CHAPTER 700 SPECIAL ELIGIBILITY CONDITIONS

701. Eligibility Criteria
The Department of Behavioral Health and Developmental Disabilities Intake and Evaluation Team (I&E Team) use the criteria below to determine whether a participant is appropriate for Comprehensive Supports Waiver Program (COMP) services. Home and Community-Based services included under the waiver may be provided only to persons who are not inpatients of a hospital, Skilled Nursing Facility (SNF), Intermediate Care Facility (ICF), Intermediate Care Facility for Persons with Intellectual Disability (ICF/ID), with the exception of the personal assistance retainer for Community Living Support Services (see COMP Part III, Policies and Procedures, Chapter 1900 for personal assistance retainer details), and who:
A. Are categorically eligible Medicaid recipients; and
B. Have a diagnosis of an intellectual disability and/or a closely related condition (see Section 706.2); and
C. Are currently receiving the level of care provided in an ICF/ID which is reimbursable under the State Plan, and for whom home and community-based services are determined to be an appropriate alternative; or,
D. Are likely to require the level of care provided in an ICF/ID that would be reimbursable under the State Plan in the absence of home and community-based services that are determined to be an appropriate alternative.
702. Notification of Participant Approval/Disapproval
COMP applicants are notified in writing of approval or disapproval for COMP services by the Regional DBHDD Office.
703. Denial of Eligibility
Eligibility for services under the waiver may be denied for the following reasons:
A. A participant fails to meet the eligibility criteria specified in this chapter.
B. The participant or his/her representative has not supplied information needed to complete the eligibility process.
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C. The participant or his/her representative has not signed the Freedom of Choice form.
D. The Individual Service Plan costs are prohibitive because it increases the average cost of the COMP beyond the average ICF/ID costs.
704. Grounds for Appeal
A participant denied service or terminated from service because he/she does not meet the level of care requirement is informed of his/her rights to appeal or to a hearing. The DMA authorized representative sends the participant a Denial of Level of Care letter that outlines the procedure to appeal the decision and to request a hearing.
705. Screening for Services
All persons requesting institutional or community services in the developmental disability service system do so through the Department of Behavioral Health and Developmental Disabilities (DBHDD) Regional Office. An individual or family participant applies for DD services by completing an Application for Developmental Disabilities Services (see Appendix B). The Regional Office requests the individual or family participant to provide copies of any previous psychological evaluations or adaptive behavior testing. The Regional Office will maintain copies of the application and related documentation.
The Intake and Evaluation (I&E) Team is responsible for the screening process. The team composition and qualifications are defined in the Official Codes of Georgia Annotated 37-4 and 37-5. An I&E Team member from the DBHDD Regional Office meets with the individual and/or his or her family member/representative to complete the Intake Screening Tool within 14 business days of the receipt of the application. Information gathered includes background information, functional abilities, developmental milestones, and behavioral and health issues.
All supporting documentation is reviewed to determine whether the individual meets the established eligibility criteria. To determine eligibility, the Intake and Evaluation Team members review available copies of prior psychological evaluations and adaptive behavior testing and determine whether additional testing is required. The I&E psychologist reviews and signs off on all determinations. Once an eligibility determination is made, a person receives services or is placed on the region’s Planning List. A Planning List Administrator will be assigned to anyone placed on the short-term planning list.
For persons recommended by the DBHDD Regional Office for enrollment in COMP funded services, a comprehensive evaluation is to be completed by the DBHDD Regional Office, including a DMA-6 or DMA-6A form (see Appendix C) signed and dated by a physician, nurse practitioner, or physician assistant and
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approved by the DBHDD Regional Office. The DBHDD Regional Office determines whether the individual’s needs place him or her at risk of institutionalization in an ICF/ID. The Initial Comprehensive Evaluation, the Individual Service Plan (ISP), and a DMA-6 or DMA-6A form is used to document this determination of eligibility and is reviewed by the Regional Office for level of care determination.
Prior to the comprehensive evaluation process at enrollment in service, an individual is determined by the DBHDD Regional Office to likely require the level of care provided in an ICF/ID through the administration of functional assessment instruments, the review of presenting documentation, and application eligibility standards as defined in Section 701. The participant and his or her legal representative are: (1) provided a brief explanation of the COMP and informed of alternatives available under the waiver and (2) given the choice of either institutional or home and community-based services. The participant and/or his or her representative must sign the Freedom of Choice Form. In those cases where the beneficiary is unable to comprehend fully the options or consequences of his or her choice, a duly authorized representative of the beneficiary may act on his or her behalf. See Appendix E for Freedom of Choice Form.
706. Initial Level of Care Determination
The DBHDD Regional Office reviews copies of the following documents for the initial level of care determination:
706.1. The Initial Individual Service Plan (ISP)
Information is gathered from a variety of assessment tools to include the Health Risk Screening Tool (HRST), Supports Intensity Scale (SIS), and any assessments completed by the Intake and Evaluation Team. The ISP should also contain any known medical documentation and any documented health history as additional sources for health information. The Planning List Administrator or an Intake and Evaluation Team member completes the initial Supports Intensity Scale (SIS) for individuals who are 16 years or older.
The I&E nurse completes the initial Health Risk Screening Tool (HRST). The HRST assesses where the individual is likely to be most vulnerable in terms of potential health risks. If the Health Care Level is a 3 or greater on the HRST or an individual scores a “2” or two “1’s” on the SIS Exceptional Medical Needs Section, a nursing assessment is completed as part of the initial level of care determination.
