DDA Waiver Renewal 2023- Services Update Summary Chart- Final 5-3-2023

Developmental Disabilities Administration

Waiver Renewals 2023

Services Update Summary Chart

The Center for Medicare and Medicaid Services (CMS) approved the Development Disabilities

Administrations (DDA) Waiver Renewals for the Family Supports, Community Supports, and Community

Pathways programs. The renewal changes go into effect on July 1, 2023.

This summary chart provides information related to upcoming changes that will affect person-centered

planning efforts for services with a July 1, 2023 start date. These service changes should be considered

when developing and reviewing Person-Centered Plans for participants with services beginning July 1,

2023.

Please note that the renewal includes additional clarifying service description information. Those will be

further reflected in policies and guidance as applicable. Changes in staff training requirements will be

reflected in the DDA’s Training Matrix.

Authorization for

enhanced rate, 1:1 or 2:1

dedicated supports, and

overnight supports

A Health Risk Screening Tool (HRST) score is not required for

authorization of an enhanced rate, 1:1 or 2:1 dedicated support, or

overnight support.

This applies to the following services:

● Day Habilitation

● Community Development Services

● Community Living - Group Home

● Community Living - Enhanced Supports

● Personal Support Services

● Supported Living

The following criteria will be used to authorize dedicated

staff-to-participant ratios:

1. The participant has an approved Behavior Support Plan (BSP)

documenting the need for 1:1 or 2:1 staff-to-participant ratio

necessary to support the person with specific behavioral needs

unless otherwise authorized by the DDA; or

2. The participant has an approved Nursing Care Plan (NCP)

documenting the need for 1:1 or 2:1 staff-to-participant ratio

necessary to support the person with specific health and safety

needs unless otherwise authorized by the DDA.

The following criteria will be used to authorize overnight supports:

1. The participant has an approved BSP documenting the need for

overnight supports necessary to support the person with specific

behavioral needs, unless otherwise authorized by the DDA; or

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2. The participant has an approved NCP documenting the need for

overnight supports necessary to support the person with specific

health and safety needs, unless

Overnight supervision support must be specifically documented within

the PCP. This includes information that details the need for the overnight

supports, including alternatives explored such as the use of assistive

technology and other strategies.

Notes:

1. The DDA may authorize dedicated, enhanced, or overnight

support for people new to services (including transitioning youth)

and people in services who have a specific behavioral, or health

and safety need while a BSP and NCP gets authorized and

developed.

2. The HRST is still used to assess the person’s health and safety

needs. It is not required for higher levels of support as noted

above.

Assistive Technology and

Services

The threshold for requiring an Assistive Technology (AT)

Assessment is increased to $2,500. This means if a person needs

AT costing more than $2,500 an assessment is required.

Note: An AT assessment can also be requested for items less than

$2,500 to ensure the item or device will meet the person’s needs.

Behavior Support

Services

Behavioral Assessment includes, but is not limited to:

1. An assessment of communication skills and how challenges with

communication may relate to behavior (if applicable).

2. Development of the Behavior Support Plan, if applicable, with

goals that are specific, measurable, attainable, relevant,

time-based, and based on a person-centered approach.

Behavioral Consultation services include, but are not limited to:

1. Developing, presenting, and providing ongoing education on

recommendations, strategies, and next steps to ensure that the

participant is able to continue to participate in home and

community environments, including those where they live, spend

their days, work, volunteer, etc. to optimize community inclusion

in the most integrated environment.

2. Ongoing review and assessment of progress in all appropriate

environments against identified goals related to the behavior

support plan.

Maryland Medicaid State Plan - Applied Behavioral Analysis should be

explored prior to accessing this service for people under the age of 21.

Note: Behavior Support Plan updates are completed under Behavioral

Consultation.

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Career Exploration

Facility-Based Supports:

1. Can be at a fixed site that is owned, operated, or controlled by a

licensed provider or an off-site location. It also includes doing

work under a contract being paid by a licensed provider.

2. People may attend any day of the week.

Note: Career Exploration may not exceed a maximum of eight (8) hours

per day or 40 hours per week including in combination with any of the

following other Waiver program services in a single day: Community

Development, Supported Employment, Employment Service – Job

Development, Employment Discovery and Customization, and Day

Habilitation services.

