Self-Direction Guidance for Providers March 10, 2022
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Self-Direction Guidance for Providers
March 10, 2022
TABLE OF CONTENTS
PART 1 – KEY CONCEPTS OF SELF-DIRECTION
INTRODUCTION
Purpose of the Self-Direction Guidance for Providers 8
What is Self-Direction? 8
CHAPTER 1
SELF-DIRECTION AUTHORITIES
Employer Authority 9
Budget Authority 9
CHAPTER 2
STAFF OPTIONS IN SELF-DIRECTION
Agency Supported Self-Directed Services 10
Self-Hired Staffing 10
Direct Provider Purchased Services 11
CHAPTER 3
SELF-DIRECTION BUDGET
OPWDD Issued Budget 12
Personal Resource Account 12
100% State Paid Services 12
Budget Review Process 12
Annual Effective Dates 13
Retroactive Amendments 13
Continuity of Care Provisions 13
Self-Direction Budgets for Children 13
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PART 2 - OVERVIEW OF SELF-DIRECTION SERVICES
CHAPTER 4
SUPPORT BROKERAGE
Start-Up Brokerage 17
Brokerage in Settings that Prevent Enrollment in the HCBS Waiver 17
Support Broker Authorization….…………………………………………………17
Support Brokerage Coverage 18
Parents and Other Unpaid Support Brokers 18
CHAPTER 5
FISCAL INTERMEDIARY
Services that Require a Fiscal Intermediary 20
Reimbursement for Prepaid Goods and Services 20
Services Delivered by Other Agencies………………………………………….21
CHAPTER 6
LIVE-IN CAREGIVER
Payment Standards 22
CHAPTER 7
INDIVIDUAL DIRECTED GOODS AND SERVICES (IDGS)
Community Classes 24
Transportation 24
Camp 25
Paid Neighbor 26
Staffing Support…………………………………………………………………...26
Health Club/ Organizational Membership………………………………………26
IDGS Billing 27
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CHAPTER 8
OTHER THAN PERSONAL SERVICES (OTPS)
OTPS Categories 29
Items Excluded from OTPS 30
OTPS Billing……………………………………………………………………….30
CHAPTER 9
SUPPORTED EMPLOYMENT, COMMUNITY HABILITATION AND RESPITE
Direct Provider Purchased and Agency Supported 32
Self-Hired Staff 32
Hiring Family Members 33
CHAPTER 10
FAMILY REIMBURSED RESPITE
Payment Standards 34
CHAPTER 11
FAMILY SUPPORT SERVICES ………………………………………………..35
CHAPTER 12
HOUSING SUBSIDY
Restrictions 36
CHAPTER 13
SHARED LIVING ARRANGEMENTS…………………………………………..37
CHAPTER 14
OUT-OF-STATE AND OUT-OF-COUNTRY SERVICES……………………..40
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PART 3 – SELF-HIRED FRINGE BENEFIT BUDGETING AND BILLING
CHAPTER 15
FRINGE BENEFIT BUDGETING AND BILLING OVERVIEW
Terms 42
Types of Self-Hired Staff 43
CHAPTER 16
ACCOUNTING INDIRECT EMPLOYMENT COSTS
Direct Accounting Method 44
Fringe Rate Method 44
CHAPTER 17
CHARGING STAFF TRAINING EXPENSES IN SELF-HIRED SERVICES
On The Job Training 46
Fiscal Intermediary Directed General Employee Orientation, Refresher,
and Classroom/Seminar Training 47
Person/Family-Directed Special Employee Training 48
Training Reimbursement as an Employee Benefit 49
CHAPTER 18
PREPARING CLAIMS TO MEDICAID FOR SELF-HIRED SERVICES
Service Unit Claiming 50
Amount Charged 50
Multi-Day Versus Single-Day Claiming 50
Reimbursement Rate Cap Logic 51
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CHAPTER 19
GUIDANCE ON OVERNIGHT SUPPORTS
Paid Neighbor 52
Personal Care 52
Respite 52
Community Habilitation 52
ATTACHMENTS
Attachment A: Self-Direction Budget Types
Attachment B: Personal Resource Account
Attachment C: Budget Review Procedure
Attachment D: Continuity of Care
Attachment E: Support Broker Training Policy
Attachment F: Live-in Caregiver Maximum Reimbursement Levels
Attachment G: List of Applicable Administrative Memoranda
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Self-Direction
Guidance for Providers
Part 1
Key Concepts of Self-Direction
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INTRODUCTION
Purpose of the Self-Direction Guidance for Providers
NYS OPWDD is committed to helping people with Intellectual and Developmental
Disabilities (I/DD) have as much control as possible over how they receive their
supports and services. Self-Directed services offer the greatest amount of control in
how, where and by whom services are provided. OPWDD has a broad range of
options available for Self-Direction. A person can choose to develop a plan that is
customized in a way that best meets their interests and needs.
The Self-Direction Guidance for Providers is predominantly meant for Providers and
Brokers. This document broadly defines the policy guidance for Self-Direction and
provides an overview of Self-Direction authority and staffing options, the services
available to self-direct, and information on budgeting and billing for Self-Directed
services. This document is technical in nature and is meant to provide detailed
direction on issues that emerge for people who self-direct their services and the
providers (Fiscal Intermediaries/ Brokers) who work with them to implement a self-
directed plan.
The Self-Direction Guidance for Providers does not replace OPWDD Administrative
Memoranda (see Attachment G) for Self-Directed services. Providers must comply
with the payment standards and service documentation requirements as described
in the applicable Administrative Memoranda (ADMs) for services that are self-
directed.
What is Self-Direction?
Self-Determination is the philosophy that all people have the freedom to develop
their own life plan. Self-Direction is based on the underlying principles of self-
determination, person-centered planning and practices.
Self-Direction is the practice of empowering people with developmental
disabilities to manage the supports and services they receive, determine who
provides the supports, and how and where they are provided. In Self-Direction
the person with developmental disabilities chooses the mix of supports and
services that work best for them, how and when they are provided, and the
staff and/or organizations that provide them.
The Self-Direction participant accepts responsibility for co-management of their
supports and services. The amount of responsibility varies depending on the level of
authority the participant chooses to exercise.
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CHAPTER 1 SELF DIRECTION AUTHORITIES
Authority is a term used by the Centers for Medicaid and Medicare Services (CMS) to
describe the control that a person receiving services uses when they choose to self-
direct their services. Participants have a range of options for choosing the level of Self-
Direction authority that they wish to have. There are two types of Self-Direction
authority: Employer Authority and Budget Authority. A person may choose to have
either one or both types of authority.
Employer Authority
The person hires, schedules and supervises the staff who support them. They
determine the activities that will be supported and the way that support will be
provided. Services are provided to the person by agency staff under a co-
employment model. In a co-employment model, the person can choose to hire staff,
train staff regarding their interests, monitor and provide feedback to staff, and end
staff services if they are not consistent with the person’s expectations. If a person
chooses to self-hire their staff, they gain Budget Authority and determine the
compensation of those staff.
Budget Authority
The person who is self-directing with Budget Authority must work within a Personal
Resource Account (PRA) and develop a Self-Direction Budget. The person makes
choices about the goods and services he/she wishes to receive and selects who is
paid to provide them or how they are purchased. A person who maintains Budget
Authority and works within a PRA may access needed goods or services through
Individual Directed Goods and Services (IDGS). A Fiscal Intermediary (FI) works
with the person to complete billing and payment for goods and services identified in
the Budget. Attachment C includes a description of services that must be included in
a person’s Self-Direction Budget. A person who chooses to have Budget Authority
can receive and budget for services that are Agency Supported, Self-Hired, or Direct
Provider Purchased. Budget types are described in Attachment A.
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CHAPTER 2 STAFF OPTIONS IN SELF-DIRECTION
A person who chooses Self-Direction has three options for selecting the staff who will
work with them:
Agency Supported Self-Directed Services
The person and agency have a Memorandum of Understanding (MOU) that
describes the person’s authority to hire staff, train staff regarding their interests,
monitor and provide feedback to staff, and end the employee’s services if they are
not consistent with the person’s expectations. The person does not have the
authority to set the staff salary in this model and the provider is paid at the provider’s
rate for the service, which includes the administrative and clinical components of the
service. The provider bills eMedNY directly for these services. If a person chooses to
have only Agency Supported Self-Directed Services, a Self-Direction Budget and
Personal Resource Account are not needed.
Community Habilitation, Supported Employment (SEMP) and Respite can be
self-directed by the participant using Employer Authority in the Agency
Supported Self-Directed Services model.
Self-Hired Staffing
The person who is self-directing determines the compensation of the staff who
delivers services to them. Services must be planned for and budgeted within a
Personal Resource Account (PRA). A Fiscal Intermediary (FI) works with the person
to implement Human Resource (HR) activities and to complete billing and payment
of the services. The person and the FI have a Memorandum of Understanding
(MOU) that describes the person’s authority to hire staff, train staff regarding their
interests, monitor and provide feedback to staff, and end the employee’s services if
they are not consistent with the person’s expectations. The amount that is billed to
eMedNY for self-hired Community Habilitation, Supported Employment and Respite
cannot exceed the amount a provider would be paid for the same service or the
OPWDD established rates for the service, whichever applies.
A person can choose to self-hire staff to deliver the following types of Home and
Community Based Services (HCBS) waiver services: Community Habilitation,
Supported Employment, and Respite.
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Direct Provider Purchased Services
A person who is self-directing can choose to purchase some services directly from a
provider agency. For these Direct Provider Purchased services, the person does not
have the authority to set the staff salary and the person chooses to let the provider
manage the staff. The provider is paid at the provider’s rate for the service, which
includes the administrative and clinical components of the service. The provider bills
eMedNY directly for these services. If a person is self-directing other services with
budget authority, the agency that provides the Direct Provider Purchased Service is
responsible for ensuring that the service is utilized within the PRA, as identified in
the Self-Direction Budget. This needs to be addressed during the planning process
and reflected in the Budget accordingly.
Supported Employment, Community Habilitation, and Respite may be Direct
Provider Purchased, Self-Hired, or Agency Supported. Group Day Habilitation
Services, Prevocational Services and Pathway to Employment are available only
as Direct Provider Purchased Services.
