CurrentWyoming Department of HealthPolicy N/A

Chapter 46 — Medicaid Supports and Comprehensive Waivers

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This Chapter governs Medicaid services, eligibility, provider requirements, service restrictions, budgets, self-directed delivery, and wait-list processes for Wyoming Medicaid Supports and Comprehensive Waivers. It applies to waiver participants, applicants, case managers, providers, and other affected parties.

Policy Summary

PayerWyoming Department of Health

PolicyChapter 46 — Medicaid Supports and Comprehensive Waivers

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization before providing any waiver service and ensure it is included in the individualized plan of care and supported by assessed medical or functional need.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Waiver programs governed

30 daysEligibility paperwork deadline

5 yearsICAP assessment interval

35 hours/weekDay-service limit for Levels 3–6

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CurrentWyoming Department of HealthPolicy N/A

Chapter 46 — Medicaid Supports and Comprehensive Waivers

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Sign up for all Wyoming Department of Health policy alerts

Know when Wyoming Department of Health releases new policies or updates existing guidance.

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Policy Summary

PayerWyoming Department of Health

PolicyChapter 46 — Medicaid Supports and Comprehensive Waivers

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization before providing any waiver service and ensure it is included in the individualized plan of care and supported by assessed medical or functional need.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

2Waiver programs governed

30 daysEligibility paperwork deadline

5 yearsICAP assessment interval

35 hours/weekDay-service limit for Levels 3–6

20 business daysECC written decision time

Eligibility, Services, Funding, and Limitations

Supports Waiver eligibility

Supports Waiver eligibility requires ALL of the following:

Application and basic eligibility
- Complete the application process and meet the citizenship, residency, and financial eligibility requirements established in Chapter 18.
- Qualify for the applicable institutional level of care.
- Have a qualifying clinical eligibility diagnosis.
- Receive a qualifying Inventory for Client and Agency Planning (ICAP) score.

Comprehensive Waiver eligibility

Comprehensive Waiver eligibility requires Supports Waiver eligibility plus ALL of the following:

Meet all Supports Waiver eligibility requirements.
Have assessed service needs in excess of the established Supports Waiver cost limit.
Additional pathway
- Meet emergency criteria approved by the Extraordinary Care Committee (ECC).
- Meet reserved-capacity criteria under Section 13(f) or (g).

Institutional level of care

The applicable institutional level of care must correspond to the qualifying diagnosis:

For a developmental or intellectual disability diagnosis, qualify for an intermediate care facility for individuals with an intellectual or developmental disability (ICF/IID) level of care, measured by the LT-104 assessment.
For an acquired brain injury diagnosis, qualify for a nursing facility level of care, measured by the LT-101 assessment.

Clinical eligibility diagnoses

At least ONE qualifying clinical diagnosis is required:

Clinical eligibility diagnosis

Intellectual disability
- Have an intellectual disability diagnosis under DSM-5, determined by a Wyoming-licensed, Medicaid-enrolled psychiatrist, neurologist, or clinical psychologist who is free of conflicts with the participant's other selected providers.
- Submit a written and signed psychological evaluation to the Division.
- Provide validated adaptive-functioning scores, such as from the Vineland Adaptive Behavior Scales or Adaptive Behavior Assessment System.
Developmental disability or related condition
- Have a determination by a qualified Wyoming-licensed, Medicaid-enrolled medical professional, neurologist, or clinical psychologist who is free of conflicts with the participant's other selected providers.

ICAP assessment requirements

The individual must meet the ICAP requirement for the applicable age group:

Qualifying ICAP assessment

Age 0 through 1
- Adaptive behavior quotient is 0.50 or below.0.50 or below
Age 2 through 5
- ICAP service score is between 30 and 44, depending on age.30 through 44, depending on age
- Adaptive behavior quotient is 0.50 or below.0.50 or below

Ongoing eligibility and reassessment

Continued clinical eligibility requires ALL of the following:

Ongoing eligibility verification

Complete clinical eligibility reassessment at least annually, or more frequently when a change in circumstances requires a higher level of services or supports to ensure health, safety, and welfare.
Complete a subsequent neuropsychological evaluation every five years when required.Every 5 years
The Division must approve the evaluation before scheduling.
Complete an ICAP assessment every five years, or more frequently at the Division's option.Every 5 years
The assessment is administered by the Division's designee.