Day Habilitation

People may attend Day Habilitation any day of the week.

Services may also be provided in small groups (i.e., 1 to 5

participants) or large groups (i.e., 6 to 10 participants).

Environmental

Assessments and

Environmental

Modifications

The maximum amount of Environmental Modifications is increased

to $50,000 every three years unless otherwise authorized by the

DDA.

Note: Details about modifications that are included and not included

and requirements for Environmental Assessments are detailed in the

approved waiver.

Employment Services

The limit of 10 hours per day with Employment Services - Ongoing

Job Supports is removed.

Additional Nursing Support Services Delegation training supports

can be authorized due to a change in the participant’s health status

or after discharge from a hospital or skilled nursing facility.

Housing Support

Services

Housing Support Services is expanded to include bill paying

services (e.g., assistance with setting up and monitoring systems to

pay rent, mortgage, utilities, and other related housing expenses).

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Individual and Family

Directed Goods and

Services (IFDGS)

Expanded scope of service to include new items/activities covered

under this service including but not limited to:

1. Activities that promote fitness, such as but not limited to fitness

membership, personal training, aquatics, and horseback riding;

2. Fees for programs and activities that promote socialization and

independence, such as but not limited to art, music, dance,

sports, or other according to the participant’s individual interests;

3. Small kitchen appliances that promote independent meal

preparation such as but not limited to air fryers, microwaves, and

toaster ovens;

4. Laundry appliances (such as but not limited to washer and/or

dryer) to promote independence and self-care, if none exist in

the home;

5. Sensory items related to the person’s disability, such as but not

limited to headphones and weighted vests/blankets;

6. Safety equipment related to the person’s disability and not

covered by health insurance, such as but not limited to protective

headgear and arm guards;

7. Personal electronic devices, including watches and tablets, to

meet an assessed health, communication, or behavioral purpose

documented in the Person-Centered Plan;

8. Day-to-day administrative supports which include assistance with

all aspects of household and personal management essential to

maintain community living, including support with scheduling and

maintaining appointments and money management; and

9. Internet services.

Note: Please see approved waiver and DDA guidance for additional

goods and services covered and standards.

Expanded scope of service not covered under this service to

include:

1. Services, goods or supports provided to or directly benefiting

persons other than the participant. They have no benefit to the

participant;

2. Items used solely for entertainment or recreational purposes,

such as televisions, video recorders, game stations, and DVD

players except as needed to meet an assessed behavioral or

sensory need documented in a Behavior Support Plan;

3. Travel adventures;

4. Personal clothing and shoes;

5. Hair cuts, nail services, and spa treatments;

6. Exercise rooms, swimming pools, and hot tubs;

7. Fines, debts, legal fees, or advocacy fees;

8. Contributions to ABLE Accounts and similar saving accounts;

9. Country club membership or dues;

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10. Leased or purchased vehicles;

11. Items purchased prior to the approved Person-Centered Plan.

Note: This list is not a complete list of exclusions. Please see approved

waiver and DDA guidance for additional exclusions.

IFDGS must meet the following criteria:

1. Relate to a need or goal identified in the Person-Centered Plan;

2. Are for the purpose of maintaining or increasing independence;

3. Promote opportunities for community living, integration, and

inclusion;

4. Are able to be accommodated without compromising the

participant’s health or safety; and

5. Are provided to, or directed exclusively toward, the benefit of the

participant.

IFDGS must meet the following requirements:

1. The item or service would decrease the need for other Medicaid

services; OR

2. Promote inclusion in the community; OR

3. Increase the participant’s safety in the home environment; AND

4. The participant does not have the funds to purchase the item or

service; AND

5. The item or service is not available through another source.

IFDGS are purchased from the participant-directed annual budget

allocation and must be documented in the participant’s record.

Service Limits Updated:

1. $5000 limit removed.

2. However, goods or services in excess of $5000 require prior

authorization by the DDA to ensure the goods/service meets the

criteria stipulated in the service specification, aligns with the

person-centered plan, and ensures that the purchase represents

the most cost-effective means of meeting the identified need.