DBHDD Regional Office staff, comprised of the Intake and Evaluation Team participants and the Planning List Administration staff, review all documents prior to facilitating the initial ISP meeting. The ISP addresses what is important
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to and for the individual. This information includes the support need areas identified in the Supports Intensity Scale for individuals 16 years or older, and any health and safety issues identified in the screening process, SIS (for individual 16 years or older), or HRST. The Planning List Administrator, in conjunction with the individual, and his or her family and/or support network develop a written Individual Service Plan that includes the services to be provided, the frequency of services, and the type of provider to deliver the service. The physician’s signature is required on the ISP when the individual has a chronic medical condition defined as a Level 2 and above on the Intake and Evaluation Screening tool.
Known medical conditions, allergies and medication summaries are also included in the ISP. Diagnoses are indicated to ensure treatment of medical conditions such as obesity and diabetes. Behavioral Health conditions are noted and connections made to community mental health services as appropriate. Needed connections to primary care physicians and specialty medical providers are incorporated into the ISP. It is the responsibility of the primary care physician to ensure all appropriate health screenings and treatment.
No service will be reimbursed which is not listed on the approved Individual Service Plan. Assurance is made that goods and services provided by the waiver are not covered under the Medicaid State Plan when applicable. The cost of service for some individual participants may exceed the average ICF/ID costs. However, the average cost for all COMP participants cannot exceed the average cost of services in an ICF/ID. Please see protocol for physician’s signature in Appendix C.
Please see Appendix C, page C-12 (Protocol for Physician Signature and Appendix D, (I & E Screening Tool for Chronic Medical Condition).
706.2 Comprehensive Evaluation
The comprehensive evaluation for initial level of care determination includes:
A. A completed DMA-6/ DMA-6A form signed by a licensed physician, nurse practitioner, or physician assistant and the participant.
 A social work assessment that must be current within one (1) year when submitted to the DBHDD Regional Office for the initial level of care determination.
 A psychological assessment for intellectual functioning and adaptive behavior based on a standardized instrument(s) recognized by professional organizations (American Psychological Association, American Association on Intellectual and Developmental Disabilities). The psychological assessment must document:
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 Diagnosis of an intellectual disability (see note below) defined by the following three criteria:
(1) Age of Onset: Onset before the age of 18 years;
(2) Significantly Impaired Adaptive Functioning: Significant limitations in adaptive functioning (two or more standard deviations below the mean) in at least two of the following skill areas: self-care, communication, home living, self-direction, functional academic skills, social/interpersonal skills, use of community resources, work, leisure, health, and safety; and
(3) Significantly Sub-average General Intellectual Functioning: Significantly sub-average general intellectual functioning defined as an intelligence quotient (IQ) of about 70 or below (approximately two standard deviations below the mean). Individuals with an IQ of 70 to 75 with appropriately measured, significant impairments to adaptive behavior that directly relate to issues of an intellectual disability may be considered as having an intellectual disability ; or
Note: A diagnosis of mental retardation according to correct diagnosis manuals is the same as a diagnosis of intellectual disability defined above (see Rosa’s Law, Federal S. 2781, signed October 2010).
 Diagnosis of a condition found to be closely related to an intellectual disability and attributable to: (a) cerebral palsy or epilepsy; or (b) any other condition, other than mental illness, found to be closely related to an intellectual disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons with an intellectual disability and requires treatment or services similar to those required for these persons; and that meets the following criteria (Code of federal Regulations, Title 42 Section 435.1010 and aligns with the definition of ICF/MR now known as ICF/ID as defined in title 42 Section 440.150):
1. Age of Onset: Onset before the age of 22 years;
2. Service Needs: The individual must require an ICF/ID level of care without home and community-based treatment or services similar to those required for individuals with a diagnosis of an intellectual disability.
3. Substantially Impaired Adaptive Functioning: Substantial limitations in adaptive functioning (two or more standard deviations
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below the mean) in three or more of the following areas of functioning: self care, receptive and expressive language, learning, mobility, self-direction, and capacity for independent living; and the adaptive impairments must be directly related to the developmental disability and cannot be primarily attributed to mental/emotional disorders, sensory impairments, substance abuse, personality disorder, specific learning disability, or attention-deficit/hyperactivity disorder; and
4. Continued Disability: The disability is likely to continue indefinitely.
5. Participants Aged 18 Years or Less: Assessment findings meet the diagnostic criteria in the Pediatric Level of Care for individuals 18 years or less (see Appendix C).
The psychological assessment must be current within one (1) year. A psychological consultation report is acceptable when submitted with a copy of the referenced evaluation. Psychological consultation reports must include a summary of the previous testing scores in the referenced evaluation (s) and must confirm an intellectual disability or other closely related condition.
706.3 Additional Assessment and Planning Requirements
A. The individual or his or her representative is informed of the findings of the assessments in language he or she can understand.
B. The Support Coordinator discusses service options with the participant, his/her family and others as appropriate in order to identify social, education, and other needs. These needs may indicate Medicaid and non-Medicaid covered services.
