[Virtual Presenter] We are delighted to present our Care Management services under Medicaid waivers. Providers who are the parents of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant are not eligible for reimbursement. Please refer to the detailed provider qualifications for Care Management services. Prior to billing, a care manager must have completed the care management curriculum to become a Medicaid certified care manager. To be eligible, education and work experience requirements include being continuously employed as a care manager by an Area Agency on Aging (A-A-A--) since June 30, 2018, having a registered nurse license, and a bachelor's degree in social work, psychology, counseling, gerontology, nursing, or health and human services; or having a bachelor's degree in any field with a minimum of two years full-time, direct service experience with the elderly or disabled. A master's degree in social work, psychology, counseling, gerontology, nursing, or health and human services may substitute for the required minimum of two full-time direct services experience. An associate degree in nursing or any field with a minimum of four years full-time, direct service experience with the elderly or disabled may also be accepted. We hope this information is helpful and look forward to providing our Care Management services to eligible participants.. 

Scene 1

Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
DDRS HCBS Waivers 
Library Reference Number: PRPR10014 
243 
Published: Sept. 9, 2024 
Policies and procedures as of July 1, 2024 
Version: 11.1 
• Reimbursement of Care Management under Medicaid waivers may not be made unless and until the 
participant becomes eligible for Medicaid waiver services. Care Management provided to 
participants who are not eligible for Medicaid waiver services will not be reimbursed as a Medicaid 
waiver service. 
• Care Management services will not be reimbursed when the owner of the agency is one of the 
following: 
– Parent of a minor child participant 
– Spouse of a participant 
– Attorney-in-fact (or POA) of a participant 
– HCR of a participant 
– Legal guardian of a participant 
Provider Qualifications 
Provider qualifications for Care Management services are presented in Table 14. Prior to billing, a care 
manager must have completed the care management curriculum to become a Medicaid certified care 
manager. 
Table 14 – Provider Qualifications for Care Management 
Waiver 
Provider 
Licensure/ 
Certification 
Other Standards 
H&W/TBI  
FSSA-approved 
Care 
Management 
Individual  
Not required  
FSSA, or its designee, approved 
455 IAC 2 Documentation of qualifications  
455 IAC 2 Care management Liability Insurance 
Training in the nursing facility LOC process by the FSSA or 
designee  
Education and work experience:  
• An individual continuously employed as a care manager 
by an Area Agency on Aging (AAA) since 
June 30, 2018 
• A registered nurse 
• A bachelor’s degree in social work, Psychology, 
Counseling, Gerontology, Nursing or Health & Human 
Services; or 
• A bachelor’s degree in any field with a minimum of two 
years full-time, direct service experience with the elderly 
or disabled (this experience includes assessment, care 
plan development, and monitoring); OR 
• A master’s degree in social work, Psychology, 
Counseling, Gerontology, Nursing or Health & Human 
Services may substitute for the required minimum of two 
full time direct services experience; OR  
• An associate degree in nursing; OR  
• An associate degree in any field with a minimum of four 
year full-time, direct service experience with the elderly 
or disabled (this experience includes assessment, care 
plan development and monitoring)

[Audio] We are here to discuss the qualifications for care management services under the DDRS HCBS Waivers. The waivers are designed to support individuals with health and wellness and traumatic brain injury needs. Provider qualifications are crucial in ensuring that care management services are delivered effectively. Providers must have the necessary licenses and certifications, adhere to other standards, and meet specific qualifications. For caregiver coaching, we will discuss the definition of the service and the requirements for providing it. Caregiver coaching is a training and support service for unpaid caregivers of waiver participants with cognitive impairments and dementia. Caregivers will be equipped with the necessary skills to manage the participant's medical conditions and associated behavioral health needs. We will also discuss other standards required for care management services, such as financial information, documentation of qualifications, and maintenance of records of services provided. It is important to note that care management services will only be reimbursed for eligible participants under specific qualifications, including completing the care management curriculum and having relevant education and work experience. Additionally, providers cannot be reimbursed if they are the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant. In conclusion, care management services are an essential component of the DDRS HCBS Waivers. Providers must meet specific qualifications, and caregiver coaching is available to support unpaid caregivers of waiver participants with cognitive impairments and dementia. We. 

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DDRS HCBS Waivers 
Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
244 
Library Reference Number: PRPR10014 
 
Published: Sept. 9, 2024 
 
Policies and procedures as of July 1, 2024 
 
Version: 11.1 
Waiver 
Provider 
Licensure/ 
Certification 
Other Standards 
H&W 
FSSA-approved 
Care 
Management 
Agency 
Not required  
FSSA, or its designee, approved  
455 IAC 2 Provider Qualifications: General requirements  
455 IAC 2 Procedures for protecting individuals  
455 IAC 2 Unusual occurrence; reporting  
455 IAC 2 Transfer of individual’s record upon change of 
provider  
455 IAC 2 Notice of termination of services  
455 IAC 2 Provider organizational chart  
455 IAC 2 Collaboration and quality control  
455 IAC 2 Data collection and reporting standards 
455 IAC 2 Quality assurance and quality improvement system 
455 IAC 2 Financial information 
455 IAC 2 Liability insurance 
455 IAC 2 Documentation of qualifications 
455 IAC 2 Maintenance of personnel records 
455 IAC 2 Adoption of personnel policies 
455 IAC 2 Operations manual 
455 IAC 2 Maintenance of records of services provided  
455 IAC 2 Case Management  
Training in the nursing facility level of care process by the 
FSSA or designee  
Education and work experience:  
• An individual continuously employed as a care manager 
by an AAA since June 30, 2018; OR  
• A qualified intellectual disability professional (QIDP) 
who meets the requirements at 42 CFR 483.430; OR  
• A registered nurse, licensed practical nurse, bachelor’s 
degree or associate degree with one year of experience 
delivering health care/social services or care 
management, or at least two or more years in care 
planning, care management or delivering healthcare or 
social services.  
• A master's degree in a related field may substitute for 
the required experience. 
Section 12.13: Caregiver Coaching for H&W Waiver 
The following subsections provide information and requirements for Caregiver Coaching for the H&W 
Waiver. 
Service Definition 
Caregiver Coaching is a training and support service for unpaid caregivers. The purpose of Caregiver 
Coaching is to enable the stabilization and continued community tenure of a waiver participant by 
equipping the participant’s unpaid caregivers with the necessary skills to manage the participant’s medical 
conditions and associated behavioral health needs related to a cognitive impairment and/or dementia. This 
is not a service provided directly to the waiver participant, but to their unpaid caregivers.

[Audio] We are on slide 3 in our presentation on Care Management services for eligible participants. To be reimbursed, participants must complete the care management curriculum and have relevant education and work experience. Additionally, the provider cannot be the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant. Now let's discuss DDRS HCBS Waivers, which are available to any and all caregivers who are not served through Structured Family Caregiving. The waiver participant will receive additional waiver services outside of what the unpaid caregiver delivers. This service allows family caregivers who are not eligible to participate in Structured Family Caregiving to access support. The goal of the caregiver coach and behavior management service is to address the caregiver's needs as far as training and education on how to best support the person. Technology will be used between the agency performing caregiver coaching and behavior management and the unpaid caregiver. If the unpaid caregiver needs assistance with the technology, the assigned caregiver coach will visit with the unpaid caregiver to provide a tutorial. Caregiver coaching is a service targeted toward the unpaid caregiver to support their needs in order for the unpaid caregiver to continue supporting the waiver participant. The caregiver coach will assess strengths and goals as well as any health and safety risks of the unpaid caregiver, such as burnout or compassion fatigue, or that the unpaid caregiver is concerned about, related to the waiver participant. These strengths, goals, health and safety concerns will be documented in the person-centered service plan along with interventions to ensure health and safety. The interventions will be assessed during each biweekly visit between caregiver coach and unpaid caregiver, and modified as needed as well as updates to the service coordinator about health and safety concerns and interventions. Through additional guidance to providers and care managers, the B-D-S will clarify that the emergency/crisis plan should be developed among all parties (waiver care manager, participant, caregiver, caregiver coach, and behavior management provider). This way, the participant and the participant's circle of support will have the same knowledge and understanding of the participant's backup plan, and emergency plan, and will support the participant in implementing that plan if needed. If there are modifications to the plan, all parties shall be involved in the plan changes as well as aware of the changes. The B-D-S will provide an example plan to both care managers and providers in guidance. Because the waiver participant receives services through the Health and Wellness (H&W) waiver as well as the Indiana Medicaid State Plan, the medically complex needs will be addressed through those services. Additionally, there are often times when unpaid caregivers render those services (if the provider is not available). The caregiver coach will identify with the unpaid caregiver the supports being rendered on an informal basis, by the unpaid caregiver to support the waiver participant. These services will be documented in the unpaid caregiver's person-centered service plan. The caregiver coach will review the services with the unpaid caregiver and care manager on a biweekly basis (or as communicated by the unpaid caregiver if more than biweekly). If the unpaid caregiver has questions or concerns about service delivery, the caregiver coach will provide training and education about delivery and/or connect with the participant, participant's waiver care manager, and other providers to ensure services are rendered as specified by the participant. Covered Services: * Initial consultation for assessment of the caregiver to determine initial coaching needs, and understand the caregiver's goals, values, needs and strengths.
* Caregiver Coaching provided in the community of the participant,. 