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CHAPTER 3 SELF-DIRECTION BUDGET
OPWDD Issued Budget
People who self-direct with budget authority must use the OPWDD issued Self-
Direction Budget. The Self-Direction Budget must be completed when a person
chooses to have Budget Authority and chooses services that have Budget Authority
associated with them. Only the budget issued by OPWDD will be accepted for
processing and approval by OPWDD.
Personal Resource Account
The Self-Direction Budget cannot exceed a person’s Personal Resource Account
(PRA). Based on the OPWDD Approved Needs Assessment Tool, the PRA
establishes cost parameters for individualized budgets based on need profiles and
comparable costs associated with supporting similarly profiled people with
developmental disabilities in other models of support. See attachment B.
100% State Paid Services
When a person has a Self-Direction Budget and receives the services listed below,
such services must be included in the Self-Direction Budget and counted against the
PRA (see Attachment C for more information):
• Family Reimbursed Respite (FRR)
• Family Support Services (FSS)
• Other Than Personal Services (OTPS)
• Housing subsidy/Individual Supports and Services (ISS)
• Assistive Supports
Budget Review Process
-See Attachment C for the Self-Direction Budget Review Procedure
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Annual Effective Dates
Budget Annual Effective Dates are fixed dates that establish the year in which a
person’s Budget is in operation. A person’s total annual expenditures for services in
their Self-Direction Budget may not exceed their PRA during any year a Budget is in
effect. The anniversary of the Budget Annual Effective Date is that date when this
annual spending cap resets. Budget Annual Effective Dates do not change when
Budgets are amended, unless the Budget type changes between “Other than
Residential,” “Residential Only” or “Both.”
Retroactive Amendments
Self-Direction Budgets may be revised proactively to accommodate the participant’s
changing needs. Full Amendments to Self-Direction Budgets are not made
retroactively. However, Cost Neutral Budget Amendments may be approved by the
Development Disabilities Regional Office retroactive to the beginning of the month
prior to the month it is approved.
Continuity of Care Provisions
Continuity of Care Provisions are not applicable to Self-Direction Budgets developed
on and after 10/1/2014. On and after 10/1/2014, OPWDD will not approve increases
or cost neutral changes to Continuity of Care Provisions found in existing Self-
Direction Budgets; OPWDD will only approve decreases to such provisions. More
information on Continuity of Care can be found in Attachment D.
Self-Direction Budgets for Children
Approval of a Self-Direction Budget is contingent on the participant’s enrollment in
the HCBS waiver. Enrollment in the waiver requires the identification of a need for
ongoing waiver services that is not available through other sources.
For children under the age of four, it is expected that Early Intervention (EI) services
would meet their needs and waiver services cannot be duplicative of services
available through EI. Children receiving EI services would not be authorized for the
HCBS waiver and, therefore, would not be eligible for self-directed services without
clinical justification.
For children who are at least four years of age and younger than seven years of age,
it would be unusual for Community Habilitation to be justified as typical supports
come from family and school. Social skill building can often be achieved through
FSS programs. This age group is typically more appropriate for respite and FSS
support use. If the family, Support Broker, and Care Manager (CM) determine that
Community Habilitation is appropriate for a child in this age range, clear age
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appropriate habilitative goals and outcomes must be included within the child’s Staff
Action Plan and would be subject to audit protocols for the waiver service.
For all children who are eligible to receive service from the State Department of
Education (SED), those services must be utilized before self-directed services. Self-
directed services cannot be duplicative, nor can they overlap with SED services. The
schedule for waiver service must not overlap with the planned schedule for
educational instruction. If a child is homeschooled, the times when the
homeschooling actually takes place can be considered, instead of standard school
hours, as the times when SED services are occurring.
Self-Directed services are not available for children who live in a certified setting and
receive SED services. As the SED services are expected to cover their service
needs during the day and the certified setting is responsible for evening, nights and
weekends, they are considered to have all of their service needs met.
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Self-Direction
Guidance for Providers
Part 2
Overview of Self-Direction Services
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CHAPTER 4 SUPPORT BROKERAGE
When a person chooses to take on Budget Authority, Support Brokerage services
support the person-centered planning process by assisting the person to develop a
Circle of Support and complete a Self-Direction Budget for his/her services. The Broker
may also provide training and support to the person to help him/her gain the skills and
competencies he/she needs to manage self-directed services. If a participant has
chosen self-hired Community Habilitation or Supported Employment services, Support
Brokerage Services include completing and updating Staff Action plans for these
services.
A person’s Support Broker cannot provide them any other HCBS waiver service, and
cannot be the person’s Care Manager (CM). A Care Manager will assist the person
participating in Self-Direction, as Self-Direction is part of the HCBS waiver.
Support Brokerage services must be established based on an agreement between the
participant and the Broker. Hourly fees are negotiated between the participant and the
Broker and should be commensurate with the level of training and experience of the
Broker. The maximum fee that can be considered for delivering Support Broker
services is $40 per hour. Self-Direction participants and Brokers can agree to a fee that
is less than this amount. The hourly fees reflected on the Support Broker Agreement
and the Self-Direction Budget must be the same.
The participant and his/her Circle of Support make decisions about the best use of the
Support Broker as a resource within the person’s Self-Direction Budget to ensure
appropriate support and achievement of valued outcomes.
For the Broker Training Policy, see Attachment E.
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Start-Up Brokerage
Start-up Brokerage services are provided to assist a Self-Direction participant in
developing his/her initial Self-Direction Budget, with reimbursement capped at
$2,400.
A person who received Start-Up Brokerage may budget for this again after one
year has passed if the person has not received any self-directed services in that
year. Self-directed services are those that would be billed by an FI, except for
Community Transition Services. In this scenario, the $2,400 cap would reset. A
second Start-Up Brokerage expense is not available to participants who have
received self-directed services and are changing FI agencies.
Brokerage in Settings that Prevent Enrollment in the HCBS Waiver
Home and Community Based Services (HCBS) Waiver Support Brokerage services
are not available to people who reside in the following settings that are non-HCBS
Waiver eligible: Intermediate Care Facilities, Nursing Homes, Residential Schools,
and Developmental Centers. For people who are seeking to transition out of these
settings and into self-directed services within the community, Start-Up Brokerage
services up to $2400 can be funded with 100% State funds.
OPWDD expects that these State funds are used exclusively to develop the Self-
Direction Budget with Start-Up Brokerage services. The person must be enrolled into
the HCBS Waiver Brokerage service in order to receive ongoing Brokerage services
after completion of the Self-Direction Budget.
Support Broker Authorization
Prospective Support Brokers must complete an OPWDD approved curriculum
utilizing trainers, or a training method, approved by OPWDD. Support Brokers who
demonstrate that they meet OPWDD training requirements will be listed in a
centralized authorization record and recognized as “Authorized”. While authorization
demonstrates the Support Broker’s adherence to OPWDD standards, it does not
demonstrate adherence to background check and other billing standards.
For Support Brokers to maintain their authorization, they must adhere to training and
authorization standards. Each year, Support Brokers must be reauthorized if they
intend to continue providing services. The Support Broker is responsible for
obtaining authorization on or before July 31st prior to the expiration of the
authorization year. To be reauthorized, the Support Broker must demonstrate that
(s)he has completed the OPWDD Mandatory Training and obtained twelve (12) or
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more hours of Yearly Professional Training during the authorization year. If
circumstances warrant, and there is a substantiated complaint (or complaints) of
requisite severity, OPWDD will engage the Support Broker in corrective action,
including placing limitations on the Support Broker’s caseload, the imposition of
additional training standards, the revocation of the Support Broker’s authorization
based on the circumstances, or take additional actions as appropriate.
ADM 2019-05R describes the Support Broker Authorization standards required to
meet billing, programmatic, and documentary requirements referenced in ADM-
#2019-06.
Support Brokerage Coverage
To maintain good continuity of care, it is best for one Broker to work with and
support the participant. However, if the Broker chooses to delegate documentation
to another qualified Broker or if a backup Broker is designated to attend meetings in
rare circumstances when the primary Broker is unable to attend, this needs to be
outlined in the agreement between the primary Broker and the participant. Any
backup Broker must meet all the same qualifications as the regular Broker as
described in ADMs #2019-05 and #2019-06.
Parents and Other Unpaid Support Brokers
Participants can choose to have their parent fill the role of the Support Broker, but a
parent cannot be paid for Support Broker services delivered to their own child.
Detailed information regarding family members delivering services can be found in
Chapter 9, Hiring Family Members section.
When participants choose to act as their own Support Broker, or have a parent or
other person fulfill the Support Broker role in an unpaid capacity, the person acting
as Support Broker must complete the Initial Broker Training Requirements, as
outlined in Attachment E. Self-Direction Budgets may be denied approval unless it is
established that there is someone to fulfill the role of the Support Broker who has
taken the required training.
A Broker Agreement should be completed when a participant chooses to have a
parent or other person fulfill the Support Broker role in an unpaid capacity. A
completed Broker Agreement ensures that the participant and the person they chose
to act as a Broker have a clear understanding of the roles and responsibilities for the
person acting as a Support Broker.
Parents and others who act as a person’s Support Broker in an unpaid capacity are
not generating any billing for Support Broker services. As such, they are not subject
to the payment and service documentation requirements outlined in Administrative
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Memorandum #2019-06 regarding Service Documentation for Support Brokerage
Services.
Unpaid Support Broker Services do not generate any billing and there is no impact
on a participant’s PRA. Therefore, the unpaid Support Broker should not be reflected
on the person’s Self-Direction Budget. When the Support Broker is unpaid, the
Support Broker service item on the Demographics tab of the Budget should be
answered as “No.”
ADM #2019-06 describes the service, programmatic and payment standards and
service documentation requirements for Support Brokerage Services.
