregivers will be allowed when the service to caregivers is for the direct benefit of the recipient and is necessary to enable the recipient to be cared for outside of an institution.
   3. (c) Occupational Therapy requires a physician's prescription and documentation in the form of an initial assessment and development of a treatment plan with established goals that must be present in the case record and must justify the need for service. Services must be listed on the care plan and be provided and billed in 15-minute units of service. Occupational therapy is limited to no more than 50 hours or 200 units for the initial plan.
   4. (d) Occupational Therapy Services under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan. Group therapy will not be reimbursed.
   5. (e) Providers of service must maintain a service log that documents specific days on which occupational therapy services were delivered. Occupational therapists must document each therapy session in a treatment note and must sign each note denoting whether or not progress is made. The use of e-signatures that meets privacy and security requirements will be allowed as a method for signing off on required documents such as the participant or legal guardian signing the PCP to indicate approval of the treatment plan.

5. (6) Speech and Language Therapy Services

   1. (a) Speech and Language Therapy Services are diagnostic, screening, preventive, corrective services provided on an individual basis, when referred by a physician (M.D., D.O.).

   2. (b) These services may include:

      1. 1. Screening and evaluation of waiver recipients’ speech and hearing functions and comprehensive speech and language evaluations when so indicated;
      2. 2. Participation in the continuing interdisciplinary evaluation of waiver recipients for purposes of implementing, monitoring and following up on waiver recipients’ habilitation programs; and

      3. 3. Treatment services as an extension of the evaluation process that include:

         1. (i) Consulting with others working with the waiver recipient for speech education and improvement,
         2. (ii) Designing specialized programs for developing a waiver recipient’s communication skills comprehension and expression.
   3. (c) Therapists may also provide training to staff and caregivers (such as a waiver recipient’s family and/or foster family). Services to direct caregivers will be allowed when the service to caregivers is for the direct benefit of the waiver recipient and is necessary to enable the waiver recipient to be cared for outside of an institution.
   4. (d) Speech and Language Therapy Services must be listed on the care plan and prescribed by the participant's physician and related to a participant’s particular diagnosis. An evaluation is required by the speech therapist to determine the need for service. The need for service must be documented in the case record. Services shall be provided and billed as an encounter unit of service. Documentation of service provided by the speech therapist is required for each encounter and each note must be signed by the therapist. Notes must be maintained in the client file. The use of e-signatures that meets privacy and security requirements will be allowed as a method for signing off on required documents such as the participant or legal guardian signing the PCP to indicate approval of the treatment plan.
   5. (e) Speech and Language Therapy Services are covered under the State Plan for eligible waiver recipients as a result of an EPSDT screening. Therefore, this service is limited to waiver recipients age 21 and over. Group therapy will not be reimbursed.
   6. (f) Providers of service must maintain a service log that documents specific days on which Speech and Language Therapy Services were delivered.

6. (6) Physical Therapy Services

   1. (a) Physical Therapy Services include assisting in the determination of a waiver recipient's level of functioning by applying diagnostic and prognostic tasks and providing treatment training programs that are designed to:

      1. 1. Preserve and improve abilities for independent function, such as range of motion, strength, tolerance, coordination and facility performing activities of daily living; and
      2. 2. Prevent irreducible progressive disabilities through means such as the use of orthotic and prosthetic appliances, assistive and adaptive devices, positioning, behavior adaptations and sensory stimulation.
   2. (b) Therapists may also provide consultation and training to staff or caregivers (such as waiver recipient’s family and/or foster family). Services to direct caregivers will be allowed when the service to caregivers is for the direct benefit of the waiver recipient and is necessary to enable the waiver recipient to be cared for outside of an institution.
   3. (c) Physical Therapy requires a physician's prescription and documentation in the form of an initial assessment and development of a treatment plan with established goals that must be present in the case record and must justify the need for service. Providers of service must maintain a service log that documents specific days on which physical therapy services were delivered. A physical therapist must document each treatment note and must sign each note denoting whether or not progress is made. The use of e-signatures that meets privacy and security requirements will be allowed as a method for signing off on required documents such as the participant or legal guardian signing the PCP to indicate approval of the treatment plan.
   4. (d) Services must be listed on the care plan and be provided and billed in 15-minute units of service. Physical therapy is limited to no more than 50 hours or 200 units for the initial plan.

