Washington

Supported employment services provide individualized assistance and ongoing support to gain and/or maintain employment. These services are tailored to individual needs, interests, abilities, and promote career development. These services are provided in individual or group settings.

(1) Individual supported employment services include activities needed to sustain minimum wage pay or higher. These services are conducted in integrated business environments and include the following:

Creation of work opportunities through job development;

On-the-job training;

Training for the supervisor and/or peer workers to enable them to serve as natural supports to the participant on the job;

Modification of the work site tasks;

Employment retention and follow along support; and

Development of career and promotional opportunities.

(2) Group supported employment services are a step on the pathway toward gainful employment in an integrated setting and include:

The activities outlined in individual supported employment services;

Daily supervision by a qualified employment provider; and

Groupings of no more than eight workers with disabilities.

ARPA funds may be expended for ISE/GSE services (subminimum wages – Supports to participants to gain minimum wage employment). ARPA funds may be expended for ISE/GSE services and supports for high school transition students.

Teleservice is an available service delivery option if chosen by the participant or their guardian (if appropriate), appropriately meets the participant’s assessed needs as documented in their person-centered service plan and is provided within the scope of the service being delivered. This service may be received in person or via teleservice as identified in the PCSP. The waiver participant selects whether they want to receive the service in person, via teleservice, or a combination of both. Teleservice is a remote service delivery method where the service is delivered by the provider to the participant via phone, video, computer, or other technology and that the technology and data storage is HIPAA compliant.

Assurances:

The well-developed person-centered service plan will document the participant’s specific health and welfare needs and how each service selected by the participant contributes to meeting the participant’s needs and does not duplicate supports. The PCSP is the first resource that will ensure the health and safety of that participant. The PCSP identifies supervision and physical assistance support needs that inform the decision making of whether teleservice is appropriate for the client. The service authorization system (ProviderOne) has distinct and separate service codes for each waiver service and has built-in system logic that prevents duplication of services. DDA policies and procedures provide guidance to Case Resource Managers on developing effective person-centered service plans that identify services and service delivery methods that best meet their unique health and welfare needs without any duplication of services.

Teleservice will be the service delivery method for a particular service at the direction of the participant, not by the preference of the service provider. A teleservice agreement form will be required prior to authorization of teleservice delivery. This form will document the client’s desired level of in person to teleservice delivery and will remind clients that they can change their mind about frequency of teleservice delivery at any time. This agreement is intended to assist in clear and documented communication between the client, DDA, and the provider (in addition to the person-centered service plan) to ensure the client is the driver of the method of service delivery they receive. Case/Resource Managers will consult with their participants and family members, if appropriate, to develop the PCSP that includes the specific services and service delivery methods that best meets the participant’s unique health and welfare needs. Participants will document in their PCSPs what approximate percentage of service delivery they desire to receive via teleservice. The State is not mandating what percentage of time teleservice can be utilized, to ensure person-centered service planning and promote client choice. Participants who need hands on assistance/physical assistance will require careful person-centered planning coordinated by their Case/Resource Manager to determine if teleservice delivery is a practical or feasible option for the successful delivery of services. Voice-activated communication devices may be an option that some participants select to ensure that remote service delivery will work for them. Other clients may require in person service delivery only to ensure safety and

successful service delivery.

State will permit recording of live interactions with the participant via audio or video technology only at the request of the participant. Policy will include specific language around bathrooms and bedrooms. Video cameras are not permissible in bathrooms. If a client requests a video camera in their bedroom, there must be an approved exception to policy in place and the device must be situated in a way that does not compromise client privacy. Live 2-way interactions are always initiated by the participant. The participant can initiate the service when needed and turn off the equipment when not needed.

The State believes teleservice will be an important component in a well-developed and balanced PCSP that focuses on the specific wants and health and welfare needs of the participant. Experience during the COVID-19 pandemic has shown that teleservice can facilitate community integration in a person-centered way. Washingtonians in the broader community utilize both technology-supported remote and in-person community service environments, and the proposed change in waiver services give waiver clients the same opportunity to participate in their community as everyone else.

Providers employing teleservice delivery will be guided by Policy and will continue to follow all service protocols and report any concerns they have to the Case/Resource Manager and make any appropriate incident reports. The provider delivering services remotely will be responsible for using an approved delivery platform that the client is able and willing to use and will provide basic technical assistance as necessary during their service delivery (device on and off, volume control, etc.). If a client is unable to use technology for teleservice delivery, then in person service delivery would be the appropriate service delivery mechanism for the client and this would be discussed during the person-centered planning meeting.

The participant utilizing the services remote support and each person who shares a residence with that participant will be fully informed of what remote service delivery entails including, but not limited to: (A) that remote staff may observe their activities if they are within the view of the participant’s video communication device; (B) that the participant decides where in the residence the remote support will occur; (C) whether or not recordings of sessions will be made (the participant’s Case/Resource Manager will document in the PCSP); (D) that the participant will control the operation of the communication device, when it is turned on and when it is turned off. Please note that this service is not approved for clients receiving residential habilitation services.

The state will use the CARE assessment to determine client need for technology and remote support through the person-centered planning process. If a client requests that a video camera be placed in their home to use in the provision of remote support, there must be an exception to policy (ETP) in place with justification as to why the camera is needed instead of a simple sensor. The ETP must be approved and documented in the client’s file before the device is installed and prior to the service being authorized. Adds that services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources. Please clarify whether individuals will not lose access to this service.

The participant utilizing the services remote support and each person who shares a residence with that participant will be fully informed of what remote service delivery entails including, but not limited to: (A) that remote staff may observe their activities if they are within the view of the participant’s video communication device; (B) that the participant decides where in the residence the remote support will occur; (C) whether or not recordings of sessions will be made (the participant’s Case/Resource Manager will document in the PCSP); (D) that the participant will control the operation of the communication device, when it is turned on and when it is turned off. Please note that this service is not approved for clients receiving residential habilitation services.

The state will use the CARE assessment to determine client need for technology and remote support through the person-centered planning process. If a client requests that a video camera be placed in their home to use in the provision of remote support, there must be an exception to policy (ETP) in place with justification as to why the camera is needed instead of a simple sensor. The ETP must be approved and documented in the client’s file before the device is installed and prior to the service being authorized. Adds that services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources. Please clarify whether individuals will not lose access to this service.

Limits on the amount, frequency or duration of this service:

Limits to Individual supported employment/group supported employment services:

Supported employment services are only available to individuals who do not have access to services available under the Rehabilitation Act of 1973, or the Individuals with Disabilities Education Improvement Act of 2004.

Payment will be made only for the adaptations, supervision, training and support with the activities of daily living a person requires as a result of his/her/their disabilities.

Payment is excluded for the supervisory activities rendered as a normal part of the business setting.

An individual can be authorized to receive supported employment services if he/she/they receives community inclusion services.

DDA contracts with the counties for expanded habilitation (including supported employment) services. The counties in turn contract provide services directly or contract with local providers for expanded habilitation services. The DDA reimburses the counties on a monthly basis for the cost of all services provided within the county. The counties in turn reimburse vendors for services provided based on the negotiated unit rates contained in their contracts with the vendors.

Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DCYF) or from Title IV-E of the Social Security Act or from other sources.

The amount of employment support will be based on the following items:

Client Employment Acuity is determined through the DDA assessment. Acuity reflects conditions typically related to the individual’s disability that are not likely to change, and are generally not impacted by outside factors.

Client acuity is determined as either High, Medium or Low.

Support level High:

Requires support in the community at all times to maintain health and safety.

Experiences significant barriers to employment or community participation.

Requires frequent supervision, training, or full physical assistance with community activities most or all of the time.

Support Level Medium:

Independent in the community some of the time and requires moderate support to obtain or maintain employment.

Able to maintain health and safety in the community for short periods of time.

May need some supervision, training, or partial physical assistance with community activities.

May need regular monitoring or prompting to perform tasks.

Support Level Low:

Generally independent in the community and requires minimal support to obtain or maintain employment.

Able to communicate with others effectively and can maintain personal health and safety most of the time without supervision.

May be able to independently transport self in the community and does not require physical assistance in community activities.

Able to perform tasks with minimal or occasional monitoring or prompting.

Employment Algorithm Components

A combination of the following acuity scales and assessment items provide the most accurate determination of a person’s employment acuity level:

• Activities of Daily Living

• Behavioral Support

• Interpersonal Support

• Environmental Support

• Level of Monitoring

• Employment Support

• Completing tasks with acceptable speed

• Completing tasks with acceptable quality

• Medical Support

• Seizure support

Client work history is determined by looking back over a 12-month period and is categorized into three main groupings:

Continuous Employment – Received wages 9 consecutive month of the 12-month period

Intermittent/Recent Employment – Received wages in at least one month of the 12-month period

Not employed or unemployed last 12 months – No wages reported as earned during a 12-month period (subminimum wages fall to not employed)

The range of support hours the client receives will be dependent upon the individual’s Employment Acuity, work history and phases of employment. DDA uses the following table to determine the number of monthly hours of individual employment service that can be authorized annually in the PCSP to permit flexibility in any given month as situations change on the job site:

Employment Employment Then Service May receive up to this many

Support Level: Status is: Level is: supported employment service

hours per month:

None Working A 0

Not Working B 0

Low Working C 4

Not Working D 7

Medium Working E 7

Not Working F 9

High Working G 11

Not Working H 12

Depending on factors detailed in the county employment plan, DDA may authorize additional hours of employment service:

May authorize up to this many

Employment Employment Employment additional hours of supp.