Scene 3

Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
DDRS HCBS Waivers 
Library Reference Number: PRPR10014 
245 
Published: Sept. 9, 2024 
Policies and procedures as of July 1, 2024 
Version: 11.1 
This service allows family caregivers who are not eligible to participate in Structured Family Caregiving to 
access support. This service is available to any and all caregivers who are not served through Structured 
Family Caregiving. The waiver participant will receive additional waiver services outside of what the 
unpaid caregiver delivers. The goal of the caregiver coach and behavior management service is to address 
the caregiver's needs as far as training and education on how to best support the person. If the unpaid 
caregiver raises issues about service delivery, the concern is documented in the caregiver's service plan 
with the caregiver coach and care manager.  
Technology will be used between the agency performing caregiver coaching and behavior management, 
and the unpaid caregivers. If the unpaid caregiver needs assistance with the technology, the assigned 
caregiver coach will visit with the unpaid caregiver to provide a tutorial. Caregiver coaching is a service 
targeted toward the unpaid caregiver to support their needs in order for the unpaid caregiver to continue 
supporting the waiver participant.  
The caregiver coach will assess strengths and goals as well as any health and safety risks of the unpaid 
caregiver, such as burnout or compassion fatigue, or that the unpaid caregiver is concerned about, related to 
the waiver participant. These strengths, goals, health and safety concerns will be documented in the person-
centered service plan along with interventions to ensure health and safety. The interventions will be 
assessed during each biweekly visit between caregiver coach and unpaid caregiver, and modified as needed 
as well as updates to the service coordinator about health and safety concerns and interventions.  
Through additional guidance to providers and care managers, the BDS will clarify that the emergency/crisis 
plan should be developed among all parties (waiver care manager, participant, caregiver, caregiver coach, 
and behavior management provider). This way, the participant and the participant's circle of support will 
have the same knowledge and understanding of the participant's backup plan, and emergency plan, and will 
support the participant in implementing that plan if needed. If there are modifications to the plan, all parties 
shall be involved in the plan changes as well as aware of the changes. The BDS will provide an example 
plan to both care managers and providers in guidance.  
Because the waiver participant receives services through the Health and Wellness (H&W) waiver as well as 
the Indiana Medicaid State Plan, the medically complex needs will be addressed through those services. 
Additionally, there are often times when unpaid caregivers render those services (if the provider is not 
available). The caregiver coach will identify with the unpaid caregiver the supports being rendered on an 
informal basis, by the unpaid caregiver to support the waiver participant. These services will be 
documented in the unpaid caregiver's person-centered service plan.  
The caregiver coach will review the services with the unpaid caregiver and care manager on a biweekly 
basis (or as communicated by the unpaid caregiver if more than biweekly). If the unpaid caregiver has 
questions or concerns about service delivery, the caregiver coach will provide training and education about 
delivery and/or connect with the participant, participant's waiver care manager, and other providers to 
ensure services are rendered as specified by the participant.  
Covered Services 
The following services are covered under Caregiver Coaching: 
• Initial consultation for assessment of the caregiver to determine initial coaching needs, and 
understand the caregiver’s goals, values, needs and strengths. 
• Caregiver Coaching provided in the community of the participant, virtually or telephonically or 
other identified location meaningful to the unpaid caregiver and through HIPAA secure 
communication platforms that allow for real-time and asynchronous communication between 
caregivers and caregiver coaches and collaboration with waiver case managers.

[Audio] We discuss Care Management services that will be reimbursed based on certain qualifications. In order to be eligible for reimbursement, the provider must not be the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant. Service standards must be followed for Caregiver Coaching. Caregiver Coaching services are family-centered, individualized, and informed by an assessment of each caregiver’s goals, values, needs, and strengths. A caregiver coach with expertise working with unpaid caregivers will conduct a caregiver assessment and deliver ongoing education and coaching. The service may be delivered telephonically and through H-I-P-A-A secure electronic communication platforms. Providers must capture any caregiver communications received through an electronic communication platform to facilitate the sharing of relevant information with care managers. The service is designed to equip unpaid caregivers with the skills to manage the participant’s medical conditions and associated behavioral health needs related to a cognitive impairment and/or dementia. The caregiver coach will assist the caregiver and participant in creating a crisis management/emergency plan to address the person and environment. The plan will be reviewed and updated on a monthly basis and provided to emergency contacts and backup caregivers.. 

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DDRS HCBS Waivers 
Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
246 
Library Reference Number: PRPR10014 
 
Published: Sept. 9, 2024 
 
Policies and procedures as of July 1, 2024 
 
Version: 11.1 
Service Standards 
These service standards must be followed for Caregiver Coaching: 
• Caregiver Coaching services are family centered, individualized to the needs of the participant and 
caregiver, and informed by an assessment of each caregiver’s goals, values, needs, and strengths.  
• A caregiver coach with expertise working with unpaid caregivers will conduct a caregiver 
assessment developed by the FSSA and deliver ongoing education and coaching that is informed by 
the assessment. 
• Caregiver Coaching services may be delivered telephonically and through HIPAA secure electronic 
communication platforms that enable a caregiver coach and a caregiver to communicate efficiently 
and, in a manner, convenient to the caregiver.  
• Provider agencies must capture any caregiver communications received through an electronic 
communication platform, such as an app or email, to facilitate the sharing of relevant information 
with care managers. Providers will communicate with care managers through traditional means to 
share any relevant information. The service does not require any specific percentage of in-person 
visits versus virtual visits. 
• The service is designed to equip the participant’s unpaid caregivers with the skills to manage the 
participant’s medical conditions and associated behavioral health needs related to a cognitive 
impairment and/or dementia. Part of the caregiver assessment rendered by the caregiver coach will 
address areas of the caregiver’s life that promote socialization and involvement within the 
community, but ultimately, the decision is based on where the caregiver needs support. If 
community integration is an area important to the participant, the caregiver coach will support the 
caregiver in ensuring the participant's goals with regards to community integration are met. 
Additionally, a caregiver's community integration and supporting a participant's community 
integration may change over time and will be consistently modified as necessary. 
• A caregiver coach engages with a caregiver on a bi-weekly basis to understand the evolving needs 
of the participant and caregiver and deliver content, strategies and tools related to the management 
of the participant’s needs and behaviors and the caregiver’s self-care needs. 
• Caregiver training will include how to address necessary precautions to prevent COVID-19 
infections/spread in the home and address anxiety that participants may experience related to the 
crisis; behavior and triggering events; effective verbal and nonverbal communication strategies; 
strategies for managing challenging behaviors; and how to address home safety concerns. Coaching 
will also support a caregiver to apply stress reduction techniques and reduce caregiver isolation. 
• Caregiver coach will assist the caregiver and participant in creation of a crisis 
management/emergency plan to address the person and environment. Plan will be reviewed and 
updated on a monthly basis (and more often as needed) and provided to the care manager and 
waiver/Indiana Medicaid State Plan/hospice providers as well as emergency contacts and backup 
caregiver. Plan shall include but is not limited to the following: 
– Health conditions 
– Advanced directives, will planning, physician orders for life sustaining treatment 
– Medications and medication management/assistance to prevent medication errors 
– Fall prevention interventions 
– Sundowning interventions 
– Healthcare providers including contact information 
– Emergency contacts 
– Identification and contact information for backup caregiver 
– Contact information for caregiver coach and waiver care manager 
– Caregiver resources available within the caregiver’s/participant’s community of choice.

