Articles

    Self-Direction Frequently Asked Questions

    TOPICS:
    Billing and Reporting Questions
    Employment Related Questions
    Service Eligibility Questions
    Service Provision Questions
    Financial and PRA Related Questions
    Service and Budget Approval Process Questions
    Miscellanous Questions

    Frequently Asked Questions (FAQs) on FI and Self-Directed Services

    Billing and Reporting Questions
    Q: How are organizations that offer direct provider supports advised that persons they have supported have started self direction? If they are not advised, they risk losing money as they might provide unauthorized services. What is the mechanism to insure direct providers are utilizing the correct number of authorized hours? 
    A: A variant of this question was addressed previously. FI's have a responsibility to monitor and track any services included in a SD plan. The FI may face liability if the PRA is exceeded or if any particular service, such as Community Habilitation, exceeds authorized levels. It is important for the FI and any partner agencies, including those that provide direct supports, to establish working relationships that allow them to monitor and track services. Care managers, brokers, FI's and providers need to be at the table together and all need to reference the Lifeplan.

    Q: How are self-hired staff paid when they attend required orientation/training?
    A: This issue is addressed in the most recent guidance document: “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.”

    The following example may help to illustrate this guidance:

    Total Employment Cost

    _______ = Effective Reimbursement Rate (ERR)

    Billable Hours
    Total Employment Costs = Direct Employment Costs + Indirect Employment Costs
    Direct Employment Costs = (Billable Work hours X Wage Rate) + (Indirect Service Time* X Wage Rate)
    Indirect Employment Costs = Direct Employment Costs X Fringe Rate OR Direct Account of all costs not associated with Wages
    *Indirect service time constitutes hours a Self?Hired staff was required to work, but billable services (as defined in the relevant Administrative Memorandum) were not delivered. Examples include attendance to a mandatory training, completing documentation, and overnight/asleep.

    Example: 24/7 coverage using Self?Hired Staff delivering Community Habilitation
    One week period.
    5 Staff, 8 hour shifts, including overnights. Assume all awake hours are billable.
    Staff #1: $15/hr – 40 hours
    Staff #2: $13/hr – 40 hours
    Staff #3 (asleep): $11/hr – 40 hours
    Staff #4 (asleep): $9/hr – 16 hours
    Staff #5: $14/hr: 32 hours
    Fringe = 25%
    (15 x 40) + (13 x 40) + (14 x 32) + (11 x 40) + (9 x 16) x 1.25/ 40 + 40 + 32 =
    2690/112 = $24.00 ERR ( Hourly Unit Cost)

    Q: According to the most recent Guidance Document, “The FI will require utilization information for services delivered by other agencies to be reflected in the person’s expenditure reports.” What is the FI’s responsibility to ensure expenditure reports accurately reflect services delivered by other agencies and what is the FI’s liability, if any, if another agency exceeds the authorized expenditure level?
    A:While the FI does not deliver those services, it has a responsibility to monitor and track any services included in a SD plan. The FI may face liability if the PRA is exceeded or if any particular service, such as Community Habilitation, exceeds authorized levels. It is important for the FI to establish working relationships with other providers that allow it to monitor and track services delivered by those providers.

    Employment Related Questions
    Q: May a person employed by the Fiscal Intermediary provide Self-Directed Staffing Support?
    A: This is an update from the first FAQ. A 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 any not for profit agency.

    Q: Are persons who provide IDGS supports (e.g. clinical supports, paid neighbor supports, staffing supports) limited to contractor status or may a FI directly employ those persons?
    A: OPWDD will not comment upon whether a particular provider of IDGS supports meets the criteria for either an employee or contractor. That question should be referred to the FI’s Human Resource Department and to its human resource counsel. However, there is no prohibition on a provider of IDGS supports being an employee of the FI. So, someone providing paid neighbor supports or clinical services through IDGS may indeed be employed by the FI.

    Q: What are OPWDD's training requirements for self-hired staff?
    A: Please see Attachment E in OPWDD’s most recent guidance document where training requirements are addressed in detail. The key to understanding Attachment E  is to know that mandated training for self hired staff is identical to mandated training for non-self hired staff in more traditional services (with the exception of SEMP. Please see the relevant ADM). More information on OPWDD’s training requirements may be found on its website here.