Service Level: Support Level: Status: employment service:

A None Working 0

B None Not Working 0

C Low Working 5

D Low Not Working 7

E Medium Working 5

F Medium Not Working 7

G High Working 12

H High Not Working 5

In rare instances, an exception to rule (ETR) may be granted to adjust support hours to meet the unique needs of a waiver participant.

Limits: Short term enhanced supports are available if a person is beginning a new job, has planned or expected change in job or job tasks, unexpected change in their condition or support is needed to maintain employment. These are short term hours determined by the county and employment vendor and may be authorized for a maximum of 6 months.

Community Inclusion is an individualized service that provides clients with opportunities to engage in community-based activities that support socialization, contribution, education, recreation and personal development for the purpose of:

(1) Building and strengthening relationships with others in the local community who are not paid to be with the person.

(2) Learning, practicing and applying skills that promote greater independence and inclusion in their community.

Limits on the amount, frequency or duration of this service:

These services are available for individuals for whom a determination has been made that employment is currently not appropriate or who have received employment-related services for at least nine months and elect to receive community inclusion services.

An individual can be authorized to receive community inclusion services if they receive supported employment services.

Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources.

DDA contracts with the counties for day habilitation and expanded habilitation services. The counties in turn provide services directly or contract with local providers for day habilitation and expanded habilitation services. DDA reimburses the counties on a monthly basis for the cost of all services provided within the county. The counties in turn reimburse vendors for services provided based on the negotiated unit rates contained in their contracts with the vendors.

The amount of Community Inclusion services the waiver participant will be eligible for will be based on the individual’s assessed need. The DDA CRM will use the DDA assessment to determine the individual’s community inclusion acuity level. The Community Inclusion acuity level utilizes the Support Intensity Scale subscales of :

1. Home Living (Part A)

2. Community Living (Part B)

3. Lifelong Learning(Part C)

4. Employment Activities (Part D)

5. Health and Safety Activities (Part E)

6. Social Activities (Part F)

Based on the individual/legal guardian and respondents’ responses the SIS score will be categorized into seven support levels which will have an associated number of hours of support the individual can expect to receive as identified in WAC 388-828.

Client Profile Level The number of hours the individual

Community Inclusion may receive each month is:

0-9 Percentile A Up through 3.0 hours

10-19 Percentile B Up through 6.0 hours

20-29 Percentile C Up through 9.0 hours

30-44 Percentile D Up through 12.0 hours

45-59 Percentile E Up through 15.0 hours

60-74 Percentile F Up through 18.0 hours

75-100 Percentile G Up through 20.0 hours

Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to from the Department of Children, Youth, and Families (DYYF) or from Title IV-E of the Social Security Act or from other sources.

Individualized technical assistance is short term professional assessment and consultation to the employment provider or community inclusion provider and/or waiver participant to identify, address, and resolve barriers to employment or barriers to community inclusion. This is in addition to supports received through supported employment or community inclusion services for individuals who have not yet achieved their goal.

Teleservice is an available service delivery option if chosen by the participant or their guardian (if appropriate), appropriately meets the participant’s assessed needs as documented in their person-centered service plan and is provided within the scope of the service being delivered. This service may be received in person or via teleservice as identified in the PCSP. The waiver participant selects whether they want to receive the service in person, via teleservice, or a combination of both. Teleservice is a remote service delivery method where the service is delivered by the provider to the participant via phone, video, computer, or other technology and that the technology and data storage is HIPAA compliant.

Assurances: The well-developed person-centered service plan will document the participant’s specific health and welfare needs and how each service selected by the participant contributes to meeting the participant’s needs and does not duplicate supports. The PCSP is the first resource that will ensure the health and safety of that participant. The PCSP identifies supervision and physical assistance support needs that inform the decision making of whether teleservice is appropriate for the client. The service authorization system (ProviderOne) has distinct and separate service codes for each waiver service and has built-in system logic that prevents duplication of services. DDA policies and procedures provide guidance to Case Resource Managers on developing effective person-centered service plans that identify services and service delivery methods that best meet their unique health and welfare needs without any duplication of services.

Teleservice will be the service delivery method for a particular service at the direction of the participant, not by the preference of the service provider. A teleservice agreement form will be required prior to authorization of teleservice delivery. This form will document the client’s desired level of in person to teleservice delivery and will remind clients that they can change their mind about frequency of teleservice delivery at any time. This agreement is intended to assist in clear and documented communication between the client, DDA, and the provider (in addition to the person-centered service plan) to ensure the client is the driver of the method of service delivery they receive. Case/Resource Managers will consult with their participants and family members, if appropriate, to develop the PCSP that includes the specific services and service delivery methods that best meets the participant’s unique health and welfare needs. Participants will document in their PCSPs what approximate percentage of service delivery they desire to receive via teleservice. The State is not mandating what percentage of time teleservice can be utilized, to ensure person-centered service planning and promote client choice. Participants who need hands on assistance/physical assistance will require careful person-centered planning coordinated by their Case/Resource Manager to determine if teleservice delivery is a practical or feasible option for the successful delivery of services. Voice-activated communication devices may be an option that some participants select to ensure that remote service delivery will work for them. Other clients may require in person service delivery only to ensure safety and successful service delivery.

State will permit recording of live interactions with the participant via audio or video technology only at the request of the participant. Policy will include specific language around bathrooms and bedrooms. Video cameras are not permissible in bathrooms. If a client requests a video camera in their bedroom, there must be an approved exception to policy in place and the device must be situated in a way that does not compromise client privacy. Live 2-way interactions are always initiated by the participant. The participant can initiate the service when needed and turn off the equipment when not needed.

The State believes teleservice will be an important component in a well-developed and balanced PCSP that focuses on the specific wants and health and welfare needs of the participant. Experience during the COVID-19 pandemic has shown that teleservice can facilitate community integration in a person-centered way. Washingtonians in the broader community utilize both technology-supported remote and in-person community service environments, and the proposed change in waiver services give waiver clients the same opportunity to participate in their community as everyone else.

Providers employing teleservice delivery will be guided by Policy and will continue to follow all service protocols and report any concerns they have to the Case/Resource Manager and make any appropriate incident reports. The provider delivering services remotely will be responsible for using an approved delivery platform that the client is able and willing to use and will provide basic technical assistance as necessary during their service delivery (device on and off, volume control, etc.). If a client is unable to use technology for teleservice delivery, then in person service delivery would be the appropriate service delivery mechanism for the client and this would be discussed during the person-centered planning meeting.

• The participant utilizing the services remote support and each person who shares a residence with that participant will be fully informed of what remote service delivery entails including, but not limited to: (A) that remote staff may observe their activities if they are within the view of the participant’s video communication device; (B) that the participant decides where in the residence the remote support will occur; (C) whether or not recordings of sessions will be made (the participant’s Case/Resource Manager will document in the PCSP); (D) that the participant will control the operation of the communication device, when it is turned on and when it is turned off. Please note that this service is not approved for clients receiving residential habilitation services.

• The state will use the CARE assessment to determine client need for technology and remote support through the person-centered planning process. If a client requests that a video camera be placed in their home to use in the provision of remote support, there must be an exception to policy (ETP) in place with justification as to why the camera is needed instead of a simple sensor. The ETP must be approved and documented in the client’s file before the device is installed and prior to the service being authorized. Adds that services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources. Please clarify whether individuals will not lose access to this service.

Limits on the amount, frequency or duration of this service:

1) Individualized technical assistance may be authorized for up to 6 months of the plan year.

2) The individual must be receiving supported employment or community inclusion unless otherwise approved by the administration.

3) Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources.

Items, equipment, or product systems, not related to a client’s physical health, that are used to increase, maintain, or improve functional capabilities of waiver participants, increase safety, or increase social engagement in the community, as well as supports to directly assist the participant and caregivers to select, acquire, and use the technology. Services are provided when outside the scope of Medicaid State Plan and EPSDT benefits. Assistive technology includes:

(1) The evaluation of the needs of the waiver participant, including a functional evaluation in their customary environment;

(2) Purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices;

(3) Selecting, designing, fitting, customizing, adapting, applying, retaining, repairing, or replacing assistive technology devices;

(4) Coordinating and using other therapies, interventions, or services with assistive technology devices, such as those associated with existing education and rehabilitation plans and programs;

(5) Training or technical assistance for the participant and/or if appropriate, the child’s or adult’s family; and

(6) Training or technical assistance for professionals, including individuals providing education and rehabilitation services, employers, or other individuals who provide services to, employ, or are otherwise involved in the assistive technology related life functions of children or adults with disabilities.