[Audio] We are pleased to introduce our Care Management services. These services will only be reimbursed for eligible participants with specific qualifications. In order to be eligible for reimbursement, participants must complete the care management curriculum and have relevant education and work experience. Additionally, providers cannot be the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant. Our Caregiver Coaching services are designed to support and empower caregivers to provide the best possible care to their loved ones. We understand the importance of providing appropriate educational content and employing caregiver coaches with the experience and qualifications appropriate to the needs of each family. Therefore, we have set certain restrictions and limitations for our Caregiver Coaching services. Firstly, structured family caregiving agencies may be service providers, but caregiver coaches must be employed by these agencies with the appropriate experience and qualifications. Secondly, educational content delivered by provider agencies to caregivers and delivery methods must be appropriate to the needs of lay caregivers. Finally, there are maximum billable quarter hours units per month, which is 32. We would like to clarify that certain activities are not allowed or reimbursed under Caregiver Coaching. Caregiver coaching services will not duplicate services provided under the Indiana Medicaid State Plan or any other waiver service. Separate payment will not be made for structured family caregiving. Additionally, caregiver coaching service will not be reimbursed when provided by a parent of a minor child participant or the spouse of a participant (also known as L-R-I-s-) as outlined in C-2-d and C-2-e of the H&W Waiver. We believe that our Caregiver Coaching services can provide valuable support and resources to caregivers, and we are committed to providing high-quality services that meet the needs of our participants. Thank you for your attention, and we are happy to answer any questions you may have.. 

Scene 5

Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
DDRS HCBS Waivers 
Library Reference Number: PRPR10014 
247 
Published: Sept. 9, 2024 
Policies and procedures as of July 1, 2024 
Version: 11.1 
Limitations 
The following restrictions are made for Caregiver Coaching: 
• Medicaid participating Structured Family Caregiving agencies may be service providers; agencies 
must employ caregiver coaches with the experience and qualifications appropriate to the needs of 
each family. 
• Educational content delivered by provider agencies to caregivers and delivery methods must be 
appropriate to the needs of lay caregivers.  
Note: Maximum billable quarter hours units per month is 32. 
Activities Not Allowed 
The following activities are not allowed or reimbursed under Caregiver Coaching: 
• Caregiver coaching services will not duplicate services provided under the Indiana Medicaid State 
Plan or any other waiver service. 
• Separate payment will not be made for Structured Family Caregiving. 
• Caregiver Coaching service will not be reimbursed when provided by a parent of a minor child 
participant or the spouse of a participant (also known as LRIs) as outlined in C-2-d and C-2-e of the 
H&W Waiver.  
Provider Qualifications 
Provider qualifications for Caregiver Coaching services are presented in Table 15. 
Table 15 – Provider Qualifications for Caregiver Coaching 
Waiver  
Provider  
Licensure/ 
Certification 
Other Standards 
H&W 
FSSA-
approved 
Structured 
Family 
Caregiving 
Provider  
Not required  
FSSA approved 
455 IAC 2  
H&W 
FSSA-
approved 
Adult Day 
Provider  
Not Required 
FSSA approved 
455 IAC 2

[Audio] In order to be eligible for reimbursement, participants must complete the care management curriculum and have relevant education and work experience. Any providers who are the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant will not be reimbursed. Now, let's move on to a closer examination of the DDRS HCBS Waivers Section 12. For Community Transition services, the participant's own home is defined as any dwelling that is owned, leased, or rented by them, including a house, apartment, condominium, trailer, or other type of lodging. All community transition items are considered the property of the participant receiving the service. Any approved community transition expenditures, such as security deposits, application fees, essential (not luxury) furnishings, moving expenses, setup fees, deposits for utilities or services, health and safety assurances, and one-time cleaning prior to occupancy, can be reimbursed through the local Area Agency on Aging (A-A-A--) or an OMPP-approved provider. These reimbursements will be based on applicable receipts and verification of the services being delivered. In order to receive community transition services, a written service plan must be created through the person-centered planning process. If the participant lacks government-issued identification items that are necessary for securing housing or utilities, the costs associated with obtaining these items will also be covered under community transition services.. 

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DDRS HCBS Waivers 
Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
248 
Library Reference Number: PRPR10014 
 
Published: Sept. 9, 2024 
 
Policies and procedures as of July 1, 2024 
 
Version: 11.1 
Section 12.14: Community Transition for H&W and TBI 
Waivers 
The following subsections provide information and requirements for Community Transition services for the 
H&W and TBI waivers. 
Service Definition 
Community Transition services (CTS) include reasonable, setup expenses for participants who make the 
transition from an institution to their own home where the person is directly responsible for their own living 
expenses in the community and will not be reimbursable on any subsequent move.  
Note: “Own home” is defined for this service as any dwelling – including a house, an 
apartment, a condominium, a trailer or other lodging – that is owned, leased or 
rented by the participant. 
Items purchased through community transition are the property of the participant receiving the service, and 
the participant takes the property with them when moving to another residence. For participants receiving 
this service under the waiver, approved community transition expenditures are reimbursed through the local 
Area Agency on Aging (AAA) or OMPP-approved provider that maintains all applicable receipts and 
verifies the delivery of services. 
Allowable Activities 
The following activities are allowed under Community Transition services: 
• Security deposits and application fees that are required to obtain a lease on an apartment or home  
• Essential (not luxury) furnishings and moving expenses required to occupy and use a community 
domicile, including a bed, table and chairs, assembly of flat-packed furniture when it is not included 
as part of the furniture purchase cost, window coverings, one land-line telephone, eating utensils, 
housekeeping supplies, food preparation items, microwave, and bed or bath linens 
• Setup fees or deposits for utility or service access including telephone, electricity, heating, internet 
and water  
• Health and safety assurances, including pest eradication, allergen control that would be used in 
instances where the participant is allergic to certain things that need to be removed from the 
residence (like animal hair), or one-time cleaning prior to occupancy 
Note: If the participant lacks the required government-issued identification items to secure 
housing or utilities (including but not limited to birth certificate, Social Security card, 
state ID and state driver’s license), costs related to obtaining these items are also 
covered under community transition services.  
Service Standards 
Community Transition services must follow a written service plan addressing specific needs determined by 
the person-centered planning process.

[Audio] We are presenting the documentation standards and limitations for Community Transition services under the Health and Wellness (H&W) and Traumatic Brain Injury (T-B-I--) waivers. These services are an essential part of the care management services provided under these waivers. It is crucial for care managers to follow the documentation standards and limitations in order to ensure efficient and effective delivery of these services. The documentation standards require care managers to document the need for Community Transition services and any reasonable furnishings or setup expenses requested by the participant in the service plan. They must also keep records of all expenditures and provide receipts. If the care manager requests the maximum lifetime cap of $1500 but not all funds are used, they must update the service plan to reduce the amount and prevent over-reimbursement by Medicaid. Moving on to the limitations for Community Transition services, reimbursement is limited to a one-time use and a lifetime cap of $1500 for setup expenses. These services can only be provided if they are deemed reasonable and necessary in the service plan, and the individual is unable to cover the expenses themselves or obtain them from other sources. It is important to note that certain activities, such as apartment or housing expenses, food, household appliances, recreational items, and allergen control, are not allowed to be covered by Community Transition services. Furthermore, federal financial participation will not be billed for until after the individual leaves the institution and becomes eligible for the waiver. It is also not reimbursed if provided by a parent or spouse of the participant. In summary, Community Transition services are a critical part of care management services.. 