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CHAPTER 5 FISCAL INTERMEDIARY
Fiscal Intermediary Services (FI Services) are HCBS Waiver services that include tasks
performed by a Fiscal Intermediary (FI) which support a participant who self directs an
individualized budget. Such tasks include billing and payment of approved goods and
services, fiscal accounting and reporting, Medicaid and corporate compliance, and
general administrative supports. The FI performs the initial review of the budgets/budget
amendments, is the employer of record for staff hired by the participant, and is
responsible for ensuring that applicable labor laws (including those related to minimum
wage and overtime) are followed. These staff are referred to as “self-hired staff.”
Services that Require a Fiscal Intermediary
A participant must choose an FI to handle billing for any of the following services:
• Individual Directed Goods and Services (IDGS)
• Live-in Caregiver (LIC)
• Support Brokerage Services
• Community Transition Services (CTS)
• Other Than Personal Services (OTPS)
• Housing Subsidy
• Any self-hired staff for Community Habilitation (CH), Supported Employment
(SEMP), and/or Respite
Reimbursement for Prepaid Goods and Services
In some circumstances, FIs may be asked to pay for an item or service before it is
received or delivered. Camp deposits and pre-payments are one potential example.
Annual memberships are another. FIs may elect to reimburse the participant/family,
immediately, or pay for the cost of pre-paid goods and services, directly. However,
the FI must wait until the service is “complete” before claiming reimbursement to
Medicaid. Each FI has the right to develop policies and procedures that define and
limit its financial risk regarding IDGS purchases, especially when the risk of
immediately reimbursing (“floating”) a pre-paid service becomes significant or
substantial. Such policies must be made known in advance to those impacted and
be applied fairly and equitably across all people served by the FI. For example, the
FI’s policy could require that it will accept full financial risk and that it may never
subsequently receive reimbursement (if the camper does not actually attend camp).
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Services Delivered by Other Agencies
When participants with Budget Authority receive Agency Supported or Direct
Provider Purchased services delivered by agencies other than the FI, these services
must be included in the Self-Direction Budgets, where applicable. The FI will require
utilization information for services delivered by other agencies to be reflected in the
person’s monthly expenditure reports. Rate information can be found on the
Department of Health website:
(http://health.ny.gov/health_care/medicaid/rates/mental_hygiene/index.htm)
ADM #2019-07 describes the payment standards and service documentation
requirements for Fiscal Intermediary Services.
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CHAPTER 6 LIVE-IN CAREGIVER
Live-in Caregiver is an HCBS Waiver service that utilizes an unrelated care provider
who resides in the same household as the waiver participant and provides as-needed
supports to address the participant's physical, social, or emotional needs so that the
participant can live safely and successfully in his or her own home.
The Live-in Caregiver must not be related to the participant by blood or marriage
to any degree.
The Live-in Caregiver must go through any required background check(s)
performed by the FI before they can begin services.
Payment Standards
Payment for this service will cover the additional costs of room and board incurred
by the waiver participant and reasonably attributed to the Live-in Caregiver. Room
and board includes rent, utilities and food. Payment may not be made directly to the
LIC. The FI will transfer the amount of reimbursement to the individual or the
property owner and utility companies, as specified in the agreement between the
individual and the FI.
The participant must reside in his/her own home or a leased residence. Payment will
not be made when the participant lives in the caregiver's home, in a residence that is
owned or leased by the provider of Medicaid services, in a Family Care home, or in
any other residential arrangement where the participant is not directly responsible for
the residence. Maximum Live-in Caregiver amounts can be found in
Attachment F at the end of this guidance.
ADM #2016-03 describes the payment standards and service documentation
requirements for Live-in Caregiver Services.
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CHAPTER 7 INDIVIDUAL DIRECTED GOODS AND SERVICES (IDGS)
Participants who choose to self-direct their services and take on Budget Authority may
receive IDGS as a waiver service. Individual Directed Goods and Services (IDGS) are
services, equipment or supplies not otherwise provided through OPWDD’s HCBS
waiver or through the Medicaid State Plan that address an identified need in a
participant’s service plan. Self-Direction funds cannot be used to purchase an IDGS
service that is available under the State Plan. Total IDGS expenditures are limited to
$32,000 annually or the person’s PRA, whichever is less. Further detail is included in
the IDGS Definitions Chart (link found in Attachment G).
Participants may manage their IDGS, as described in their Individualized
Service Plan and Self-Direction Budget, to fully purchase or contribute towards
the purchase of items or services which meet all of the following criteria:
1. Are related to a need or goal identified in the person-centered care
plan/Individualized Service Plan;
2. Are for the purpose of increasing independence or substituting for human
assistance, to the extent the expenditures would otherwise be made for
human assistance;
3. Promote opportunities for community living and inclusion and/or increase
the participant’s safety and independence in his/her home environment;
4. Are able to be accommodated without compromising the participant’s health
or safety;
5. Are provided to, or directed exclusively toward, the benefit of the
participant.
In addition to these requirements, the IDGS chart lists additional criteria that must be
met for specific categories of IDGS.
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Community Classes
Self-directed supports through IDGS offer great opportunities for people with
developmental disabilities to purchase community based classes that teach a
subject, are open to the public, and result in active engagement and participation in
integrated community settings.
Each of the following are excluded from being funded with the IDGS as a
Community Class:
• Classes that duplicate any Medicaid State Plan or HCBS Waiver service or
are conducted by an entity that delivers such services;
• Classes where participation is restricted solely to people with
intellectual/developmental disabilities (I/DD);
• Classes where there are not established published fees;
• Classes that are credit bearing for matriculating students;
• Classes in a setting accessed only by people with I/DD (not including paid
staff support), including all certified settings; and
• Classes that do not adhere to the standards identified in the broader IDGS
rules and standards (e.g. experimental therapies).
Participation in specialized classes that take special needs, such as physical
limitations or beginner level learning, into consideration are appropriate as long as
those specialized classes are open to the broader public.
Private classes and lessons are allowable as long as they relate to an integration
goal and the lessons are not taking place privately for the purpose of segregating the
participant.
Transportation
When a person needs transportation to/from a service-related activity, IDGS can be
used to reimburse service related mileage, or pay for public transportation. In order
to be reimbursable under IDGS, however, transportation costs and mileage must be
related to a Medicaid reimbursable service within the Self-Direction Budget.
Additionally, Transportation in IDGS is only available for those services that do not
have transportation built into the fee and/or are not covered by the State Plan.
Transportation related to IDGS services or those delivered by Self-Hired staff would
be considered allowable reimbursable costs.
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Camp
For a person who has Budget Authority, Camp programs may be funded using
IDGS. Reimbursement from Medicaid is not available until after a person has
attended the camp. When a camp deposit or prepayment is made, but the person
never attends camp, no service has been rendered to the person and, therefore, no
reimbursement may be claimed from Medicaid. Medicaid does not reimburse
services that are not rendered. If the FI or the family made a non-refundable deposit
or prepayment, whoever made the payment to the camp accepted the financial risk.
When a camp deposit or prepayment is made, and the person arrives at camp,
participates in some programs, but leaves camp early, then the terms of the camp’s
policy should be consulted. If there is opportunity to request a partial refund, such
refund should be requested. If there is a strict no-refund policy, the full cost of the
service term may be submitted to Medicaid as long as it does not exceed one
month. The maximum service term Medicaid reimburses is one month. Since most
camps have terms measured in weeks, it is unlikely that the FI (or family) would be
left with an unreimbursed liability. However, if a participant were to enroll at a camp
that demanded prepayment for a full three-month summer term (i.e., June, July, and
August), it is possible that an unreimbursed liability could be generated. The FI
would be forced to break up the camp term into units no greater than a
month. Some service must be delivered in a given month in order to bill a service
unit for that month. Therefore, if a camper were to leave in the second week of June
and not return, the FI (or family) could be left with an unreimbursed liability for two-
thirds of the total cost of the camp.
IDGS Camp Reimbursement is available for Camps that are not funded as
Medicaid Waiver Respite Camps. Self-Direction participants can choose to
attend Waiver Respite funded Camps. However, those camps must be
included in their Self-Direction Budget as Direct Provider Purchased Respite.
IDGS funds may not be used for camps that are outside New York State, as
these camps are not issued a permit by New York State.
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Paid Neighbor
The Paid Neighbor stipend is paid to a neighbor to serve as an “on-call” support. A
Paid Neighbor is someone who should be available to respond when needed.
Proximity in relation to the needs of the participant should be considered when hiring
a Paid Neighbor, and be based upon the participant’s likely need for a particular
response time. In no case should a Paid Neighbor live with the participant nor should
a Paid Neighbor be more than 30 minutes from the participant.
The Paid Neighbor cannot be a “family member” of the Self-Direction
participant. See Chapter 9 “Hiring Family Members” Section for more
details.
Staffing Support
Staffing Support cannot deliver services that would duplicate FI services or Broker
responsibilities as related to development of the SD plan. The staffing support role
can only include tasks in the spectrum of, “Assistance with scheduling self-hired staff
and with assisting the person to complete staffing related paperwork.”
The person who provides Self-Directed Staffing Support through IDGS may be
someone who provides self-hired CH, Respite or SEMP services to that participant
or other participants, however, they cannot be otherwise employed by a not for profit
agency. The billing must reflect what service is being provided. The documentation
and time tracked should reflect what service the staff is providing at the time, either
Community Habilitation/Respite/SEMP or Staffing Support.
Health Club/Organizational Memberships
Funding for a gym or health club may be reimbursed through IDGS in the self-
directed plan for reasons of health and fitness or community integration. A person
may have multiple memberships to health clubs. Memberships are for the individual
only. Family or staff memberships cannot be reimbursed with IDGS funding. The
club/organization must offer open enrollment to the public and the reimbursed fee
must be the same as the published membership duties/fees.
A Self-Direction Participant’s activity fees, expenses (such as related supplies) and
meals are explicitly prohibited from IDGS funding. The following chart is provided to
assist with establishing the difference between reimbursable memberships and non-
reimbursable activity fees/expenses:
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Organizational Memberships
(Reimbursable as Memberships)
Ski club membership dues
Museum or zoo membership
Softball league fees
Pony Club membership
Girl Scout/Boy Scout dues
Membership dues for a Bowling
League
Community group membership fees
(e.g., 4-H, Kiwanis, Elks)
Activity Fees/Expenses
(Not Reimbursable as Memberships)
Ski resort lift tickets and equipment rental
Tickets or season passes to a water park
Tickets to a baseball game
Horseback riding helmet
Scout uniform and trip expenses
Bowling shoe rental fee
Group shopping discounts (Wholesale
“club” memberships, farm shares)
Online dating websites
IDGS Billing
For Medicaid billing purposes, the reported date of service (DOS) for IDGS should
be the date that funds are paid out by the Fiscal Intermediary, or the date that the
good or service is actually received by the participant, whichever is later.