ARPA funds may be expended for assistive technology items and not internet connectivity (remote technology support).

Teleservice is an available service delivery option if chosen by the participant or their guardian (if appropriate), appropriately meets the participant’s assessed needs as documented in their person-centered service plan and is provided within the scope of the service being delivered. This service may be received in person or via teleservice as identified in the PCSP. The waiver participant selects whether they want to receive the service in person, via teleservice, or a combination of both. Teleservice is a remote service delivery method where the service is delivered by the provider to the participant via phone, video, computer, or other technology and that the technology and data storage is HIPAA compliant.

Assurances: The well-developed person-centered service plan will document the participant’s specific health and welfare needs and how each service selected by the participant contributes to meeting the participant’s needs and does not duplicate supports. The PCSP is the first resource that will ensure the health and safety of that participant. The PCSP identifies supervision and physical assistance support needs that inform the decision making of whether teleservice is appropriate for the client. The service authorization system (ProviderOne) has distinct and separate service codes for each waiver service and has built-in system logic that prevents duplication of services. DDA policies and procedures provide guidance to Case Resource Managers on developing effective person-centered service plans that identify services and service delivery methods that best meet their unique health and welfare needs without any duplication of services.

Teleservice will be the service delivery method for a particular service at the direction of the participant, not by the preference of the service provider. A teleservice agreement form will be required prior to authorization of teleservice delivery. This form will document the client’s desired level of in person to teleservice delivery and will remind clients that they can change their mind about frequency of teleservice delivery at any time. This agreement is intended to assist in clear and documented communication between the client, DDA, and the provider (in addition to the person-centered service plan) to ensure the client is the driver of the method of service delivery they receive. Case/Resource Managers will consult with their participants and family members, if appropriate, to develop the PCSP that includes the specific services and service delivery methods that best meets the participant’s unique health and welfare needs. Participants will document in their PCSPs what approximate percentage of service delivery they desire to receive via teleservice. The State is not mandating what percentage of time teleservice can be utilized, to ensure person-centered service planning and promote client choice. Participants who need hands on assistance/physical assistance will require careful person-centered planning coordinated by their Case/Resource Manager to determine if teleservice delivery is a practical or feasible option for the successful delivery of services. Voice-activated communication devices may be an option that some participants select to ensure that remote service delivery will work for them. Other clients may require in person service delivery only to ensure safety and successful service delivery.

State will permit recording of live interactions with the participant via audio or video technology only at the request of the participant. Policy will include specific language around bathrooms and bedrooms. Video cameras are not permissible in bathrooms. If a client requests a video camera in their bedroom, there must be an approved exception to policy in place and the device must be situated in a way that does not compromise client privacy. Live 2-way interactions are always initiated by the participant. The participant can initiate the service when needed and turn off the equipment when not needed.

The State believes teleservice will be an important component in a well-developed and balanced PCSP that focuses on the specific wants and health and welfare needs of the participant. Experience during the COVID-19 pandemic has shown that teleservice can facilitate community integration in a person-centered way. Washingtonians in the broader community utilize both technology-supported remote and in-person community service environments, and the proposed change in waiver services give waiver clients the same opportunity to participate in their community as everyone else.

Providers employing teleservice delivery will be guided by Policy and will continue to follow all service protocols and report any concerns they have to the Case/Resource Manager and make any appropriate incident reports. The provider delivering services remotely will be responsible for using an approved delivery platform that the client is able and willing to use and will provide basic technical assistance as necessary during their service delivery (device on and off, volume control, etc.). If a client is unable to use technology for teleservice delivery, then in person service delivery would be the appropriate service delivery mechanism for the client and this would be discussed during the person-centered planning meeting.

• The participant utilizing the services remote support and each person who shares a residence with that participant will be fully informed of what remote service delivery entails including, but not limited to: (A) that remote staff may observe their activities if they are within the view of the participant’s video communication device; (B) that the participant decides where in the residence the remote support will occur; (C) whether or not recordings of sessions will be made (the participant’s Case/Resource Manager will document in the PCSP); (D) that the participant will control the operation of the communication device, when it is turned on and when it is turned off. Please note that this service is not approved for clients receiving residential habilitation services.

• The state will use the CARE assessment to determine client need for technology and remote support through the person-centered planning process. If a client requests that a video camera be placed in their home to use in the provision of remote support, there must be an exception to policy (ETP) in place with justification as to why the camera is needed instead of a simple sensor. The ETP must be approved and documented in the client’s file before the device is installed and prior to the service being authorized. Adds that services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources. Please clarify whether individuals will not lose access to this service.

Limits on the amount, frequency or duration of this service:

(1) Assistive technology is limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

(2) Clinical and support needs for assistive technology are identified in the waiver participant’s DDA person-centered assessment and documented in the person-centered service plan.

(3) Assistive technology may be authorized as a waiver service only after Medicaid, EPSDT, and any other private health insurance plan benefits have been exhausted by obtaining an initial denial of funding or information showing that the technology is not covered by Medicaid or private insurance.

(4) The Department does not pay for technology determined by DSHS to be experimental.

(5) The Department requires a written recommendation regarding her/his/their need for the technology. This recommendation must take into account that: (a)The professional has personal knowledge of and experience with the requested assistive technology; and (b)The professional has recently examined the waiver participant, reviewed her/his/their medical records when applicable, and conducted a functional evaluation.

(6) The Department may require a written second opinion from a department selected professional.

(7) Assistive technology requires prior approval by the DDA regional administrator or designee when $550 or more.

(8) The waiver participant’s Basic Plus Waiver aggregate and emergency funding amounts limit the amount of assistive technology service s/he is authorized to receive as indicated in Appendix C-4.a.

(9) Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to from the Department of Children, Youth, and Families (DCYF) or from Title IV-E of the Social Security Act or from other sources.

Transportation services are also available under this waiver to support access to community activities as identified through the individual’s person-centered plan.

Supported employment services provide individualized assistance and ongoing support to gain and/or maintain employment. These services are tailored to individual needs, interests, abilities, and promote career development. These services are provided in individual or group settings.

(1) Individual supported employment services include activities needed to sustain minimum wage pay or higher. These services are conducted in integrated business environments and include the following:

Creation of work opportunities through job development;

On-the-job training;

Training for the supervisor and/or peer workers to enable them to serve as natural supports to the participant on the job;

Modification of the work site tasks;

Employment retention and follow along support; and (f) Development of career and promotional opportunities.

(2) Group supported employment services are a step on the pathway toward gainful employment in an integrated setting and include:

The activities outlined in individual supported employment services;

Daily supervision by a qualified employment provider; and

Groupings of no more than eight workers with disabilities.

ARPA funds may be expended for ISE/GSE services (subminimum wages – Supports to participants to gain minimum wage employment).

Teleservice is an available service delivery option if chosen by the participant or their guardian (if appropriate), appropriately meets the participant’s assessed needs as documented in their person-centered service plan and is provided within the scope of the service being delivered. This service may be received in person or via teleservice as identified in the PCSP. The waiver participant selects whether they want to receive the service in person, via teleservice, or a combination of both. Teleservice is a remote service delivery method where the service is delivered by the provider to the participant via phone, video, computer, or other technology and that the technology and data storage is HIPAA compliant.

Assurances:

The well-developed person-centered service plan will document the participant’s specific health and welfare needs and how each service selected by the participant contributes to meeting the participant’s needs and does not duplicate supports. The PCSP is the first resource that will ensure the health and safety of that participant. The PCSP identifies supervision and physical assistance support needs that inform the decision making of whether teleservice is appropriate for the client. The service authorization system (ProviderOne) has distinct and separate service codes for each waiver service and has built-in system logic that prevents duplication of services. DDA policies and procedures provide guidance to Case Resource Managers on developing effective person-centered service plans that identify services and service delivery methods that best meet their unique health and welfare needs without any duplication of services.

Teleservice will be the service delivery method for a particular service at the direction of the participant, not by the preference of the service provider. A teleservice agreement form will be required prior to authorization of teleservice delivery. This form will document the client’s desired level of in person to teleservice delivery and will remind clients that they can change their mind about frequency of teleservice delivery at any time. This agreement is intended to assist in clear and documented communication between the client, DDA, and the provider (in addition to the person-centered service plan) to ensure the client is the driver of the method of service delivery they receive. Case/Resource Managers will consult with their participants and family members, if appropriate, to develop the PCSP that includes the specific services and service delivery methods that best meets the participant’s unique health and welfare needs. Participants will document in their PCSPs what approximate percentage of service delivery they desire to receive via teleservice. The State is not mandating what percentage of time teleservice can be utilized, to ensure person-centered service planning and promote client choice. Participants who need hands on assistance/physical assistance will require careful person-centered planning coordinated by their Case/Resource Manager to determine if teleservice delivery is a practical or feasible option for the successful delivery of services. Voice-activated communication devices may be an option that some participants select to ensure that remote service delivery will work for them. Other clients may require in person service delivery only to ensure safety and successful service delivery.