C. Individuals direct decisions that impact their life.
D. Others assisting in the development of the individualized plan are persons who:
a. Are significant in the life of the individual;
b. Have a historical perspective of the desires of the individual;
c. The individual gives consent to have input from family and friends if desired; and
d. Will deliver the specific services, supports, care and treatment identified in the plan;
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For individuals with coexisting, complex and confounding needs, cross disciplinary approaches to planning should be used;
Planning should be facilitated by professional(s) qualified to plan or provide services to persons with this level of complexity; and
Representatives of other agencies outside of DBHDD or providers affecting the daily life of the individual should be present and participating.
E. Each individualized plan should be:
1. Driven by the individual and focused on outcomes the individual desires to achieve;
2. Fully explained to the individual using language/communication he or she can understand and agreed to by the individual;
3. Identify and prioritize the needs of the individual and include a page for signatures of the individual or guardian or other members to indicate who participated in the planning of services. Subsequent addendums must also document individual/guardian’s signature;
4. A page for signature, title and date by participants (including the individual and professionals) that is attached to the plan, to indicate all participants presence and involvement in the plan that provide services, supports, care and treatment to the individual.
F. Statement of goals or objectives of the individual are:
1. Each goal/objective is specific to the services provided:
a. Specific to the desired outcomes;
b. Measurable for progress;
c. Achievable skills;
d. Relevant to service provision;
e. Realistic to service provision; and
f. Time-limited with specified target dates.
2. The frequency or intensity that the specific service, support, care and treatment will be given or provided;
3. Identification of staff responsible to deliver or provide the specific service, support, care and treatment;
4. There is evidence of involvement in the formal individualized plan of all traditional service delivery providers of services and supports to the individual and specification of any participant-directed service delivery for the individual, as applicable;
5. Waiver participants or their families/representative who opt for participant direction and become the employer of record of support workers must specify specific support worker qualifications required to meet the exact medical, education, social and other
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support needs of the waiver participants.
6. Clear authorization of the plan:
a. Refer to COMP Part III definitions of service to determine who must authorize the plan;
b. A physician must authorize the plan when it includes medical care and treatment (Please see protocol for physician’s signature in Appendix C);
c. When more than one physician is involved in individual care, there is evidence that an RN or MD has reviewed all in-field information to assure there are no contradictions or inadvertent contraindications within the care and treatment orders or plan.
Note: A physician, nurse practitioner, or physician assistant must authorize the level of care of a participant as required by Georgia Department of Community Health Division of Medicaid, Part II Policies and Procedures for the NOW & COMP Waiver Program. No Medicaid reimbursement will be made for any service period of an individualized plan for which there is no level of care (DMA-6/DMA-6A or DMA-7) in effect.
G. Behavior Support Practices
1. In policies, procedures and practices, the organization outlines and defines the adaptive, supportive, medical protection devices and the restrictive interventions that are implemented or prohibited by the organization and licensure requirements. These devices include but are not limited to:
a. Use of adaptive supportive devices or medical protective devises (devices which restrain movement but are applied for the protection of accidental injury, required for medical treatment or for corrective/supportive needs):
i. May be used in any service, support, care and treatment environment;
ii. Use is defined by a physician’s order (order not to exceed twelve calendar months);
iii.Written order to include rationale and instructions for the use of the device;
iv. Authorized in the individual service plan (ISP); and
v. Are used for medical and/or protection against injury and not for treatment of challenging behavior(s).
b. Time out (also known as withdrawal to a quiet area):
i. Under no circumstance is egress physically or manually restricted;
ii. Time out periods must be brief, not to exceed 15 minutes;
iii. Procedure for time out utilization is incorporated in the behavior support plan; and
iv. The justification for use and implementation details for time out utilization is documented.
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c. Manual Hold/Restraint(also known as Personal Restraints): The application of physical force, without the use of any device, for the purpose of restricting the free movement of a person’s body:
i. May be used in all community settings except residential settings licensed as Personal Care Homes;
ii. Circumstances of use must represent an emergency safety intervention of last resort affecting the safety of the individual or of others;
iii. Brief handholding (less than 10 seconds) support for the purpose of providing safe crossing, safety or stabilization does not constitute a personal hold;
iv. If permitted, Manual/Personal Restraint (ten seconds or more), shall not exceed five (5) minutes and use of personal restraint is documented;
v. Use of manual/personal restraints must be outlined as an approved intervention in his/her safety plan; and
vi. If manual/personal restraints are implemented more than three (3) times in a six (6) month period, there must be corresponding procedures to teach the individual skills that will decrease/eliminate the use of personal restraints.
d. Mechanical Restraint (also known as Physical Restraints): A device attached or adjacent to the individual’s body that one cannot easily remove and that restricts freedom of movement or normal access to one’s body or body parts. Mechanical/Physical restraints are prohibited in community settings.
e. Seclusion: The involuntary confinement of an individual alone in a room or in any area of a room where the individual is prevented from leaving, regardless of the purpose of the confinement. The practice of “restrictive time-out” (RTO) is seclusion and may not be utilized except in compliance with the requirement related to seclusion. The phrase “prevented from leaving” includes not only the use of a locked door, but also the use of physical control or verbal threats to prevent the individual from leaving. Seclusion is not permitted in COMP services.
f. Chemical restraint may never be used under any circumstance. Chemical restraint is defined as a medication or drug that is:
i. Not a standard treatment for the individual’s medical or psychiatric condition;
ii. Used to control behavior; and
iii. Used to restrict the individual’s freedom of movement.