7. (7) Positive Behavior Support Services

   1. (a) Positive Behavior Support Services provide systematic functional behavior analysis, behavior support plan (BSP) development, consultation, environmental manipulation and training to implement the BSP, for waiver recipients whose maladaptive behaviors are significantly disrupting their progress in habilitation, self-direction or community integration, whose health is at risk, and/or who may otherwise require movement to a more restrictive environment. Positive Behavior Support Services may include consultation provided to families, other caretakers, and habilitation services providers. Positive Behavior Support Services shall place primary emphasis on the development of desirable adaptive behavior rather than merely the elimination or suppression of undesirable behavior.
   2. (b) A behavior management plan may only be used after positive behavioral approaches have been tried, and its continued use must be reviewed and re-justified in the case record every thirty (30) days. The unit of service is 15 minutes.

   3. (c) The Positive Behavior Support Service has three service provider levels: two professional levels and one technical level, each with its own procedure code and rate of payment. The Positive Behavior Support Service levels are distinguished by the supervision requirements and qualifications of the provider. Both professional and technical level service providers may perform tasks within both service categories, adhering to supervision requirements that are described under provider qualifications.

      1. 1. Level 1 professional providers are required to have advanced degrees, specialization, and board certification in behavior analysis.
      2. 2. Level 2 professional providers are required to have advanced degrees and specialization with three years of experience working with waiver recipients. Professional providers at Level 2 who do not have a Doctorate degree require supervision by a Level 1 professional provider.
      3. 3. Level 3 technical providers are required to be either a QIDP or a Board Certified Assistant Behavior Analyst (BCABA). Level 3 technical providers require supervision by either a Level 1 professional provider or a Level 2 professional Doctoral provider.
   4. (d) Positive Behavior Support Services tasks include the development of a BSP and implementation of the BSP in accordance with functional behavior analyses.
   5. (e) Providers of Positive Behavior Support Service must maintain a service log that documents specific days on which services are delivered. Group therapy will not be reimbursed.
   6. (f) The maximum units of Positive Behavior Support Service per year of both professional and technician level units combined cannot exceed 1200 and the maximum units of service of professional level cannot exceed 800.
   7. (g) Positive Behavior Support Services under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan.

8. (8) Respite Care Services

   1. (a) Respite care is a service provided in or outside a family's home to temporarily relieve the primary caregiver. Respite care provides short-term care to an adult or child for a brief period of rest or relief for the family from day-to-day care giving for a dependent family member. Respite is intended for participants whose primary caregivers typically are the same persons day after day (e.g. family members and/or adult family foster care providers) and is provided during those portions of the day when the caregivers typically provide care. Relief needs of hourly or shift staff workers will be accommodated by staffing substitutions, plan adjustments, or location changes, and not by respite care. Respite care typically is scheduled in advance, but it can also serve as relief in a crisis situation.
   2. (b) The limitation on either in-home or out-of-home Respite Care Services shall be provided up to a maximum of 1080 hours or 45 days per waiver recipient per waiver year.

   3. (c) Respite Care Services can be self-directed, and the employer of record (EOR) may hire, supervise, or fire the employee delivering the services. A relative may serve as a self-directed respite worker to a waiver participant as long as

      1. 1. The relative is not a legally responsible individual or legal guardian
      2. 2. The relative is not a primary caregiver to the participant
      3. 3. The relative is otherwise qualified to provide these services and
      4. 4. The relative does not also serve as the same participant’s representative/Employer of Record (EOR). The participant, EOR, and worker must be trained on identifying Abuse, Neglect and Exploitation, who to report to and the timeframes to report any incidents.
   4. (d) Out-of-home Respite Care Services may be provided in a certified group home or ICF/IID. In addition, if the waiver recipient is less than 21 years of age, out-of-home Respite Care Services may be provided in a JCAHO Accredited Hospital or Residential Treatment Facility (RTF). While a waiver recipient is receiving Out-of-Home Respite Care Services, no additional Medicaid reimbursement will be made for other services in the institution.
   5. (e) Medicaid reimbursement shall not be claimed for the cost of room and board except when provided as part of respite care furnished in a facility approved by the State that is not a private residence.

