Prior Authorization Services

Initial: No Prior Authorization first 72 hours. Concurrent: 3 days(State Facilties can request 7 days)

• State Funded Policy

Prior Authorization Required 

Medicaid: Initial180 days.  Concurrent 180 days 

State: 30 days for all authrorizations. 5 month limit per rolling year. *Medicaid application required within first 30 days.  

• Medicaid Policy
• State Funded Policy

Prior Authorization Required 

Medicaid Initial: 180 days.  Concurrent 180 days 

State Funded: 30 days for all Authrorizations; 5 month limit per rolling year.

*Medicaid application required within first 30 days; 

• Medicaid Policy
• State Funded Policy

Initial: 7 days, Concurrent: 3 day max limit of 10 days 

• Medicaid Policy
• State Funded Policy

$50,000 limit over the course of five years (the duration of the waiver) when combined with Home Modifications 

• Clinical Coverage Policy

Maximum of 64 units (16 hrs/day) in 24 hr period. Maximum 1536 units (384 hrs or 24 days) per calendar year.

• Medicaid Policy

Maximum of 64 units (16 hrs/day) in 24 hr period. Maximum 1536 units (384 hrs or 24 days) per calendar year.

• Medicaid Policy

No Prior Authorization

• Policy

No Prior Authorization

• Policy

Initial 60 calendar days of treatment without prior authorization to completed comprehensive battery nof assessments. Services provided after this initial 60 day "pass through" period require authorization. This pass through is only available once per fiscal year. Average length of stay is 9 months. Services may continue beyond 12 months with preapproval

• Policy

Initial 60 calendar days of treatment without prior authorization to completed comprehensive battery nof assessments. Services provided after this initial 60 day "pass through" period require authorization. This pass through is only available once per fiscal year. Average length of stay is 9 months. Services may continue beyond 12 months with preapproval

• Policy

28 hours/week (Indiv or Group; or combination of Indiv & group)

• State Funded Policy

28 hours/week (Indiv or Group; or combination of Indiv & group)

• State Funded Policy

Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, Community Living and Supports.When school is not in session, up to 84 hours per week may be Authrorizationorized. Adult beneficiary who lives in private homes: No more than 84 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports. 

• Clinical Coverage Policy

Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, Community Living and Supports.When school is not in session, up to 84 hours per week may be Authrorizationorized. Adult beneficiary who lives in private homes: No more than 84 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports. 

• Clinical Coverage Policy

Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, Community Living and Supports.When school is not in session, up to 84 hours per week may be Authrorizationorized. Adult beneficiary who lives in private homes: No more than 84 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports. 

• Clinical Coverage Policy

Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, Community Living and Supports.When school is not in session, up to 84 hours per week may be Authrorizationorized. Adult beneficiary who lives in private homes: No more than 84 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports. 

• Clinical Coverage Policy

Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, Community Living and Supports.When school is not in session, up to 84 hours per week may be Authrorizationorized. Adult beneficiary who lives in private homes: No more than 84 hours per week is Authrorizationorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports. 

• Clinical Coverage Policy

Prior authorization is required. Reauthorization every 6 months to ensure level of care eligibility

• Policy

Prior authorization is required. Reauthorization every 6 months to ensure level of care eligibility

• Policy

Prior authorization is required. Reauthorization every 6 months to ensure level of care eligibility

• Policy

Prior authorization is required. Reauthorization every 6 months to ensure level of care eligibility

• Policy

Prior authorization is required. Reauthorization every 6 months to ensure level of care eligibility

• Policy

• Clinical Coverage Policy

• Clinical Coverage Policy

• Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week can be authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.   
• Community Network Classes and Conference- Payment for attendance at classes and conferences cannot exceed $1,000/ per beneficiary plan year. 
• Community Network Transportation does not cover transportation to/from school settings. (Transportation to/from beneficiary’s home or any community location where the beneficiary may be receiving services before/after school is covered for this service.)

• Clinical Coverage Policy

• Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week can be authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.   
• Community Network Classes and Conference- Payment for attendance at classes and conferences cannot exceed $1,000/ per beneficiary plan year. 
• Community Network Transportation does not cover transportation to/from school settings. (Transportation to/from beneficiary’s home or any community location where the beneficiary may be receiving services before/after school is covered for this service.)

• Clinical Policy Coverage

• Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week can be authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.   
• Community Network Classes and Conference- Payment for attendance at classes and conferences cannot exceed $1,000/ per beneficiary plan year. 
• Community Network Transportation does not cover transportation to/from school settings. (Transportation to/from beneficiary’s home or any community location where the beneficiary may be receiving services before/after school is covered for this service.)

• Clinical Coverage Policy

• Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week can be authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.   
• Community Network Classes and Conference- Payment for attendance at classes and conferences cannot exceed $1,000/ per beneficiary plan year. 
• Community Network Transportation does not cover transportation to/from school settings. (Transportation to/from beneficiary’s home or any community location where the beneficiary may be receiving services before/after school is covered for this service.)