State will permit recording of live interactions with the participant via audio or video technology only at the request of the participant. Policy will include specific language around bathrooms and bedrooms. Video cameras are not permissible in bathrooms. If a client requests a video camera in their bedroom, there must be an approved exception to policy in place and the device must be situated in a way that does not compromise client privacy. Live 2-way interactions are always initiated by the participant. The participant can initiate the service when needed and turn off the equipment when not needed.

The State believes teleservice will be an important component in a well-developed and balanced PCSP that focuses on the specific wants and health and welfare needs of the participant. Experience during the COVID-19 pandemic has shown that teleservice can facilitate community integration in a person-centered way. Washingtonians in the broader community utilize both technology-supported remote and in-person community service environments, and the proposed change in waiver services give waiver clients the same opportunity to participate in their community as everyone else.

Providers employing teleservice delivery will be guided by Policy and will continue to follow all service protocols and report any concerns they have to the Case/Resource Manager and make any appropriate incident reports. The provider delivering services remotely will be responsible for using an approved delivery platform that the client is able and willing to use and will provide basic technical assistance as necessary during their service delivery (device on and off, volume control, etc.). If a client is unable to use technology for teleservice delivery, then in person service delivery would be the appropriate service delivery mechanism for the client and this would be discussed during the person-centered planning meeting.

The participant utilizing the services remote support and each person who shares a residence with that participant will be fully informed of what remote service delivery entails including, but not limited to: (A) that remote staff may observe their activities if they are within the view of the participant’s video communication device; (B) that the participant decides where in the residence the remote support will occur; (C) whether or not recordings of sessions will be made (the participant’s Case/Resource Manager will document in the PCSP); (D) that the participant will control the operation of the communication device, when it is turned on and when it is turned off. Please note that this service is not approved for clients receiving residential habilitation services.

The state will use the CARE assessment to determine client need for technology and remote support through the person-centered planning process. If a client requests that a video camera be placed in their home to use in the provision of remote support, there must be an exception to policy (ETP) in place with justification as to why the camera is needed instead of a simple sensor. The ETP must be approved and documented in the client’s file before the device is installed and prior to the service being authorized. Adds that services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources. Please clarify whether individuals will not lose access to this service.

Limits on the amount, frequency or duration of this service:

Limits to Individual supported employment/group supported employment services: Supported employment services are only available to individuals who do not have access to services available under the Rehabilitation Act of 1973, or the Individuals with Disabilities Education Improvement Act of 2004.

• Payment will be made only for the adaptations, supervision, training and support with the activities of daily living a person requires as a result of his/her disabilities.

• Payment is excluded for the supervisory activities rendered as a normal part of the business setting.

DDA contracts with the counties for expanded habilitation (including supported employment) services. The counties in turn contract provide services directly or contract with local providers for expanded habilitation services. The DDA reimburses the counties on a monthly basis for the cost of all services provided within the county. The counties in turn reimburse vendors for services provided based on the negotiated unit rates contained in their contracts with the vendors.

The amount of employment support will be based on the following items:

Client Employment Acuity is determined through the DDA assessment. Acuity reflects conditions typically related to the individual’s disability that are not likely to change, and are generally not impacted by outside factors.

Client acuity is determined as either High, Medium or Low.

Support level High

Requires support in the community at all times to maintain health and safety.

Experiences significant barriers to employment or community participation.

Requires frequent supervision, training, or full physical assistance with community activities most or all of the time.

Support Level Medium

Independent in the community some of the time and requires moderate support to obtain or maintain employment.

Able to maintain health and safety in the community for short periods of time.

May need some supervision, training, or partial physical assistance with community activities.

May need regular monitoring or prompting to perform tasks.

Support Level Low

Generally independent in the community and requires minimal support to obtain or maintain employment.

Able to communicate with others effectively and can maintain personal health and safety most of the time without supervision.

May be able to independently transport self in the community and does not require physical assistance in community activities.

Able to perform tasks with minimal or occasional monitoring or prompting.

Employment Algorithm Components

A combination of the following acuity scales and assessment items provided the most accurate determination of a person’s employment acuity level:

• Activities of Daily Living

• Behavioral Support

• Interpersonal Support

• Environmental Support

• Level of Monitoring

• Employment Support

• Completing tasks with acceptable speed

• Seizure support

Client work history is determined by looking back over a 12-month period and is categorized into three main groupings:

Continuous Employment Received wages 9 consecutive month of the 12-month period

Intermittent/Recent Employment – Received wages in at least one month of the 12-month period

Not employed or unemployed last 12 months – No wages reported as earned during a 12-month period (subminimum wages fall to not employed)

The range of support hours the client receives will be dependent upon the individual’s Employment Acuity, work history and phases of employment. DDA uses the following table to determine the number of monthly hours of individual employment service that can be authorized annually in the PCSP to permit flexibility in any given month as situations change on the job site:

Employment Employment Then Service May receive up to this many

Support Level: Status is: Level is: supported employment service

hours per month:

None Working A 0

Not Working B 0

Low Working C 4

Not Working D 7

Medium Working E 7

Not Working F 9

High Working G 11

Not Working H 12

Depending on factors detailed in the county employment plan, DDA may authorize additional hours of employment service:

May authorize up to this many

Employment Employment Employment additional hours of supp.

Service Level: Support Level: Status: employment service:

A None Working 0

B None Not Working 0

C Low Working 5

D Low Not Working 7

E Medium Working 5

F Medium Not Working 7

G High Working 12

H High Not Working 5

In rare instances, an exception to rule (ETR) may be granted to adjust support hours to meet the unique needs of a waiver participant.

Limits: Short term enhanced supports are available if a person is beginning a new job, has planned or expected change in job or job tasks, unexpected change in their condition or support is needed to maintain employment. These are short term hours determined by the county and employment vendor and may be authorized for a maximum of 6 months.

Individualized technical assistance is short term professional assessment and consultation to the employment provider and/or waiver participant to identify, address, and resolve barriers to employment. This is in addition to supports received through supported employment for individuals who have not yet achieved their goal.

Teleservice is an available service delivery option if chosen by the participant or their guardian (if appropriate), appropriately meets the participant’s assessed needs as documented in their person-centered service plan and is provided within the scope of the service being delivered. This service may be received in person or via teleservice as identified in the PCSP. The waiver participant selects whether they want to receive the service in person, via teleservice, or a combination of both. Teleservice is a remote service delivery method where the service is delivered by the provider to the participant via phone, video, computer, or other technology and that the technology and data storage is HIPAA compliant.

Assurances: The well-developed person-centered service plan will document the participant’s specific health and welfare needs and how each service selected by the participant contributes to meeting the participant’s needs and does not duplicate supports. The PCSP is the first resource that will ensure the health and safety of that participant. The PCSP identifies supervision and physical assistance support needs that inform the decision making of whether teleservice is appropriate for the client. The service authorization system (ProviderOne) has distinct and separate service codes for each waiver service and has built-in system logic that prevents duplication of services. DDA policies and procedures provide guidance to Case Resource Managers on developing effective person-centered service plans that identify services and service delivery methods that best meet their unique health and welfare needs without any duplication of services.

Teleservice will be the service delivery method for a particular service at the direction of the participant, not by the preference of the service provider. A teleservice agreement form will be required prior to authorization of teleservice delivery. This form will document the client’s desired level of in person to teleservice delivery and will remind clients that they can change their mind about frequency of teleservice delivery at any time. This agreement is intended to assist in clear and documented communication between the client, DDA, and the provider (in addition to the person-centered service plan) to ensure the client is the driver of the method of service delivery they receive. Case/Resource Managers will consult with their participants and family members, if appropriate, to develop the PCSP that includes the specific services and service delivery methods that best meets the participant’s unique health and welfare needs. Participants will document in their PCSPs what approximate percentage of service delivery they desire to receive via teleservice. The State is not mandating what percentage of time teleservice can be utilized, to ensure person-centered service planning and promote client choice. Participants who need hands on assistance/physical assistance will require careful person-centered planning coordinated by their Case/Resource Manager to determine if teleservice delivery is a practical or feasible option for the successful delivery of services. Voice-activated communication devices may be an option that some participants select to ensure that remote service delivery will work for them. Other clients may require in person service delivery only to ensure safety and successful service delivery.

State will permit recording of live interactions with the participant via audio or video technology only at the request of the participant. Policy will include specific language around bathrooms and bedrooms. Video cameras are not permissible in bathrooms. If a client requests a video camera in their bedroom, there must be an approved exception to policy in place and the device must be situated in a way that does not compromise client privacy. Live 2-way interactions are always initiated by the participant. The participant can initiate the service when needed and turn off the equipment when not needed.

The State believes teleservice will be an important component in a well-developed and balanced PCSP that focuses on the specific wants and health and welfare needs of the participant. Experience during the COVID-19 pandemic has shown that teleservice can facilitate community integration in a person-centered way. Washingtonians in the broader community utilize both technology-supported remote and in-person community service environments, and the proposed change in waiver services give waiver clients the same opportunity to participate in their community as everyone else.