Scene 7

Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
DDRS HCBS Waivers 
Library Reference Number: PRPR10014 
249 
Published: Sept. 9, 2024 
Policies and procedures as of July 1, 2024 
Version: 11.1 
Documentation Standards 
The care manager must follow these documentation standards: 
• Document the need for Community Transition services and reasonable furnishings or set-up 
expenses being requested by the participant (determined through the person-centered planning 
process) in the service plan. 
• Maintain receipts for all expenditures, showing the amount and what item or deposit was covered.  
• If a care manager requests the full $1,500 lifetime cap (described in the Limitations section) and not 
all funds are used, the care manager must complete a service plan update to reduce the amount to 
ensure Medicaid is not over-reimbursing for these services. 
Limitations 
The following restrictions are made for Community Transition services: 
• Reimbursement for community transition is limited to a single use and lifetime cap for setup 
expenses of up to $1,500.  
• Community Transition services are furnished only to the extent that they are reasonable and 
necessary as determined through the service plan development process, clearly identified in the 
service plan, and the person is unable to meet such expense or when the services cannot be obtained 
from other sources. 
Activities Not Allowed 
The following activities are not allowed through Community Transition services: 
• Apartment or housing rental or mortgage expenses 
• Food 
• Regular utility charges 
• Household appliances or items that are intended for purely diversional/recreational purposes 
• Allergen control to fund the mitigating or removal of items that would be the responsibility of the 
landlord or homeowner 
• The state will not bill for federal financial participation (FFP) until after the individual departs the 
institution and meets waiver eligibility. 
• This service will not be reimbursed when provided by the parent of a minor child participant or the 
spouse of a participant (also known as LRIs) as outlined in C-2-d and C-2-e of the H&W and TBI 
waivers.

[Audio] The qualifications for Community Transition services under Health and Wellness (H&W) and Traumatic Brain Injury (T-B-I--) waivers are being presented. These services aim to support participants in their homes with instrumental activities of daily living (I-A-D-L-) when they are unable to meet their needs or when their caregiver cannot help them. To become an approved provider, community transition service agencies must fulfill specific requirements. This includes having a valid license or certification from a recognized healthcare organization and following FSSA-approved standards for Community Transition Service Agencies. In addition to these general requirements, providers must also meet specific qualifications for H&W/TBI waivers. These include financial information, liability insurance, transportation arrangements, professional qualifications and requirements, documentation of qualifications, maintenance of personnel records, adoption of personnel policies, operations manual, maintenance of records of services provided, individual's personal file, site of service delivery, and other relevant qualifications. We hope this information is helpful and encourages you to consider these requirements when selecting a provider for your community transition service needs. Thank you for your attention.. 

Scene 8

DDRS HCBS Waivers 
Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
250 
Library Reference Number: PRPR10014 
 
Published: Sept. 9, 2024 
 
Policies and procedures as of July 1, 2024 
 
Version: 11.1 
Provider Qualifications 
Provider qualifications for Community Transition services are presented in Table 16. 
Table 16 – Provider Qualifications for Community Transition Services 
Waiver 
Provider 
Licensure/ 
Certification 
Other Standards 
H&W/TBI  FSSA-
approved 
Community 
Transition 
Service 
Agency  
Not required  
FSSA Approved 
455 IAC 2 Becoming an approved provider; 
maintaining approval 
455 IAC 2 Provider qualifications: General 
requirements 
455 IAC 2 Transfer of individual’s record upon change 
of provider 
455 IAC 2 Financial information 
455 IAC 2 Liability insurance 
455 IAC 2 Transportation of an individual 
455 IAC 2 Professional qualifications and 
requirements; documentation of qualifications 
455 IAC 2 Maintenance of personnel records 
455 IAC 2 Adoption of personnel policies 
455 IAC 2 Operations manual 
455 IAC 2 Maintenance of records of services provided  
455 IAC 2 Individual’s personal file; site of service 
delivery  
Section 12.15: Home and Community Assistance for 
H&W and TBI Waivers 
The following subsections provide information and requirements for Home and Community Assistance 
services for the H&W and TBI waivers. 
Service Definition 
Home and Community Assistance services provide instrumental activities of daily living (IADL) for 
participants in their home. The services are provided when participants are unable to meet their needs or 
when their informal caregiver or helper is unable to perform these needs for the participant. 
Allowable Activities 
The following activities are allowed under the Home and Community Assistance services: 
• IADL care that may include but are not limited to the following: 
– Dusting and straightening furniture 
– Cleaning floors and rugs by wet or dry mop and vacuum sweeping 
– Cleaning the kitchen, including washing dishes, pots and pans; cleaning the outside of 
appliances and counters and cupboards; cleaning ovens; and defrosting and cleaning refrigerators 
– Maintaining a clean bathroom, including cleaning the tub, shower, sink, toilet bowl and medicine 
cabinet; emptying and cleaning commode chair or urinal

[Audio] Slide number 9 out of 14 in the presentation titled "Care Management Services" is now displayed. This slide contains information on the service standards that must be followed for care management services. These standards are crucial in ensuring the safe and effective delivery of care management services. The slide begins with a list of allowable activities that can be provided as part of care management services. These activities include assistance with meal planning and preparation, essential errands and unassisted transportation, correspondence and bill paying, minor pet care, and outdoor tasks such as raking leaves, snow removal, lawn mowing, and weeding. These activities are all important in supporting the well-being of participants. Following this, the slide outlines the documentation standards that must be adhered to for care management services. This includes documenting the need for Home and Community Assistance, the frequency of need, and the specific type of assistance required. The Home and Community Assistance providers are also responsible for documenting the data record of services provided, including the date and time of service, specific tasks carried out, notification to the participant's care manager, time spent traveling and completing the errand, and the signature of the employee providing the service. Lastly, it is stated that each staff member who directly provides care or supervises care for the participant must make at least one entry per day, describing any issues or circumstances pertaining to the participant. This helps to ensure that all aspects of the participant's care are carefully monitored and recorded. Overall, adherence to these service standards is crucial in providing participants with the necessary care and support they need to lead healthy and fulfilling lives.. 

Scene 9

Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
DDRS HCBS Waivers 
Library Reference Number: PRPR10014 
251 
Published: Sept. 9, 2024 
Policies and procedures as of July 1, 2024 
Version: 11.1 
– Laundering clothes in the home or laundromat, including washing, drying, folding, putting away, 
ironing, and basic mending and repair 
– Changing linen and making beds 
– Washing insides of windows 
– Removing trash from the home 
• Assistance with meal planning and preparation, including special diets under the supervision of a 
registered dietitian or health professional 
• Completing essential errands and/or unassisted transportation for nonmedical, community activities  
• Assistance with correspondence and bill paying 
• Minor pet care (Note: This activity may be allowed at the discretion of the agency.) 
• Assistance with outdoor tasks including raking leaves, snow removal, lawn mowing and weeding 
Service Standards 
These service standards must be followed: 
• The care manager will document through the PCA the need for Home and Community Assistance, 
the frequency of need, the required type of Home and Community Assistance activities. 
Documentation Standards 
The care manager will document the following through the PCA: 
• Need for Home and Community Assistance 
• Frequency of need 
• Required type of Home and Community Assistance activities 
Home and Community Assistance providers are responsible for the following documentation standards: 
• Data record of services provided must include the following: 
– Complete date and time of service (in and out) 
– Specific services/tasks provided 
– Notification to the participant’s care manager, within 48 hours, upon any changes in the 
participant’s person-centered service plan 
– Time spent traveling and completing the errand as well as the specific tasks and necessity of the 
task being completed (for errands such as using a laundromat due to there not being a washer or 
dryer in the participant’s home) 
Note:  If Home and Community Assistance services take place outside the participant’s 
home (such as errands being required due to no washer/dryer in home, or travel 
for other allowable tasks), travel expenses beyond the time spent on the errand 
are the responsibility of the agency providing Home and Community Assistance 
services. 
– Signature of employee providing the service (minimally the last name and first initial) (Note: If 
the person providing the service is required to be a professional, that title must also be 
included.) 
• Each staff member providing direct care or supervision of care to the participant must make at least 
one entry on each day of service. All entries should describe an issue or circumstance concerning 
the participant.

