1916 IN-HOME SUPPORTS SERVICES

1916.1 The purpose of this section is to establish standards governing Medicaid eligibility for in-home supports services for persons enrolled in the Home and Community-Based Services Waiver for Individuals with Intellectual and Developmental Disabilities (Waiver), and to establish conditions of participation for providers of these services.

1916.2 In order to be reimbursed by Medicaid, in-home supports are services that may only be provided to people enrolled in the Waiver who have an assessed need for assistance with acquisition, retention or improvement in skills related to activities of daily living that are necessary to enable the person to reside successfully at home in his or her community and participate in community activities based upon what is important to and for the person as documented in his or her Individual Support Plan (ISP) and reflected in his or her Person-Centered Thinking and Discovery tools.

1. (a) Services may be provided to people in the home or community, with the place of residence as the primary setting. A person may receive in-home supports services when his or her place of residence is his or her own home, a family home, a friend's home, or transitional housing.
2. (b) Services may be provided in person, by phone or by any other technology device that supports the use of video-audio communication, such as Skype, FaceTime, etc., as approved by the person and his or her support team and documented in the ISP. In-home supports services using technology to communicate with the person shall not exceed twenty (20) percent of the total hours of in-home supports services that the person receives each week.
3. (c) For people with higher intensity support needs, high acuity in-home supports services are available with the additional supports described below in Subsection 1916.4.

1916.3 To be eligible for reimbursement, in-home supports services shall be:

1. (a) Included in a person's ISP and Plan of Care and related to the person's ISP goals;
2. (b) Habilitative in nature; and

(c) Provided to a person living independently or with family or friends and not receiving other residential supports such as supported living, supported living with transportation, residential habilitation, or host home support services.

1916.4 In order to be reimbursed by Medicaid, in-home supports services shall include a combination of hands-on care, habilitative supports, skill development and assistance with activities of daily living. Supports provided shall be aimed at teaching the person to increase his or her skills and self-reliance. In addition to the direct in-home supports eligible for reimbursement below in Subsection 1916.5, high acuity in-home supports shall also include the following:

1. (a) Assistance in the coordination of behavioral, health and wellness services that a person may receive, including working with the person's natural supports, if any, to ensure that each person enrolled in the Waiver receives the professional services required to meet his or her goals as identified in the person's ISP and Plan of Care;
2. (b) Development and implementation of the person's Health Care Management Plan, in accordance with the DDS Health and Wellness Standards;
3. (c) Training on the Health Care Management Plan for high acuity in-home supports Direct Support Professionals and any other residents of the person's home who provide natural (unpaid) supports; and
4. (d) Supports to ensure that staff delivering day habilitation, individualized day supports, companion, employment readiness, or supported employment services shall receive training about the person's health care needs as identified in the person's Health Care Management Plan, and are informed about those needs that are relevant to the person in those settings and that are identified in the person's Health Care Management Plan and Behavior Support Plan, if applicable.

1916.4 In-home supports eligible for reimbursement shall include the following:

1. (a) Training and support in activities of daily living and independent living skills;
2. (b) Support to enhance opportunities for meaningful adult activities and skills acquisition that support community integration and a person's independence, including management of financial and personal affairs and awareness of health and safety precaution;
3. (c) Support to enhance opportunities for community exploration aimed at discovery of new and emerging interests and preferences, including activities aimed at supporting the person to have one or more new relationships;
4. (d) Support to build community membership;
5. (e) Training on, and assistance in the monitoring of health, nutrition, and physical wellness;
6. (f) Implementation of a home therapy program under the direction of a licensed clinician;
7. (g) Training and support to coordinate or manage tasks outlined in the Health Care Management Plan, if applicable;
8. (h) Assistance in performing personal care, household, and homemaking tasks that are specific to the needs of the person, except that this may not comprise the entirety of the service;
9. (i) Assistance with developing the skills necessary to reduce or eliminate behavioral episodes by implementing a Behavioral Support Plan (BSP) or positive strategies;
10. (j) Opportunities for the person to seek employment and vocational supports to work in the community in a competitive and integrated setting;
11. (k) Assistance with the acquisition of new skills or maintenance of existing skills based on individualized preferences and goals identified in the In-Home Supports Plan, ISP, and Plan of Care; and
12. (l) Coordinating transportation to participate in community events consistent with this service.

1916.6 Each provider rendering in-home supports services shall:

1. (a) Be a Waiver provider agency; and
2. (b) Comply with Sections 1904 (Provider Qualifications) and 1905 (Provider Enrollment Process) of Chapter 19 of Title 29 DCMR.1916.7 Each Direct Support Professional (DSP) rendering in-home supports services shall comply with Section 1906 (Requirements for Direct Support Professionals) of Chapter 19 of Title 29 DCMR.1916.8 In-home support services shall be authorized in accordance with the following provider requirements:- (a) The Department on Disability Services (DDS) shall provide a written service authorization before the commencement of services;
3. (b) The service name and provider delivering services shall be identified in the ISP and Plan of Care;
4. (c) The ISP and Plan of Care shall document the amount and frequency of services to be received;
5. (d) The In-Home Supports Plan, ISP, and Plan of Care shall be submitted to and authorized by DDS annually or as needed; and
6. (e) The provider shall submit each quarterly review to the person's DDS Service Coordinator no later than seven (7) business days after the end of the first quarter, and each subsequent quarter thereafter.1916.9 Each provider shall comply with the requirements under Section 1908 (Reporting Requirements) of Chapter 19 of Title 29 DCMR, Section 1909 (Records and Confidentiality of Information) of Chapter 19 of Title 29 DCMR, and Section 1911 (Individual Rights) of Chapter 19 of Title 29 DCMR, except that the progress notes as described in Subsection 1909.2(m) shall be maintained on a per visit basis.1916.10 Each provider of Medicaid reimbursable in-home support services shall assist each person in the acquisition, retention, and improvement of skills related to activities of daily living, such as personal grooming, household chores, eating and food preparation, and other social adaptive skills necessary to enable the person to reside in the community. To accomplish these goals, the provider shall:- (a) Use the DDS-approved person-centered thinking tools and the person's Positive Personal Profile and Job Search and Community