Providers employing teleservice delivery will be guided by Policy and will continue to follow all service protocols and report any concerns they have to the Case/Resource Manager and make any appropriate incident reports. The provider delivering services remotely will be responsible for using an approved delivery platform that the client is able and willing to use and will provide basic technical assistance as necessary during their service delivery (device on and off, volume control, etc.). If a client is unable to use technology for teleservice delivery, then in person service delivery would be the appropriate service delivery mechanism for the client and this would be discussed during the person-centered planning meeting.

• The participant utilizing the services remote support and each person who shares a residence with that participant

will be fully informed of what remote service delivery entails including, but not limited to: (A) that remote staff may observe their activities if they are within the view of the participant’s video communication device; (B) that the participant decides where in the residence the remote support will occur; (C) whether or not recordings of sessions will be made (the participant’s Case/Resource Manager will document in the PCSP); (D) that the participant will control the operation of the communication device, when it is turned on and when it is turned off. Please note that this service is not approved for clients receiving residential habilitation services.

• The state will use the CARE assessment to determine client need for technology and remote support through the person-centered planning process. If a client requests that a video camera be placed in their home to use in the provision of remote support, there must be an exception to policy (ETP) in place with justification as to why the camera is needed instead of a simple sensor. The ETP must be approved and documented in the client’s file before the device is installed and prior to the service being authorized. Adds that services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources. Please clarify whether individuals will not lose access to this service.

Limits on the amount, frequency or duration of this service:

1) Individualized technical assistance may be authorized for up to 6 months of the plan year.

2) The individual must be receiving supported employment unless otherwise approved by the administration.

Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to from the Department of Children, Youth, and Families (DCYF) or from Title IV-E of the Social Security Act or from other sources.

Items, equipment, or product systems, not related to a client’s physical health, that are used to increase, maintain, or improve functional capabilities of waiver participants, increase safety, or facilitate social communication as well as supports to directly assist the participant and caregivers to select, acquire, and use the technology. Services are provided when outside the scope of Medicaid State Plan and EPSDT benefits. Technology includes:

(1) The evaluation of the needs of the waiver participant, including a functional evaluation in their customary environment;

(2) Purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices;

(3) Selecting, designing, fitting, customizing, adapting, applying, retaining, repairing, or replacing assistive technology devices;

(4) Coordinating and using other therapies, interventions, or services with assistive technology devices, such as those associated with existing education and rehabilitation plans and programs;

(5) Training or technical assistance for the participant and/or if appropriate, the child’s or adult’s family; and

(6) Training or technical assistance for professionals, including individuals providing education and rehabilitation services, employers, or other individuals who provide services to, employ, or are otherwise involved in the assistive technology related life functions of children or adults with disabilities.

(7) Assistive Technology is available when a participant requires basic technology to receive waiver-funded services via teleservice. Technology includes tablets, switches, telephones, or other devices necessary for the client to receive teleservice from the waiver service provider.

ARPA funds may be expended for assistive technology items and not internet connectivity (remote technology support).

Teleservice is an available service delivery option if chosen by the participant or their guardian (if appropriate), appropriately meets the participant’s assessed needs as documented in their person-centered service plan and is provided within the scope of the service being delivered. This service may be received in person or via teleservice as identified in the PCSP. The waiver participant selects whether they want to receive the service in person, via teleservice, or a combination of both. Teleservice is a remote service delivery method where the service is delivered by the provider to the participant via phone, video, computer, or other technology and that the technology and data storage is HIPAA compliant.

Assurances: The well-developed person-centered service plan will document the participant’s specific health and welfare needs and how each service selected by the participant contributes to meeting the participant’s needs and does not duplicate supports. The PCSP is the first resource that will ensure the health and safety of that participant. The PCSP identifies supervision and physical assistance support needs that inform the decision making of whether teleservice is appropriate for the client. The service authorization system (ProviderOne) has distinct and separate service codes for each waiver service and has built-in system logic that prevents duplication of services. DDA policies and procedures provide guidance to Case Resource Managers on developing effective person-centered service plans that identify services and service delivery methods that best meet their unique health and welfare needs without any duplication of services.

Teleservice will be the service delivery method for a particular service at the direction of the participant, not by the preference of the service provider. A teleservice agreement form will be required prior to authorization of teleservice delivery. This form will document the client’s desired level of in person to teleservice delivery and will remind clients that they can change their mind about frequency of teleservice delivery at any time. This agreement is intended to assist in clear and documented communication between the client, DDA, and the provider (in addition to the person-centered service plan) to ensure the client is the driver of the method of service delivery they receive. Case/Resource Managers will consult with their participants and family members, if appropriate, to develop the PCSP that includes the specific services and service delivery methods that best meets the participant’s unique health and welfare needs. Participants will document in their PCSPs what approximate percentage of service delivery they desire to receive via teleservice. The State is not mandating what percentage of time teleservice can be utilized, to ensure person-centered service planning and promote client choice. Participants who need hands on assistance/physical assistance will require careful person-centered planning coordinated by their Case/Resource Manager to determine if teleservice delivery is a practical or feasible option for the successful delivery of services. Voice-activated communication devices may be an option that some participants select to ensure that remote service delivery will work for them. Other clients may require in person service delivery only to ensure safety and successful service delivery.

State will permit recording of live interactions with the participant via audio or video technology only at the request of the participant. Policy will include specific language around bathrooms and bedrooms. Video cameras are not permissible in bathrooms. If a client requests a video camera in their bedroom, there must be an approved exception to policy in place and the device must be situated in a way that does not compromise client privacy. Live 2-way interactions are always initiated by the participant. The participant can initiate the service when needed and turn off the equipment when not needed.

The State believes teleservice will be an important component in a well-developed and balanced PCSP that focuses on the specific wants and health and welfare needs of the participant. Experience during the COVID-19 pandemic has shown that teleservice can facilitate community integration in a person-centered way. Washingtonians in the broader community utilize both technology-supported remote and in-person community service environments, and the proposed change in waiver services give waiver clients the same opportunity to participate in their community as everyone else.

Providers employing teleservice delivery will be guided by Policy and will continue to follow all service protocols and report any concerns they have to the Case/Resource Manager and make any appropriate incident reports. The provider delivering services remotely will be responsible for using an approved delivery platform that the client is able and willing to use and will provide basic technical assistance as necessary during their service delivery (device on and off, volume control, etc.). If a client is unable to use technology for teleservice delivery, then in person service delivery would be the appropriate service delivery mechanism for the client and this would be discussed during the person-centered planning meeting.

• The participant utilizing the services remote support and each person who shares a residence with that participant will be fully informed of what remote service delivery entails including, but not limited to: (A) that remote staff may observe their activities if they are within the view of the participant’s video communication device; (B) that the participant decides where in the residence the remote support will occur; (C) whether or not recordings of sessions will be made (the participant’s Case/Resource Manager will document in the PCSP); (D) that the participant will control the operation of the communication device, when it is turned on and when it is turned off. Please note that this service is not approved for clients receiving residential habilitation services.

• The state will use the CARE assessment to determine client need for technology and remote support through the person-centered planning process. If a client requests that a video camera be placed in their home to use in the provision of remote support, there must be an exception to policy (ETP) in place with justification as to why the camera is needed instead of a simple sensor. The ETP must be approved and documented in the client’s file before the device is installed and prior to the service being authorized. Adds that services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources. Please clarify whether individuals will not lose access to this service.

Limits on the amount, frequency or duration of this service:

1) Assistive technology is limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

2) Clinical and support needs for assistive technology are identified in the waiver participant’s DDA person-centered assessment and documented in the person-centered service plan.

3) Assistive technology may be authorized as a waiver service only after Medicaid, EPSDT, and any other private health insurance plan benefits have been exhausted by obtaining an initial denial of funding or information showing that the technology is not covered by Medicaid or private insurance.

4) The Department does not pay for technology determined by DSHS to be experimental.

5) The Department requires a written recommendation regarding her/his/their need for the technology. This recommendation must take into account that: a) The professional has personal knowledge of and experience with the requested assistive technology; and b) The professional has recently examined the waiver participant, reviewed her/his/their medical records when applicable, and conducted a functional evaluation.

6) The Department may require a written second opinion from a department selected professional.

7) Phone cards and minutes will not be funded as part of these services.

8) Assistive technology requires prior approval by the DDA regional administrator or designee when $550 or more.

9) Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to from the Department of Children, Youth, and Families (DCYF) or from Title IV-E of the Social Security Act or from other sources.

Transportation services are also available under this waiver to support access to community activities as identified through the individual’s person-centered plan.

Supported employment services provide individualized assistance and ongoing support to gain and/or maintain employment. These services are tailored to individual needs, interests, abilities, and promote career development. These services are provided in individual or group settings.