Waiver service medical and functional necessity

Each covered waiver service must satisfy ALL of the following:

Service coverage requirements

Be specified in the individualized plan of care.
Be based on the participant's assessed needs.
Meet the applicable service definition.
Be medically or functionally necessary.
Align with the participant's preferences for services, supports, and providers.
Be prioritized within the participant's available individual budget amount.

Funding, budgets, and wait lists

Enrollment, budgets, and access to funding are subject to ALL of the following conditions:

Funding, budget, and capacity conditions

Be determined eligible under the applicable waiver requirements before enrollment or wait-list placement.
Be subject to available appropriations and CMS approval.
Have an assessed Level of Service score and individual budget amount used to plan services and supports.
Remain within the applicable waiver budget and CMS-approved institutional cost limit, unless the individualized plan of care and budget are approved by the ECC.
Have an available waiver slot before transitioning from the Supports Waiver to the Comprehensive Waiver.
Comprehensive Waiver transition occurs only when funding and a slot are available.

Wait-list eligibility and prioritization

Wait-list placement and prioritization require the applicable pathway and eligibility conditions:

Supports Waiver wait list

Be determined eligible under Section 4 before being added to the Supports Waiver wait list.
Be prioritized first come, first served based on the date eligibility was determined.
For identical eligibility dates, the date the Case Manager Selection form was received determines priority.

Comprehensive Waiver wait-list pathways

Need services in excess of the Supports Waiver and lack an available funding opportunity; preference is given to individuals with a Level of Service score of 4 or higher.Level of Service score 4 or higher

Emergency waiver services

An emergency case must involve an eligible person requiring immediate action or an urgent need for waiver services, including placement in the least restrictive and most appropriate environment necessary to maintain vital functions, and must meet at least ONE of the following:

Emergency waiver criteria

An immediate threat or high probability of immediate danger exists to the life, health, property, or environment of the person or another individual because of a medical, mental-health, or behavioral condition.
The primary caregiver has died, become incapacitated, developed a critical medical condition, or become unable to provide continuous care.
The person has been homeless for 30 days without an adequate residence with appropriate support and supervision resources, with evidence of serious harm to life or health without that support.30 days
The person was removed from the home by an appropriate agency because of abuse, neglect, abandonment, exploitation, or self-neglect.

Extraordinary Care Committee funding

ECC review and funding require ALL of the following:

ECC request requirements

The participant is eligible for a waiver operated by the Division.
The request concerns an emergency, extraordinary change in service need, temporary funding increase, Level of Service concern, or other supplemental request requiring ECC approval.
The plan of care team meets, reaches consensus that the request is necessary, and documents that other supports or resources have been explored.
The case manager submits the request on the Division-provided form.
The request includes supporting statements or reports from relevant state or regional agencies, specific incidents and condition or injury information, witnesses, follow-up or treatment summaries, and documentation of approaches or supports already attempted.

Coverage limitations and denial conditions

Waiver services or funding may be denied, revoked, or excluded under ANY of the following conditions:

The service is institutional care or is furnished to a person residing in a hospital, nursing facility, ICF/IID, or other institutional placement.
The service is furnished by a prohibited spouse, legally authorized representative, or provider owner or officer arrangement.
The request includes room and board, except approved respite in a Medicaid-approved facility other than a private residence.
The service is covered under the Medicaid State Plan, exceeds the CMS-approved institutional cost limit, or is provided in a setting reimbursed by another state agency.
The service duplicates another available service, including a service available through the Rehabilitation Act, IDEA, Medicaid State Plan, school district, or Division of Vocational Rehabilitation, without an approved exemption.