Examples of chemical restraint are the following:
i. The use of over the counter medications such as Benadryl for the purpose of decreasing an individual’s activity level during regular waking hours;
ii. The use of an antipsychotic medication for a person who is not psychotic but simply ‘pacing’ or agitated.
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g. PRN anti-psychotic medications for behavior control are not permitted. See Appendix R for list of medications.
2. The approach to developing a positive behavior support plan (including a safety plan) and treatment for individuals demonstrating challenging behaviors should be consistent with the definitions and protocols in the Guidelines for Supporting Adults with Challenging Behaviors in Community Settings and Best Practice Standards for Behavioral Support Services found in Appendix B of the COMP Part III Policies and Procedures Manual. Behavior Support activities outlined in the PBSP is guided by an overall emphasis on not only decreasing target behaviors but also concurrently increasing skills in appropriate areas.
3. The PBSP and Safety Plan for challenging behaviors should be a collaborative effort among each provider providing services for the individual. The providers must work to develop and implement one plan that includes any modification for implementation for each service site and the modification must be addressed and approved prior to finalizing the plan. The final approved PBSP is incorporated by reference into the ISP. A copy of the individual’s PBSP must be available at all service sites for implementation.
4. a) A behavior support plan should be developed and implemented for individuals with developmental disabilities who receive psychotropic medications for symptom management of challenging behavior that continues to pose a significant risk to the individual, others, or the environment (e.g., self-injury, physical aggression, property destruction) and is not specifically related to mental illness or epilepsy requiring treatment with psychotropic medications. The behavior support plan must minimally include:
1) An operationally defined behavior(s) for which the drug is intended to affect;
2) Measuring target behaviors which shall constitute the basis on which medication adjustments will be made; and
3) A focus on teaching replacement behaviors in an effort to replace the use of medication with behavioral programming.
b) A behavior support plan is not required for individuals receiving psychotropic medication to treat mental illness (e.g., schizophrenia, bi-polar disorder) or epilepsy when the record documents that the medication addresses the symptoms of the mental illness or epilepsy.
5. When positive behavior support plan is used to reduce challenging behaviors there must evidence that the following issues have been addressed. The plan is:
a. Individualized;
b. Based on a functional assessment;
c. One that has addressed potential medical causes;
d. Developed and overseen by a qualified professional (Refer to Appendix I for Developmental Disability Professional categories
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of Psychologist, Behavior Specialist, and Board Certified Behavior Analyst);
e. Inclusive of methods outlined to teach alternative appropriate behaviors that will achieve the same results as the challenging behavior(s);
f. Inclusive of rationale for the following:
i. Use of identified approaches;
ii. The time of their use;
iii. An assessment of the impact on personal choice of the individual;
iv. The targeted behavior; and
v. How the targeted behavior will be recognized for success.
g. Implemented by trained and competent staff as documented by individual who developed the BSP/Safety Plan and trained the staff.
h. Has monitoring plans for review, analyzing trends, and summarizing the effectiveness of the plan and termination criteria;
i. Consent provided by the individual and his or her legal guardian;
j. Discussed with the individual and family/natural supports (as permitted by the individual); and
k. Developed in accordance with Best Practice Standards for Behavioral Support Services for Providers of Developmental Disabilities Services (www.dbhdd.georgia.gov).
6. Intrusive or restrictive procedures must be clearly justified through documentation of less restrictive procedures ineffectiveness and/or the need for more intrusive procedures due to the safety or health risks presented by the targeted behaviors. These procedures are authorized, incorporated into the BSP and/Safety Plan, approved by ISP interdisciplinary team, reviewed by organization’s Rights Committee and supervised by qualified professional(s) and may not be in conflict with Federal or State Laws, Rules and Regulations, Clients Rights or Department standards to include but not limited to the document Guidelines for Supporting Adults with Challenging Behaviors in Community Settings and the Best Practice Standards for Behavioral Support when developing a behavior support/safety plan.
7. Providers must have processes in place to implement crisis intervention as needed. The staff must be trained to respond to a crisis situation that occurs at the service site and have an agency’s crisis plan, that at a minimum addresses:
a. Approved interventions to be utilized by staff;
b. Availability of additional resources to assist in diffusing the crisis;
c. If the acute crisis presents a substantial risk of imminent harm to self and others, that community based crisis services to include the Georgia Crisis Response System(GCRS) serves as an alternative to emergency room care, calling 911, institutional placement, and/or
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law enforcement involvement (including incarceration) is implemented;
d. Protocols to access community-based crisis services to include the Georgia Crisis Response System must be included in agency’s policy and procedures with staff trained to implement this protocol; and
e. Notification process by Direct Support Staff that includes informing the designated on-call management staff and/or Director.
8. All organizations must have the capacity to address individual’s behavioral needs. If the cause of the challenging behavior cannot be determined or satisfactorily addressed by the provider, there should be evidence of consultation with an outside professional who is licensed or qualified through education, supervised training and experience to address the behavior needs of the Individual. Those authoring such plans should minimally meet professional criteria as a Psychologist, Behavioral Specialist or a Board Certified Behavior Analyst (see Appendix I for Developmental Disability Professional qualifications for these professions).
9. If the need for behavior supports is identified, the individual or guardian is given a choice to select the qualified person to develop the BSP and /or Safety plan.