9. (9) Personal Care Services

   1. (a) Personal Care Services provide assistance with any activity of daily living (ADL) or instrumental activity of daily living (IADL). Assistance for ADLs includes bathing, toileting, transfer and ambulation, skin care, grooming, dressing, extension of therapies and exercise, routine care of adaptive equipment primarily involving cleaning as needed, meal preparation, assistance with eating, and incidental household cleaning and laundry. IADLs include shopping, banking, budgeting, using public transportation, social interaction, recreation, and leisure activities. Assistance with IADLs includes accompaniment, coaching and minor problem-solving necessary to achieve the objectives of increased independence, productivity and inclusion in the community.
   2. (b) Personal Care Services under the Living at Home Waiver may also include general supervision and protective oversight reasonable to the accomplishment of health, safety and inclusion. The worker may directly perform some activities and support the waiver recipient in learning how to perform others; the planning team (composed at minimum of the waiver recipient and family, and a case manager or community specialist) shall determine the composition of the Personal Care Service and assure it does not duplicate, nor is duplicated by, any other service provided to the waiver recipient.
   3. (c) A written description of what the personal care worker will provide to the waiver recipient is required to be submitted to the state as part of or in addition to the waiver recipient’s approved person-centered care plan and will require approval by the Division of Developmental Disabilities and be subject to review by the Single State Agency for Medicaid.
   4. (d) While in general, Personal Care Services will not be approved for a waiver recipient living in a group home or other residential setting, the Division of Developmental Disabilities may approve it for specific purposes that are not duplicative.
   5. (e) The person-centered care plan or an addendum shall specify any special requirements for training, more than basic training, which may be needed to support the waiver recipient. Parents and other caretakers shall be key informers on the matter of special training and will be encouraged to participate in the training and supervision of the worker.
   6. (f) When Personal Care Services are provided to minor children living with their parents or guardians, it shall not supplant the cost and provision of support ordinarily provided by parents to children without disabilities, nor shall it supplant educationally related services and support that is the responsibility of local education authorities. Otherwise, the only limitation on hours provided is the waiver recipient’s documented need for Personal Care Services as an alternative to institutional care and the reasonable cost effectiveness of his or her plan.
   7. (g) There is no restriction on the place of service so long as the waiver recipient is eligible for the LAH Waiver in that setting and no duplication of payment occurs. This would preclude personal care being provided in, for instance, a day habilitation or respite setting where payment would already be made for the same services. Payment is for a 15-minute unit of service, not including worker’s time of travel to and from the place of work.
   8. (h) Any relatives, or friends, who are employed to provide services shall meet the qualifications for providers of care and, as for all other personal care workers, payment shall only be made for services actually rendered. Employment of a relative or friend shall be noted and justified in the waiver recipient’s record by the provider agency. Siblings who do not reside in the home with the waiver recipient can be paid to provide Personal Care Services to the waiver recipient.
   9. (i) Personal Care Services can also include supporting a waiver recipient at an integrated worksite where the waiver recipient is paid a competitive wage. Personal Care Services at an integrated worksite must be billed under a separate code to distinguish it from other Personal Care Services. Personal care is limited to no more than 12 hours/48 units each day for individuals living in the home with relatives or caregivers. The number of hours provided may exceed the 12 hours/48 per day for those individuals who live independently and assessed needs indicate the need for additional support and/or for participant whose hours need to exceed the 12 hours can be provided, but the approval should be based on the emergent need (i.e. illness or death of the primary caregiver). A record of the Personal Care visit will be captured by an Electronic Visit Verification Monitoring System.

   10. (j) Personal Care Services may be self-directed to allow waiver recipients and their families to recruit, hire, train, supervise, and if necessary to discharge, their own personal care workers. Personal Care Services cannot be self-directed for children under the age of 21 on the State Plan. Payment may be made to legally responsible individuals (i.e. the parent (biological or adoptive) and/or guardian of a waiver participant under the age of 18 or the spouse of a waiver participant) for furnishing Self-Directed Personal Care (and Personal Care transportation where applicable) services. The self-directed personal care workers will be employed by the family and participant, who will be employers of record. A relative, including a legally responsible relative, and/or a legal guardian may serve as a self-directed worker to a waiver participant for Personal Care self-directed services as long as

       1. 1. The relative/legal guardian is otherwise qualified to provide these services and
       2. 2. The relative/legal guardian does not also serve as the same participant’s representative/Employer of Record (EOR). The participant and, as applicable, the participant’s legal guardian, may designate another trusted individual as the representative/EOR.