A participant loses waiver eligibility when the participant no longer meets clinical or financial eligibility requirements or changes residence to another state. Eligibility may also be terminated after three consecutive months without voluntarily receiving waiver services, 30 or more consecutive calendar days in an institutional placement, six consecutive months out of state, or selection of another waiver. Services following a clinical ineligibility determination must end no later than 45 calendar days after the determination.

Waiver services may not duplicate the same or a similar service available through Section 110 or Section 504 of the Rehabilitation Act, the Individuals with Disabilities Education Act (IDEA), or the Medicaid State Plan. An exemption may be requested through a third-party-liability form included with the individualized plan of care, documenting that another program or agency cannot meet the participant's assessed needs; the Division must approve the exemption.

Providers may not serve children under age 18 and adults at the same time unless the Division provides written authorization.

Participants receiving Levels 3 through 6 community living services may receive an average of no more than 35 hours of day services per week. The limit includes adult day, community support, and companion services.

A provider whose certification has been revoked under Chapter 45 may not provide self-directed services.

Care furnished to an individual residing in a hospital, nursing facility, ICF/IID, or other institutional placement is not eligible for waiver reimbursement.

Waiver reimbursement is not available for services furnished by a spouse who is also the participant's legally authorized representative, by the legally authorized representative of a participant age 18 or older, or by an owner or officer of a provider organization serving a participant for whom that person is the legally authorized representative.

Room and board is excluded from waiver reimbursement, except when provided as part of respite in a Medicaid-approved facility other than a private residence.

Waiver reimbursement is unavailable for services covered under the Medicaid State Plan, services reasonably expected to exceed the institutional cost limit in the most current CMS-approved Comprehensive Waiver application, or services provided in settings reimbursed by another state agency. Individuals eligible for specialized services must also apply for and accept available federal Medicaid benefits and other applicable agency funding to the maximum extent possible.

Emergency waiver placement may not be used as an alternative to incarceration or jail, and emergency services may not be provided to a person who has not been determined eligible for waiver services. Direct waiver services that are the responsibility of the school system may not be authorized during school or vocational-program hours. An exception applies when an individualized education plan identifies specific times the school system will not cover the services.

The Division may deny or revoke waiver funding when the participant's needs are not being met through waiver services, the individualized plan of care has not been implemented, or the requested service is available through another funding source. Authorization may also be denied or revoked for failure to meet eligibility or emergency criteria, lack of consent or cooperation, missing information or required signatures, election of institutional services, insufficient appropriated resources, failure to obtain available benefits, or availability of educational services during the applicable school day through the end of the school year in which the individual turns 21.

Assessment and Operational Thresholds

Mayo Portland Adaptability Inventory

Threshold42 or more

California Verbal Learning Test Trials 1-5 T

Threshold40 or less

Supervision Rating Scale

Threshold4 or more

ICAP Adaptive Behavior Quotient, Age 0 Through 1

Threshold

Authorization, Documentation, and Denial Risks

Prior Authorization

Prior Authorization Required

Obtain prior authorization before providing any waiver service. Services must be authorized and included in the participant’s individualized plan of care.

Prior Authorization

Approval for Repeat Evaluations

Obtain Division approval before scheduling a subsequent psychological evaluation when it is necessary because of a change in condition or otherwise determined necessary by the Division. Subsequent neuropsychological evaluations also require prior Division approval and must be performed every five years.

Reassessments must be completed by an appropriately enrolled and Wyoming-licensed psychiatrist, neurologist, or clinical psychologist who is free of conflicts with the participant’s other providers.

Program Overview

The Supports and Comprehensive Waivers provide Medicaid services for individuals who meet specified financial, clinical, functional, and institutional level-of-care requirements. Eligibility and service planning rely on diagnoses, adaptive or functional assessments, ICAP results, individualized plans of care, and Level of Service scores. Covered services are intended to promote independence, choice, self-management, and community participation.

Defined Terms

Case Manager

DefinitionAn individual who provides case management services, as established in Chapter 45, Section 9.