H. Documents Referenced in Individual Service Plan
Documents to be incorporated by reference into an individual service plan include, but are not be limited to:
1. Medical updates as indicated by physician orders or notes;
2. Known medical conditions, allergies and medication summaries;
3. Medical documentation and any documented health history
4. Addenda as required when a portion of the plan requires reassessment;
5. A personal crisis plan which directs in advance the individual’s desires/wishes/plans/objectives in the event of a crisis;
6. A behavior support plan and/or a safety plan for individuals demonstrating challenging behaviors:
7. A behavior support plan and safety plan for individuals who receive psychotropic medications for symptom management;
8. Diagnoses are indicated to ensure treatment of medical conditions such as obesity and diabetes.
I. Summaries of Progress toward Goals
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There is evidence that the participant data from tracking sheets and learning logs have been reviewed, analyzed for trends and summarized against progress toward goals at least quarterly.
J. Individual Referrals Based on Assessment of Individual Need
Policies, procedures, and practice describe processes for referral of the individual based on ongoing assessment of individual need:
a. Internally to different programs or staff; or
b. Externally to services, supports, care and treatment not available within the organization including, but not limited to:
i. Health care for
1. Routine assessment such as annual physical examinations;
2. Chronic medical issues;
3. Ongoing psychiatric issues;
4. Acute and emergent needs;
a. Medical
b. Psychiatric
ii. Diagnostic testing such as psychological testing or labs; and
iii. Dental services
707. Level of Care Re-Evaluation
A. The level of care re-assessments are completed at a minimum of every 12 months. LOC service approval may not exceed 365 days.
B. Psychological/Behavioral Assessment Updates: The interdisciplinary team determines if there has been a change in the participant’s condition and recommends a psychological/behavioral assessment update as follows:
 For participants below 18 years of age, a psychological assessment (or psychological consultation report as indicated in Section 706) will be conducted every three (3) years for any individual whose initial level of care determination was not based on a diagnosis of moderate to profound mental retardation or severe autism.
 For participants over 18 years of age, a behavioral assessment update will be conducted when the participant scores a “2” and a total greater than 5 on the SIS Exceptional Behavioral Support Needs Section.
C. Social Work Assessment Updates: The interdisciplinary team determines if there have been major changes in a participant’s home or family environment or other life circumstances, including but not limited to, loss or illness of caregiver, extended hospitalization,(i.e., one month or more), or loss of home
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due to fire or natural disaster. Social work assessments are updated when the interdisciplinary team determines these changes have occurred.
D. Nursing Assessment Updates: If the Health Care Level of the participant is a 3 or greater on the HRST or the participant scores a “2” (Extensive Support Needed) on Lifting and/or Transferring, Turning or Positioning, or Seizure Management or a total greater than 5 on the SIS Exceptional Medical Needs Section, the nursing assessment is updated.
E. The participant’s support coordinator or service provider may request at any time technical assistance from the DBHDD Regional Office due to changing needs of a participant, including but not limited to, loss or illness of primary caregiver, extended hospitalization, deteriorating neurological functioning, mental illness, severe aberrant behaviors, and significant decline in functioning.
F. The Support Coordinator submits to the DBHDD Regional Office the participant’s Level of Care Re-Evaluation form and Individual Service Plan, along with any required copies of updated psychological, social work, and/or nursing assessment(s) as indicated above.
G. The Level of Care Re-Evaluation form (DMA-7) must be signed by the participant’s support coordinator and the participant or participant’s representative (see Appendix C for DMA-7 form and instructions).
H. The I&E Level of Care RN reviews the Level of Care Re-Evaluation (DMA-7) form, the ISP, and any accompanying assessment updates to determine whether the person continues to meet the level of care requirement.
708. Level of Care Approval Requirements
 Each participant approved for COMP services must have a level of care determination authorized by the DBHDD Regional Office (see Appendix A).
 The DBHDD Regional Office will not approve any level of care or re-evaluation until all required documents submitted for approval are complete. The initial date the completed Level of Care Re-Evaluation (DMA-7) form is received by the DBHDD Regional Office with all additional required documentation for recertification will be the date that is entered into DBHDD Regional Office system and will constitute the earliest re-certification date once approved. The annual date of the participant’s current level of care is the date that the level of care is made effective by DBHDD Regional Office.
 The signatures of the physician, nurse practitioner, or physician assistant on the DMA-6/DMA-6A form for initial level of care determination must be no
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more than 30 days prior to the LOC approval date. The need for institutional care shall be considered to have been satisfied for persons who are currently receiving the level of care provided in an ICF/ID or SNF, unless otherwise indicated in the most recent utilization review of the participant.
 The approved initial level of care (DMA-6/DMA-6A) or re-certification of level of care (DMA-7) form is uploaded to a web based system so that all providers have access. Initial services must begin within 60 days of DBHDD Regional Office approval. In the event services do not begin within 60 days, the DMA-6/DMA-6A form and assessment will be reviewed by the clinicians and physician and updated as needed.
 Each participant must have a current level of care (DMA-6/DMA-6A for initial level of care and DMA-7 form for level of care re-evaluations) approved by the Regional DBHDD office and with required signatures. No Medicaid reimbursement will be made for any service period for which there is no level of care (DMA-6/DMA-6A or DMA-7) in effect.
 Each enrolled provider service type must maintain a copy of the current and approved DMA-6/DMA-6A or DMA-7 forms covering all periods of services rendered, in the participant’s record. Noncompliance to this program requirement will result in a request for refund from the Department.