[Audio] The Health and Wellness (H&W) and Traumatic Brain Injury (T-B-I--) Waivers in Section 12 of the DDRS HCBS Waivers outline the qualifications for reimbursement of Care Management services. These qualifications include completing the care management curriculum and having relevant education and work experience. Providers must not fall under certain categories, such as being the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant. The participant or designated participant representative must sign off on service delivery documentation. Home and Community Assistance services are not allowed to provide hands-on assistance with Activities of Daily Living (ADLs), assisted transportation to community activities or errands, or to household members other than the participant. The owner of the organization must not fall under certain categories, such as being a parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, legal guardian of the participant, or a member of the participant's household. Home and Community Assistance services cannot be provided to participants already receiving Adult Family Care, Structured Family Caregiving, or Assisted Living services. Home and Community Assistance services will not be reimbursed if they are provided by the parent of a minor child participant or the spouse of a participant (also known as LRIs), as outlined in C-2-d and C-2-e of the Health and Wellness and Traumatic Brain Injury waivers. Providers must meet the qualifications outlined in Table 17 in our library reference number PRPR10014, published on September 9th. We appreciate your attention to these important guidelines to ensure the best care for eligible participants.. 

Scene 10

DDRS HCBS Waivers 
Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
252 
Library Reference Number: PRPR10014 
 
Published: Sept. 9, 2024 
 
Policies and procedures as of July 1, 2024 
 
Version: 11.1 
• Documentation of service delivery is to be signed by the participant or designated participant 
representative. 
Activities Not Allowed 
The following services are not allowed under Home and Community Assistance services: 
• Assistance with ADL hands-on care (Note: Specifically Home and Community Assistance services 
do not include any ADL assistance, such as eating, bathing, dressing, personal hygiene, or 
medication setup and administration.) 
• Hands-on and/or assisted transportation of participants to community activities or errands 
• Home and Community Assistance services provided to household members other than to the 
participant 
• Home and Community Assistance services when the owner of the organization is one of the 
following: 
– Parent of a minor child participant 
– Spouse of a participant 
– Attorney-in-fact (or POA) of a participant 
– HCR of a participant 
– Legal guardian of the participant 
– Any member of the participant’s household 
• Services provided to participants receiving any of the following waiver services: 
– Adult Family Care  
– Structured Family Caregiving 
– Assisted Living 
This service will not be reimbursed when provided by the parent of a minor child participant or the spouse 
of a participant (also known as LRIs) as outlined in C-2-d and C-2-e of the H&W and TBI waivers.  
Provider Qualifications 
Provider qualifications for Home and Community Assistance services are presented in Table 17.

[Audio] During the presentation, we will cover the rules and regulations that must be followed in order for care management services to be reimbursed for eligible participants. It is crucial to have a clear understanding of these guidelines in order to ensure that care management services are provided effectively and efficiently. Our focus will primarily be on the health and wellness (H&W) and traumatic brain injury (T-B-I--) waivers, as well as the DDRS HCBS waivers. We will also discuss the qualifications for being a provider of home and community assistance services, which include becoming an approved provider and maintaining approval, having liability insurance, meeting professional qualifications and requirements, and keeping accurate personnel records. We will also address compliance with IC 16-27-4, if applicable, and the requirements for being an F-S-S-A approved home health agency, as stated in IC 16-27-1, IC 16-27-4, and section 12.16: Home-Delivered Meals for H&W and T-B-I waivers. It is important to note that care management services will only be reimbursed for eligible participants who meet specific qualifications, such as completing the care management curriculum and having relevant education and work experience. Furthermore, reimbursement will not be provided if the provider is the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant. It is crucial to adhere to these qualifications and restrictions in order to receive proper reimbursement for care management services.. 

Scene 11

Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
DDRS HCBS Waivers 
Library Reference Number: PRPR10014 
253 
Published: Sept. 9, 2024 
Policies and procedures as of July 1, 2024 
Version: 11.1 
Table 17 – Provider Qualifications for Home and Community Assistance Services 
Waiver 
Provider 
Licensure/ 
Certification 
Other Standards 
H&W/TBI  Licensed Personal 
Services Agency  
IC 16-27-4 
FSSA Approved 
H&W/TBI  FSSA-approved 
Homemaker Individual  
IC 16-27-4 
FSSA Approved 
455 IAC 2 Provider qualifications: 
becoming an approved provider; 
maintaining approval 
455 IAC 2 Provider qualifications: general 
requirements 
455 IAC 2 Liability insurance  
455 IAC 2 Professional qualifications and 
requirements 
455 IAC 2 Personnel records 
Compliance with IC 16-27-4, if applicable 
H&W/TBI  Licensed Home Health 
Agency  
IC 16-27-1 
IC 16-27-4  
FSSA approved 
Section 12.16: Home-Delivered Meals for H&W and TBI 
Waivers 
The following subsections provide information and requirements for Home-Delivered Meals for the H&W 
and TBI waivers. 
Service Definition 
A Home-Delivered Meal is a nutritionally balanced meal. This service is essential in preventing 
institutionalization because the absence of proper nutrition in individuals with frail and disabling conditions 
presents a severe risk to health. No more than two meals per day will be reimbursed under the waiver. 
Allowable Activities 
The Home-Delivered Meals service may include but is not limited to: 
• Diet and nutrition counseling provided by a registered dietician 
• Nutritional education based on needs of each participant 
• Diet modification according to a physician’s order, as required, meeting the individual’s medical 
and nutritional needs 
Service Standards 
These service standards must be followed: 
• Home-Delivered Meals services must follow a written service plan addressing specific needs 
determined by the participant’s PCA. 
• Home-Delivered Meals services will be provided to persons who are unable to prepare their own 
meals and for whom there are no other persons available to do so or where the provision of a Home-

[Audio] Our Delivered Meal service is an essential component of Care Management services that provides a nutritionally adequate meal to eligible participants in a safe and cost-effective manner. The meals we provide must contain at least one-third of the current daily recommended dietary allowance as established by the Food and Nutrition Board of the National Academy of Sciences, National Research Council. Meals should also contain less than 10% daily calories from added sugars, saturated fats, and sodium, unless prior F-S-S-A or registered dietitian approval is received. Documentation standards must be followed, including the care manager documenting the need for Home-Delivered Meals and the amount being requested, and the provider documenting the date of delivery, how many meals are included, and the name of the care professional or care manager that involved the participant. Food allergies, food preferences, or gluten sensitivity for waiver participants must also be documented. It is important to note that more than two meals per day are not allowed, and services provided to participants receiving either of the following waiver services: Adult Family Care or Assisted Living, are not reimbursed when provided by the parent of a minor child participant or the spouse of a participant as outlined in C-2-d and C-2-3 of the H&W and T-B-I waivers. Proper documentation and adherence to the documentation standards and activities not allowed are crucial to ensure that the service is reimbursable and effective.. 

Scene 12

DDRS HCBS Waivers 
Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
254 
Library Reference Number: PRPR10014 
 