Level of Service Score

DefinitionA participant's support needs for various parts of their everyday routine and their level of independence, tied to a score ranging from 1 (lowest level of support) to 6 (highest level of support). The score is based on comprehensive assessments of functioning, behavioral and health factors, and essential staffing and support requirements.

Relative

DefinitionA participant's biological, step, or adoptive parent or parents.

Policy Summary

PayerWyoming Department of Health

PolicyChapter 46 — Medicaid Supports and Comprehensive Waivers

Policy CodePolicy N/A

Change TypeNo material change

Effective DateN/A

Next Review DateN/A

Key ActionObtain prior authorization before providing any waiver service and ensure it is included in the individualized plan of care and supported by assessed medical or functional need.

SourceLink

On This Page

Submit medical records and a written psychological evaluation with assessment scores.

Document a severe, chronic disability that manifested before age 22, requires lifelong or extended-duration services, is attributable to a cognitive or physical impairment other than mental illness, is likely to continue indefinitely, and causes substantial functional limitations in at least 3 major life activity areas.At least 3 major life activity areas

Areas include self-care, receptive and expressive language, learning, mobility, self-direction, independent living, and economic self-sufficiency.

Acquired brain injury

Be between ages 21 and 64.Age 21 through 64
Have a qualifying score on at least one Division-accepted evaluation completed by a Wyoming-licensed, Medicaid-enrolled psychiatrist, neurologist, or clinical psychologist who is free of conflicts with the participant's other selected providers.
Accepted evaluation threshold
- Score 42 or more on the Mayo Portland Adaptability Inventory (MPAI).42 or more
- Score 40 or less on the most current California Verbal Learning Test Trials 1-5 T.40 or less
- Score 4 or more on the Supervision Rating Scale.4 or more

Age 6 through 20

ICAP service score is between 48 and 70, depending on age.48 through 70, depending on age
Adaptive behavior quotient is 0.70 or below.0.70 or below

Age 21 or older

ICAP service score is 70 or less.70 or less
Have a functional limitation in at least 3 ICAP areas.At least 3 areas
Areas include self-care, language, learning/cognition, mobility, self-direction, and independent living.

Ensure psychological and neuropsychological reassessments are completed by a Wyoming-licensed, Medicaid-enrolled psychiatrist, neurologist, or clinical psychologist who is free of conflicts with the participant's other selected providers.

Receive prior authorization before delivery.

Qualify for reserved capacity after residing in a Wyoming institution and meeting the applicable institutional-transition conditions.

Be a qualifying dependent of an active military service member assigned to Wyoming, or retiring or separating from active duty and intending to reside in Wyoming within 18 months.

Be transitioning from institutional services at the individual's request when capacity remains after required reservations.

Extraordinary residential needs create a significant health or safety risk that cannot be met in the current living arrangement, including a substantial corroborated threat, serious behavioral risk, critical medical need for ongoing 24-hour support, or loss of the primary caregiver.

The individual must be eligible for waiver services; emergency services may not be provided to an ineligible person.

A credentialed professional explains the significant change in functioning, assessed need for additional supports or services, and jeopardy to the person's life or health without those supports.

The request includes evidence that the person does not qualify for other agency funding or services that would alleviate the emergency.

The request includes information not adequately captured in the ICAP or the Division's electronic records.

The participant or plan of care team accepts any additional assessments, referrals, or outside consultation requested by the ECC.

Funding is available in the Division's waiver budget appropriation.

A direct service is the responsibility of the school system or is requested for hours when a child attends school or a vocational program, except for times specifically identified in an individualized education plan as not covered by the school system.

The individual fails to meet waiver eligibility or applicable emergency criteria, or the individual or legally authorized representative does not consent to waiver services.

Required information, signatures, cooperation, or implementation of the individualized plan of care is missing.

The participant's needs are not being met through waiver services.

Sufficient legislative resources are unavailable, or the individual fails to apply for or accept available Medicaid or other agency benefits to the maximum extent possible.

The individual or legally authorized representative chooses ICF/IID or nursing facility services.