Participation Plan to develop a functional assessment that includes what is important to and for the person, within the first thirty (30) calendar days of providing services. This assessment shall be reviewed and revised annually or more frequently as needed;

(b) Assist with and actively participate in the development of the person's In-Home Supports Plan, ISP, and Plan of Care, at the person's preference;

(c) Review the person's In-home Supports Plan, ISP and Plan of Care goals, DDS-approved person-centered thinking tools, Positive Personal Profile and Job Search and Community Participation plan, objectives, and activities at least quarterly, and more often as necessary and submit quarterly reports to the person, family or representative, as appropriate, guardian, and the DDS Service Coordinator no later than seven (7) business days after the end of the first quarter or each subsequent quarter thereafter and in accordance with the requirements described under Section 1908 (Reporting Requirements) and Section 1909 (Records and Confidentiality of Information) of Chapter 19 of Title 29 DCMR.

1916.11 In order to be reimbursed by Medicaid, an In-Home Supports Plan shall be developed by the provider within thirty (30) days of the start of the service authorization and shall be revised as needed and on an annual basis. The In-Home Supports Plan shall be maintained in the home where services are provided with a copy also maintained at the Provider's main office. The In-Home Supports Plan shall include:

(a) Activities and supports that will be provided during the service, based upon what is important to and important for the person, as identified in the Person-Centered Thinking and Discovery tools and reflected in the person's ISP;

(b) A staffing plan and schedule;

(c) A list of licensed non-medical professionals who will be providing services, if applicable; and

(d) Emergency and contingency plans to address potential behavioral, health or emergency events.

1916.12 In-home supports services shall only be provided for up to eight (8) hours per day unless there is a temporary emergency. In the event of a temporary emergency, DDS may authorize up to sixteen (16) hours per day for up to one hundred and eighty (180) days, during the person's ISP year.

1916.13 In the event of a temporary emergency, a written justification for an increase in hours shall be submitted with the In-Home Supports Plan, ISP, and Plan of Care by the provider to DDS. The written justification must include:

1. (a) An explanation of why no other resource is available;
2. (b) A description of the temporary emergency;
3. (c) An explanation of how the additional hours of in-home supports services will support the person's habilitative needs;
4. (d) A revised copy of the in-home Supports Plan, ISP, and Plan of Care reflecting the increase in habilitative supports to be provided; and
5. (e) The service authorization from the Medicaid Waiver Supervisor or other Department on Disability Services Administration designated staff.

1916.14 All Direct Support Professionals, including family members, who provide in-home supports services shall comply with Section 1906 (Requirements for Direct Support Professionals) of Chapter 19 of Title 29 DCMR.

1916.15 Family members who provide in-home supports services and reside in the same home as the person receiving services may only be paid for in-home support services that are in accordance with the person's ISPs goals.

1916.16 In-home supports services shall not be provided to persons receiving the following residential services:

1. (a) Host Home;
2. (b) Residential Habilitation;
3. (c) Supported Living; and
4. (d) Supported Living with Transportation.

1916.17 In-home supports services may be used on the same day, or in combination with Medicaid State Plan Personal Care Aide (PCA) services, ID/DD PCA services, and Companion services, provided the services are not rendered at the same time.

1916.18 In-home supports services shall not be used to provide supports that are normally provided by medical professionals.

1916.19 In-home supports services, including those provided in the event of a temporary emergency, shall be billed at the unit rate of fifteen (15) minutes and shall not exceed eight (8) hours per twenty-four (24) hour day. A standard unit of fifteen (15) minutes requires a minimum of eight (8) minutes of continuous service to be billed. There shall be a Medicaid reimbursement rate for both the in-home supports identified in Subsection 1916.5 and the high acuity in-home supports identified in Subsection 1916.4. Reimbursement shall be limited to those time periods in which the provider is rendering services directly to the person.

1916.18 Reimbursement for in-home supports services shall not include:

(a) Room and board costs;

(b) Routine care and general supervision normally provided by the family or unpaid individuals who provide supports, or for services furnished to a minor by the child's parent or step-parent or by a person's spouse;

(c) Services or costs for which payment is made by a source other than Medicaid;

(d) Travel or training of travel skills to Supportive Employment, Day Habilitation, Individualized Day Supports, or Employment Readiness; and

(e) Costs associated with the DSP engaging in community activities with the people they support.

SOURCE: Final Rulemaking published at 55 DCR 2896 (March 21, 2008); as amended by Final Rulemaking published at 61 DCR 2464 (March 21, 2014); as amended by Final Rulemaking published at 63 DCR 43 (January 1, 2016); as amended by Final Rulemaking published at 63 DCR 7279 (May 13, 2016); as amended by Final Rulemaking published at 64 DCR 7469 (August 4, 2017); as amended by Final Rulemaking published at 65 DCR 2190 (March 2, 2018); as amended by Final Rulemaking published at 69 DCR 010218 (August 12, 2022).