Published: Sept. 9, 2024 
 
Policies and procedures as of July 1, 2024 
 
Version: 11.1 
Delivered Meal is the most cost-effective method of delivering a nutritionally adequate meal and it 
is not otherwise available through other funding sources. 
• All meals must meet state, local, and federal laws, and regulations regarding the safe handling of 
food. The provider must also hold adequate and current Servsafe certification. 
• All home delivered meals provided must contain at least one-third of the current daily recommended 
dietary allowance (RDA) as established by the Food and Nutrition Board of the National Academy 
of Sciences, National Research Council, including but not limited to the following foods: 
– A variety of vegetables (dark green, red, and orange), legumes (beans and peas), and starchy and 
other vegetables 
– Fruits, especially whole fruit 
– Grains, at least half of which are whole grain 
– Fat-free or low-fat dairy, including milk, yogurt, cheese and/or fortified soy beverages 
– A variety of protein foods, including seafood, lean meats and poultry, eggs, legumes (beans and 
peas), soy products, and nuts and seeds 
– Oils, including those from plants: canola, corn, olive, peanut, safflower, soybean, and sunflower. 
Oils also are naturally present in nuts, seeds, seafood, olives and avocados 
• Meals shall contain less than 10% daily calories from added sugars unless prior FSSA or registered 
dietitian approval is received. 
• Meals shall contain less than 10% of daily calories from saturated fats unless prior FSSA or 
registered dietitian approval is received. 
• Meals shall contain less than 2,300 mg of sodium per day unless prior FSSA or registered dietitian 
approval is received. 
Documentation Standards 
These documentation standards must be followed: 
• The care manager is responsible for documenting the need for Home-Delivered Meals and the 
amount being requested. 
• The provider is responsible for the following: 
– Documenting the date of delivery, how many meals are included and the name of the care 
professional or care manager that involved the participant 
– Documenting any food allergies, food preferences, or gluten sensitivity for waiver participants 
– Ensuring date of expiration is included on all meals 
– Written or oral instruction for: 
➢ Appropriate storage of meal 
➢ Preparing meal 
Activities Not Allowed 
The following activities are not allowed or reimbursed under Home-Delivered Meals: 
• More than two meals per day 
• Services provided to participants receiving either of the following waiver services: 
– Adult Family Care 
– Assisted Living 
This service will not be reimbursed when provided by the parent of a minor child participant or the spouse 
of a participant (also known as LRIs) as outlined in C-2-d and C-2-3 of the H&W and TBI waivers.

[Audio] We are pleased to announce the availability of Care Management services through the Health and Wellness (H&W) and Traumatic Brain Injury (T-B-I--) waivers. In order to be eligible for reimbursement, participants must complete the care management curriculum, have relevant education and work experience, and not be the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant. The Home-Delivered Meals (H-D-M--) services have specific provider qualifications which are outlined in Table 18. These qualifications include being an approved provider, maintaining approval, and adhering to all state and local health laws and ordinances related to food preparation, handling, and serving. For Home Modification Assessment (H-M-A--) services under the H&W and T-B-I waivers, participants must select a certified waiver provider before any home modifications are made and must undergo a home modification inspection upon completion of the work. Reimbursement for home modifications will only be granted after a final inspection has taken place. The assessor will be responsible for determining specifications, assessing feasibility, and conducting the post-project inspection. We hope that this information will help ensure the safety, suitability, and practicality of Care Management services for eligible participants.. 

Scene 13

Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
DDRS HCBS Waivers 
Library Reference Number: PRPR10014 
255 
Published: Sept. 9, 2024 
Policies and procedures as of July 1, 2024 
Version: 11.1 
Provider Qualifications 
Provider qualifications for Home-Delivered Meals services are presented in Table 18. 
Table 18 – Provider Qualifications for Home-Delivered Meals 
Waiver 
Provider 
Licensure/ 
Certification 
Other Standards 
H&W/TBI  FSSA-
Approved  
Home  
Delivered  
Meals Agency  
Not required  
FSSA Approved 
455 IAC 2 Becoming an approved provider; 
maintaining approval 
455 IAC 2 Provider qualifications: General 
requirements 
455 IAC 2 Maintenance of records of services provided 
455 IAC 2 Liability insurance 
455 IAC 2 Maintenance of records of services provided 
Must comply with all state and local health laws and 
ordinances concerning preparation, handling and 
serving of food.  
Section 12.17: Home Modification Assessment for H&W 
and TBI Waivers 
The following subsections provide information and requirements for Home Modification Assessment 
services for the H&W and TBI waivers. 
Service Definition 
The service will be used to objectively determine the specifications for a home modification that is safe, 
appropriate, and feasible to ensure accurate bids and workmanship. All participants must receive a Home 
Modification Assessment with a certified waiver provider selected by the participant prior to any 
subsequent home modifications as well as a home modification inspection upon completion of the work. A 
home modification will not be reimbursed until the final inspection has been completed. 
The Home Modification Assessment will assess the home for physical adaptations to the home, that, as 
indicated by the individual’s service plan, are necessary to ensure the health, welfare, and safety of the 
individual and enable the individual to function with greater independence in the home. Without the 
modifications, the individual would require institutionalization. 
The assessor will be responsible for writing the specifications, review of feasibility and the post-project 
inspection: 
• Upon completion of the specifications and a review of feasibility, the assessor will prepare and 
submit the project specifications to the care manager and the participant for the bidding process. The 
assessor will be paid first installment for the completion of the home specifications. 
• After the project is complete, the assessor, participant, and care manager will each be present on an 
agreed upon date and time to inspect the work and sign-off indicating that it was completed per the 
agreed-upon bid and be paid the final installment of the home modification work. In the event the 
participant, provider, assessor and/or care manager become aware of discrepancies for complaints 
about the work being completed, the provider shall stop work immediately and contact the care 
manager and the FSSA for further instruction. The FSSA also has the ability to request additional 
assessment visits to help resolve a disagreement between the home modification provider and the 
participant. This payment is not included in the actual home modification cost category and shall not

[Audio] Home Modification Assessment Service Standards The Home Modification Assessment service is a critical component of DDRS HCBS Waivers. According to Section 12 of the DDRS HCBS Waivers, the Home Modification service will only be deducted from the participant's lifetime cap if completed by an eligible provider and if the participant meets specific qualifications. It is important to note that the provider cannot be a parent, spouse, attorney-in-fact, H-C-R--, or legal guardian of the participant. The allowable activities for the Home Modification Assessment service include evaluating the current environment and identifying any barriers that may prevent desired modifications, reimbursing for nonfeasible assessments, drafting specifications, and submitting them for approval. The modification must also undergo an inspection and approval process, and the county code enforcement must be contacted. Service standards require the participant's plan of care to indicate a need for home modification, and the proposed modifications must address the participant's level of service needs. The specifications must comply with the requirements and limitations outlined in the approved service definition for Home Modifications. The assessment itself must be conducted by an approved and qualified individual who is independent from the entity providing the modifications. Documentation standards require proper contact to be made regarding potential code violations. In conclusion, the Home Modification Assessment service is a critical component of DDRS HCBS Waivers, and it must adhere to specific standards to ensure the safety and well-being of participants.. 

Scene 14

DDRS HCBS Waivers 
Section 12: Health and Wellness (H&W) and Traumatic Brain Injury (TBI) Waivers 
256 
Library Reference Number: PRPR10014 
 
Published: Sept. 9, 2024 
 
Policies and procedures as of July 1, 2024 
 
Version: 11.1 
be subtracted from the participant’s lifetime cap for Home Modifications. The care management 
provider entity will be responsible for maintaining related records that can be accessed by the state.  
Allowable Activities 
The Home Modification Assessment service includes the following activities: 
• Evaluation of the current environment, including the identification of barriers underneath the home, 
electrical and plumbing, which may prevent the completion of desired modifications 
• Reimbursement for nonfeasible assessments 
• Drafting of specifications 
• Preparation and submission of specifications 
• Examination of the modification (inspection/approval) 
• Contact county code enforcement 
Service Standards 
These service standards must be followed for the Home mMdification Assessment: 
• The need for home modification must be indicated in the participant’s plan of care. 
• The modification must address the participant’s level-of-service needs. 
• Proposed specifications for the modification must conform to the requirements and limitations of the 
current approved service definition for Home Modifications. 
• The assessment should be conducted by an approved, qualified individual who is independent of the 
entity providing the home modifications. 
• The appropriate authority must be contacted regarding potential code violations. 
Documentation Standards 
These documentation standards must be followed: 
• The need for home modification must be indicated in the participant’s plan of care. 
• The modification must address the participant’s level-of-service needs. 
• Any discrepancy noted by the provider, care manager and/or participant shall be detailed in the final 
inspection and addressed by the assessor. 
Limitations 
An annual cap of $628 is available for Home Modification Assessment services, unless the FSSA requests 
an additional assessment to help mediate disagreements between the home modification provider and the 
participant. 
Activities Not Allowed 
The following activities are not allowed: 
• Home Modification Assessment services shall not be performed by the same provider that performs 
the subsequent Home Modification.

 part 19

We are here to discuss the qualifications for care management services under the DDRS HCBS Waivers. The waivers are designed to support individuals with health and wellness and traumatic brain injury needs.
                                    