IDGS is a Medicaid program that reimburses costs already incurred for goods and
services. Reimbursement may be made to the person/designee who made the
qualifying purchase. A good or service can also be purchased directly from a vendor
by the FI on behalf of the person who self-directs. Medicaid rules generally require a
service to happen prior to billing. For IDGS the “service” constitutes both the
person’s receipt of the reimbursable item and the FI’s reimbursement or direct
purchase.
For some IDGS categories (e.g., mileage reimbursement under “Transportation”),
the payment is made by the FI after the service is delivered. In this scenario, the
date of service would be the date that the FI issued the reimbursement. However,
sometimes an FI will choose to reimburse an item or service that has not yet been
delivered (for example, deposits or payments made in advance for camp). Generally,
Medicaid does not reimburse services or items before they are delivered and, in
terms of services, before the service is “complete.” In this scenario, the DOS would
be the date of the last day that the participant attended the camp. The time limits for
billing Medicaid do not start until the DOS. If the FI has not made the
reimbursement, the DOS has not occurred. This should not be construed to indicate
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that there is an unlimited “begin” date for reimbursements to be submitted by the FI.
Good judgement and business practices should be applied to individual scenarios,
but in general a reimbursement should never qualify if the item/service was
purchased prior to the approval of the person’s SD budget.
In scenarios where a person is participating in a service funded by IDGS that spans
more than one month, the FI may bill for an appropriate prorated portion of the cost,
using the last day of the service month as the billing date of service. For example, a
person is attending camp that runs from July 1 through August 31 and the cost of the
camp is $1,000. The FI may submit a claim for half the reimbursement on July 31 in
the amount of $500 and the remaining $500 balance would be submitted with an
August 31 date of service.
When a Self-Direction participant’s IDGS service provider demands substantial
“deposits” or “pre-payment” months in advance of actual service delivery, the FI
should follow its own established policies as explained in Chapter 5 Fiscal
Intermediary.
IDGS is billed to Medicaid in $10 increments. Each unit must be for $10 and
there will be no rounding up. A maximum of 99 units may be billed to Medicaid
on a given date of service. This limits billing to $990 per date of service for
IDGS. In instances where the FI has receipts and documentation
substantiating allowable expenditures beyond the daily billing limit of $990,
eMedNY can be billed using consecutive dates of service. For example, if
receipts and documentation substantiate $1,500 in qualified IDGS
reimbursement, an FI may submit one claim for 99 units totaling $990 on a
given date of service and submit an additional claim for the remaining balance
of 51 units totaling $510 on the next date of service.
ADM #2015-05 describes the payment standards and service documentation
requirements for Individual Directed Goods and Services.
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CHAPTER 8 OTHER THAN PERSONAL SERVICES (OTPS)
People who are self-directing their services with Budget Authority may elect to use up to
$3,000 in 100% state funding for items that are not Medicaid-fundable. This budget
category is called “Other Than Personal Services” or OTPS.
For any item or service to be approved for OTPS funding in any category, it
must pass ALL of the following four tests:
1. Be related to a valued outcome in the person’s plan
2. Increase the person’s independence and/or health and safety
3. Not be an OTPS excluded item (see page 29 of the SD Guidance)
4. Not be funded through any other source
Other resources (including community based and Medicaid funded) must be explored
and exhausted prior to utilizing state OTPS funds for the purchase of such items. For
example, cell phones are often made available to people who have Social Security
eligibility.
OTPS Categories
The OTPS section of the budget is limited to the following categories of supports:
• Phone service – cell and/or land line*
• Internet* (in instances where a participant has a cable package, OTPS can be
used for phone and internet only, but not the cable portion)
• Software related to the person’s disability
• Staff activity fees ( self-hired staff only) to cover meals, admissions, fees,
transportation or other costs incurred by staff when providing support to the self-
directing person in activities that support a valued outcome
• Staff advertising/recruitment costs
• Cost associated with staff time for planning or training meetings where such
costs exceed the hourly limits of the service
• Personal Use Transportation
• Clothing* (capped at $250)
• Board Stipend* (must first request and be denied for food stamps, or approved,
but not sufficient to cover needs)
• Utilities*
• Other goods and services that increase independence
• Other goods and services related to health and safety
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* In general, landline, internet, clothing, utilities, and board stipend expenses are not
reimbursable in OTPS for children under 18 years old where parents are responsible for
these costs. Exceptions may be granted by the Developmental Disability Regional
Office (DDRO) in cases where justification for a specific need is established (e.g., the
family would not otherwise have internet in the home but it is necessary to support a
technology system utilized by the FI and self-hired staff).
.
Items Excluded From OTPS
OTPS cannot be used to pay for certain excluded items. Excluded items include, but
are not limited to:
• Medical visit co-pays
• Any expenses related to hospitalization or nursing home stays (including staff or
respite supports or family expenses)
• Any illegal item or activity
• Cable television
• Common household supplies (e.g., paper towels, wipes, soap)
• Treatments that are experimental in nature
• Repairs, like a broken step or railing, as they should be covered under the lease
or are the responsibility of the home owner
• A self-directing person’s activity fees or related supplies for an activity or
community class, even if funded through Individual Directed Goods and Services
• Rental cars (this OTPS exclusion does not apply to vehicles leased in the
participant’s name)
• Vehicle purchases, payments towards a purchased vehicle
• Legal fees
• OTPS cannot be used to apply against housing costs in excess of housing
subsidies. If a person’s rent is in excess of allowable housing subsidies, this will
have to be reimbursed with the person’s or the family’s own resources.
OTPS Billing
Reimbursement may be made to the person/designee who made the qualifying
purchase. A good or service can also be purchased directly from a vendor by the FI on
behalf of the person who self-directs. For OTPS the “service” constitutes both the
person’s receipt of the reimbursable item and the FI’s reimbursement or direct
purchase.
For OTPS the service month is considered instead of the date of service. The service
month will be the month when the good/service was purchased, or reimbursed/direct
purchased by the FI, whichever occurs later. The time limit for vouchering state
payments begins on the last date of the service month.
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This should not be construed to indicate that there is an unlimited “begin” date for
reimbursements to be submitted by the FI. Good judgement and business practices
should be applied to individual scenarios, but in general a reimbursement should never
qualify if the item/service was purchased prior to the approval of the person’s SD
budget.
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CHAPTER 9 SUPPORTED EMPLOYMENT, COMMUNITY HABILITATION
AND RESPITE
The services described in this chapter can be varied in the way in which they are self-
directed. Supported Employment includes both direct and indirect activities associated
with helping a person get a job and gain skills necessary to retain the job. Community
Habilitation is a service delivered in the community (i.e., non‐certified settings) to
facilitate inclusion, integration, and relationship building. Respite is a service that
provides relief to unpaid caregivers who are responsible for the primary care and
support of a person with a developmental disability. The methodology for budgeting
these services depends on the authorities and staffing options chosen by the
participant. Other rules and considerations for these services can be found in the
respective ADMs (see Attachment G)
Direct Provider Purchased and Agency Supported
If a person has a Self-Direction Budget and chooses to receive Direct Provider
Purchased or Agency Supported Community Habilitation, Supported Employment
and/or Respite services, the cost of those services are included in the Self-Direction
Budget and deducted from the person’s PRA.
Self-hired Staff
A person can use self-hired staff to provide Supported Employment, Community
Habilitation and/or Respite with a Self-Directed Budget.
Centers for Medicare and Medicaid Services (CMS) is very clear that within Self-
Direction, a person can hire their own staff to deliver services but the payment
cannot exceed the rate a provider would be paid for the service. Hence:
A person can have self-hired staff persons but payment to the self-hired staff
persons (including all allowable costs that comprise the total employment cost)
cannot exceed the provider rate that would be paid to an agency providing the
same service.
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Hiring Family Members
There are specific restrictions regarding self-hired staff who are related to a Self-
Direction participant. Except where specifically prohibited (e.g., relatives cannot be
hired to deliver Live-In Caregiver or Paid Neighbor services), relatives may be paid
as service providers as long as all of the five following criteria are met:
1. They are at least 18 years of age.
2. They are not the parents, legal guardians, spouses, or adult children
(including sons and daughters-in-law) of the participant.
3. The service is a function not ordinarily performed by a family member.
4. The service is necessary and authorized and would otherwise be provided
by another qualified provider of waiver services.
5. The relative does not reside in the same residence as the participant.
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CHAPTER 10 FAMILY REIMBURSED RESPITE
In addition to, or in lieu of, Respite that is Direct Provider Purchased, Agency
Supported, and Self-Hired, participants in Self-Direction can include Family Reimbursed
Respite (FRR) in their budgets. FRR is paid for with 100% State funds and capped at
$3,000 annually.
Payment Standards
This service is designed to be used as needed, up to the amount budgeted. The
FRR provider and wage do not require prior authorization or approval.
The Fiscal Intermediary may not pay the FRR provider directly. To receive
reimbursement, the Self-Direction participant sends the FI an invoice or statement
specifying the date, times, hours and cost for the FRR utilization.
FRR is a reimbursement service to the family for the expense they incur in being
relieved of their primary caregiver responsibilities. OPWDD is not paying the
person/agency that provides this relief and does not track or regulate who they may
be.
A person who self-directs and receives a Housing Subsidy cannot receive Family
Reimbursed Respite.
For FRR the “service” constitutes both the family incurring the expense and the FI’s
reimbursement.
For FRR the service month is considered instead of the date of service. The service
month will be the month when the family incurred the expense, or is reimbursed by
the FI, whichever occurs later. The time limit for vouchering state payments begins
on the last date of the service month.
