CurrentAlabama MedicaidPolicy N/A
Home and Community-Based Waiver for Persons with Intellectual Disabilities (ID Waiver)
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State Medicaid rules defining authority, purpose, settings requirements, and descriptions of Home and Community-Based Services (HCBS) for individuals with intellectual disabilities who would otherwise require ICF/IID-level care; applies to providers, program administrators, and eligible Medicaid recipients under the ID Waiver.
Policy Summary
PayerAlabama Medicaid
PolicyHome and Community-Based Waiver for Persons with Intellectual Disabilities (ID Waiver)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateAug 14, 2025
Last ReviewJun 30, 2025
Next Review DateN/A
Key ActionInclude all services in the approved person-centered care plan and obtain prior approval for Crisis Intervention Services from the ADMH regional community service office before initiating services.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
age 3+waiver minimum age
50 hrsOT initial plan limit
8 hrsIn‑Home Habilitation limit/day
5 hrsDay Habilitation limit/day
1,200Max annual PBS units
12 monthsclaims submission window
Coverage criteria and service rules
Eligibility and necessity — General coverage criteria and program scope
General coverage criteria and program scope
Beneficiary must be Medicaid‑eligible under the ID Waiver and would, without HCBS, require the level of care available in an ICF/IID.
Waiver enrollment limited to individuals with a diagnosis of intellectual disability age 3 and above.
Each HCBS must be necessary to prevent institutionalization of the waiver recipient.
Providers must have a signed provider contract, meet provider qualifications, and comply with all applicable state and federal laws and regulations.
Services reimbursable through Medicaid EPSDT shall not be reimbursed as waiver HCBS.
HCBS settings compliance — Settings and person-centered safeguards
Settings and person-centered safeguards
Services must be provided in settings that are integrated in and support full access to the greater community, selected by the individual, ensure privacy, dignity and freedom from coercion, and optimize autonomy and independence.
Services must facilitate individual choice regarding services and who provides them.
Provider-owned or -controlled residential settings must be physically accessible, offer tenant‑like protections (lease/residency agreement or comparable protections), provide lockable entrance doors, choice of roommate, freedom to furnish and decorate, control over schedules and access to food, and visitor rights.
Any modifications or restrictions in provider‑owned/controlled residential settings must be supported by a specific assessed need, justified and documented in the person‑centered service plan, and include prior interventions and ongoing data measuring effectiveness.
Service descriptions and limits — Service-specific coverage limits and delivery requirements
Service-specific coverage limits and delivery requirements
In‑Home Residential Habilitation is limited to 8 hours per day, cannot overlap other services, and is not available to new waiver participants (existing recipients may continue).
Day Habilitation Services are furnished in community settings (not the member's residence except as hub), cannot exceed five hours per day, may not be used for paid work, and transportation between facility and community sites is included in the rate.
Occupational Therapy requires physician prescription, an initial assessment and treatment plan with established goals, is billed in 15‑minute units, and is limited to no more than 50 hours (200 units) for the initial plan; not available under waiver for children under 21 when provided via EPSDT.
Supported Living is intended for individuals needing intermittent staff support (not 24/7); shared living may include up to three waiver recipients per residence; dwelling maintenance costs are excluded from reimbursement.
Service-level coverage criteria (therapy, supports, and supplies) — Service-specific coverage criteria, provider qualifications, documentation, unit/billing rules, age/EPSDT exclusions, self-direction rule...
Service-specific coverage criteria, provider qualifications, documentation, unit/billing rules, age/EPSDT exclusions, self-direction rules, and limits as specified in the waiver.
Therapies (OT, PT, Speech)
- Therapies require a physician's prescription, an initial assessment and a documented treatment plan with established goals present in the case record.
- Services must be listed on the person‑centered care plan and documented in service logs and treatment notes; therapists must sign notes and may use compliant e‑signatures.
- Occupational and Physical Therapy are billed in 15‑minute units and are limited to no more than 50 hours (200 units) for the initial plan; group therapy will not be reimbursed.
- Speech and Language Therapy is billed as encounter units with documentation required for each encounter; Therapies are not available under the waiver for children under age 21 when provided as a result of EPSDT screening because they are covered under the State Plan.