709. Re-Evaluation of Participants
The participant, his or her support network, and support coordinator as often as necessary, but no less frequently than annually will review each participant’s ISP. ISP reviews will also occur anytime there is a major life change for the individual. These reviews will explain in detail the reason for failure to achieve any anticipated outcomes. The ISP will be revised as needed to assure appropriate provision of services to each participant. All team members in attendance will sign the new ISP or addendum. I & E Team members’ signatures, for those not in attendance but who contributed to this annual ISP, can be found on the annual assessments or reviews included with the ISP. The revised start date listed on the ISP addendum is the approval date for any ISP addendum, but is no instance can the revised start date be prior to the date of the ISP addendum meeting.
709.1 Reduction or Termination of Services
1. Reduction of COMP Services: The participant and/or his/her representative (family member or legal guardian) will receive written notice of the rights to appeal any reduction of COMP services from the DBHDD regional office. The notice will outline the process for requesting a fair hearing.
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2. Termination from the COMP Waiver Program due to Medicaid Eligibility Discontinuance: COMP Waiver Program eligibility is dependent upon Medicaid eligibility, and discontinuance of Medicaid eligibility for an individual results in his or her termination from the COMP Waiver Program. The participant and/or his/her representative will receive written notice of the rights to appeal discontinuance of Medicaid eligibility from the local Department of Family and Children Services (DFCS) Office. The notice will outline the process for requesting a fair hearing.
3. Termination from the COMP Waiver Program due to Department of Community Health Adverse Decision: Part I Policies and Procedures for Medicaid/Peachcare for Kids, Chapter 500, Section 508 provides procedures for the request of a fair hearing should a decision of the Department of Community Health be adverse to a participant.
4. Termination from the COMP Waiver Program due to DBHDD Adverse Decision: The participant and/or his/her representative (family member or legal guardian) will receive written notice from the DBHDD regional office of the rights to appeal any COMP Waiver Program termination resulting from a DBHDD adverse decision. The notice will outline the process for requesting a fair hearing.
710. Outcomes for Participants
710.1 Respect for the Dignity of the Individual
1. Access to appropriate services, supports, care and treatment is available regardless of:
a. Age;
b. Race, National Origin, Ethnicity;
c. Gender;
d. Religion;
e. Social status;
f. Physical disability;
g. Mental disability;
h. Gender identity; or
i. Sexual orientation.
2. There are no barriers in accessing the services, supports, care and treatment offered by the organization, including but not limited to:
a. Geographic;
b. Architectural;
c. Communication:
i. Language access is provided to individuals with limited English proficiency or who are sensory impaired;
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ii. All applicable DBHDD policies regarding Limited English Proficiency and Sensory Impairment are followed.
d. Attitudinal;
e. Procedural; and
f. Organizational scheduling or availability
3. There is evidence of organizational person-centered planning and service delivery that demonstrates:
a. Sensitivity to individual differences and preferences is evident;
b. Practices and activities that reduce stigma; and
c. Interactions that are respectful, positive and supportive.
4. The organization must have written policies and procedures regarding the visitation rights of individuals, including a requirement that any reasonable restrictions must be based on the seriousness of the individual’s mental or physical condition as ordered in writing by the attending physician. Such orders shall state the type and extent of the restriction. The order shall be reviewed for changes as needed and renewed at least annually. Additional orders shall follow the same procedure. The organization must meet the following requirements:
a. Inform each individual (or guardian, or parent or custodian of a minor, as applicable) of his or her visitation rights, including any clinical restriction of such rights, when he or she is informed of his or her other rights under this section;
b. Inform each individual (or guardian, or parent or custodian of a minor, as applicable) of the right, subject to his or her consent, to receive visitors whom he or she designates, including, but not limited to, a spouse, a domestic partner (including a same sex domestic partner), another family member, or a friend, and his or her right to withdraw or deny such consent at any time. However, the parent, guardian or custodian of a minor may restrict his or her visitation rights;
c. Not restrict, limit, or otherwise deny visitation privileges on the basis of race, color, national origin, religion, sex, gender identify, sexual orientation or disability;
d. Ensure that all visitors enjoy full and equal visitation privileges consistent with the preferences of the individual;
e. Not restrict visitation by an individual’s attorney or personal physician on the basis of the individual’s physical or mental condition;
f. Visitors/guardians are also expected to adhere to any reasonable restrictions as ordered in writing by the attending physician in the area of diet; and
g. If visitation facilitates/results in problematic behaviors, reasonable restrictions may be ordered and incorporated into the Safety Plan.
710.2 Human and Civil Rights
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1. The organization has policies and promotes practices that:
a. Do not discriminate;
b. Promote receiving equitable supports from the organization;
c. Provide services, supports, care and treatment in the least restrictive environment possible;
d. Emphasize the use of teaching functional communication, functional adaptive skills to increase independence, and using least restrictive interventions that are likely to be effective;
e. Incorporate DBHDD Clients Rights or Patients Rights Rules, as applicable to the organization; and
f. Delineates the rights and responsibilities of persons served.
2. In policy and practice the organization makes it clear that under no circumstances will the following occur:
a. Threats of harm or mistreatment (overt or implied);
b. Corporal punishment;
c. Fear-eliciting procedures;
d. Abuse or neglect of any kind;
e. Withholding basic nutrition or nutritional care; or
f. Withholding of any basic necessity such as clothing, shelter, rest or sleep.