This should not be construed to indicate that there is an unlimited “begin” date for
reimbursements to be submitted by the FI. Good judgement and business practices
should be applied to individual scenarios, but in general a reimbursement should
never qualify if the expense was incurred prior to the approval of the person’s SD
budget.
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CHAPTER 11 FAMILY SUPPORT SERVICES
For people who Self-Direct with Budget Authority, Family Support Services (FSS) is a
service that must be included in Self Direction Budgets under Contracted Services. FSS
requires prior authorization from the DDRO and/or FSS Provider, as applicable. These
services are paid for with State funds.
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CHAPTER 12 HOUSING SUBSIDY
Self-Direction participants who choose to live independently, or who share a living
environment and have tenancy rights, may be able to include a Housing Subsidy in their
budgets, funded with 100% State funds. The amount of available Housing Subsidy is
calculated based on a participant’s income and Housing and Community Renewal
(HCR) payment standards. Housing Subsidy follows the same rules as Individual
Supports and Services (ISS).
If an individual qualifies for both Community Transition Services (CTS), and an ISS
Transition Stipend, it is the expectation that the CTS funding be maximized before
requesting funding through an ISS transition stipend. If an individual receives the
maximum payment through CTS, they can only request the difference between the
maximum ISS transition stipend and the amount reimbursed through CTS.
Restrictions
Housing Subsidy is restricted to participants in Self-Direction who are at least 18
years old. The rental lease or mortgage must be in the name of the person who is
self-directing, or the person who is self-directing must have clear tenancy rights in a
shared living environment.
A person who self-directs and receives a Housing Subsidy cannot receive Family
Supports and Services (FSS) nor Family Reimbursed Respite (FRR).
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CHAPTER 13 SHARED LIVING ARRANGEMENTS
The following policy applies to all individuals who Self-Direct with Budget Authority.
Furthermore, the guidance below is applicable to all services/supports that are included
within an individual’s Self-Direction budget regardless of the funding source (i.e.,
Medicaid versus 100% State funded).
An individual enrolled in Self-Direction may choose to live in a shared living
arrangement with other individuals enrolled in the Self-Direction program. These shared
living arrangements may include the sharing of staff or the cost of other routine
household expenses (e.g., rent/mortgage expenses). No more than four (4) individuals
in a shared living arrangement may share staffing supports.
OPWDD Administrative Directive Memorandum (ADM) #2015-01, Service
Documentation for Community Habilitation Services Provided to Individuals Residing in
Certified and Non-Certified Locations and 14 NYCRR Subpart 635-10.5 describes the
limitation of the staff to individual ratio for each service session. A Community
Habilitation service session may include a maximum of four (4) individuals per one staff
person. Therefore, if a group of individuals would like to share staffing to provide
Community Habilitation supports throughout a given day within a shared living
arrangement, the maximum number of individuals who engage in shared staffing
arrangements is four (4) individuals (or less) per staff person.
Community Habilitation services are reimbursed via a fee schedule. The fee schedule
describes the appropriate fee to be billed based on the staff to individual ratio during the
service session as follows:
• Individuals living in non-certified settings with self-hired or agency supported
staff:
o One staff to one individual; or
o One staff to group of two to four individuals.
• Individuals living in non-certified settings with direct provider purchased staff:
o One staff to one individual;
o One staff to two individuals; or
o One staff to three or four individuals.
Shared staffing arrangements must be billed based on the number of hours that staff
are providing services to individuals and the number of individuals who engage in
shared staffing who reside in a shared living arrangement (whether a single residence
or apartment complex). For example, if a group of four individuals engage in shared
self-hired staffing in a non-certified living arrangement, Community Habilitation supports
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provided throughout the day would be billed at the group fee schedule. The Community
Habilitation fee schedule is available on the Department of Health Mental Hygiene Rate
Setting website at:
https://www.health.ny.gov/health_care/medicaid/rates/mental_hygiene/.
Example
An example of a Community Habilitation schedule for a group of four (4)
individuals who are engaging in shared staffing and live together in one non-
certified apartment may include the following ‘shifts’ for their self-hired staff:
• Staffing support hours from 12am-6am.
• Staffing support hours from 6am-12pm.
• Staffing support hours from 12pm-6pm.
• Staffing support hours from 6pm-12am.
In this example, twenty-four (24) hours of Community Habilitation services would
be billed at the group rate code for each person.
Example
An example of a Community Habilitation schedule for two individuals who live in
a non-certified living arrangement comprised of separate apartments who choose
to share self-hired staffing supports to deliver Community Habilitation services,
but the staff person does not simultaneously deliver services to both individuals
may include:
• Individual A: Staffing support hours from 8:00am-12pm
• Individual B: Staffing support hours from 12pm-2pm
In this example, Individual A would claim four (4) staffing support hours at the
one staff to one individual fee. Individual B would claim two (2) staffing support
hours at the one staff to one individual fee.
Additionally, when using a shared staffing arrangement, individuals and providers must
continue to follow the Guidance on Overnight Supports from Chapter 18 of this manual.
In situations where individuals would like to use Self-Direction funding resources for
expenses related to their shared living arrangement, funds must be allocated
individually from each person’s budget consistent with existing budget methodologies.
For example, three (3) individuals share a non-certified residence. The rent for the
residence is $1,500 a month. Each individual would be responsible for contributing a
proportional share of the rent costs consistent with existing methodologies, up to a
maximum of $500 per individual per month.
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In all of the situations described above, an agreement must be reached between all
participating parties when staffing supports, or other Self-Direction resources are being
shared. Individuals and their Fiscal Intermediaries (FIs) will need to work cooperatively
to determine proportional contributions for shared expenses. Payment arrangements
will also need to be specified in the agreements between each individual and their FI.
The terms of these agreements must be provided in each individual’s care planning
record.
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CHAPTER 14 OUT-OF-STATE- and OUT-OF-COUNTRY-SERVICES
Self-directed services delivered outside of New York State must adhere to the
requirements in ADM 2019-02R: Permissible Out-of-State or Country Home and
Community-Based Services (HCBS) Waiver Services Delivery.
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Self-Direction
Guidance for Providers
Part 3
Self-Hired Fringe Benefit
Budgeting and Billing
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CHAPTER 15 FRINGE BENEFIT BUDGETING AND BILLING OVERVIEW
Part 3 provides guidance on claiming self-hired services to Medicaid. Topics
discussed include distinctions between work hours and billable hours and between
wage rates and reimbursement rates, types of self-hired staff, accounting for indirect
costs associated with self-hired employees, and issues related to the processing
logic in Medicaid for self-hired services.
Terms
Understanding the distinctions between these terms is essential to ensure correct
budgeting and claiming for self-hired services.
Work Hours: The actual hours worked by the employee. Per federal and state
labor law, employees must be paid for all hours they are "suffered or permitted to
work."
Wage Rate: The standard rate of pay per hour worked as negotiated by the
participant/family and the self-hired employee. Nonstandard wage rates may
apply in special circumstances (e.g., "overtime" pay).
Billable Hours: The subset of work hours spent by the employee on billable
service activities, as described and defined in OPWDD regulation and
administrative memoranda.
Indirect Employment Cost: Expenses of employment other than wage costs,
including the employer-paid portions of employee benefits, payroll taxes, etc.
Total Employment Cost: Employee wages for hours worked plus indirect
expenses related to the employment of the self-hired worker.
Effective Reimbursement Rate: Total employment costs for the service period
claimed divided by the billable service hours delivered and documented during
the same service period.
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Types of Self-Hired Staff
Employees: The participant and the FI share responsibilities as "co-employer"
of self-hired employees. FIs should permit the participant broad leeway to
negotiate the wage rates of self-hired staff, within the reimbursement restrictions
described in Chapter 16. Because the FI is the legal "employer of record," benefit
packages and other terms of employment typically must follow the FI's policies.
In these cases, the participant may not be able to negotiate further. Nearly all
true employees drive indirect costs in addition to their wage payments. These
indirect costs, in addition to the direct wage costs, must be appropriately
accounted and included in the fee billed to Medicaid.
Self-hired staff who perform Community Habilitation, Respite, and Supported
Employment services must be employees of the participant and Fiscal
Intermediary due to the nature of the work performed by such staff.
Contractors: Staff members who perform services at a negotiated payment per
hour of service rendered as outlined in a formal service contract. Some examples
of a self-hired contractor are a clinician, consultant and therapist. Self-hired
contractors may be self-employed (i.e., an "independent contractor") or may be
the formal employees of a staffing agency. In either case, the legal relationship
between the participant and the self-hired contractor is "purchaser-contractor,"
not "employer-employee." The negotiated service rate is considered "payment-in-
full" for services rendered and there are no indirect costs to be reimbursed. There
are no fringe or indirect costs related to these services when self-hired as a
contractor.
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CHAPTER 16 ACCOUNTING INDIRECT EMPLOYMENT COSTS
In addition to wage expenses, there are "indirect" costs associated with self-hired
employees. Indirect costs include mandated expenses such as the employer portion of
payroll taxes, costs associated with workers compensation and unemployment
insurance, and the employer's cost of providing health insurance to eligible employees.
FI agencies often elect to provide additional employee benefits including life insurance,
pension/retirement plan, and paid time off. Indirect employment costs are part of the
total cost of delivering a service and must be properly charged on the service claim in
order to be reimbursed by Medicaid. There are two basic methods for calculating and
charging indirect employment costs to Medicaid:
Direct accounting method
The FI may elect to record and charge indirect employment costs in the precise
month in which they are incurred for the specific self-hired employees in each Self-
Direction Budget. This method is most feasible when the employee benefit package
is sparse and the FI submits reimbursement claims on a monthly billing cycle.
Fringe rate method
As an alternative, the FI may create a separate pooled account to cover indirect
employment expenses across all of the Self-Direction Budgets it administers. This
pooled account/fund should be funded by fixed percentage surcharges on the wages
of self-hired employees, so that each payment of employee wages yields a
corresponding and proportionate payment into the FI's pooled fringe account. In this
case, the fringe would also include shared overtime and travel costs. FIs have
freedom to establish and administer their own fringe benefits programs and it is
expected that these programs may differ substantially between FIs.