Positive Behavior Support
- Positive Behavior Support (PBS) provides functional behavior analysis, BSP development and implementation, consultation and training focused on developing adaptive behavior.
- Unit of service for PBS is 15 minutes; BSP usage must be re‑justified in the case record every 30 days.
- Maximum annual units of PBS combined (professional + technician) cannot exceed 1,200 and professional‑level units cannot exceed 800; group therapy will not be reimbursed.
Crisis Intervention Services
- Crisis Intervention provides immediate 24‑hour therapeutic intervention, is brief (maximum 10 weeks), and a unit of service is 15 minutes provided by the waiver planning team directed by a graduate psychologist or licensed social worker.
- When needed, Crisis Intervention will be added to the approved person‑centered care plan and a separate crisis intervention plan developed; all Crisis Intervention Services require prior approval by the ADMH regional community service office before initiation.
Self‑direction and provider qualifications
- Some services (Environmental Accessibility Adaptations, Assistive Technology, Skilled Nursing, Respite, Personal Care) may be self‑directed subject to service‑specific restrictions (e.g., not self‑directable for children under 21 for certain services) and adherence to standard service rules.
- Providers of services (including habilitation aides, attendants, and supported employment providers) must meet required certifications, training and qualifications specified by ADMH/waiver rules; habilitation aides require ADMH‑approved course completion and annual retraining as needed.
Environmental/Equipment and Supplies
- Environmental Accessibility Adaptations are limited to extraordinary alterations necessary for health, welfare and independence and must comply with building codes; total costs shall not exceed $5,000 per waiver year per recipient.
- Assistive Technology items require verbal/written orders from a physician or licensed provider and are limited to $5,000 per waiver year per recipient; Specialized Medical Supplies cover necessary supplies and exclude common over‑the‑counter personal care items.
Respite and other limits
- Respite Care is available up to a maximum of 1080 hours (45 days) per waiver recipient per waiver year; respite may be self‑directed with restrictions on legally responsible individuals.
- Personal Care Services may be self‑directed except for children under 21 on the State Plan; relatives may be employed when qualified and justified in the record, subject to restrictions.
Billing and units
- A unit of service is 15 minutes for applicable services and payment is fee‑for‑service by procedure code with payment based on HCPCS units reported.
- Providers must maintain service logs documenting specific days services were delivered; claims must be submitted within 12 months of date of service and providers should bill no more than one month's services per claim.
Assessment and planning
- An Individual Habilitation Plan (IHP) / person‑centered care plan is required for each recipient; assessments and annual reevaluations must be performed and documented.
- Benefits and Career Counseling includes Benefits Reporting Assistance (BRA) and Benefits Counseling delivered by Certified Work Incentives Counselors (CWIC) who must be SSA‑trained and certified.
Community Experience and Transportation
- Community Experience Services are non‑work community activities with staffing ratios of one‑to‑one for individual services or up to one‑to‑four for group services; transportation for these services is included in the rate.
- Supported Employment Transportation may be authorized when necessary to support employment and is limited in scope/duration and not to exceed applicable annual caps.
Payment and exclusions
- Services, items or supplies that are the responsibility of other agencies, general‑utility home improvements, or covered under the State Plan are excluded from waiver payment.
Waiver coverage criteria and service rules — Eligibility and limits for HCBS under the ID Waiver
Eligibility and limits for HCBS under the ID Waiver:
Financial eligibility limited to specified Medicaid categories (e.g., SSI, POCR, certain children, adoption subsidy groups, former foster care, and special HCBS optional group with income not greater than 300% of the SSI federal benefit rate).
Medical eligibility requires meeting the ICF/IID level of care; waiver services are not provided to recipients residing in institutional facilities, those with a primary diagnosis of mental illness, or whose health and safety are at risk in the community.
Crisis Intervention Services must be added to the approved person‑centered care plan, require a separate crisis intervention plan, and prior approval by the ADMH regional office before initiation; Crisis services are not covered under waiver for children under 21 when provided via EPSDT.
Community Experience Services are non‑work community activities; individual services staffed one‑to‑one and group services up to one‑to‑four; transportation is included in the rate; cannot be provided at participant's home or during Residential Habilitation.