    Q: The Guidance Document states that a Live In Caregiver may not be related by “blood or marriage” to a SD participant nor may a “family member” provide Paid Neighbor supports. Elsewhere in New York’s waiver, an exception to these exclusions is provided:
    In extraordinary circumstances, the following are exceptions to this policy:
    -The Commissioner or designee may authorize a parent or legal guardian of an adult child (over the age of 18) to be paid to provide waiver services, when it can be clearly documented that the arrangement is in the best interests of the participant.
    -The Commissioner or designee may authorize an otherwise qualified relative who resides in the same residence as the participant to be paid to provide waiver services when it can be clearly demonstrated that the arrangement is pursuant to the participant's choice, is in the best interests of the participant, and does not potentially jeopardize the health, safety, rights and informed choice of the participant.
    Does this process to seek an exception also apply in SD? If not, why are SD participants not offered the same service exceptions as other persons enrolled in the waiver?
    A. These exceptions are not applicable to the Live-In Caregiver and Paid Neighbor services. Family members are explicitly restricted from providing those services.

    Q: The Guidance Document states that a person who provides the IDGS “Staffing Support cannot otherwise be employed by a not for profit agency”.  Please clarify the intent and meaning of this restriction.
    A: The intent of the restriction is to avoid conflicts of interest. It applies to employees of providers other than the FI or, employed by the FI in roles other than the provision of Self-Hired Community Habilitation, Respite or Supported Employment. It also applies to employees of any not for profit organization, whether or not that organization is involved in the delivery of supports to persons with I/DD.

    Q: Are persons who provide Staffing Support considered employees or contractors of the FI?
    A: OPWDD does not generally provide legal guidance on human resource or wage and hour questions. This question should be referred to the FI’s Human Resource Department and to its human resource counsel.

    Q: During a hearing for an employee who provided both Community Habilitation and Paid Neighbor services, the Department of Labor indicated that the person should be treated as an employee when providing either service.
    A: OPWDD does not generally provide legal guidance on human resource or wage and hour questions. This question should be referred to the FI’s Human Resource Department and to its human resource counsel. Another good resource is New York Alliance’s Toolkit for Providing Shared Living in New York

    Q: May a FI contract with a staffing company to serve as the employer of record for direct support workers hired by individuals doing self-direction? It would still manage all other FI tasks (working with the individuals on their budget, etc.).
    A: Such a contract would be permissible. OPWDD would still view the Self-Hired staff as co-employed between the individual and the agency.OPWDD would advise a FI considering such an arrangement to consult with human resource professionals and attorneys to insure compliance with all applicable wage and hour laws and regulations.

    Service Eligibility Questions

    Q: We support a person who attends a rowing class that has been modified for persons with physical disabilities. Are the costs of that class reimbursable?
    A: Yes, as long as the class is not restricted to only persons with I/DD. If the class has been modified for persons with physical disabilities and is not restricted to only persons with I/DD, its costs are eligible within IDGS.

    Q: Why are children under the age of 18 prohibited from accessing the OTPS category of Personal Use Transportation?
    A: There is no explicit restriction on children under the age of 18 accessing Personal Use Transportation. However, in general, OPWDD considers routine transportation unrelated to valued outcomes to be part of a family’s responsibility. If Personal Use Transportation is part of a child’s SD budget, such transportation must be related to a Valued Outcome, as documented in the child’s ISP.

    Q: May a SD participant who still lives in the family home with family members receive Live in Caregiver supports?
    A: A participant who lives with family members in the family home is eligible for Live In Caregiver supports, with caveats.
    First, no family member may provide Live In Caregiver support.
    Secondly, as stated in ADM 2016-3, the participant must “live in his/her own home or leased residence” and must be “directly responsible for the residence”. This might be achieved, for example, if the family leases the residence and the SD participant’s name appears on the lease as a lessee. In this example, the participant may also qualify for a housing subsidy.
    Similarly, if the participant leases an in-law type apartment from his or her parents, the participant could be eligible for Live In Caregiver supports. The apartment must be a legal dwelling according to local law and regulations and otherwise legally rentable to any person in the community.
    Or, if the family home is owned by a trust and the participant’s name appears on a lease between the family and the trust, Live In Caregiver supports may be provided.
    Finally, a participant cannot lease just a room from his or her family. As stated above, the residence must be a legal dwelling.