The following principles should be adhered to when using the Fringe Rate Method:
1. Uniformity: The fringe program administered by the FI should be uniform
across all Self-Direction Budgets participating within it. At their option, FIs may
offer single or multiple fringe packages. When multiple packages are offered, the
FI may charge differing fringe assessment rates reflecting the cost differences
among the various packages offered. All benefits packages must be potentially
available to all Self-Direction Budgets administered by the FI and the assessment
rate charged for each benefits package offered should be the same for all
participants.
2. Disclosure: The participant should understand what he/she is "buying" for
employees through the fringe assessment. The FI should provide participants
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with a clear, concise, and complete outline of all indirect employment costs and
employee benefits funded under each fringe package(s) offered and the
assessment rate associated with each package.
3. Impact on permissible wage ranges: The impact of fringe assessment rates
on the permissible wage rates that may be negotiated with self-hired employees
should be explained to participants and their brokers.
4. Advance notice of benefit package and fringe assessment rate changes:
FI agencies shall give participants with self-hired employees at least two months
prior notice before adjusting benefits packages and/or fringe assessment rates.
The implications of an assessment rate change on the effective budget plan
should be reviewed with the participant. Assessment rates shall not be adjusted
retroactively.
5. No administration charge: Costs associated with the FI's administration of
the fringe benefits pool are included in the FI's monthly fee for FI services.
Fringe assessment rates shall not include any component reimbursing the FI for
its administrative cost and effort in managing the fringe pool account.
6. Management of fringe account balances: The FI is responsible for setting
assessment rates that fully fund all fringe program obligations and permit timely
payment of such obligations.
7. Separate Account: A separate, dedicated account or fund must be
established for the self-hired fringe program. Funds in the pooled fringe account
are only for use in addressing indirect employment costs outlined in the
description provided to Self-Direction participants.
8. Surpluses: Surplus funds in the fringe account should not be transferred or
skimmed to cover other costs, losses, or obligations of the FI agency. When
account balances become excessive, surplus funds should be used to reduce the
fringe assessment percentage.
9. Deficits: If the fringe account is temporarily in deficit, the FI will be expected
to honor any financial obligations on behalf of participating Budgets using its own
operational funds until such time it implements an increase in the fringe
assessment rate.
10. Monitoring by OPWDD: OPWDD may develop procedures and protocol to
monitor pooled fringe accounts for compliance with the above principles. This
may include compliance with requirements for submitting Consolidated Fiscal
Reports (CFRs) and compliance with auditing protocols.
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CHAPTER 17 CHARGING STAFF TRAINING EXPENSES IN SELF-HIRED
SERVICES
The term "training" is a broad term that describes many potential forms of instructing
and teaching employees in the skills, duties, and responsibilities required of their
positions. The following guidelines instruct FIs how to handle various forms of training
when billing self-hired services.
On-The-Job Training: Employee training and orientation at the place of work while
the employee is doing the actual job. Such training focuses on the specific tasks and
responsibilities of employees at the work location and the unique needs of the
particular person served. This instruction may be delivered by the person (and/or
family member or designee), by an experienced employee in concert with the person
(and/or family member or designee), or by a professional trainer or employee trainer.
Billable Charges: Employee time receiving employer-mandated training
typically constitutes "time worked" and should be paid as such. When the
person's current self-hired staff assists in the instruction, that employee must also
be paid for time worked. The total employment cost of all self-hired staff (i.e.,
wages + fringe assessment for both trainee and self-hired employee trainer) may
be included in the billed service charges for that service date. See Chapter 16 for
further information on inclusion of costs in the billable fee.
Billable Service Units: Self-hired employee work time spent entirely on
receiving instruction and orientation does not constitute billable time. Even while
under instruction, time spent delivering respite or habilitation services, is billable.
Remember, however, that a period of service time may be charged only once per
person served. Therefore, when an experienced self-hired employee assists in
delivering instruction to a new self-hired employee, only one of the two worker's
time is countable during the period of instruction, even though the billed charges
that day will include wages and fringe for both workers. See Chapter 16 for
further information on inclusion of costs in the billable fee.
Other Costs: Costs associated with the use of professional or employee trainers
(e.g., a FI employee who is not a member of the person's regular self-hired staff)
should be funded from the FI's monthly administrative fee. Costs associated with
developing, producing, and printing any training aids or instructional materials
shall also be covered by the FI's monthly administrative fee. Such costs may not
be included among the billable charges for the self-hired service itself. Any
training or instruction provided directly by the person receiving services, or
his/her family members or designees, shall be delivered free of any charge to the
State or Medicaid.
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Fiscal Intermediary Directed General Employee Orientation, Refresher, and
Classroom/Seminar Training
This is training and instruction provided to all self-hired staff who are co-employed by
the participant and the FI agency on professional, health, safety, and welfare skills,
procedures, and standards. It includes all direct support professional training
mandated by OPWDD or by the FI agency itself.
Billable Charges: Employee time spent receiving employer-mandated training
typically constitutes "time worked" and should be paid as such. Although
employee training time does not represent billable service time, the employment
costs (wages + fringe assessment) associated with such training do represent a
reimbursable cost of delivering the self-hired service. As such, training-related
employment costs may be included in the billed service charges for the service
date the employee training is attended. If there were no claimable service units
for the person on that particular day (e.g., all of the person's self-hired
community habilitation staff attended training that day, there was no substitute
staff, and, therefore, the person did not receive any billable community
habilitation service units that day), the training-related employment costs may be
added to the regular charges on the next day claimable service units were
delivered. Training should be scheduled and paced to minimize the potential of
exceeding the effective reimbursement rate (ERR) caps (see Chapter 16
Preparing Claims to Medicaid for Self-Hired Services) in any billing cycle.
Billable Service Units: Since the staff receiving training renders no habilitation
or respite services, this form of employee training will not yield billable service
units.
Substitute Staff: During the planning process, the person and their Circle of
Support should determine whether substitute staff will be required when regular
self-hired staff attend training. When substitute staff is required, the cost should
be included in the person's budget. This may be accomplished by either
budgeting additional staff hours for self-hired workers who will cover the trainee's
absence or adding Agency Supported or Direct Provider Purchased services to
the budget.
Other Costs: The FI agency is responsible for all other costs of such training
using funds derived from its monthly administrative fee. This includes the wages,
fees, and/or reimbursed expenses of the trainer or instructor, costs of all
instructional materials and their reproduction, facility costs, lodging, refreshments
and meals. Such costs may not be included among the billable charges for self-
hired service itself.
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Person/Family-Directed Special Employee Training
This is a special required employee training identified by the person (or his/her
family or designee) to address a specific need of the particular person served. It is
not delivered by the person who is self-directing or his/her family members or
designees. It is not general training required of all employees delivering self-directed
community habilitation, supported employment or respite services.
Billable Charges: Employee time spent receiving employer-mandated training
typically constitutes "time worked" and should be paid as such. Such paid time
will be claimed as a billable charge on the Medicaid claim. Follow the same
charging rules as described in the "FI-directed General Employee Training"
section above.
Billable Service Units: Since the staff receiving training renders no habilitation
or respite services, this form of employee training will not yield billable service
units.
Substitute Staff: During the planning process, the person and their Circle of
Support should determine whether substitute staff will be required when regular
self-hired staff attend training. Follow the same budgeting rules as described in
the "FI-directed General Employee Training" section above.
Other Costs: When appropriate, OTPS funding may be accessed, up to
specified limits, to cover the costs of course/seminar admission fees, materials,
mileage, meals and lodging for the self-hired employee being trained.
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Training Reimbursement as an Employee Benefit
At its discretion, the FI may offer training reimbursement as an employee benefit.
Most commonly, this involves full or partial reimbursement of college or technical
school tuition and fees. It may also include reimbursement of job or career-related
seminars, workshops, continuing education courses, professional conferences, etc.
As an employee benefit, attendance must be at the employee's own volition and may
not constitute a condition of continued employment. Neither should attendance be
otherwise coerced by any co-employing party (i.e., not by the FI agency nor the
person nor the person's family or designee). Time spent attending and preparing for
such training is not considered hours worked by the employee.
Billable Charges: The employee attends training on his or her own personal
time. Since no wages are paid, no billable charges against a self-hired service
are incurred.
Billable Service Units: Since the staff receiving training renders no habilitation
or respite services, this form of employee training will not yield billable service
units.
Substitute Staff: Since the employee attends training voluntarily on his or her
own personal time and not during duty hours, substitute staff should not be
required to support this form of training.
Other Costs: As an employee benefit, the cost of reimbursed tuition, fees, and
incidentals are charged to the FI agency's fringe rate (see Chapter 14).
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CHAPTER 18 PREPARING CLAIMS TO MEDICAID FOR SELF-HIRED
SERVICES
Self-hired services billed to Medicaid are processed using special logic. Ordinarily,
eMedNY ignores the charge amount submitted by providers when paying HCBS waiver
services. Instead, eMedNY calculates the amount due to the provider by multiplying the
submitted units times the official rate on file for the provider for the rate code billed.
Under Self-Direction, however, when they successfully arrange to reduce the total cost
of Community Habilitation, Respite, or Supported Employment services using self-hired
staff, participants free up PRA resources that can be used to fund additional or different
services. Because of this, eMedNY must be able to pay claims for self-hired services at
reimbursement rates that are at or below, but not above, the official rate for the
equivalent Direct Provider Purchased or Agency Supported service. This has the
following implications for claims submission and adjudication:
Service Unit Claiming
Just as with equivalent Direct Provider Purchased or Agency Supported services, FI
agencies will submit the total billable service units provided on each date services
were rendered. If multiple self-hired employees rendered services to the participant
on a service date, the sum of billable service units delivered by all staff should be
entered for that date. It is important to note that wage hours and billable time may
differ. FI agencies must ensure only billable time, as described in OPWDD
regulations and administrative memoranda, is entered on the claim form.
Amount Charged
The total employment cost paid out by the FI for self-hired services rendered to the
participant on the service date should be entered into the amount charged field on
the claim. Total employment cost includes both the wage payment to the employee
plus indirect costs paid out (typically, the fringe assessment taken as percentage of
wages and transferred to the FI's pooled account for that purpose). If multiple self-
hired staff rendered services to the participant on the service date, the sum of total
employment cost for all employees should be entered.