Benefits and Career Counseling comprises Benefits Reporting Assistance and Benefits Counseling; Benefits Counseling must be delivered by a Certified Work Incentives Counselor (CWIC).
Housing Stabilization services include assessment and assistance securing housing, individualized housing stabilization plan, landlord communications, and supports to retain or obtain housing when at risk.
Individual Directed Goods and Services (IDGS) must meet identified needs in the person‑centered plan, be cost‑effective, promote independence or safety, and are limited to annual purchases not to exceed $10,000 per recipient.
Supported Employment Transportation permits work‑related transportation when necessary to support employment and is limited in scope/duration and subject to annual caps as described in service rules.
Personal Emergency Response Systems include equipment, installation, monthly fees and maintenance as needed; privacy and informed consent safeguards are required.
Medicaid reimbursement is fee‑for‑service by procedure code; providers should bill no more than one month's services per claim; services are paid based on HCPCS units and claims must be submitted within 12 months of the date of service; waiver year is 12 consecutive months from approval date.
An Individual Habilitation Plan (IHP) is required for each recipient; assessments, annual reevaluations, and screening aligned with ICF/IID criteria are required for eligibility and continued service authorization.
Review team and other staff qualifications are specified (e.g., nurse LPN/RN with minimum two years ID experience, social worker with four‑year degree and two years ID experience, licensed psychologist with Ph.D. and two years experience); staffing and qualification rules apply to service delivery.
Beneficiaries must be informed of feasible service alternatives, have choice between institutional care and HCBS, and be provided fair hearing and appeal rights.
Admission and level-of-care criteria — Criteria and process for admission, level-of-care determination, and initiation of services under the ID Waiver
Criteria and process for admission, level-of-care determination, and initiation of services under the ID Waiver.
Operating agency (or designee/case manager) will review applicant's medical and financial eligibility and assist with financial application and documentation routing to Medicaid District Office.
Applicants determined to need disability determination will have that determination made by the Medicaid Medical Review team when required; Regional Office completes slot confirmation upon disability determination.
Qualified Intellectual Disabilities Professional (QIDP) completes the level of care determination and development of the plan of care; ADMH designates a qualified medical professional to approve level of care and develop Plan of Care.
Assessment must determine that, without waiver services, the client is at risk of institutionalization; operating agency ensures screening and assessment demonstrate that ID Waiver services meet the applicant's needs in the community.
Alabama Medicaid will provide approved level of care criteria and policies/procedures; ADMH conducts assessments, admissions, readmissions, and annual redeterminations and may utilize Medicaid staff for consultation prior to final decision.
Upon receipt of financial award letter, the LTC Admissions Notification Form must be transmitted electronically to Medicaid's Fiscal Agent; if accepted, services may begin and billing may commence; if rejected, operating agency must determine reason and retransmit.
The Alabama Medicaid Agency will conduct retrospective reviews of random samples monthly and may initiate recoupment if state/federal medical necessity or eligibility requirements are not met.
Per capita cost limit — Cost limitation for waiver services
Cost limitation for waiver services
Average per capita cost for waiver services shall not exceed the total expenditures that would be incurred for such individuals if Home and Community‑Based services were not available (i.e., per capita cost neutrality to institutional care).