   11. (k) Personal Care Transportation

       1. 1. Personal care attendants may transport waiver recipients in their own (the attendant’s) vehicles as an incidental component of the personal care service. In order for this component to be reimbursed, the personal care attendant must be needed to support the waiver recipient in accessing the community, and not merely to provide transportation. The Personal Care Transportation service will provide transportation into the community to shop, attend recreational and civic events, go to work and participate in People First and other community building activities. Additional payment will be made for mileage and the provider’s cost of an insurance waiver to cover any harm that might befall the waiver recipient as a result of being transported.
       2. 2. The attendant must have a valid Alabama driver’s license, and his/her own insurance coverage as required by State law. The provider agency shall assure the attendant has a good driving record and is in-serviced on safety procedures when transporting a waiver recipient.
       3. 3. Personal Care Transportation shall not replace transportation that is already reimbursable under Day or Residential Habilitation Services nor the Medicaid non-emergency medical transportation program. The planning team must also assure the most cost-effective means of transportation, which would include public transport where available. Transportation by a personal care attendant is not intended to replace generic transportation nor to be used merely for convenience.

10. (10) Environmental Accessibility Adaptations Services

    1. (a) Environmental Accessibility Adaptations Services will provide physical adaptations to the home, required by the waiver recipient's approved person-centered care plan, which are necessary to ensure the health, welfare and safety of the waiver recipient, or which enable the waiver recipient to function with greater independence in the home and without which, the waiver recipient would require institutionalization.
    2. (b) Environmental Accessibility Adaptations Services may include adaptations which are necessary to accommodate the medical equipment and supplies necessary for the welfare of the waiver recipient and may include the installation of ramps and grab-bars, widening of doorways, modification of bathroom facilities, or installation of specialized electric and plumbing systems. Environmental Accessibility Adaptations Services shall exclude those adaptations or improvements to the home which are of general utility and not of direct medical or remedial benefit to the waiver recipient, such as carpeting, roof repair, central air conditioning, adding square footage to the home, etc. All Environmental Accessibility Adaptations Services shall be provided in accordance with applicable State or local building codes.
    3. (c) The waiver recipient’s home may be a house or an apartment that is owned, rented or leased. Environmental Accessibility Adaptations to the work environment covered by the Americans with Disabilities Act, or those that are the responsibility of other agencies are not covered. Covered Environmental Accessibility Adaptations of rented or leased homes should be those extraordinary alterations that are uniquely needed by the waiver recipient and for which the property owner would not ordinarily be responsible.
    4. (d) Environmental Accessibility Adaptations Services may be directed by waiver recipients or family but must adhere to all the traditional service rules. Self-Directed Environmental Accessibility Adaptations are only available to those participants who are self-directing personal care and/or LPN/RN services.
    5. (e) Total costs of Environmental Accessibility Adaptations Services shall not exceed $5,000 per waiver year, per waiver recipient.

11. (11) Specialized Medical Supplies Services

    1. (a) Specialized Medical Supplies Services provide supplies that are necessary to maintain the waiver recipient’s health, safety, and welfare and to prevent further deterioration of a condition or increase an individual's ability to perform activities of daily living. This includes personal protective equipment (PPE). These supplies do not include common over-the-counter personal care items such as toothpaste, mouthwash, soap, shampoo, Q-tips, deodorant, etc.
    2. (b) Specialized Medical Supplies Services will only be provided when authorized by the waiver recipient’s physician and shall meet applicable standards of manufacturer, design, and installation. Providers of Specialized Medical Supplies Services will be those who have a signed provider agreement with Medicaid and ADMH. Verbal/written orders from a physician or other licensed health care provider for non-prescription assistive technology items authorized in an individual's person-centered plan is required. Specialized Medical Supplies Services are limited to a maximum of 2,400.00 per waiver recipient per year. The operating agency must maintain documentation of items purchased for the waiver recipient. All items shall meet applicable standards of manufacture and design.
    3. (c) Specialized Medical Supplies Services may be directed by waiver recipients or family but must adhere to all the traditional service rules.
    4. (d) Specialized Medical Supplies Services under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan.

12. (12) Assistive Technology Services

    1. (a) Assistive Technology Services means an item or piece of equipment (including any equipment not covered by Medicaid State Plan Services), service animal or product system, whether acquired commercially, modified or customized that is used to increase, maintain, or improve functional capabilities of participants. Assistive Technology Services means a service that directly assist an individual in the selection, acquisition, or use of an assistive technology device.
    2. (b) Verbal/written orders from a physician or other licensed health care provider for non-prescription assistive technology items authorized in an individual's person-centered plan is required. Providers of this service must maintain documentation of items purchased for each individual, including the receipt of any verbal orders. Items reimbursed with waiver funds shall be in addition to any medical equipment and supplies furnished under the State Plan and shall exclude those items which are not of direct medical or remedial benefit to the recipient. Costs are limited to $5,000 per waiver recipient, per year.
    3. (c) Assistive Technology Services under the waiver are not available to children under the age of 21 when provided as the result of an EPSDT screening, because this service is covered under the State Plan.
    4. (d) Assistive Technology Services may be directed by waiver recipients or family but must adhere to all the traditional service rules. Assistive Technology Services cannot be self-directed for children under the age of 21 under the State Plan.
    5. (e) Self-Directed Assistive Technology is only available to those participants who are self-directing Personal Care, Adult Companion and/or Skilled LPN/RN services.