Multi-day versus Single-day Claiming
The eMedNY system permits providers to submit claims covering multiple dates of
service in a single claim transaction. For a variety of reasons, OPWDD typically
recommends against such bundling for most HCBS services. For self-hired services,
however, this bundling technique may be advantageous. The effective
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reimbursement rate, which is later compared to the fee for the equivalent Direct
Provider Purchased or Agency Supported service (see below), is calculated at the
claim document level. This means eMedNY will calculate the effective
reimbursement rate as an average over multiple service dates. In situations where a
participant’s effective reimbursement rate is over the provider-purchased, or agency-
supported fee, on some days but under on other days, FI agencies will want to
submit multi-day claims. Claims for OPWDD service may not span calendar months,
however. All such "averaging," therefore, must take place within the course of a
single calendar month.
Reimbursement Rate Cap Logic
The State may not pay self-directed services at reimbursement rates that exceed the
rate paid for equivalent Direct Provider Purchased or Agency Supported services.
Payment processing logic enforces the rate cap as follows:
1. Medicaid calculates the effective reimbursement rate claimed for the self-
directed services submitted on the claim: total charges / total service units.
2. Medicaid retrieves the fee rate for the equivalent Direct Provider Purchased or
Agency Supported service.
3. If the effective reimbursement rate on the claim for self-directed services is less
than or equal to the equivalent Direct Provider Purchased or Agency Supported
service fee, eMedNY pays the precise amount charged by the FI agency.
4. If the effective reimbursement rate on the claim for self-directed services is
greater than the equivalent Direct Provider Purchased or Agency Supported
service fee, eMedNY pays the submitted units times the equivalent Direct
Provider Purchased or Agency Supported service fee.
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CHAPTER 19 GUIDANCE ON OVERNIGHT SUPPORTS
People may need supports during the overnight hours when they spend some or most
of the time sleeping. These supports could include monitoring for events that will require
hands-on assistance or ongoing activities, such as developing the person’s skills or
tending to the person’s safety. If nighttime supports are needed the following services
should be considered when developing the Self-Direction Budget.
Paid Neighbor
Funded via IDGS. A Paid Neighbor can be available to the person so that, if the
person has a need, the Paid Neighbor can respond and provide the appropriate
support. A Paid Neighbor provides as-needed support. See the IDGS chart for Paid
Neighbor specifics.
Personal Care
Funded via State Plan Medicaid. If the need for support relates to the provision of
personal care, it may be appropriate to obtain supports from a personal care
assistant through a community-based program where those supports are delivered.
This does not count against the PRA.
Respite
If a participant lives in a setting with an unpaid support giver, respite may be an
appropriate option for overnight supports.
Community Habilitation
The Community Habilitation (CH) service requires that a face-to-face service be
delivered during the course of the continuous time period where the service is
provided. A review of the hours that the CH staff person works should be part of
service planning to determine and clarify the service expectations.
CH is a means of support for people attempting to live as independently as possible.
A portion of the CH service includes implementing person-specific safeguards that
are foundational to ensuring a person’s health and safety. There is no one-size-fits-
all approach in determining if CH is an appropriate service during overnight hours.
Each situation needs to be considered during a person-centered planning process
and the specific needs to the participant considered.
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Many people need supports during the night to ensure their safety, but do not need
direct observation during sleep hours. These people may need available support
staff who can provide direct service if a specific need arises during the night.
A Community Staff Action Plan can include the identification of indirect service time
for a portion of the CH service that is integral to the overall plan, but is not delivered
in a face-to-face manner.
Components of indirect service time for the CH service can include:
• Staff training time (hours worked to attend training)
• Planning time (hours worked as part of person-centered planning
team/Circle of Support)
• Documentation time (time spent completing pertinent and required notes and
service documentation)
• Staff coordination and scheduling
• On-call time (hours spent on site by staff who are “available as needed” to
implement the Staff Action Plan)
• Asleep overnight staff
The following parameters must be met if asleep overnight staff time is built
into the indirect cost:
• The total hourly cost cannot exceed the regional rate for CH;
• There are enough billable hours to ensure that indirect costs cover sleep
time;
• The CH plan provides justification that asleep staff are able to provide
adequate oversight to the participant;
• CH staff who are also Live-In Caregivers or Paid Neighbors for the person
must not be paid for time spent asleep or in "on-call" status.
Under no circumstances does asleep staff support count as billable CH
service time.
Indirect service time must be documented as indirect service time in support of the
CH service, and must be tracked and paid as hours worked. However, indirect
service time cannot be billed as CH service hours. The indirect service time is paid
as part of the rate provided to agencies for the CH service, or as a component of the
self-hired staff wage established by the participant or designee.
All revenue and payments for both direct and indirect service time for staff must be
reported on the Consolidated Fiscal Report (CFR).
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Self-Direction
Guidance for Providers
Attachments
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Attachment A: Self-Direction Budget Types
A person who chooses Self-Direction can choose from three different budget types,
depending on what services they need. The budget types are Residential Only (RES),
Other Than Residential (OTR) and Both. The chart below outlines the services available
within each budget type. Note that some services may not be available depending on
the setting where a person lives.
Residential Only
(RES)
Other Than
Residential
(OTR)
Both
Support Broker X X X
Live in Caregiver X X
Individualized Goods and
Services (IDGS)
X X X
Other Than Personal
Services (OTPS)
X X X
Community Habilitation X X X
Supported Employment
(SEMP)
X X
Respite X X
Group Day Habilitation X X
Family Supports and
Services (FSS)
X X X
Prevocational Services X X
Pathway to Employment X X
Housing Subsidy X X
Family Reimbursed
Respite (FRR)
X X
Available to People Who
Live In a Certified Setting
X
Available to People Who
Do Not Live In a Certified
Setting
X X X
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Attachment B: Personal Resource Account (PRA)
Applies to people who self-direct with Budget Authority (includes those with Self-Hired
staff):
Services which must be included in
Self –Direction Budget and budgeted
for within a person’s Personal
Resource Account
Services which may be delivered
without being included in a person’s
Self-Direction Budget and do not
count against a person’s Personal
Resource Account
Support Broker (SB) Startup Brokerage
Live in Caregiver (LIC) Fiscal Intermediary (FI)
Individualized Goods and Services
(IDGS)
Community Transition Services (CTS)
Other Than Personal Services (OTPS)
State Plan Services (e.g. Personal Care,
Nursing)
Community Habilitation (CH) Article 16 Clinical Services
Supported Employment (SEMP)
Long Term Sheltered Employment (State-
Funded Contracts)
Respite
Intensive Behavioral Services (IBS),
Crisis Services for Individuals with
Intellectual and/or Developmental
Disabilities (CSIDD) and Resource
Center
Group Day Habilitation (GDH) Environmental Modifications
Family Supports and Services (FSS) and
Assistive Supports
Adaptive Technologies
Prevocational Services (Pre-Voc) Care Management
Pathways to Employment
Residential Habilitation: Supervised,
Supportive, Family Care**
Housing Subsidy/ISS Family Education and Training (FET)
Family Reimbursed Respite (FRR) Transition Stipend
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**A person who receives Residential Habilitation is limited to receiving only an Other
Than Residential (OTR) type budget. As such, these residential services are not
included in a person’s budget.
Attachment C: Budget Review Procedure
Intent:
For people who choose to self-direct their supports and services with Budget Authority,
Start-up, Initial and Amended Budgets need to be reviewed and approved by the Fiscal
Intermediary (FI) before they are submitted to the OPWDD for review. The purpose of
this procedure is to establish a consistent practice for reviewing Budgets to begin on
March 1, 2016.
Process:
1. The person who is self-directing and the Support Broker fill out the Budget
completely.
2. The Support Broker sends the completed Budget to the Fiscal Intermediary for
review.
3. The FI reviews the Budget and advises the Support Broker on any necessary
modifications. Once any needed changes have been made and returned to the FI, the
FI informs the Support Broker by letter or email that the FI agrees to the Budget and will
act as the FI for the person who is self-directing.
4. The Support Broker or FI sends the Budget and a copy of the FI’s affirmation to the
DDRO Self-Direction Liaison.
5. The DDRO Self-Direction Liaison reviews the Budget and advises the Support Broker
and the FI on any necessary modifications. Once any needed changes have been made
and returned to the DDRO Liaison, the DDRO Liaison sends the Budget* to OPWDD
Central Office for review.
*Cost Neutral Budget Amendments do not need to be approved by the OPWDD Central
Office
6. OPWDD Central Office reviews the Budget and advises the DDRO Liaison on any
necessary modifications. The DDRO Liaison notifies the Support Broker and the FI to
incorporate any needed changes. Once any required alterations have been made and
returned to OPWDD Central Office, OPWDD Central Office returns the final approved
Budget to the DDRO Liaison with an effective date when self-directed services can
begin.
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7. The DDRO Liaison sends the final approved budget to the person who is self-
directing, the Support Broker, the FI and any other appropriate party.
Secure Communication:
Self-Direction Budgets contain Personal Health Information (PHI). Any transition should
be by a method that is compliant with the Health Insurance Portability and
Accountability Act (HIPPA) and the Health Information Technology for Economic and
Clinical Health Act (HITECH Act).
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Attachment D: Continuity of Care
Prior to billing over-PRA Continuity of Care funding, an analysis needs to be done to
determine if there are unused resources still available in a participant’s budget that may
be able to be accessed. The participant should work with their Support Broker to
complete this analysis. If there are other Medicaid resources available in the budget
that are not expected to be used during the budget cycle, the participant/Support Broker
will need to complete a cost-neutral amendment form to move the dollars into
Community Habilitation. If, after the analysis, it is determined that there are no unused
dollars available in the budget to shift into Community Habilitation then the over-PRA
Continuity of Care funding may be accessed. The amount billed would be reflective of
the total cost, based on the current Community Habilitation fee in effect, in $10
increments, up to the funding level authorized.