Procedure codes, units, and billing limits
Therapy service units and limitsmixedCovered
| No codes listed |
Positive Behavior Support levelsmixed
| Level 1 professional; Level 2 professional; Level 3 technical — each level has its own procedure code and rate; specific codes not listed in source. |
Procedure coding and unit reportingHCPCS
| HCPCS | Payment will be based on the number of units of service reported for HCPCS codes. |
Procedure code / HCPCS billingHCPCSCovered
| HCPCS | Each covered service is identified on a claim by a procedure code; payment is based on reported HCPCS units; claims must be submitted within 12 months of date of service. |
Occupational Therapy initial plan limit
Occupational Therapy initial-plan limit50 hours (200 units) for the initial plan
In‑Home Residential Habilitation daily limit
In‑Home Residential Habilitation daily limit8 hours per day
Day Habilitation daily limit
Day Habilitation daily limitCannot exceed 5 hours per day
Positive Behavior Support annual unit limits
Positive Behavior Support combined annual capMaximum 1,200 units per year (professional + technician combined)
Positive Behavior Support professional-level capMaximum 800 professional-level units per year
Unit lengthUnit of service is 15 minutes
Therapy initial plan limit
Therapy initial-plan limit (OT & PT)Occupational and Physical Therapy limited to 50 hours (200 units) for the initial plan
Billing unitServices provided and billed in 15‑minute units
Prescription and documentationRequires a physician's prescription, initial assessment and treatment plan with goals documented in the case record
claim_submission_deadline
Claim submission deadlineAll claims must be submitted within 12 months from the date of service
Payment basisPayment is based on the number of HCPCS units reported
Waiver year accounting noteServices provided during the 12‑month waiver year are attributed to that year for accounting
Claim spanning restriction
Claim spanning restrictionA single claim may not cover services performed in different months; providers should bill no more than one month's services per claim
Multiple claims allowedThere may be multiple claims in a month, but no single claim may span months
Rejection exampleClaims covering October 15 to November 15 would not be allowed and will be rejected if overlapping previously paid dates
Provider responsibilities, documentation, and operational steps
Documentation Required
Provider contract, qualifications, and legal compliance required
Each provider of Home and Community-Based Services (HCBS) must have a signed provider contract, meet provider qualifications, and comply with all applicable state and federal laws and regulations before providing waiver services.
- Ensure signed provider contract is on file prior to service delivery.
- Maintain and document provider qualifications consistent with state and federal requirements.
- Comply with applicable laws and regulations; services reimbursable through EPSDT cannot be billed as waiver HCBS.
Documentation Required
Therapy prescription, assessment, treatment plan, documentation, and unit billing
Occupational and physical therapy require a physician's prescription, an initial assessment and a treatment plan with established goals documented in the case record; services must be listed on the person-centered care plan and are billed in 15‑minute units.
- Maintain physician prescription and initial assessment/treatment plan in the case record.
- Document goals and justify ongoing need for service in the case record and on the person-centered plan.
- Bill therapy services in 15-minute units; occupational and physical therapy initial plan limited to 50 hours (200 units).
- Keep service logs and signed treatment notes (physical therapist must sign each note; e-signatures permitted if they meet privacy/security requirements).
Billing Rule
Positive Behavior Support: level-based coding, rates, and 30-day review
Positive Behavior Support (PBS) services use distinct level-based procedure codes and rates tied to provider level and supervision requirements; the BSP must be reviewed and re-justified in the case record every 30 days.
- Use the appropriate procedure code and rate for the provider level (professional levels and technician level as specified).
- Document BSP implementation and review progress; re-justify continued BSP use every 30 days.
- Bill PBS in 15-minute units.
Prior Authorization
Obtain ADMH regional prior approval for Crisis Intervention Services
All Crisis Intervention Services must be approved by the regional community service office of the Alabama Department of Mental Health (ADMH) before initiation and added to the approved person-centered care plan with a separate crisis intervention plan.
- Obtain regional ADMH prior approval before starting Crisis Intervention Services.
- Ensure Crisis Intervention Service is added to the recipient's approved person-centered care plan.
- Develop and maintain a separate crisis intervention plan detailing activities and supports.
Note
Include services in approved care plan; prior approval and 12‑month claim deadline
Services must be included in the approved person-centered care plan; Crisis Intervention Services require ADMH regional prior approval; claims must be filed within 12 months of the date of service and payment is based on HCPCS units reported.
- Verify that every billed service appears on the approved person-centered care plan prior to billing.
- For Crisis Intervention Services, secure ADMH regional approval before service initiation and document it in the care plan.
- Submit claims within 12 months from date of service; report number of HCPCS units for payment.
Documentation Required
Screening, assessment, QIDP level-of-care determination, and ADMH approval
The operating agency or its designee (case manager) must screen and assess applicants; the Qualified Intellectual Disabilities Professional (QIDP) completes the level-of-care determination and plan of care; ADMH designates a qualified medical professional to approve level of care.
- Ensure applicant is screened and assessed to determine whether ID Waiver services meet community needs.
- Have the QIDP complete level-of-care determination and develop the plan of care.