Educational services could be provided during a regular or adjusted school day through the end of the school year in which the individual turns 21.

Emergency placement is requested as an alternative to incarceration or jail.

ICAP Service Score, Age 2 Through 5

Threshold30 through 44, depending on age

ICAP Adaptive Behavior Quotient, Age 2 Through 5

Threshold0.50 or below

ICAP Service Score, Age 6 Through 20

Threshold48 through 70, depending on age

ICAP Adaptive Behavior Quotient, Age 6 Through 20

Threshold0.70 or below

ICAP Score, Age 21 or Older

Qualifying thresholdService score 70 or less, or functional limitation in at least 3 specified ICAP areas

Comprehensive Waiver Wait-List Preference

Preference thresholdLevel of Service score of four (4) or higher

Homelessness Emergency Criterion

Required durationLacks an adequate residence for thirty (30) days

Residential Emergency Risk

Emergency riskOngoing twenty-four (24) hour support and supervision may be required

ECC Decision Time

Decision deadlineWritten decision within twenty (20) business days of ECC review

Documentation Required

ECC Funding Request

Before submitting an Extraordinary Care Committee (ECC) request, the plan of care team must meet, reach consensus that the request is necessary, and document that other support or resource options have been explored. Submit the request on the Division’s form with all required supporting information.

The ECC may approve, partially approve, or deny a request, subject to available waiver-budget funding.
The ECC issues its written decision within 20 business days of review.

Prior Authorization

Emergency Referral

Direct anyone requesting emergency consideration to work with the chosen case manager, the Division, and other community resources to review emergency-service options. The case manager must submit the emergency-services request on the person’s behalf, and emergency cases must be referred to the ECC.

Emergency cases may include eligible people on the wait list and current participants whose circumstances meet Section 14 emergency criteria.

Documentation Required

Eligibility Paperwork Timelines

The case manager must complete all eligibility paperwork within 30 calendar days after selection. The Division must review submitted paperwork within 30 calendar days of receipt.

Documentation Required

Clinical Eligibility Records

Submit the clinical records required to establish the applicable diagnosis, including written and signed psychological evaluations, adaptive-behavior or other assessment scores, medical records, and documentation of the condition’s onset, expected duration, and functional limitations. Records must be completed by the required enrolled and Wyoming-licensed professionals and submitted to the Division.

For intellectual disability, include adaptive-behavior scores from a validated instrument such as the Vineland Adaptive Behavior Scales or Adaptive Behavior Assessment System.
For developmental disability, document a severe, chronic disability that began before age 22, is likely to continue indefinitely, and causes substantial limitations in at least three major life-activity areas.
For ASD, submit a current Division-accepted autism evaluation.
For ABI, submit a qualifying evaluation score: MPAI 42 or more, California Verbal Learning Test Trials 1–5 T score 40 or less, or Supervision Rating Scale 4 or more.

Prior Authorization

Assessment Currency and Approval

Diagnoses and assessments used for initial clinical eligibility must be accurate and completed within the past five years. Eligibility assessments and reassessments are subject to Division review before acceptance and may require additional evidence or verification.

The Division’s designee administers the ICAP assessment; it is completed every five years, or more frequently at the Division’s option.
Obtain Division approval before scheduling a subsequent psychological evaluation; subsequent neuropsychological evaluations require approval and occur every five years.
Participants are reassessed for clinical eligibility at least annually or more often when circumstances change and a higher level of support may be needed.

Documentation Required

Individualized Plan of Care

Ensure the individualized plan of care identifies services and actual units agreed to for the plan year and specifies the supports, settings, times of day, and activities requiring additional support. Services must be based on assessed needs, meet service definitions, be medically or functionally necessary, align with participant preferences, and be prioritized within the available individual budget.

Documentation Required

Self-Directed Service Records

For self-directed services, document the authorized services, specific tasks, employee schedule, service delivery, and timesheets in the manner agreed by the Employer of Record and Financial Management Service. The Employer of Record must make documentation available to the case manager by the 10th business day of the following month and maintain records as required by Medicaid rules.