    Q: Can the costs related to attending a conference be reimbursed through a SD budget?
    A: Yes, a conference may be considered a Community Class within the IDGS category, if it meets the four criteria specified in the Guidance Document. If it meets those criteria, registration fees for a conference may be reimbursed as could travel costs to and from the conference if they meet the Guidance Document criteria. In no instance, however, are separatelodging costs reimbursable as they are considered to be activity fees and therefore are not reimbursable.

    Q: We recently heard from one of our liaisons that a participant is not eligible for Agency Supported Community Habilitation for their day service if he/she has a “residential only” budget. We believe this is institutional bias, because someone who lives in an IRA can have ASCH for their day service. This is how we have been supporting people who need 24/7 supports. How can this be rectified?
    A: A person with a “residential only” budget is indeed eligible for Agency Supported Community Habilitation. See the table on page 51 of the most recent Guidance Documentwhich lists the services available within each type of self-direction budget. The Community Habilitation ADM governs these services.

    Service Provision Questions
    Q: Are participants who attend overnight summer camp allowed to have self-hired or provider purchased comm hab staff working with them on or off premises?
    A: Summer camp may be funded as either an IDGS service (if the camp is not already waiver funded) or as a Direct Provider Purchased service (if the camp is funded as a waiver service). In either instance, the funds are used to pay for camp tuition. If the camp is billing Waiver Respite, then self hired staff may not be paid as this would constitute double billing. If the camp is not billing a waiver service, the self hired staff may provide services (such as Community Habilitation) as long as a documented habilitative need has been identified in the person’s ISP and Hab Plan. The same logic applies to self hired staff providing supports to a person while attending a Community Class, health club or other organization funded by IDGS.

    Q: Are self-hired staff permitted to observe a person who administers his/her own medications?
    A: There is no prohibition on simple observation, as long as the self hired staff person does not improperly assist with the administration of the medications.

    Q:  May a Live In Caregiver provide support with physical dependency needs or Activities of Daily Living?
    A: The role of a Live In Caregiver does not include providing support with activities of daily living. However, there is no prohibition on an individual who is a Live In Caregiver also providing other waiver services, such as Community Habilitation.  Live In Caregiver and Community Habilitation are discrete waiver services and may be provided by the same individual to one participant.When exploring these types of dual role situations, it is important that the provider is aware of and complies with the applicable labor laws relating to caregivers living in an individual’s home.

    Q: Can a person providing Paid Neighbor supports also provide Community Habilitation services to the same individual?
    A: Yes, that is core concept of the Paid Neighbor support. Paid Neighbor, within Individual Goods and Services (IDGS), is an on-call stipend. If the paid neighbor is called to duty, they need to be paid for the delivery of self-hired or agency supported community habilitation for the time worked. IDGS and Community Habilitation do not duplicate eachother.

    Financial and PRA Related Questions
    Q: We would like to not have to collect receipts from restaurants, etc. Does OPWDD require such receipts? If so, are scanned and uploaded electronic receipts permissible?
    A: Receipts are required only for staff related reimbursements, such as for meals and activity fees within OTPS. OPWDD has no specific requirements regarding the form of those receipts although it considers paper originals to be best practice.

    Q: Does the Social Security Administration consider the Housing Subsidy to be income to the person?
    A: As long ago as 1994, then OMRDD reached an agreement with the Social Security Administration and with the then New York Department of Social Services that ISS services will not adversely affect a person’s Social Security eligibility, benefit level or Medicaid eligibility.

    Q: Is there an annual cap on Support Broker services?
    A: There is no annual cap on Support Broker services. However, since their costs count against the participant’s Personal Resource Account, care should be taken when considering how much to budget in this category. And it is important for the FI to beware of potential abuse of this service…if requested hours of SB services appear excessive, the FI should require justification.
    There is an annual cap of $2400 on Start Up broker services. This does not count against the participant’s PRA.