(1) Individual supported employment services include activities needed to sustain minimum wage pay or higher. These services are conducted in integrated business environments and include the following:

Creation of work opportunities through job development;

On-the-job training;

Training for the supervisor and/or peer workers to enable them to serve as natural supports to the participant on the job;

Modification of the work site tasks;

Employment retention and follow along support; and

Development of career and promotional opportunities.

(2) Group supported employment services are a step on the pathway toward gainful employment in an integrated setting and include:

The activities outlined in individual supported employment services;

Daily supervision by a qualified employment provider; and

Groupings of no more than eight workers with disabilities.

ARPA funds may be expended for ISE/GSE services (subminimum wages – Supports to participants to gain minimum wage employment).

Teleservice is an available service delivery option if chosen by the participant or their guardian (if appropriate), appropriately meets the participant’s assessed needs as documented in their person-centered service plan and is provided within the scope of the service being delivered. This service may be received in person or via teleservice as identified in the PCSP. The waiver participant selects whether they want to receive the service in person, via teleservice, or a combination of both. Teleservice is a remote service delivery method where the service is delivered by the provider to the participant via phone, video, computer, or other technology and that the technology and data storage is HIPAA compliant.

Assurances:

The well-developed person-centered service plan will document the participant’s specific health and welfare needs and how each service selected by the participant contributes to meeting the participant’s needs and does not duplicate supports. The PCSP is the first resource that will ensure the health and safety of that participant. The PCSP identifies supervision and physical assistance support needs that inform the decision making of whether teleservice is appropriate for the client. The service authorization system (ProviderOne) has distinct and separate service codes for each waiver service and has built-in system logic that prevents duplication of services.

DDA policies and procedures provide guidance to Case Resource Managers on developing effective person-centered service plans that identify services and service delivery methods that best meet their unique health and welfare needs without any duplication of services. Teleservice will be the service delivery method for a particular service at the direction of the participant, not by the preference of the service provider. A teleservice agreement form will be required prior to authorization of teleservice delivery. This form will document the client’s desired level of in person to teleservice delivery and will remind clients that they can change their mind about frequency of teleservice delivery at any time. This agreement is intended to assist in clear and documented communication between the client, DDA, and the provider (in addition to the person-centered service plan) to ensure the client is the driver of the method of service delivery they receive. Case/Resource Managers will consult with their participants and family members, if appropriate, to develop the PCSP that includes the specific services and service delivery methods that best meets the participant’s unique health and welfare needs. Participants will document in their PCSPs what approximate percentage of service delivery they desire to receive via teleservice. The State is not mandating what percentage of time teleservice can be utilized, to ensure person-centered service planning and promote client choice. Participants who need hands on assistance/physical assistance will require careful person-centered planning coordinated by their Case/Resource Manager to determine if teleservice delivery is a practical or feasible option for the successful delivery of services. Voice-activated communication devices may be an option that some participants select to ensure that remote service delivery will work for them. Other clients may require in person service delivery only to ensure safety and successful service delivery.

State will permit recording of live interactions with the participant via audio or video technology only at the request of the participant. Policy will include specific language around bathrooms and bedrooms. Video cameras are not permissible in bathrooms. If a client requests a video camera in their bedroom, there must be an approved exception to policy in place and the device must be situated in a way that does not compromise client privacy. Live 2-way interactions are always initiated by the participant. The participant can initiate the service when needed and turn off the equipment when not needed.

The State believes teleservice will be an important component in a well-developed and balanced PCSP that focuses on the specific wants and health and welfare needs of the participant. Experience during the COVID-19 pandemic has shown that teleservice can facilitate community integration in a person-centered way. Washingtonians in the broader community utilize both technology-supported remote and in-person community service environments, and the proposed change in waiver services give waiver clients the same opportunity to participate in their community as everyone else.

Providers employing teleservice delivery will be guided by Policy and will continue to follow all service protocols and report any concerns they have to the Case/Resource Manager and make any appropriate incident reports. The provider delivering services remotely will be responsible for using an approved delivery platform that the client is able and willing to use and will provide basic technical assistance as necessary during their service delivery (device on and off, volume control, etc.). If a client is unable to use technology for teleservice delivery, then in person service delivery would be the appropriate service delivery mechanism for the client and this would be discussed during the person-centered planning meeting.

The participant utilizing the services remote support and each person who shares a residence with that participant will be fully informed of what remote service delivery entails including, but not limited to: (A) that remote staff may observe their activities if they are within the view of the participant’s video communication device; (B) that the participant decides where in the residence the remote support will occur; (C) whether or not recordings of sessions will be made (the participant’s Case/Resource Manager will document in the PCSP); (D) that the participant will control the operation of the communication device, when it is turned on and when it is turned off. Please note that this service is not approved for clients receiving residential habilitation services.

The state will use the CARE assessment to determine client need for technology and remote support through the person-centered planning process. If a client requests that a video camera be placed in their home to use in the provision of remote support, there must be an exception to policy (ETP) in place with justification as to why the camera is needed instead of a simple sensor. The ETP must be approved and documented in the client’s file before the device is installed and prior to the service being authorized. Adds that services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources. Please clarify whether individuals will not lose access to this service.

Limits on the amount, duration or frequency of this service:

Limits to Individual supported employment/group supported employment services: Supported employment services are only available to individuals who do not have access to services available under the Rehabilitation Act of 1973, or the Individuals with Disabilities Education Improvement Act of 2004.

Payment will be made only for the adaptations, supervision, training and support with the activities of daily living a person requires as a result of his/her/their disabilities.

Payment is excluded for the supervisory activities rendered as a normal part of the business setting.

An individual can be authorized to receive supported employment services if he/she/they receives community inclusion services.

Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DCYF) or from Title IV-E of the Social Security Act or from other sources.

DDA contracts with the counties for expanded habilitation (including supported employment) services. The counties in turn provide services directly or contract with local providers for expanded habilitation services. The DDA reimburses the counties on a monthly basis for the cost of all services provided within the county. The counties in turn reimburse vendors for services provided based on the negotiated unit rates contained in their contracts with the vendors.

The amount of employment support will be based on the following items:

Client Employment Acuity is determined through the DDA assessment. Acuity reflects conditions typically related to the individual’s disability that are not likely to change, and are generally not impacted by outside factors.

Client acuity is determined as either High, Medium or Low.

Support level High

Requires support in the community at all times to maintain health and safety.

Experiences significant barriers to employment or community participation.

Requires frequent supervision, training, or full physical assistance with community activities most or all of the time.

Support Level Medium

Independent in the community some of the time and requires moderate support to obtain or maintain employment.

Able to maintain health and safety in the community for short periods of time.

May need some supervision, training, or partial physical assistance with community activities.

May need regular monitoring or prompting to perform tasks.

Support Level Low

Generally independent in the community and requires minimal support to obtain or maintain employment.

Able to communicate with others effectively and can maintain personal health and safety most of the time without supervision.

May be able to independently transport self in the community and does not require physical assistance in community activities.

Able to perform tasks with minimal or occasional monitoring or prompting.

Employment Algorithm Components

A combination of the following acuity scales and assessment items provided the most accurate determination of a person’s employment acuity level:

• Activities of Daily Living

• Behavioral Support

• Interpersonal Support

• Environmental Support

• Level of Monitoring

• Employment Support

• Completing tasks with acceptable speed

• Completing tasks with acceptable quality

• Medical Support

• Seizure support

Client work history is determined by looking back over a 12-month period and is categorized into three main groupings:

Continuous Employment

Received wages 9 consecutive month of the 12-month period

Intermittent/Recent Employment Received wages in at least one month of the 12-month period

Not employed or unemployed last 12 months

No wages reported as earned during a 12-month period (subminimum wages fall to not employed)

The range of support hours the client receives will be dependent upon the individual’s Employment Acuity, work history and phases of employment. DDA uses the following table to determine the number of monthly hours of individual employment service that can be authorized annually in the PCSP to permit flexibility in any given month as situations change on the job site:

Employment Employment Then Service May receive up to this many

Support Level: Status is: Level is: supported employment

service hours per month:

None Working A 0

Not Working B 0

Low Working C 4

Not Working D 7

Medium Working E 7

Not Working F 9

High Working G 11

Not Working H 12

Depending on factors detailed in the county employment plan, DDA may authorize additional hours of employment service:

May authorize up to this many

Employment Employment Employment additional hours of supp.

Service Level: Support Level: Status: employment service:

A None Working 0

B None Not Working 0

C Low Working 5

D Low Not Working 7

E Medium Working 5

F Medium Not Working 7

G High Working 12

H High Not Working 5

In rare instances, an exception to rule (ETR) may be granted to adjust support hours to meet the unique needs of a waiver participant.

Limits: Short term enhanced supports are available if a person is beginning a new job, has planned or expected change in job or job tasks, unexpected change in their condition or support is needed to maintain employment. These are short term hours determined by the county and employment vendor and may be authorized for a maximum of 6 months.

Community Inclusion is an individualized service that provides clients with opportunities to engage in community based activities that support socialization, contribution, education, recreation and personal development for the purpose of:

(1) Building and strengthening relationships with others in the local community who are not paid to be with the person.