- Follow ADMH/Alabama Medicaid procedures and federal/state guidelines for level-of-care approval.
Billing Rule
Submit LTC Admissions Notification electronically; begin services after acceptance
Upon receipt of the financial award letter, submit the LTC Admissions Notification Form electronically to Medicaid's Fiscal Agent; services can begin when the transmission is accepted.
- Complete and electronically forward the LTC Admissions Notification Form after the financial award letter is received.
- Begin rendering and billing services only after the Fiscal Agent accepts the transmission and the information is written to the Long Term Care file.
Documentation Required
Handle LTC Admissions transmission rejections and retransmit
If the Fiscal Agent rejects the LTC Admissions Notification Form, the operating agency or designee must determine the rejection reason and retransmit the form until accepted.
- Monitor transmission status the next business day following submission.
- Investigate rejection reason promptly and correct/retransmit the LTC Admissions Notification Form.
Prior Authorization
Appeal to DMH Associate Commissioner within 15 days; continuation of services rules
Individuals may appeal a Notice of Action to the DMH Associate Commissioner within 15 calendar days of the effective date; services continue if appealed within 10 days of the effective date unless limited by specific conditions, and the DMH Associate Commissioner will issue a written decision within 21 days of review.
- Inform recipients of appeal rights and timelines in the Notice of Action.
- If the recipient files an appeal within 10 days, continue services pending the hearing outcome unless the issue is strictly a matter of federal/state law or policy and the beneficiary is notified in writing.
- If dissatisfied with the DMH Associate Commissioner's decision, the individual may request a Fair Hearing from Alabama Medicaid within 15 days of that decision letter.
Terms and definitions
Compliant provider-owned or controlled residential setting
DefinitionA physically accessible unit or dwelling that can be owned, rented, or occupied under a legally enforceable agreement by the individual receiving services
Tenant‑like protectionsIndividual must have comparable protections from eviction and a lease or residency agreement where landlord‑tenant laws do not apply
Privacy and choiceUnits must provide privacy (lockable doors), freedom to furnish/decorate, choice of roommates, control over schedule, and visitor rights
Supported Living Services
ScopeServices that include training and assistance to maintain an individual's own home (not owned/controlled by a waiver provider), supporting tenancy/ownership, money management, meal preparation, shopping, and community participation
Health tasksMay include oversight of self‑administered medication and non‑complex health maintenance as permitted by State law
Staffing intensityAppropriate for individuals needing intermittent staff support and not requiring 24/7 staffing; shared living allowed with up to 3 waiver recipients per residence
Day Habilitation Services
DefinitionRegularly scheduled non‑residential activities separate from the member's residence that focus on self‑help, socialization, adaptive skills and community participation
Delivery settingsFurnished in community settings or a provider hub compliant with HCBS Settings Rule
Daily limitDay Habilitation services cannot exceed five hours per day
Occupational Therapy Services
DefinitionOccupational Therapy includes evaluation, treatment, consultation and caregiver training to improve function
Prescription & documentationRequires a physician's prescription, initial assessment and treatment plan with established goals documented in the case record
Billing unit and initial limitBilled in 15‑minute units; limited to 50 hours (200 units) for the initial plan
Speech and Language Therapy Services
DefinitionSpeech and Language Therapy are diagnostic and treatment services when referred by a physician and related to the participant's diagnosis
DocumentationEvaluation required, services listed on care plan, documentation required for each encounter and each note must be signed by the therapist
EPSDT exclusionNot available under the waiver for children under 21 when provided through EPSDT (State Plan)
Physical Therapy Services
DefinitionPhysical Therapy provides evaluation and treatment to preserve or improve function using therapeutic programs and assistive devices
Documentation & prescriptionRequires a physician's prescription, initial assessment and treatment plan with goals documented; service logs and signed treatment notes required
Billing unit and initial limitBilled in 15‑minute units; limited to 50 hours (200 units) for the initial plan
Positive Behavior Support Services
DefinitionPositive Behavior Support provides functional behavior analysis, BSP development and implementation, consultation, and training to support adaptive behavior