                                    Provider qualifications are crucial in ensuring that care management services are delivered effectively. Providers must have the necessary licenses and certifications, adhere to other standards, and meet specific qualifications.
                                    
                                    For caregiver coaching, we will discuss the definition of the service and the requirements for providing it. Caregiver coaching is a training and support service for unpaid caregivers of waiver participants with cognitive impairments and dementia. Caregivers will be equipped with the necessary skills to manage the participant's medical conditions and associated behavioral health needs.
                                    
                                    We will also discuss other standards required for care management services, such as financial information, documentation of qualifications, and maintenance of records of services provided.
                                    
                                    It is important to note that care management services will only be reimbursed for eligible participants under specific qualifications, including completing the care management curriculum and having relevant education and work experience. Additionally, providers cannot be reimbursed if they are the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant.
                                    
                                    In conclusion, care management services are an essential component of the DDRS HCBS Waivers. Providers must meet specific qualifications, and caregiver coaching is available to support unpaid caregivers of waiver participants with cognitive impairments and dementia. We

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We are on slide 3 in our presentation on Care Management services for eligible participants. To be reimbursed, participants must complete the care management curriculum and have relevant education and work experience. Additionally, the provider cannot be the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant.

Now let's discuss DDRS HCBS Waivers, which are available to any and all caregivers who are not served through Structured Family Caregiving. The waiver participant will receive additional waiver services outside of what the unpaid caregiver delivers. This service allows family caregivers who are not eligible to participate in Structured Family Caregiving to access support. The goal of the caregiver coach and behavior management service is to address the caregiver's needs as far as training and education on how to best support the person.

Technology will be used between the agency performing caregiver coaching and behavior management and the unpaid caregiver. If the unpaid caregiver needs assistance with the technology, the assigned caregiver coach will visit with the unpaid caregiver to provide a tutorial. Caregiver coaching is a service targeted toward the unpaid caregiver to support their needs in order for the unpaid caregiver to continue supporting the waiver participant.

The caregiver coach will assess strengths and goals as well as any health and safety risks of the unpaid caregiver, such as burnout or compassion fatigue, or that the unpaid caregiver is concerned about, related to the waiver participant. These strengths, goals, health and safety concerns will be documented in the person-centered service plan along with interventions to ensure health and safety. The interventions will be assessed during each biweekly visit between caregiver coach and unpaid caregiver, and modified as needed as well as updates to the service coordinator about health and safety concerns and interventions.

Through additional guidance to providers and care managers, the B-D-S will clarify that the emergency/crisis plan should be developed among all parties (waiver care manager, participant, caregiver, caregiver coach, and behavior management provider). This way, the participant and the participant's circle of support will have the same knowledge and understanding of the participant's backup plan, and emergency plan, and will support the participant in implementing that plan if needed. If there are modifications to the plan, all parties shall be involved in the plan changes as well as aware of the changes. The B-D-S will provide an example plan to both care managers and providers in guidance.

Because the waiver participant receives services through the Health and Wellness (H&W) waiver as well as the Indiana Medicaid State Plan, the medically complex needs will be addressed through those services. Additionally, there are often times when unpaid caregivers render those services (if the provider is not available). The caregiver coach will identify with the unpaid caregiver the supports being rendered on an informal basis, by the unpaid caregiver to support the waiver participant. These services will be documented in the unpaid caregiver's person-centered service plan.

The caregiver coach will review the services with the unpaid caregiver and care manager on a biweekly basis (or as communicated by the unpaid caregiver if more than biweekly). If the unpaid caregiver has questions or concerns about service delivery, the caregiver coach will provide training and education about delivery and/or connect with the participant, participant's waiver care manager, and other providers to ensure services are rendered as specified by the participant.

Covered Services:

* Initial consultation for assessment of the caregiver to determine initial coaching needs, and understand the caregiver's goals, values, needs and strengths.
* Caregiver Coaching provided in the community of the participant,

We discuss Care Management services that will be reimbursed based on certain qualifications. In order to be eligible for reimbursement, the provider must not be the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant. Service standards must be followed for Caregiver Coaching. Caregiver Coaching services are family-centered, individualized, and informed by an assessment of each caregiver’s goals, values, needs, and strengths. A caregiver coach with expertise working with unpaid caregivers will conduct a caregiver assessment and deliver ongoing education and coaching. The service may be delivered telephonically and through H-I-P-A-A secure electronic communication platforms. Providers must capture any caregiver communications received through an electronic communication platform to facilitate the sharing of relevant information with care managers. The service is designed to equip unpaid caregivers with the skills to manage the participant’s medical conditions and associated behavioral health needs related to a cognitive impairment and/or dementia. The caregiver coach will assist the caregiver and participant in creating a crisis management/emergency plan to address the person and environment. The plan will be reviewed and updated on a monthly basis and provided to emergency contacts and backup caregivers.

We are pleased to introduce our Care Management services. These services will only be reimbursed for eligible participants with specific qualifications. In order to be eligible for reimbursement, participants must complete the care management curriculum and have relevant education and work experience. Additionally, providers cannot be the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant.
                                  Our Caregiver Coaching services are designed to support and empower caregivers to provide the best possible care to their loved ones. We understand the importance of providing appropriate educational content and employing caregiver coaches with the experience and qualifications appropriate to the needs of each family. Therefore, we have set certain restrictions and limitations for our Caregiver Coaching services.
                                  Firstly, structured family caregiving agencies may be service providers, but caregiver coaches must be employed by these agencies with the appropriate experience and qualifications. Secondly, educational content delivered by provider agencies to caregivers and delivery methods must be appropriate to the needs of lay caregivers. Finally, there are maximum billable quarter hours units per month, which is 32.
                                  We would like to clarify that certain activities are not allowed or reimbursed under Caregiver Coaching. Caregiver coaching services will not duplicate services provided under the Indiana Medicaid State Plan or any other waiver service. Separate payment will not be made for structured family caregiving. Additionally, caregiver coaching service will not be reimbursed when provided by a parent of a minor child participant or the spouse of a participant (also known as L-R-I-s-) as outlined in C-2-d and C-2-e of the H&W Waiver.
                                  We believe that our Caregiver Coaching services can provide valuable support and resources to caregivers, and we are committed to providing high-quality services that meet the needs of our participants. Thank you for your attention, and we are happy to answer any questions you may have.

In order to be eligible for reimbursement, participants must complete the care management curriculum and have relevant education and work experience. Any providers who are the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant will not be reimbursed. Now, let's move on to a closer examination of the DDRS HCBS Waivers Section 12. For Community Transition services, the participant's own home is defined as any dwelling that is owned, leased, or rented by them, including a house, apartment, condominium, trailer, or other type of lodging. All community transition items are considered the property of the participant receiving the service. Any approved community transition expenditures, such as security deposits, application fees, essential (not luxury) furnishings, moving expenses, setup fees, deposits for utilities or services, health and safety assurances, and one-time cleaning prior to occupancy, can be reimbursed through the local Area Agency on Aging (A-A-A--) or an OMPP-approved provider. These reimbursements will be based on applicable receipts and verification of the services being delivered. In order to receive community transition services, a written service plan must be created through the person-centered planning process. If the participant lacks government-issued identification items that are necessary for securing housing or utilities, the costs associated with obtaining these items will also be covered under community transition services.

We are presenting the documentation standards and limitations for Community Transition services under the Health and Wellness (H&W) and Traumatic Brain Injury (T-B-I--) waivers. These services are an essential part of the care management services provided under these waivers. It is crucial for care managers to follow the documentation standards and limitations in order to ensure efficient and effective delivery of these services. The documentation standards require care managers to document the need for Community Transition services and any reasonable furnishings or setup expenses requested by the participant in the service plan. They must also keep records of all expenditures and provide receipts. If the care manager requests the maximum lifetime cap of $1500 but not all funds are used, they must update the service plan to reduce the amount and prevent over-reimbursement by Medicaid. Moving on to the limitations for Community Transition services, reimbursement is limited to a one-time use and a lifetime cap of $1500 for setup expenses. These services can only be provided if they are deemed reasonable and necessary in the service plan, and the individual is unable to cover the expenses themselves or obtain them from other sources. It is important to note that certain activities, such as apartment or housing expenses, food, household appliances, recreational items, and allergen control, are not allowed to be covered by Community Transition services. Furthermore, federal financial participation will not be billed for until after the individual leaves the institution and becomes eligible for the waiver. It is also not reimbursed if provided by a parent or spouse of the participant. In summary, Community Transition services are a critical part of care management services.