Employees must document services in accordance with Chapter 45 and the agreed documentation process.
The Financial Management Service tracks authorized services and rates and processes wages in compliance with state and federal law.

Documentation Required

Verification of Self-Directed Services

The Employer of Record, with case-manager assistance as needed, must review employee service documentation and timesheets for accuracy against the individualized plan of care. Verify the type, scope, amount, frequency, and duration of services before submission or payment.

Documentation Required

ECC Request Preparation

The plan of care team must reach consensus that an ECC request is necessary and confirm that other support or resource options have been explored before submission. The case manager is responsible for ensuring the request is complete.

Documentation Required

Clinical and Agency Evidence

Support an ECC request with reports and statements from relevant state or regional agencies and credentialed professionals. The evidence must describe incidents, the condition or injury, witnesses, follow-up and treatment, the significant change in functioning, the additional assessed need, and the risk to the person’s life or health without added support.

Include documentation of other approaches or supports that have been attempted.
The professional statement must address the area of concern and explain the need for additional services or supports.

Documentation Required

Alternative-Resource Documentation

Document that other agency funding or services are unavailable or insufficient to alleviate the emergency situation. For homelessness-related requests, show that appropriate temporary or community resources are unavailable, inappropriate, or insufficient to meet immediate health and safety needs.

Also document evidence of immediate and serious harm when relying on insufficient community resources.
Explain why waiver services are the necessary and appropriate intervention.

Documentation Required

Supplemental Information and Assessments

Submit any additional information that the participant and plan of care team believe is not adequately captured in the ICAP or the Division’s electronic records. The ECC may require additional assessments, referrals, or outside consultation; refusal or failure to participate results in denial of the ECC request.

Requests that do not meet the required submission criteria will not be considered.

Documentation Required

Ongoing Authorization Documentation

Maintain signatures, cooperation, and records needed to support ongoing authorization. Authorization may be denied or revoked if required documentation is not signed, the plan of care is not implemented, participant needs are not being met, or the participant or legally authorized representative refuses or fails to cooperate.

The individual or legally authorized representative must consent to waiver services and provide requested information.
Document implementation of the individualized plan of care and continued delivery of authorized supports.

Denial Risk

Failure to Meet Eligibility Requirements

Confirm that the individual completes the application process and meets all general waiver eligibility requirements before delivering or requesting services. Failure to satisfy any required criterion creates a denial or revocation risk.

Citizenship, residency, and financial eligibility under Chapter 18 are required.
The individual must meet the applicable institutional level of care, clinical diagnosis requirements, and age-appropriate qualifying ICAP score.
The individual must consent to services, provide required information and signatures, cooperate with the Division, and implement the plan of care.

Denial Risk

Failure to Meet Comprehensive Waiver Criteria

For Comprehensive Waiver eligibility, confirm that the individual meets all general waiver requirements, has assessed service needs exceeding the Supports Waiver cost limit, and meets either ECC-approved emergency criteria or reserved-capacity criteria.

Denial Risk

No Qualifying Level of Care

Establish the applicable institutional level of care before requesting waiver services. A developmental or intellectual disability requires ICF/IID level of care measured by LT-104; an acquired brain injury requires nursing-facility level of care measured by LT-101.

Denial Risk

Service Not Supported by Plan or Assessed Need

Request only services supported by the participant’s assessed needs, applicable service definition, medical or functional necessity, preferences, and individualized plan of care. Services or units not defined or implemented in the plan may be denied or revoked.

The plan must identify the actual units, settings, times, and supports to be provided.
Authorization may be denied when participant needs are not being met through the authorized waiver services.

Denial Risk

Duplicative Service

Do not use waiver services to duplicate the same or a similar service available through another program, including Rehabilitation Act Sections 110 or 504, IDEA, or the Medicaid State Plan.

A participant may request an exemption by submitting a third-party-liability form with the individualized plan of care documenting that another program or agency cannot meet the assessed need.