13. (13) Skilled Nursing Services

    1. (a) Skilled Nursing Services are services listed in the waiver recipient’s approved person-centered care plan which are within the scope of the State’s Nurse Practice Act and are provided by a registered professional nurse, or licensed practical or vocational nurse under the supervision of a registered nurse, licensed to practice in the State.
    2. (b) Skilled Nursing Services consist of nursing procedures that meet the waiver recipient’s health needs as ordered by a physician.
    3. (c) Skilled Nursing Services will be billed by the hour. There is no restriction on the place of service.
    4. (d) Skilled Nursing Services may also be self-directed when provided to a waiver recipient or family which is self-directing Personal Care Services. Skilled Nursing Services include training and supervision related to medical care and/or assistance with ordinarily self-administered medications to be provided by the personal care worker.

14. (14) Community Specialist Services

    1. (a) Community Specialist Services are a time limited, task specific service that can include professional observation and assessment, individualized program design and implementation, training of waiver recipients and family members, consultation with caregivers and other agencies, and monitoring and evaluation of planning and service outcomes as needed to facilitate and implement the Person-Centered Plan. Community Specialist Services may also include, at the choice of the waiver recipient or family, advocating for the consumer and assisting him or her in locating and accessing both waiver and non-waiver services and supports. The Community Specialist will serve as both a qualified planner and, at the consumer’s or family’s request, a broker. The functions outlined for Community Specialist Services differs from case management in the skill level and independence of the specialist, as well as the focus on self-determination and advocacy for the individual.
    2. (b) The provider must meet QIDP qualifications and be free of any conflict of interest with other providers serving the waiver recipient. The Community Specialist Services will assist the consumer and his caregivers to design and implement specialized programs to enhance self-direction, independent living skills, community integration, social, leisure and recreational skills, and behavior management. A community specialist with expertise in person-centered planning may also be selected by the waiver recipient to facilitate the interdisciplinary planning team meeting.
    3. (c) Targeted case managers will continue to perform traditional duties of intake, completion of paperwork regarding eligibility, serving in the capacity of referral and resource locating, monitoring and assessment.
    4. (d) The planning team shall first ensure that provision of Community Specialist Services does not duplicate the provision of any other services, including Targeted Case Management provided outside the scope of the waiver.
    5. (e) The community specialist will frequently be involved for only a short time (30 to 60 days); in such an instance, the functions will not overlap with case management. If the waiver recipient or family chooses to have the community specialist remain involved for a longer period of time, it must be agreed upon by the team and extended on the waiver recipient’s approved person-centered care plan. The need to extend the service must be fully justified in writing by the case manager. Community Specialist Services are limited to a 90-day period per waiver recipient per waiver year.
    6. (f) The community specialist will share information with the case manager quarterly in an effort to remain abreast of the waiver recipient’s needs and condition.
    7. (g) A community specialist who facilitates the planning meeting for a waiver recipient shall not have any conflict of interest with any provider who may wish to serve the waiver recipient.
    8. (h) Community Specialist Services are a cost effective and necessary alternative to placement in an ICF/IID. A unit of service is 15 minutes.