(2) Learning, practicing and applying skills that promote greater independence and inclusion in their community.

Limits on the amount, duration or frequency of this service:

These services are available for individuals for whom a determination has been made that employment is currently not appropriate or who have received employment-related services for at least nine months and elect to receive community inclusion services.

An individual can be authorized to receive community inclusion services if they receive supported employment services.

Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources.

DDA contracts with the counties for day habilitation and expanded habilitation services. The counties in turn provide services directly or contract with local providers for day habilitation and expanded habilitation services. DDA reimburses the counties on a monthly basis for the cost of all services provided within the county. The counties in turn reimburse vendors for services provided based on the negotiated unit rates contained in their contracts with the vendors.

The amount of Community Inclusion services the waiver participant will be eligible for will be based on individual’s assessed need. The DDA CRM will use the DDA assessment to determine the individual’s community inclusion acuity level. The Community Inclusion acuity level utilizes the Support Intensity Scale subscales of:

1. Home Living (Part A)

2. Community Living (Part B)

3. Lifelong Learning(Part C)

4. Employment Activities (Part D)

5. Health and Safety Activities (Part E)

6. Social Activities (Part F)

Based on the client/legal guardian and respondents’ responses the SIS score will be categorized into seven support levels which will have an associated number of hours of support the individual can expect to receive as identified in WAC 388-828:

Client Profile Level The number of hours the individual

Community Inclusion may receive each month is:

0-9 Percentile A Up through 3.0 hours

10-19 Percentile B Up through 6.0 hours

20-29 Percentile C Up through 9.0 hours

30-44 Percentile D Up through 12.0 hours

45-59 Percentile E Up through 15.0 hours

60-74 Percentile F Up through 18.0 hours

75-100 Percentile G Up through 20.0 hours

Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to from the Department of Children, Youth, and Families (DCYF) or from Title IV-E of the Social Security Act or from other sources.

Individualized technical assistance is short term professional assessment and consultation to the employment provider or community inclusion provider and/or waiver participant to identify, address, and resolve barriers to employment or barriers to community inclusion. This is in addition to supports received through supported employment or community inclusion services for individuals who have not yet achieved their goal.

Teleservice is an available service delivery option if chosen by the participant or their guardian (if appropriate), appropriately meets the participant’s assessed needs as documented in their person-centered service plan and is provided within the scope of the service being delivered. This service may be received in person or via teleservice as identified in the PCSP. The waiver participant selects whether they want to receive the service in person, via teleservice, or a combination of both. Teleservice is a remote service delivery method where the service is delivered by the provider to the participant via phone, video, computer, or other technology and that the technology and data storage is HIPAA compliant.

Assurances: The well-developed person-centered service plan will document the participant’s specific health and welfare needs and how each service selected by the participant contributes to meeting the participant’s needs and does not duplicate supports. The PCSP is the first resource that will ensure the health and safety of that participant. The PCSP identifies supervision and physical assistance support needs that inform the decision making of whether teleservice is appropriate for the client. The service authorization system (ProviderOne) has distinct and separate service codes for each waiver service and has built-in system logic that prevents duplication of services. DDA policies and procedures provide guidance to Case Resource Managers on developing effective person-centered service plans that identify services and service delivery methods that best meet their unique health and welfare needs without any duplication of services.

Teleservice will be the service delivery method for a particular service at the direction of the participant, not by the preference of the service provider. A teleservice agreement form will be required prior to authorization of teleservice delivery. This form will document the client’s desired level of in person to teleservice delivery and will remind clients that they can change their mind about frequency of teleservice delivery at any time. This agreement is intended to assist in clear and documented communication between the client, DDA, and the provider (in addition to the person-centered service plan) to ensure the client is the driver of the method of service delivery they receive. Case/Resource Managers will consult with their participants and family members, if appropriate, to develop the PCSP that includes the specific services and service delivery methods that best meets the participant’s unique health and welfare needs. Participants will document in their PCSPs what approximate percentage of service delivery they desire to receive via teleservice. The State is not mandating what percentage of time teleservice can be utilized, to ensure person-centered service planning and promote client choice. Participants who need hands on assistance/physical assistance will require careful person-centered planning coordinated by their Case/Resource Manager to determine if teleservice delivery is a practical or feasible option for the successful delivery of services. Voice-activated communication devices may be an option that some participants select to ensure that remote service delivery will work for them. Other clients may require in person service delivery only to ensure safety and successful service delivery.

State will permit recording of live interactions with the participant via audio or video technology only at the request of the participant. Policy will include specific language around bathrooms and bedrooms. Video cameras are not permissible in bathrooms. If a client requests a video camera in their bedroom, there must be an approved exception to policy in place and the device must be situated in a way that does not compromise client privacy. Live 2-way interactions are always initiated by the participant. The participant can initiate the service when needed and turn off the equipment when not needed.

The State believes teleservice will be an important component in a well-developed and balanced PCSP that focuses on the specific wants and health and welfare needs of the participant. Experience during the COVID-19 pandemic has shown that teleservice can facilitate community integration in a person-centered way. Washingtonians in the broader community utilize both technology-supported remote and in-person community service environments, and the proposed change in waiver services give waiver clients the same opportunity to participate in their community as everyone else.

Providers employing teleservice delivery will be guided by Policy and will continue to follow all service protocols and report any concerns they have to the Case/Resource Manager and make any appropriate incident reports. The provider delivering services remotely will be responsible for using an approved delivery platform that the client is able and willing to use and will provide basic technical assistance as necessary during their service delivery (device on and off, volume control, etc.). If a client is unable to use technology for teleservice delivery, then in person service delivery would be the appropriate service delivery mechanism for the client and this would be discussed during the person-centered planning meeting.

• The participant utilizing the services remote support and each person who shares a residence with that participant will be fully informed of what remote service delivery entails including, but not limited to: (A) that remote staff may observe their activities if they are within the view of the participant’s video communication device; (B) that the participant decides where in the residence the remote support will occur; (C) whether or not recordings of sessions will be made (the participant’s Case/Resource Manager will document in the PCSP); (D) that the participant will control the operation of the communication device, when it is turned on and when it is turned off. Please note that this service is not approved for clients receiving residential habilitation services.

• The state will use the CARE assessment to determine client need for technology and remote support through the person-centered planning process. If a client requests that a video camera be placed in their home to use in the provision of remote support, there must be an exception to policy (ETP) in place with justification as to why the camera is needed instead of a simple sensor. The ETP must be approved and documented in the client’s file before the device is installed and prior to the service being authorized. Adds that services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources. Please clarify whether individuals will not lose access to this service.

Limits on the amount, duration or frequency of this service:

1) Individualized technical assistance may be authorized for up to 6 months of the plan year.

2) The individual must be receiving supported employment or community inclusion unless otherwise approved by the administration.

Individualized Technical Assistance is available to clients receiving Community Inclusion as “short term professional assessment and consultation to the community inclusion provider and/or waiver participant to identify, address, and resolve barriers to community inclusion. This is in addition to supports received through community inclusion services for individuals who have not yet achieved their goal.” Both services must be separately authorized and both have unique billing codes that prevent duplicate billing.

• Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to from the Department of Children, Youth, and Families (DCYF) or from Title IV-E of the Social Security Act or from other sources.

Items, equipment, or product systems, not related to a client’s physical health, that are used to increase, maintain, or improve functional capabilities of waiver participants, increase safety, or increase social engagement in the community, as well as supports to directly assist the participant and caregivers to select, acquire, and use the technology. Services are provided when outside the scope of Medicaid State Plan and EPSDT benefits. Assistive technology includes:

(1) The evaluation of the needs of the waiver participant, including a functional evaluation in their customary environment;

(2) Purchasing, leasing, or otherwise providing for the acquisition of assistive technology devices;

(3) Selecting, designing, fitting, customizing, adapting, applying, retaining, repairing, or replacing assistive technology devices;

(4) Coordinating and using other therapies, interventions, or services with assistive technology devices, such as those associated with existing education and rehabilitation plans and programs;

(5) Training or technical assistance for the participant and/or if appropriate, the child’s or adult’s family; and

(6) Training or technical assistance for professionals, including individuals providing education and rehabilitation services, employers, or other individuals who provide services to, employ, or are otherwise involved in the assistive technology related life functions of children or adults with disabilities.

ARPA funds may be expended for assistive technology items and not internet connectivity (remote technology support).

Teleservice is an available service delivery option if chosen by the participant or their guardian (if appropriate), appropriately meets the participant’s assessed needs as documented in their person-centered service plan and is provided within the scope of the service being delivered. This service may be received in person or via teleservice as identified in the PCSP. The waiver participant selects whether they want to receive the service in person, via teleservice, or a combination of both. Teleservice is a remote service delivery method where the service is delivered by the provider to the participant via phone, video, computer, or other technology and that the technology and data storage is HIPAA compliant.