Billing Rule

Unauthorized Service or Separate Transportation Charge

Do not provide services without authorization, and do not charge separately for routine transportation associated with waiver activities. Routine transportation is included in the service reimbursement rate regardless of the number of trips, unless the special activity is outside the participant’s community or normal routine.

Denial Risk

Self-Direction Termination Triggers

Self-direction may be involuntarily terminated for misuse of waiver funds, unmet health or welfare needs, exceeding the self-directed budget, fraud or criminal activity, or choosing not to receive self-directed services for 90 calendar days after active enrollment.

The Division must provide written notice; the participant may request an administrative hearing under Chapter 4.

Denial Risk

Eligibility and Consent Failures

Authorization may be denied or revoked when the individual or legally authorized representative does not meet eligibility requirements, consent to services, provide needed information or signatures, cooperate with the Division, or accept funded services.

Denial Risk

Missing Information or Noncooperation

Ensure all required information and Department documentation are supplied and signed, and that the participant and legally authorized representative cooperate with the Division and accept the services funded. Missing information, unsigned records, refusal, or noncooperation may result in denial or revocation.

Denial Risk

Funding or Alternate-Source Denial

Confirm that requested waiver funding is available and that the participant has applied for and accepted available Medicaid and other applicable agency benefits. Requests may be denied when fiscal resources are insufficient or another funding source can provide a similar service.

Other potential sources include the Department of Health, Department of Education, Department of Workforce Services, Division of Vocational Rehabilitation, school districts, and other agencies.

Denial Risk

Institutional or Educational Alternatives

Waiver authorization may be denied when the individual has chosen ICF/IID or nursing-facility services or could receive educational services during a regular or adjusted school day through the end of the school year in which the individual turns 21.

Billing Rule

Prohibited Reimbursement

Do not seek waiver reimbursement for institutional care, prohibited representative or provider-owner services, room and board except permitted facility respite, Medicaid State Plan services, services exceeding the applicable institutional cost limit, or settings reimbursed by another state agency.

Prohibited provider categories include a spouse who is also the participant’s legally authorized representative, a legally authorized representative of an adult participant, and an owner or officer serving a participant for whom the person is the legally authorized representative.

Billing Rule

School-Hour Service Restriction

Do not authorize direct waiver services that are the responsibility of the school system during school or vocational-program hours. Regular school hours and days also apply to home schooling and adjusted school days.

Waiver services may be used at specific times identified in an individualized education plan when the school system does not cover the services.

Denial Risk

Emergency Service Limitations

Emergency services may be requested only for a person who is eligible for waiver services; no emergency services may be provided to an ineligible person. Emergency placement may not be used as an alternative to incarceration or jail.

Emergency requests must meet the applicable Section 14 criteria and be reviewed through the required referral process.
The ECC may review emergency cases involving eligible people on the wait list or current waiver participants.

Acquired Brain Injury

DefinitionAcquired Brain Injury as defined by Chapter 1 of the Department of Health's Medicaid Rules.

Caregiver

DefinitionAny person, agency, or other entity responsible for a person's physical and supervisory care because of a family relationship, voluntary assumption of responsibility, court-ordered responsibility or placement, residential or institutional services, or acceptance of a legal obligation or responsibility of care.

Homelessness

DefinitionA situation in which, for a period of thirty days, a person lacks access to an adequate residence with appropriate resources to meet support and supervision needs and, without that support, there is evidence of serious harm to the person's life or health.

Extraordinary Care Committee (ECC)

CompositionA Division waiver manager, Medicaid manager, the Participant Support Specialist presenting the case, and a representative from the Department's fiscal unit; additional clinical or behavioral specialists may be included when appropriate.

RoleReviews emergency, extraordinary, and other supplemental funding requests and may approve, partially approve, or deny a submitted funding request for an eligible person.

Extraordinary Case

DefinitionA significant change in service need due to the onset of a behavioral or medical condition or injury, including a temporary change requiring a higher level of service or support, temporary funding increases, concerns about a Level of Service score, or other requests requiring ECC approval.