15. (15) Crisis Intervention Services

    1. (a) Crisis Intervention Services provide immediate therapeutic intervention, available to a waiver recipient on a 24-hour basis, to address personal, social, and/or behavioral problems which otherwise are likely to threaten the health and safety of the waiver recipient or of others and/or to result in the waiver recipient’s removal from his current living arrangement.
    2. (b) Crisis Intervention Services may be provided in any setting in which the waiver recipient resides or participates in a program. Crisis Intervention Services include consultation with family members, providers and other caretakers to design and implement individualized crisis treatment plans and provide additional direct services as needed to stabilize the situation.
    3. (c) Individuals with intellectual disabilities are occasionally at risk of being moved from their residences to institutional settings because the person, or his or her family members or other caretakers, are unable to cope with short term, intense crisis situations. Crisis intervention can respond intensively to resolve the crisis and prevent the dislocation of the person at risk. The consultation which is provided to caregivers also helps to avoid or lessen future crises.
    4. (d) Crisis Intervention Services are expected to be of brief duration (10 weeks, maximum). When Crisis Intervention Services of a greater duration are required, the waiver recipient shall be transitioned to a more appropriate service program or setting.
    5. (e) Crisis Intervention Services providers shall consist of a team under the direction and supervision of a psychologist, counselor or social worker licensed by the State of Alabama and meeting the requirements of a QDDP (as defined at 42 CFR 483.430). All team members shall have at least one year of work experience in serving individuals with intellectual disabilities and have a minimum of 40 hours training in crisis intervention techniques prior to providing Crisis Intervention Services.
    6. (f) A unit of service is 15 minutes and must be provided by the waiver planning team, directed by a graduate psychologist or licensed social worker.
    7. (g) When the need for Crisis Intervention Services arises, the service will be added to the waiver recipient’s approved person-centered care plan.
    8. (h) A separate crisis intervention plan will be developed to define in detail the activities and supports that will be provided.
    9. (i) All Crisis Intervention Services shall be approved by the Regional Community Service Office of the ADMH prior to the service being initiated.
    10. (j) Crisis Intervention Services will not count against the $58,000 per waiver recipient per year cap in the LAH Waiver, since the need for the Crisis Intervention Service cannot accurately be predicted and planned for ahead of time.

    11. (k) Specific Crisis Intervention Service components may include the following:

        1. 1. Analyzing the psychological, social and ecological components of extreme dysfunctional behavior or other factors contributing to the crisis;
        2. 2. Assessing which components are the most effective targets of intervention for the short-term amelioration of the crisis;
        3. 3. Developing and writing an intervention plan;
        4. 4. Consulting and, in some cases, negotiating with those connected to the crisis in order to implement planned interventions, and following up to ensure positive outcomes from interventions or to make adjustments to interventions;
        5. 5. Providing intensive direct supervision when a waiver recipient is physically aggressive or there is concern that the waiver recipient may take actions that threaten the health and safety of self and others;
    12. (l) These services are limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

16. (16) Individual Directed Goods and Services

    1. (a) Individual Directed Goods and Services are services, equipment or supplies not otherwise provided through the LAH Waiver or through the Medicaid State Plan that address an identified need in the service plan (including improving and maintaining the waiver recipient’s opportunities for full membership in the community and meet the following requirements: the item or service would decrease the need for other Medicaid service; and/or promote inclusion in the community; and/or increase the waiver recipient’s safety in the home environment; the item or service is not illegal or otherwise prohibited by Federal and State statutes and regulations, and the waiver recipient does not have the funds to purchase the item or service or the item or service is not available through another source.
    2. (b) Individual Directed Goods and Services are required to meet the identified needs and outcomes in the waiver recipient’s Person-Centered Plan, or the most cost effective to meeting the assessed need, assures health, safety, and welfare, and are directly beneficial to the waiver recipient in achieving at least one of the following outcomes: Improved cognitive, social, or behavioral functioning; maintain the waiver recipient’s ability to remain in the community; enhance inclusion and family involvement; develop or help maintain personal, social, or physical skills; decrease dependency on formal supports services, and increase independence.
    3. (c) The limit on the amount of Goods and Services that can be purchased is determined individually based on the balance of the waiver recipient’s saving account at the time of the request, which is maintained by the Financial Management Services Agency, but not to exceed $10,000 annually.

17. (17) Assistance in Community Integration Services

    1. (a) The Assistance in Community Integration Service enables waiver recipients to maintain their own housing as set forth in the waiver recipient’s approved person-centered care plan. Assistance in Community Integration Services must be provided in the home or a community setting. Assistance in Community Integration Service includes the following components:

       1. 1. Conducting a community integration assessment identifying the waiver recipient’s preferences related to housing and needs for support to maintain community integration.
       2. 2. Assisting waiver recipient with finding and securing housing as needed. This may include arranging for or providing transportation.
       3. 3. Assisting waiver recipient in securing supporting documents/records, completing/submitting applications, securing deposits, and locating furnishings.
       4. 4. Developing an individualized community integration plan based upon the assessment as part of the overall Person-Centered Plan. Identify and establish short and long-term measurable goal(s) and establish how goals will be achieved and how concerns will be addressed.
       5. 5. Participating in waiver recipients Person-Centered Plan meetings at re-determination and/or revision plan meetings as needed.
       6. 6. Providing supports and interventions per the waiver recipient’s Person-Centered Plan (individualized community integration portion). Identify any additional supports or services needed outside the scope of Community Integration services and address among the team.
       7. 7. Supports to assist the waiver recipient in communicating with the landlord and/or property manager regarding the waiver recipient’s disability (if authorized and appropriate), detailing accommodations needed, and addressing components of emergency procedures involving the landlord and/or property manager.
       8. 8. Assistance in Community Integration Services will provide supports to preserve the most independent living arrangement and/or assist the waiver recipient in locating the most integrated option appropriate to the waiver recipient.