3. Federal and state laws and rules are evident in policy and practice including, but not limited to:
a. For all community based programs, practices promulgated by DBHDD or the Rules and Regulations for Clients Rights, Chapter 290-4-9 are incorporated into the care of individuals served. Issues addressed include but are not limited to the right to:
i. Care in the least restrictive environment;
ii. Humane treatment or habilitation that affords protection from harm, exploitation or coercion.
iii. Unless adjudicated incompetent by a court of law, be considered legally competent for any purpose without due process of law, including to maintain
1. Civil;
2. Political
3. Personal; or
4. Property rights.
4. There is evidence of the individual or legal guardian’s signature on notication that all individuals are informed about their rights and responsibilities:
a. At the onset of services, supports, care and treatment;
b. At least annually during care;
c. Through written information that is well prepared and in a language/format understandable by the individual; and
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d. How confidentiality will be addressed including but not limited to who they wish to be informed about their services, supports, care and treatment.
710.3 Community Integration and Inclusion into the Larger Natural Community
Community integration and inclusion into the larger natural community is supported and evident. Terms “Integration and Inclusion” mean:
a. Use of community resources that are available to other citizens;
b. Providing the opportunity to actively participate in community activities and types of employment as citizens without disabilities;
c. The organization has community partnerships for capacity building and advocacy of activities to achieve this goal of integration;
d. The organization must provide supports and inclusion activities that show respect for the individual’s dignity, personal preference and cultural differences;
e. There is documentation of individualized preferences, person-centered integration and inclusion in the community;
f. Building of community relationships (natural/paid/unpaid); and
g. Supporting individual’s choice as measured by the amount of control an individual has over his/her life.
710.4 Participant Rights and Responsibilities
Providers must acknowledge that participants have rights and responsibilities regarding participation in the COMP Waiver. At the time of admission the provider reviews participant rights and responsibilities with the participant and/or participant’s representative. After the participant reads and signs a copy of the participant’s rights and responsibilities, the provider gives a copy of the rights and responsibilities to the participant and the participant’s representative if applicable. The provider places a copy in the participant’s record.
Participant rights recognized by the provider include:
i. The right of access to accurate and easy-to-understand information
ii. The right to be treated with respect and to maintain one’s dignity and individuality
iii. The right to voice grievances and complaints regarding services and supports that is furnished or not furnished, without fear of retaliation, discrimination, coercion, or reprisal
iv. The right to a choice of approved service provider(s)
v. The right to accept or refuse services
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vi. The right to be informed of and participate in preparing the Individual Service Plan and any changes in the plan
vii. The right to be advised in advance of the provider(s) who will furnish services and the frequency and duration of services
viii. The right to confidential treatment of all information, including information in the participant’s record
ix. The right to receive services in accordance with the current Individual Service Plan
x. The right to be informed of the name, business telephone number and business address of the person supervising the services and how to contact that person
xi. The right to have property and residence treated with respect
xii. The right to be fully and promptly informed of any cost share liability and the consequences if any cost share is not paid
xiii. The right to review participant’s records on request
xiv. The right to receive adequate and appropriate services without discrimination.
xv. The right to be free from mental, verbal, sexual and physical abuse, neglect, exploitation, isolation, corporal or unusual punishment, including interference with daily functions of living
xvi. The right to be free from chemical or physical restraints
NOTE:
Providers must be aware of additional participant rights and responsibilities required under specific program licensure and must include signed copies of these rights and responsibilities in the participant’s record.
711. Eligibility Determination for Medical Assistance Only (MAO)
Participants who receive SSI are eligible for Medicaid. Participants whose income exceeds SSI eligibility may be considered to be Medicaid eligible as a result of a Medical Assistance Only (MAO) determination. The county Division of Family & Children Services determines eligibility and cost share responsibility. The MAO determination will indicate a monthly cost share amount calculated from the participant’s income as the participant’s cost share or participant liability
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for services being rendered. The cost share is reassessed no less than annually, sometimes more frequently.
The Intake and Evaluation Team is responsible for initiating the eligibility process by completion of the initial MAO Communicator and the responsible provider will assist the participants in setting an appointment at the local DFCS office subsequent to DBHDD Regional Director/Designee authorization to serve the participant. The Support Coordinator is responsible for assisting providers in the timely completion of subsequent MAO renewals annually.
A. Persons currently residing in ICF/MRs or SNFs and receiving Medicaid reimbursed services but not receiving SSI, and who have been approved by the DBHDD Regional Director/Designee and the DBHDD designated agency (through a DMA-6/DMA-6A) as meeting the service need criteria for the COMP are to comply with the following procedures.
1. The MAO Determination Form (see Appendix F), the application for Medical Assistance and the approved DMA-6/DMA-6A should be submitted by the responsible provider to the local DFCS office in the county where the participant resides.
2. The responsible provider must contact the DFCS office by telephone to schedule an appointment with the eligibility worker and to obtain additional information regarding the MAO determination process.
3. Participants that are currently community residents must be receiving a service that is a defined COMP service but is not reimbursed under the COMP.
B. Persons who live in the community, but who do not receive Medicaid services or SSI payments, but have been identified by the DBHDD Regional Director/Designee and DBHDD designated agency as meeting the service need criteria for the COMP waiver, must comply with the procedures outlined in Section 708.
C. The DHS Division of Family and Children Services (DFCS) is responsible for determining the amount of cost share.
D. MAO status must be reviewed annually according to DFCS guidelines. The Support Coordinator is responsible for this process.