OTPS & Continuity of Care
For plans in existence prior to 10/1/2014, OTPS may be used for clinical consulting and
additional living expenses not covered by a lease. This is on a time-limited basis and
OTPS cannot be used for those purposes any plan implemented after October 1, 2014.
Continuity of care will not apply to experimental treatments or non-evidenced practices
or for direct provision of clinical services. Continuity of Care Provisions are not
applicable to Self-Direction Budgets developed on and after 10/1/2014. On and after
10/1/2014, OPWDD will not approve increases or cost neutral changes to Continuity of
Care Provisions found in existing Self-Direction Budgets; OPWDD will only approve
decreases to such Provisions.
General Continuity of Care Provisions - In order to ensure continuity, the following
guidelines were followed:
• The state paid option for over-PRA is only available to the people who
transitioned from the Consolidated Supports and Services model and is
temporary. OPWDD will notify people when an end date has been established
and work with affected parties to transition for state funding of costs over-
PRA.
• Supports for Community Habilitation, SEMP and Respite must utilize the
defined methodology and support must be provided within the defined costs
of those services. State funds are not to be used to augment the rate paid for
the self-hired staff costs of those services. See detailed guidance for
Employment supports.
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Clinician and Certain Therapy Services
Clinical Consultation – To ensure continuity of care, a Self-Direction participant
may augment the hourly rate paid to a consulting clinician with 100% state funds.
This is allowed when the participant’s CSS budget (prior to 10/1/14) included the
consulting clinician’s services, and the hourly rate paid to the consulting clinician
exceeds the hourly rate paid through IDGS. OPWDD will evaluate the timeframe
that this continuity of care provision will be allowed.
Clinician - Direct Service provision - No use of state funds is allowed.
Therapies – To ensure continuity of care, a Self-Direction participant may augment
with 100% state funds the hourly rate paid for Hippotherapy, Therapeutic Riding,
Aquatic Therapy, Art Therapy, Massage Therapy, Music Therapy, and Play Therapy.
This is allowed when the person’s CSS budget (prior to 10/1/14) included the
therapy, and the hourly rate paid to the consulting clinician exceeds the hourly rate
paid through IDGS. OPWDD will evaluate the timeframe that this continuity of care
provision will be allowed.
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Attachment E: Support Broker Training Policy
Support Brokers assist people with developmental disabilities who choose to self-direct
their Office for People with Developmental Disabilities services with Budget Authority to
develop a Circle of Support and complete and manage a Self-Direction Budget. Self-
Direction provides individuals more responsibility in the management of their supports
and services. People who participate in Self-Direction may self-hire and manage their
own staff supports (employer authority) and decide on the supports and services they
need and how the funding allowed for these supports and services is allocated (budget
authority). This policy reiterates the training requirements and expectations for all
Brokers.
There are two phases of Support Broker services:
1. Start-Up Support Brokerage - Design and completion of an approvable Self-
Direction Budget. Completion of a Self-Direction Budget is typically accomplished
within six (6) months of the approval of a Broker Agreement for Start-Up
Brokerage and issuance of a Start-up Broker approval letter. Start-up Support
Broker services may be accessed once, with a lifetime funding limit of $2400 for
the Self-Direction participant’s use in paying for Broker services needed to create
an initial Budget.
2. Ongoing Support Brokerage - A variety of supports and services to ensure
successful implementation and continuation of the approved Self-Direction
Budget. The primary functions of the Support Broker are to maintain a Circle of
Support and manage the Self-Direction Budget. If a participant has chosen self-
hired Community Habilitation or Supported Employment services, Support
Brokerage Services include completing and updating Staff Action Plans for these
services.
Support Brokers are required to maintain copies of the training certificates for all
trainings they have completed to fulfill the requirements included here-in, and provide
(copies of) these certificates to the DDRO Self-Direction Liaison when requesting to
work in a DDRO. Copies also need to be provided to each Fiscal Intermediary that bills
for the Broker’s Support Broker services. Each year, Brokers must prove fulfillment of
the annual OPWDD and Professional Development training requirements.
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Initial Broker Training Requirements
Completed PRIOR TO delivering any Support Broker services.
1. Self-Advocacy/Self-Determination - should be taken prior to BTI.
2. Person-Centered Planning – must include both Introduction to Person-
Centered Planning and Advanced Person-Centered Planning. These courses
may be taken together or separately.
3. Broker Training Institute (BTI) - provides the philosophy of Self-Direction, details
regarding the responsibilities of Support Brokers, information regarding billing
and documentation requirements, and Circle of Support training.
4. Self-Direction Budget/Template – required to access the Budget Template.
Other OPWDD Required Trainings
Available from the DDRO Self-Direction Liaison for Independent Brokers.
1. Privacy and Security of Health Information - annual
2. Overview of Developmental Disabilities - once
3. Infection Control/ Blood Borne Pathogens/TB - annual
4. Medicaid Compliance - annual
5. PICA (if working with an individual for whom this training would be relevant) -
once
6. PRAISE (replaces Incident and Abuse Reporting) – annual
7. Right to Know – annual
8. Rights and Responsibilities of Persons Receiving Services - once
OPWDD Required Trainings must be completed by the end of the Broker’s first
calendar year. Trainings with an “annual” designation must be completed within
every calendar year.
Professional Development Training Requirements
Annual requirements to continue to provide Broker services
Support Brokers must attend professional development training annually. The minimum
number of training hours required is 12 hours annually. This professional development
may include lectures, workshops, and other training sessions conducted by OPWDD, a
Support Brokerage Learning Network, other agencies, or educational institutions. This
may include online courses, webcasts or other electronic communication media, offered
by OPWDD or other entities. The subject of the training must enhance the Support
Broker’s ability to serve individuals with developmental disabilities. The Support Broker
is responsible for ensuring that the subject matter of all training applied to the 12-hour
annual training requirement is appropriate. Attendance at the initial Broker Trainings
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cannot be counted towards the required annual professional development training
hours.
The twelve-month period in which the Support Broker must participate in the required 12
hours of annual training is called the “training year.” For brokers who were providing
brokerage services prior to October 1, 2014, the training year remains the same. For
brokers who began providing brokerage services on or after October 1, 2014, the
training year is the twelve-month period following the month the Support Broker first
began providing Support Brokerage services. The Support Broker is responsible for
maintaining his/her training records that verify attendance.
Family members who reside in the same household as the person who self-
directs their services or who are the parents of the person may NOT be paid for
providing Broker services. If a family member of a person with ID/DD is interested
in providing unpaid Broker service for that person, he/she must meet the initial
Broker training requirements as described above.
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Attachment F: Live-In Caregiver Maximum Reimbursement Levels
As of 10/01/2014, the maximum Live-in Caregiver reimbursement levels* are as follows:
Rate Setting Region 1
– New York City
Rate Setting Region 2
– Putnam, Rockland,
Westchester, Suffolk
and Nassau Counties
Rate Setting Region 3
- Rest of State
Rent - $17,676
annually
Food - $5,000
annually
Utilities - $ 3,500
annually
Annual Total -
$26,176
Monthly Max - $2,181
Rent - $19,200 annually
Food - $5,000 annually
Utilities - $ 3,500
annually
Annual Total - $27,700
Monthly Max - $2,308
Rent - $13,872
annually
Food - $5,000
annually
Utilities - $ 3,000
annually
Annual Total -
$21,872
Monthly Max - $1,823
*These are the maximum amounts by Region. Actual amount allowed in a person’s
budget will be limited by certain factors including county of residence, number of
bedrooms and calculations determined by the ISS formula and the Self-Direction
Budget.
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Attachment G: List of Applicable Administrative Memoranda
The links to the ADMs referenced in this guidance are:
• OPWDD ADM #2019-07 Service Documentation for Fiscal Intermediary Services
https://opwdd.ny.gov/adm-2019-07-service-documentation-fiscal-
intermediary-services-0
• OPWDD ADM #2019-06 Service Documentation for Support Brokerage Services
https://opwdd.ny.gov/adm-2019-06-service-documentation-support-
brokerage-services-0
• OPWDD ADM 2019-05R Authorization Standards for Support Brokers
https://opwdd.ny.gov/adm-2019-05r-authorization-standards-support-
brokers
• OPWDD ADM #2015-05 Individual Directed Goods and Services
https://opwdd.ny.gov/adm-2015-05-service-documentation-individual-
directed-goods-and-services-idgs-0
o Individual Directed Goods and Services (IDGS) Definitions Chart
https://opwdd.ny.gov/adm-2015-05-service-documentation-individual-
directed-goods-and-services-idgs-0
• OPWDD ADM #2015-02 Service Documentation for Community Transition
Services
https://opwdd.ny.gov/adm-2015-02-service-documentation-community-
transition-services-0
• OPWDD ADM #2015-01 (Supersedes OPWDD ADM #2010 – 05) Service
Documentation for Community Habilitation Services Provided to Individuals
Residing in Certified and Non-Certified Locations
Self-Direction Guidance for Providers March 10, 2022
Page 66 of 66
https://opwdd.ny.gov/adm-2015-01-service-documentation-community-
habilitation-services-provided-individuals-residing-0
• OPWDD ADM #2005-02 HCBS Respite/Non Waiver Enrolled (NWE) Respite
Service Documentation Requirements
https://opwdd.ny.gov/regulations-guidance/adm-2005-02-hcbs-respitenon-
waiver-enrolled-respite-service-documentation
• OPWDD ADM #2016-01 Supported Employment Service Delivery And
Documentation Requirements
https://opwdd.ny.gov/adm-2016-01-supported-employment-semp-0
• OPWDD ADM #2016-03 Live-in Caregiver Service Documentation
https://opwdd.ny.gov/adm-2016-03-live-caregiver-service-documentation-0
• OPWDD ADM #2018-09R Staff Action Plan Program and Billing Requirements
https://opwdd.ny.gov/adm-2018-09r-staff-action-plan-program-and-billing-
requirements-0
• ADM #2019-02R Permissible Out-of-State or Country Home and Community-
Based Services (HCBS) Waiver Services Delivery
https://opwdd.ny.gov/adm-2019-02r-permissable-out-state-or-country-
home-and-community-based-services-hcbs-waiver-0