18. (18) Benefits and Career Counseling Services

    1. (a) Benefits and Career Counseling Services comprise two distinct services: Benefits Reporting Assistance (BRA) and Benefits Counseling.

       1. 1. The BRA is designed to assist waiver recipients and their families to understand general information on how SSI/SSDI benefits are affected by employment. Once the waiver recipient enters employment, the BRA will be available to answer questions, assist in the execution of the work incentive plan, and assist with the submission of income statement and/or Impairment Related Work Expenses to SSA as required to the extent needed as indicated by the waiver recipient.
       2. 2. The Benefits Counseling is a more intensive service provided by a Community Work Incentives Coordinator (CWIC) who will provide intensive individualized benefits counseling, benefits analysis, develop a work incentive plan and ongoing benefits planning for a waiver recipient changing jobs or for career advancement. The CWIC will work in conjunction with the BRA to develop trainings and webinars based on SSA information provided and may assist or provide trainings and education as needed.
    2. (b) The Benefits Counselor must be a Certified Work Incentives Counselor (CWIC) through a recognized training by the Social Security Administration for delivery of Career Counseling Services. This may include a level 5 security clearance from the Social Security Administration/Department of Homeland Security due to Personally Identifiable Information.

19. (19) Community Experience Services

    1. (a) Community Experience Services are non-work-related activities that are customized to the waiver recipient(s) desires to access and experience community participation. Community Experience Services are provided outside of the waiver recipient’s residence and can be provided during the day, evening, or weekends. The intent of Community Experience Services is to engage in activities that will allow the waiver recipient to either acquire new adaptive skills or support the waiver recipient in utilizing adaptive skills in order to become actively involved in their community.

    2. (b) Community Experience Services has two distinct categories: Individual and Group Community Experience Services.

       1. 1. Community Experience Individual Services are provided to a waiver recipient, with a one-to-one staff to waiver recipient ratio which is determined necessary through functional and health risk assessments prior to approval. Additionally, a behavioral assessment will need to support this specialized staffing if related to behavioral challenges prior to approval.
       2. 2. Community Experience Group Services are provided to groups of waiver recipients, with a staff to waiver recipient ratio of one to two or more, but no greater than four (4) waiver recipients.

20. (20) Personal Emergency Response System (PERS) Services

    1. (a) Personal Emergency Response System Services (PERS) provides a direct telephonic or other electronic communications link between waiver recipients and health professionals to secure immediate assistance in the event of a physical, emotional or environmental emergency. PERS may also include cellular telephone service used when a conventional PERS is less cost-effective or is not feasible. PERS may include installation, monthly fee (if applicable), upkeep and maintenance of devices or systems as appropriate.
    2. (b) The use of PERS requires assurance that safeguards are in place to protect privacy, provide informed consent, and that documented needs are addressed in the least restrictive manner. The waiver recipient’s Person-Centered Plan should identify options available to meet the need of the waiver recipient in terms of preference while also ensuring health, safety, and welfare.
    3. (c) (PERS) can be directed by waiver recipients or family but must adhere to all the traditional service rules.

21. (21) Supported Employment Transportation Services

    1. (a) Supported Employment Transportation Services permit waiver recipients transportation to and from their place of employment in the event that the support team is unable to facilitate transportation through other means. Supported Employment Transportation Services must be necessary to support the waiver recipient in work related travel and cannot be reimbursed for merely transportation.
    2. (b) Transportation must be provided by public carriers (e.g., charter bus or metro transit bus) or private carriers (e.g., taxicab). The waiver recipient may use a commercial transportation agency.

22. (22) Remote Support Services

    1. (a) Remote Support Services are services provided to recipients who are 18 years of age or older, at their place of residence, by Remote Support staff housed at a remote location and who are engaged with the recipient through equipment with the capability for live, two-way communication.
    2. (b) Remote Support Services shall be provided in real time, not via a recording, by awake staff at a remote monitoring base using an appropriate, stable, and reliable electronic connection.
    3. (c) Remote Support Services are intended to address a person’s assessed needs in his/her residence and are to be provided in a manner that promotes autonomy, minimizes dependence on paid support staff, and reduces the need for in-person services that may be more intrusive.