712. Katie Beckett
TEFRA/Katie Beckett is an eligibility category that is defined as a Medicaid service made available to certain children with disabilities. It allows states to make Medicaid services available to these children who would not
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ordinarily be eligible for Social Security Income (SSI) benefits because of their parents’ income.
A. Eligibility Determination for Katie Beckett
States are allowed, at their option, to make Medicaid benefits available to children (age 18 or under) at home who qualify as individuals with disabilities under the Social Security Act provided when certain conditions are met. TEFRA/Katie Beckett is defined as a Medicaid service made available to certain children with disabilities. It allows states to make Medicaid services available to these children who would not ordinarily be eligible for Social Security Income (SSI) benefits because of their parents’ income.
In order for a child to establish Medicaid eligibility under this program, it must be determined that:
If the child was in a medical institution, he/she would be eligible for medical assistance under the State plan for Title XIX;
The child requires a level of care provided in a hospital, skilled nursing facility, or intermediate care facility (including an intermediate care facility for the mentally retarded);
 It is appropriate to provide the care to the child at home; and
 The estimated cost of caring for the child outside of the institution will not exceed the estimated cost of treating the child within the institution.
The criteria used to determine a child’s eligibility in the program is found in Title 42 Code of Federal Regulations. Medical necessity is not based on specific medical diagnoses. The reviewer must review all available medical information to determine whether services are medically necessary. In addition, the reviewer must determine whether the child requires the level of care provided in a hospital, nursing facility, or intermediate care facility (including an intermediate care facility for the mentally retarded).
Income qualifications for “Katie Beckett” are based solely on the child’s income, but a number of different factors are considered for approval. If approved, the same eligibility for health coverage will be available to the child as other Medicaid members. Eligibility for Medicaid under “Katie Beckett” will only be approved if ALL of the following conditions are met:
 Child is 18 years of age or younger
 Child meets the federal criteria for childhood disability
 Child meets an institutional level of care criteria
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 Even though the child may qualify for institutional care, it is appropriate to care for the child at home
 The Medicaid cost of caring for the child at home does not exceed the Medicaid cost of appropriate institutional care
B. Hearing and Appeals Process
Due process rights associated with the denial of admission to the “Katie Beckett” program are initially commenced after the level of care assessment by Georgia Medical Care Foundation (GMCF). Participants in the “Katie Beckett” program are subject to yearly assessments by GMCF. If the level of care assessment results in the denial of admission/continuation into the “Katie Beckett” program, GMCF will send an “Initial Denial of Admission/Continued Stay” to the family (with a copy to the DFCS care worker). This notice informs the parents of the reason for the denial and the administrative review rights. To ask for a hearing, the family must make the request in writing.
The Georgia Medical Care Foundation must receive requests for administrative review within the 30-day time limit. When counting days, the family has a two (2) day period for receipt of the letter. Then, beginning on the third day after the date of the letter, regardless of whether that day is a weekend or holiday, the count of the 30 days begins. However, if the 30th day falls on the weekend or holiday, the next full business day is counted as the 30th day. The family’s request must be submitted to the following address:
Department of Community Health
Legal Services Section
Two Peachtree Street, NW – 40th Floor
Atlanta, Georgia 30303-3159
713. Georgia Pediatric Program (GAPP)
The Georgia Pediatric Program (GAPP) is designed to serve eligible members under the age of 20 years 11 months based on medical necessity determination(s). Eligible pediatric members age out of the GAPP program on their 21st birthday. Members must be medically fragile with multiple systems diagnoses and require continuous skilled nursing care or skilled nursing care in shifts in order to be considered for services in the Georgia Pediatric Program. A portion of the services in the GAPP operates under a Home and Community-Based Waiver [1915(c)] approved by the Center for Medicare and Medicaid Services. This pediatric program allows the Department of Community Health to use Title XIX funds to provide approved services to medically fragile children in their homes and communities as well as in a ‘medical’ daycare setting as an alternative to placing children in a nursing care facility. Members served by the GAPP are
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required to meet the same level of care as for admission to a hospital or nursing facility and must be Medicaid eligible.
The Georgia Pediatric Program (GAPP) offers the following services:
A. In-Home Skilled Nursing Services
Skilled nursing care is provided in the home. Nurses caring for GAPP members must have a current background in pediatric critical care nursing within the past two years.
B. Medical Day Care Services
The medical day care service provides specialized pediatric services to medically fragile members, with a current Individualized Family Service Plan, (IFSP) in a licensed medical day care facility.
There are services that a person can not receive through GAPP while receiving those same services through the MR/DD waivers. Those services as follows:
 Community Living Supports Services (CLS)
 Community Residential Alternative Services (CRA)
 Natural Supports Training
If the MR/DD provider bills a claim for services that are provided by GAPP, the claim will deny for duplication. Claims that deny as a result of apparent duplication of services may be reviewed on a case-by-case basis. When the claim denies the providers may submit for review the denied TCN’s and address all submittals related to the TCN’s to the New Options Waiver and Comprehensive Supports Waiver (NOW/COMP) Program Specialist at the Department of Community Health at the following address:
Department of Community Health
New Options Waiver/Comprehensive Supports Waiver (NOW/COMP)
Program Specialist
2 Peachtree Street, NW, 37th Floor
Atlanta, Georgia 30303

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