Provider levels & supervisionThree provider levels (professional levels 1 & 2 and technical level 3) with associated supervision requirements and distinct procedure codes/rates
Annual unit limitsCombined professional and technician units cannot exceed 1,200 per year; professional‑level units cannot exceed 800 per year
Personal Care Services
DefinitionPersonal Care Services assist with activities of daily living (ADLs) and instrumental ADLs (IADLs) and may include incidental transportation for community access
Self‑direction and age restrictionMay be self‑directed with restrictions: cannot be self‑directed for children under 21 on the State Plan
Daily capsPersonal Care is limited to no more than 12 hours/48 units per day for individuals living with relatives; higher hours may be approved for independent living based on assessed need
Environmental/Equipment services
Environmental Accessibility AdaptationsPhysical adaptations (e.g., ramps, grab bars, widen doorways) required by the person‑centered plan to ensure health/safety and independence; excludes general‑utility home improvements
Specialized Medical Supplies & Assistive TechnologySpecialized supplies and assistive devices must have physician or documented orders and are additional to State Plan items
Annual capsEnvironmental Accessibility Adaptations and Assistive Technology limited to $5,000 per recipient per year; Specialized Medical Supplies limited to $2,400 per year
Crisis Intervention Services
DefinitionCrisis Intervention Services provide immediate 24‑hour therapeutic intervention to address crises that threaten health/safety or risk institutionalization
Duration limitExpected to be brief with a maximum duration of 10 weeks; longer needs require transition to another service
Interdisciplinary team & approvalDelivered by a team led by a licensed psychologist, counselor or social worker meeting QDDP requirements; all services require prior approval by the ADMH regional community service office
Benefits and Career Counseling
DefinitionBenefits and Career Counseling comprises Benefits Reporting Assistance (BRA) and Benefits Counseling delivered by a Certified Work Incentives Counselor (CWIC)
Provider qualificationBenefits Counseling must be delivered by a CWIC certified per SSA training requirements
ComponentsIncludes assistance with benefits reporting and individualized benefits counseling to support employment and financial planning
Unit of service
Unit length and provider teamA unit of service is 15 minutes and must be provided by the waiver planning team directed by a graduate psychologist or licensed social worker
ApplicationApplies to services billed in 15‑minute units across therapies and crisis services per policy provisions
DocumentationServices must be documented in service logs and treatment notes as required by each service's rules
Individual Directed Goods and Services (IDGS)
DefinitionIndividual Directed Goods and Services (IDGS) are services, equipment or supplies not otherwise provided through the ID Waiver or State Plan that meet identified needs in the person‑centered plan
Cost‑effectiveness and purposePurchases must be cost‑effective, assure health/safety, and directly benefit the recipient toward specified outcomes
Annual purchase limitAnnual purchases not to exceed $10,000 (determined by the recipient's savings account balance at time of request)
Remote Support Services
DefinitionRemote Support Services are real‑time two‑way electronic supports provided to recipients 18 years or older at their residence by awake remote staff
Delivery modeMust be live, two‑way communication (not recordings) using stable, reliable electronic connection
GoalIntended to address assessed needs, promote autonomy, minimize dependence on in‑person paid supports, and reduce intrusive services
waiver year
Waiver year definitionA waiver year consists of 12 consecutive months starting with the approval date specified in the approved waiver document
Accounting attributionAll services provided during the 12‑month waiver year are attributed to that year for reporting and fee‑setting
Use in reportingWaiver year used for HCFA form 372 accounting of costs and units
expenditure
Expenditure definitionAn expenditure occurs when cash or its equivalent is paid in a quarter by a state agency for waiver benefits; for public providers, when paid or recorded, whichever is earlier
Non‑cash paymentsNon‑cash payments (e.g., depreciation) are recorded when transactions are recorded by the state agency
Reporting implicationExpenditures drive accounting and audit figures used in establishing interim fees
Policy Summary
PayerAlabama Medicaid
PolicyHome and Community-Based Waiver for Persons with Intellectual Disabilities (ID Waiver)
Policy CodePolicy N/A
Change TypeNo material change
Effective DateAug 14, 2025
Last ReviewJun 30, 2025
Next Review DateN/A
Key ActionInclude all services in the approved person-centered care plan and obtain prior approval for Crisis Intervention Services from the ADMH regional community service office before initiating services.
SourceLink
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