Assurances: The well-developed person-centered service plan will document the participant’s specific health and welfare needs and how each service selected by the participant contributes to meeting the participant’s needs and does not duplicate supports. The PCSP is the first resource that will ensure the health and safety of that participant. The PCSP identifies supervision and physical assistance support needs that inform the decision making of whether teleservice is appropriate for the client. The service authorization system (ProviderOne) has distinct and separate service codes for each waiver service and has built-in system logic that prevents duplication of services. DDA policies and procedures provide guidance to Case Resource Managers on developing effective person-centered service plans that identify services and service delivery methods that best meet their unique health and welfare needs without any duplication of services.

Teleservice will be the service delivery method for a particular service at the direction of the participant, not by the preference of the service provider. A teleservice agreement form will be required prior to authorization of teleservice delivery. This form will document the client’s desired level of in person to teleservice delivery and will remind clients that they can change their mind about frequency of teleservice delivery at any time. This agreement is intended to assist in clear and documented communication between the client, DDA, and the provider (in addition to the person-centered service plan) to ensure the client is the driver of the method of service delivery they receive. Case/Resource Managers will consult with their participants and family members, if appropriate, to develop the PCSP that includes the specific services and service delivery methods that best meets the participant’s unique health and welfare needs. Participants will document in their PCSPs what approximate percentage of service delivery they desire to receive via teleservice. The State is not mandating what percentage of time teleservice can be utilized, to ensure person-centered service planning and promote client choice. Participants who need hands on assistance/physical assistance will require careful person-centered planning coordinated by their Case/Resource Manager to determine if teleservice delivery is a practical or feasible option for the successful delivery of services. Voice-activated communication devices may be an option that some participants select to ensure that remote service delivery will work for them. Other clients may require in person service delivery only to ensure safety and successful service delivery.

State will permit recording of live interactions with the participant via audio or video technology only at the request of the participant. Policy will include specific language around bathrooms and bedrooms. Video cameras are not permissible in bathrooms. If a client requests a video camera in their bedroom, there must be an approved exception to policy in place and the device must be situated in a way that does not compromise client privacy. Live 2-way interactions are always initiated by the participant. The participant can initiate the service when needed and turn off the equipment when not needed.

The State believes teleservice will be an important component in a well-developed and balanced PCSP that focuses on the specific wants and health and welfare needs of the participant. Experience during the COVID-19 pandemic has shown that teleservice can facilitate community integration in a person-centered way. Washingtonians in the broader community utilize both technology-supported remote and in-person community service environments, and the proposed change in waiver services give waiver clients the same opportunity to participate in their community as everyone else.

Providers employing teleservice delivery will be guided by Policy and will continue to follow all service protocols and report any concerns they have to the Case/Resource Manager and make any appropriate incident reports. The provider delivering services remotely will be responsible for using an approved delivery platform that the client is able and willing to use and will provide basic technical assistance as necessary during their service delivery (device on and off, volume control, etc.). If a client is unable to use technology for teleservice delivery, then in person service delivery would be the appropriate service delivery mechanism for the client and this would be discussed during the person-centered planning meeting.

• The participant utilizing the services remote support and each person who shares a residence with that participant will be fully informed of what remote service delivery entails including, but not limited to: (A) that remote staff may observe their activities if they are within the view of the participant’s video communication device; (B) that the participant decides where in the residence the remote support will occur; (C) whether or not recordings of sessions will be made (the participant’s Case/Resource Manager will document in the PCSP); (D) that the participant will control the operation of the communication device, when it is turned on and when it is turned off. Please note that this service is not approved for clients receiving residential habilitation services.

• The state will use the CARE assessment to determine client need for technology and remote support through the person-centered planning process. If a client requests that a video camera be placed in their home to use in the provision of remote support, there must be an exception to policy (ETP) in place with justification as to why the camera is needed instead of a simple sensor. The ETP must be approved and documented in the client’s file before the device is installed and prior to the service being authorized. Adds that services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to or receives from the Department of Children, Youth, and Families (DYYF) or from a Tribe in Washington State or from Title IV-E of the Social Security Act or from other sources. Please clarify whether individuals will not lose access to this service.

Limits on the amount, duration or frequency of this service:

(1) Assistive technology is limited to additional services not otherwise covered under the state plan, including EPSDT, but consistent with waiver objectives of avoiding institutionalization.

(2) Clinical and support needs for assistive technology are identified in the waiver participant’s DDA person-centered assessment and documented in the person-centered service plan.

(3) Assistive technology may be authorized as a waiver service only after Medicaid, EPSDT, and any other private health insurance plan benefits have been exhausted by obtaining an initial denial of funding or information showing that the technology is not covered by Medicaid or private insurance.

(4) The Department does not pay for technology determined by DSHS to be experimental.

(5) The Department requires a written recommendation regarding her/his/their need for the technology. This recommendation must take into account that: (a) The professional has personal knowledge of and experience with the requested assistive technology; and (b) The professional has recently examined the waiver participant, reviewed her/his/their medical records when applicable, and conducted a functional evaluation.

(6) The Department may require a written second opinion from a department selected professional.

(7) Phone cards and minutes will not be funded as part of these services.

(8) Assistive technology requires prior approval by the DDA regional administrator or designee when $550 or more.

(9) Services under this waiver are intended to supplement, and not supplant, the child welfare services and supports a child or youth is entitled to from the Department of Children, Youth, and Families (DCYF) or from Title IV-E of the Social Security Act or from other sources.

Transportation services are also available under this waiver to support access to community activities as identified through the individual’s person-centered plan.

The IPS benefit package will be offered to eligible clients through a person-centered planning process where eligible services are identified in the plan of care. IPS includes services that would otherwise be allowable under a Section 1915(i) authority, and are determined to be necessary for an individual to obtain and maintain employment in the community. IPS services are individualized and may include any combination of the following services:

Pre-employment services

a. Pre-vocational/job-related discovery or assessment

b. Person-centered employment planning

Including the purchase of pay-as-you-go cell phone devices as a means to access telehealth services for pre-employment services.

c. Individualized job development and placement

d. Job carving

Job carving is defined as working with client and employer to modify an existing job description— containing one or more, but not all, of the tasks from the original job description when a potential applicant for a job is unable to perform all of the duties identified in the job description.

Benefits education and planning

Benefits education and planning is defined as counseling to assist the client in fully understanding the range of state and federal benefits they might be eligible for, the implications that work and earnings would have for continued receipt of these benefits, and the client’s options for returning to work.

Transportation (only in conjunction with the delivery of an authorized service)

Employment sustaining services

Career advancement services

Career advancement services are defined as services that expand opportunities for professional growth, assist with enrollment in higher education or credentialing and certificate programs to expand job skills or enhance career development, and assist the individual in monitoring his/her satisfaction with employment, and determining level of interest and opportunities for advancement with current employer, and/or changing employers for career advancement.

Negotiation with employers

Negotiation with employers is defined as services where a provider identifies and addresses job accommodations or assistive technology needs with the employer on behalf of the individual. Job accommodations can include the following: adjusting work schedule to reduce exposure to triggering events (i.e., heavy traffic triggering symptoms of agoraphobia); providing a private area for individuals to take breaks if they experience an increase in symptoms; access to telephone to contact support person if needed while at work; adjusting job schedule to accommodate scheduled appointments; and small, frequent breaks as opposed to one long one. Assistive Technology can include the following: bedside alarms, electronic medication reminders while at work or at home, and use of headset/iPod to block out internal or external distractions.

c. Job analysis

Job analysis is defined as the gathering, evaluating, and recording of accurate, objective data about the characteristics of a particular job to ensure the specific matching of skills and amelioration of maladaptive behaviors.

d. Job coaching

e. Benefits education and planning

Benefits education and planning is defined as counseling to assist the client in fully understanding the range of state and federal benefits they might be eligible for, the implications that work and earnings would have for continued receipt of these benefits, and the clients’ options for returning to work.

Transportation (only in conjunction with the delivery of an authorized service)

g. Asset development

Asset development is defined as services supporting the client’s accrual of assets that have the potential to help clients improve their economic status, expand opportunities for community participation, and positively impact their quality of life experience. Assets as defined as something with value that is owned by an individual, such as money in the bank, property, and retirement accounts.

h. Follow-along supports

Follow-along supports are defined as on-going supports necessary to assist an eligible client to sustain competitive work in an integrated setting of their choice. This service is provided for, or on behalf of, a client, and can include communicating with the client’s supervisor or manager, whether in the presence of the client or not (if authorized and appropriate). There is regular contact and follow-up with the client and employer to reinforce and stabilize job placement. Follow along support and/or accommodations are negotiated with an employer prior to client starting work or as circumstances arise.

Including the purchase of pay-as-you-go cell phone devices as a means to access telehealth services for follow-along supports.

Limits on the amount, duration or frequency of this service:

The IPS benefit does not include:

a. Generalized employer contacts that are not connected to a specific enrolled individual or an authorized service

b. Employment support for individuals in sub-minimum wage, or sheltered workshop settings

c. Facility-based habilitation or personal care services

d. Wage or wage enhancements for individuals

e. Duplicative services from other state or federal programs

f. Ongoing minutes or data plan for cell phone devices