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Nursing Support Services

Limitations for both service models (SDS and Traditional) include:

1. Nurse Consultation services – Assessment and document

revisions and recommendations of the participant’s health needs,

protocols, and environment are limited to up to a four (4) hour

period within a three (3) month period.

2. Nurse Health Case Management services are limited up to a four

(4) hour period within a three (3) month period.

3. Nurse Delegation – The frequency of assessment is minimally

every 45 days, but may be more frequent based on the MBON

10.27.11 regulation and the prudent nursing judgment of the

delegating RN in meeting conditions for delegation. This is a

person-centered assessment and evaluation by the RN that

determines the duration and frequency of each assessment.

Personal Supports

Personal Supports include overnight supports.

Overnight supervision support must be specifically documented within

the PCP. This includes information that details the need for the overnight

supports, including alternatives explored such as the use of assistive

technology and other strategies.

Limitation Updates:

1. Personal Supports overnight supports cannot be provided

virtually.

2. Personal Support services are limited to 82 hours per week

under the traditional model unless otherwise pre-authorized by

the DDA.

Note: Please refer to the Personal Supports policy for additional

information.

Respite Care Services

Respite may be used as an emergency backup plan for unpaid

caregivers.

Respite does not include travel adventures (unless it is a day trip)

or vacations.

Shared Living

Service levels updated to reflect:

“Level 2” - The person may participate in meaningful day services or

have a job.

“Level 3” - Various reasons a person may have this level of support and

that not all conditions need to be present concurrently.

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Support Broker

What a Support Broker can do was broadened to include, but not

limited to:

1. Assistance with:

a. Making informed decisions in arranging for, directing, and

managing services the individual receives, including decisions

related to personnel requirements and resources needed to

meet the requirements;

b. Accessing and managing identified supports and services;

c. Arranging for, directing, and managing services;

d. Identifying immediate and long-term needs, developing options

to meet those needs and accessing identified supports and

services;

e. Practical skills training to enable families and participants to

independently direct and manage waiver services. Examples

of skills training include providing information on recruiting and

hiring direct support professionals, managing workers, and

providing information on effective communication and

problem-solving.

f. Providing information to ensure that participants understand

the responsibilities involved with directing their services;

g. Defining goals, needs, and preferences;

h. Identifying resources and accessing services, supports and

resources;

i. Development of an emergency backup plan; Independent

advocacy, to assist in filing grievances and complaints when

necessary;

j. Participating/assisting in initial and ongoing PCP

development;

k. Reviewing and submitting staff hours at the direction of the

participant;

l. Preparing and submitting vendor requests; and

m. General advocacy to support participant choices.

2. Information, coaching, and mentoring including but not

limited to:

a. Person-centered planning and how it is applied;

b. The range and scope of individual choices and options;

c. The grievance process;

d. Free choice of providers;

e. Other subjects that are pertinent to the participant in managing

and directing waiver services.

Note: The extent of the assistance furnished to the participant or family

should be specified in the service implementation plan.

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Support Broker Services are required when a relative, legally

responsible individual, representative payee, and guardian serve as

paid staff in order to assure proper oversight and quality assurance

as well as reduce conflicts of interest.

Support Brokers shall not make any decision for the participant,

sign off on their own timesheets or invoices, or hire or fire workers.

Person-Centered Plan authorization includes:

1. Initial orientation and assistance up to 15 hours.

2. Support Broker Services up to 4 hours per month.

Additional Support Broker Services may be provided:

1. Up to 30 hours per month, as needed by the participant and

within the participant’s total approved annual budget, may be

purchased with unallocated funds due to:

a. The scope, frequency, and intensity of supports needed (for

example 24/7 supports, multiple staff and services);

b. Language barriers; and

c. The lack of a support network to assist with the self-directed

service model requirements.

Transportation

Day trips outside the state are covered.

Transportation is limited to $7,500 per year per participant.

Note: This relates to the stand-alone transportation support services. It

does not relate to transportation supports within meaningful day,

residential, and personal supports services.

Note: This chart is a summary of important information. There are more requirements and clarifications in

the Medicaid Waiver Program applications, laws, regulations, guidance, and policies.

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