    Q: We have been told that SEMP and Respite rates are determined by the location of the FI and not by the location of the service recipient. Please clarify.
    A: SEMP fees are determined by the program that the individual is enrolled in and which OPWDD region this program falls.  This would mean that if an individual is enrolled in a SEMP program designated as being in NYC, the cap associated with Self-Hired SEMP would be OPWDD Geographical Region 1, even if the FI agency is headquartered in Franklin County in OPWDD Region 3. 
    For Non-Self-Hired Respite fees are determined by where the provider is headquartered and which DOH region this falls.  This would mean that even if an individual lives in NYC, the fee associated would be DOH Region 4 if the individual’s FI agency is located in Franklin County.
    For Self-Hired Respite the billing is based upon the county in which the individual lives.  This would mean that if an individual lives in Queens, the cap associated with Self-Hired Respite would be DOH Region 1, no matter where the FI is located.
    Community Habilitation fees are determined by where the individual lives.  This means that for an individual living in NYC and receiving Self-hired Community Hab, the cap associated would be OPWDD Geographical Region 1, no matter where the FI is located.
    Please note that although OPWDD oversees the services, the development of rates and fees is a function of the Department of Health.  They use various models and methodologies to determine the reimbursement to providers.

    Q: When people go over their budget in a particular category, and it is not an option to try to move money to cover the overage (for example, a full budget amendment is needed and therefore the effective date can’t be retroactive) is the FI expected to pay back the billing if overall, the person is within their PRA? Would the answer be different if the individual is over their total PRA?
    A: FI’s are responsible for tracking expenditures and reporting them in a timely fashion. It is important that FI’s insure adherence to authorized service levels and should institute audit protocols and internal controls to insure such adherence.

    Service and Budget Approval Process Questions
    Q: An individual is currently receiving an ISS rental subsidy. She wishes to move to Self-Direction. Does she have to "convert" her ISS rent subsidy to a self-direction rent subsidy or is it just left out of her budget and she continues getting the rent subsidy as she currently does?
    A: In general, the answer is “yes”, the ISS subsidy must be converted to a self-direction housing subsidy. See Attachment B in the most recent Guidance Document. However, there is an exception to this. If for some reason an Other Than Residential Self Directed budget makes sense for a person, than there would be no conversion. The person would keep her ISS subsidy.

    Q: What can be done to make the approval process for brokerage, budgets and budget amendments more transparent and easier to track? For example, can OPWDD require both DDRO’s and FI’s to acknowledge receipt of submissions, with time stamps and provide estimated time to review and approve (or disapprove)?
    A: OPWDD does not govern the business operations of FI’s. Participants and their families are customers of FI’s and can ask them to provide services such as receipts and time stamps. Transparency with participants and their families is a best practice. OPWDD has not considered requiring DDRO’s to provide services suggested in this question and will take it under advisement.

    Miscellaneous Questions
    Q: If circumstances require it, may a Fiscal Intermediary co-sign a lease with a SD participant?
    A: There is no prohibition of a Fiscal Intermediary co-signing a lease with a SD participant as long as it is clear the participant is a tenant, has tenancy rights and has responsibility for the residential arrangement.  There may be other co-signers as well, such as family members.

    Q: Will there be a way to fund housing navigators going forward?
    A: Housing Navigator service could be a reimbursable service under the following parameters:
    1. 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. Housing Navigation (“HN”) services; housing access start-up services, development of an individual housing action plan and or implementation of the housing action plan are eligible to be funded through OTPS for people with Self-Direction budgets.
    Where HN services could also be delivered by a Broker or Community Habilitation (CH) staff as part of their responsibilities for those services, those Brokers or CH staff may not separately charge for HN services through OTPS.
    To summarize; HN services can be provided by the Broker or the CH staff, if qualified, or be paid separately as OTPS. The Broker or CH staff may not separately charge a person they provide HN services to through OTPS.”
    2. Support Broker: If you are a Support Broker, and HN is part of someone’s plan, you can bill for HN work performed at the Support Broker rate. Housing navigation work is typically work that could be completed within the broker role. Brokers could do housing related tasks and be reimbursed through an SD plan. The billing would be for the broker service – the tasks completed would be housing related.
    3. Community Habilitation Services: If an individual is receiving Community Habilitation (CH), and the ISP includes Housing as a goal and Housing Navigation (HN) as a way to get to it you can pay for that time with Comm. Hab. If direct, then it must be in person and focused on a specific ISP goal. If Indirect, then it must also align with the goals. The methodology for covering the indirect cost would vary based on whether the CH staff support is through agency supported/purchased or through self-hired staffing. The provider or FI would need to manage the indirect elements of the service depending on the method used. Again, the service provided is CH not HN the CH service needs to relate back to a valued outcome and activity under the service to meet that outcome.”
    *Housing Navigators- professionals that have expertise in the development and implementation of an individual housing action plan.