The qualifications for Community Transition services under Health and Wellness (H&W) and Traumatic Brain Injury (T-B-I--) waivers are being presented. These services aim to support participants in their homes with instrumental activities of daily living (I-A-D-L-) when they are unable to meet their needs or when their caregiver cannot help them. To become an approved provider, community transition service agencies must fulfill specific requirements. This includes having a valid license or certification from a recognized healthcare organization and following FSSA-approved standards for Community Transition Service Agencies. In addition to these general requirements, providers must also meet specific qualifications for H&W/TBI waivers. These include financial information, liability insurance, transportation arrangements, professional qualifications and requirements, documentation of qualifications, maintenance of personnel records, adoption of personnel policies, operations manual, maintenance of records of services provided, individual's personal file, site of service delivery, and other relevant qualifications. We hope this information is helpful and encourages you to consider these requirements when selecting a provider for your community transition service needs. Thank you for your attention.

Slide number 9 out of 14 in the presentation titled "Care Management Services" is now displayed. This slide contains information on the service standards that must be followed for care management services. These standards are crucial in ensuring the safe and effective delivery of care management services. 

The slide begins with a list of allowable activities that can be provided as part of care management services. These activities include assistance with meal planning and preparation, essential errands and unassisted transportation, correspondence and bill paying, minor pet care, and outdoor tasks such as raking leaves, snow removal, lawn mowing, and weeding. These activities are all important in supporting the well-being of participants. 

Following this, the slide outlines the documentation standards that must be adhered to for care management services. This includes documenting the need for Home and Community Assistance, the frequency of need, and the specific type of assistance required. The Home and Community Assistance providers are also responsible for documenting the data record of services provided, including the date and time of service, specific tasks carried out, notification to the participant's care manager, time spent traveling and completing the errand, and the signature of the employee providing the service. 

Lastly, it is stated that each staff member who directly provides care or supervises care for the participant must make at least one entry per day, describing any issues or circumstances pertaining to the participant. This helps to ensure that all aspects of the participant's care are carefully monitored and recorded. 

Overall, adherence to these service standards is crucial in providing participants with the necessary care and support they need to lead healthy and fulfilling lives.

The Health and Wellness (H&W) and Traumatic Brain Injury (T-B-I--) Waivers in Section 12 of the DDRS HCBS Waivers outline the qualifications for reimbursement of Care Management services. These qualifications include completing the care management curriculum and having relevant education and work experience. Providers must not fall under certain categories, such as being the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant. The participant or designated participant representative must sign off on service delivery documentation. Home and Community Assistance services are not allowed to provide hands-on assistance with Activities of Daily Living (ADLs), assisted transportation to community activities or errands, or to household members other than the participant. The owner of the organization must not fall under certain categories, such as being a parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, legal guardian of the participant, or a member of the participant's household. Home and Community Assistance services cannot be provided to participants already receiving Adult Family Care, Structured Family Caregiving, or Assisted Living services. Home and Community Assistance services will not be reimbursed if they are provided by the parent of a minor child participant or the spouse of a participant (also known as LRIs), as outlined in C-2-d and C-2-e of the Health and Wellness and Traumatic Brain Injury waivers. Providers must meet the qualifications outlined in Table 17 in our library reference number PRPR10014, published on September 9th. We appreciate your attention to these important guidelines to ensure the best care for eligible participants.

During the presentation, we will cover the rules and regulations that must be followed in order for care management services to be reimbursed for eligible participants. It is crucial to have a clear understanding of these guidelines in order to ensure that care management services are provided effectively and efficiently.

Our focus will primarily be on the health and wellness (H&W) and traumatic brain injury (T-B-I--) waivers, as well as the DDRS HCBS waivers. We will also discuss the qualifications for being a provider of home and community assistance services, which include becoming an approved provider and maintaining approval, having liability insurance, meeting professional qualifications and requirements, and keeping accurate personnel records. We will also address compliance with IC 16-27-4, if applicable, and the requirements for being an F-S-S-A approved home health agency, as stated in IC 16-27-1, IC 16-27-4, and section 12.16: Home-Delivered Meals for H&W and T-B-I waivers.

It is important to note that care management services will only be reimbursed for eligible participants who meet specific qualifications, such as completing the care management curriculum and having relevant education and work experience. Furthermore, reimbursement will not be provided if the provider is the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant. It is crucial to adhere to these qualifications and restrictions in order to receive proper reimbursement for care management services.

Our Delivered Meal service is an essential component of Care Management services that provides a nutritionally adequate meal to eligible participants in a safe and cost-effective manner. The meals we provide must contain at least one-third of the current daily recommended dietary allowance as established by the Food and Nutrition Board of the National Academy of Sciences, National Research Council. Meals should also contain less than 10% daily calories from added sugars, saturated fats, and sodium, unless prior F-S-S-A or registered dietitian approval is received.

Documentation standards must be followed, including the care manager documenting the need for Home-Delivered Meals and the amount being requested, and the provider documenting the date of delivery, how many meals are included, and the name of the care professional or care manager that involved the participant. Food allergies, food preferences, or gluten sensitivity for waiver participants must also be documented.

It is important to note that more than two meals per day are not allowed, and services provided to participants receiving either of the following waiver services: Adult Family Care or Assisted Living, are not reimbursed when provided by the parent of a minor child participant or the spouse of a participant as outlined in C-2-d and C-2-3 of the H&W and T-B-I waivers. Proper documentation and adherence to the documentation standards and activities not allowed are crucial to ensure that the service is reimbursable and effective.

We are pleased to announce the availability of Care Management services through the Health and Wellness (H&W) and Traumatic Brain Injury (T-B-I--) waivers. In order to be eligible for reimbursement, participants must complete the care management curriculum, have relevant education and work experience, and not be the parent of a minor child participant, spouse of a participant, attorney-in-fact (or P-O-A--) of a participant, H-C-R of a participant, or legal guardian of a participant. The Home-Delivered Meals (H-D-M--) services have specific provider qualifications which are outlined in Table 18. These qualifications include being an approved provider, maintaining approval, and adhering to all state and local health laws and ordinances related to food preparation, handling, and serving. For Home Modification Assessment (H-M-A--) services under the H&W and T-B-I waivers, participants must select a certified waiver provider before any home modifications are made and must undergo a home modification inspection upon completion of the work. Reimbursement for home modifications will only be granted after a final inspection has taken place. The assessor will be responsible for determining specifications, assessing feasibility, and conducting the post-project inspection. We hope that this information will help ensure the safety, suitability, and practicality of Care Management services for eligible participants.

Home Modification Assessment Service Standards

                                    The Home Modification Assessment service is a critical component of DDRS HCBS Waivers. According to Section 12 of the DDRS HCBS Waivers, the Home Modification service will only be deducted from the participant's lifetime cap if completed by an eligible provider and if the participant meets specific qualifications. It is important to note that the provider cannot be a parent, spouse, attorney-in-fact, H-C-R--, or legal guardian of the participant.

                                    The allowable activities for the Home Modification Assessment service include evaluating the current environment and identifying any barriers that may prevent desired modifications, reimbursing for nonfeasible assessments, drafting specifications, and submitting them for approval. The modification must also undergo an inspection and approval process, and the county code enforcement must be contacted.

                                    Service standards require the participant's plan of care to indicate a need for home modification, and the proposed modifications must address the participant's level of service needs. The specifications must comply with the requirements and limitations outlined in the approved service definition for Home Modifications. The assessment itself must be conducted by an approved and qualified individual who is independent from the entity providing the modifications.

                                    Documentation standards require proper contact to be made regarding potential code violations.

                                    In conclusion, the Home Modification Assessment service is a critical component of DDRS HCBS Waivers, and it must adhere to specific standards to ensure the safety and well-being of participants.