23. (23) Adult Companion Services

    1. (a) Adult Companion Services are non-medical supervision and socialization, provided to a functionally impaired adult. Companions may assist the waiver recipient with such tasks as meal preparation, and shopping, but may not perform these activities as discrete services.

       1. 1. The provision of Adult Companion Services does not entail hands-on medical care.
       2. 2. Companions may perform light housekeeping tasks which are incidental to the care and supervision of the waiver recipient.
       3. 3. Adult Companion Services are provided in accordance with a therapeutic goal in the waiver recipient’s approved person-centered care plan and are not merely diversional in nature.
       4. 4. Adult Companion Services must be necessary to prevent institutionalization of the waiver recipient.

    2. (b) Adult Companion Services can be self-directed to allow waiver recipients and their families to recruit, hire, train, supervise, and if necessary to discharge, their own workers. Self-Directed workers must adhere to all the traditional service rules. Payment may be made to legally responsible individuals (i.e. the parent (biological or adoptive) and/or guardian of a waiver participant under the age of 18 or the spouse of a waiver participant) for furnishing Self-Directed Adult Companion services. The self-directed Adult Companion workers will be employed by the family and participant, who will be employers of record. A relative, including a legally responsible relative, and/or a legal guardian may serve as a self-directed worker to a waiver participant for Adult Companion self-directed services as long as

       1. 1. The relative/legal guardian is otherwise qualified to provide these services and
       2. 2. The relative/legal guardian does not also serve as the same participant’s representative/Employer of Record (EOR). The participant and, as applicable, the participant’s legal guardian, may designate another trusted individual as the representative/EOR.

24. (24) Housing Stabilization Services

    1. (a) The Housing Stabilization Service enables waiver recipients to maintain their own housing as set forth in the waiver recipient’s approved person-centered care plan. Housing Stabilization Services must be provided in the home or a community setting. Housing Stabilization Services include the following components:

       1. 1. Conducting a Housing Coordination and Stabilization Assessment identifying the waiver recipient’s preferences related to housing and needs for support to maintain housing, budgeting for housing/living expenses, obtaining/accessing sources of income necessary for rent, home management, establishing credit and understanding and meeting obligations of tenancy as defined in lease terms.
       2. 2. Assisting waiver recipients with finding and securing housing as needed, this may include arranging or providing transportation.
       3. 3. Assisting waiver recipients in securing supporting documents/records, completing/submitting applications, securing deposits, and locating furnishings.
       4. 4. Developing an individual housing stabilization plan based upon the Housing Coordination and Stabilization Assessment as part of the overall Person-Centered Plan.
       5. 5. Participating in waiver recipient’s Person-Centered Plan meetings at redetermination and/or revision plan meetings as needed.
       6. 6. Providing supports and interventions per the waiver recipient’s Person-Centered Plan (individualized housing stabilization portion).
       7. 7. Communicating with the landlord and/or property manager regarding the waiver recipient’s disability (if authorized and appropriate), detailing accommodations needed, and addressing components of emergency procedures involving the landlord and/or property manager.
       8. 8. If at any time the waiver recipient’s housing is placed at risk (e.g., eviction, loss of roommate, or loss of income), Housing Stabilization Services will provide supports to retain housing or locate and secure new housing or sources of income to continue community-based supports which includes locating new housing, sources of income, etc.

Author: Riyyah James, Associate Director, Specialized Waiver Unit, LTC Healthcare Reform Development Division

Statutory Authority: Social Security Act §1915(c); 42 C.F.R. −Section 441, Subpart G Home and Community-Based Services: Waiver Requirements.

Editor’s Note: Entire chapter was repealed as per certification filed December 7, 1995; effective January 11, 1996.

History: New Rule: Filed November 21, 2002; effective December 26, 2002. Amended: Filed May 11, 2007; effective June 15, 2007. Amended: Filed January 7, 2009; effective February 11, 2009. Amended: Filed June 11, 2014; effective July 16, 2014. Amended: Filed July 12, 2017; effective August 26, 2017. Amended: Filed November 9, 2018; effective December 24, 2018. Amended: Published August 31, 2021; effective October 15, 2021. Amended: Published June 30, 2025; effective August 14, 2025.