• Clinical Coverage Policy

Medicaid:

• 36 units/30 day pass through once per fiscal year for admission;
• Initial Authorization 128 unit/60 days
• Concurrent: 192 units/90 days. 6 month limit per rolling year; for additional time must submit CCA, updated PCP.
• If member is seeking permanent supportive housing, then can authorize for 420 units/60 days for initial and for 630 units/90 days for concurrent.                                                            

State:

• Must be stepping down from/at risk of inpatient and must apply for Medicaid within first 30 days. 
• One 3 month episode of CST per rolling year. Initial Authorization 128 units (32 hrs) per 60 days; Concurrent: no more than 128 units (32 hrs) per 60 days

• Medicaid Policy
• State Funded Policy

Medicaid:

• 36 units/30 day pass through once per fiscal year for admission;
• Initial Authorization 128 unit/60 days
• Concurrent: 192 units/90 days. 6 month limit per rolling year; for additional time must submit CCA, updated PCP.
• If member is seeking permanent supportive housing, then can authorize for 420 units/60 days for initial and for 630 units/90 days for concurrent.                                                            

State:

• Must be stepping down from/at risk of inpatient and must apply for Medicaid within first 30 days. 
• One 3 month episode of CST per rolling year. Initial Authorization 128 units (32 hrs) per 60 days; Concurrent: no more than 128 units (32 hrs) per 60 days

• Medicaid Policy
• State Funded Policy

Medicaid:

• 36 units/30 day pass through once per fiscal year for admission;
• Initial Authorization 128 unit/60 days
• Concurrent: 192 units/90 days. 6 month limit per rolling year; for additional time must submit CCA, updated PCP.
• If member is seeking permanent supportive housing, then can authorize for 420 units/60 days for initial and for 630 units/90 days for concurrent.                                                            

State:

• Must be stepping down from/at risk of inpatient and must apply for Medicaid within first 30 days. 
• One 3 month episode of CST per rolling year. Initial Authorization 128 units (32 hrs) per 60 days; Concurrent: no more than 128 units (32 hrs) per 60 days

• Medicaid Policy
• State Funded Policy

Medicaid:

• 36 units/30 day pass through once per fiscal year for admission;
• Initial Authorization 128 unit/60 days
• Concurrent: 192 units/90 days. 6 month limit per rolling year; for additional time must submit CCA, updated PCP.
• If member is seeking permanent supportive housing, then can authorize for 420 units/60 days for initial and for 630 units/90 days for concurrent.                                                            

State Funded:

• Must be stepping down from/at risk of inpatient and must apply for Medicaid within first 30 days. 
• One 3 month episode of CST per rolling year. Initial Authorization 128 units (32 hrs) per 60 days; Concurrent: no more than 128 units (32 hrs) per 60 days

• Medicaid Policy
• State Funded Policy

Medicaid:

• 36 units/30 day pass through once per fiscal year for admission;
• Initial Authorization 128 unit/60 days
• Concurrent: 192 units/90 days. 6 month limit per rolling year; for additional time must submit CCA, updated PCP.
• If member is seeking permanent supportive housing, then can authorize for 420 units/60 days for initial and for 630 units/90 days for concurrent.                                                            

State:

• Must be stepping down from/at risk of inpatient and must apply for Medicaid within first 30 days. 
• One 3 month episode of CST per rolling year. Initial Authorization 128 units (32 hrs) per 60 days; Concurrent: no more than 128 units (32 hrs) per 60 days

• Medicaid Policy
• State Funded Policy

The cost of Community Transition has a life of the waiver limit of $5,000.00 per beneficiary. Community Transition includes the actual cost of services and does not cover provider overhead charges. Authorization per plan year.

• Clinical Coverage Policy

Per Plan Year, Crisis Supports are an immediate intervention available 24 hours per day, 7 days per week, to support the individual. Following Authorization any modification to the ISP and budget must occur within 5 working days of the verbal service Authorization. Crisis Intervention & Stabilization Supports may be Authrorizationorized for periods of up to 14 calendar day increments per event.

• Clinical Coverage Policy

Per Plan Year, Crisis Supports are an immediate intervention available 24 hours per day, 7 days per week, to support the individual. Following Authrorization any modification to the ISP and budget must occur within 5 working days of the verbal service Authorization. Crisis Intervention & Stabilization Supports may be Authorization for periods of up to 14 calendar day increments per event.

• Clinical Coverage Policy
• Clinical Coverage Policy

Utilization review up to 7 days

Required Documentation

• Hospital discharge plan

• Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized  for any combination of community networking, day supports, supported employment, Community Living and Supports.
• When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.    
• Developmental Day: For school-aged or younger children. Developmental Day provides individual habilitative programming in a licensed childcare center. Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized. 

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized  for any combination of community networking, day supports, supported employment, Community Living and Supports.
• When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.    
• Developmental Day: For school-aged or younger children. Developmental Day provides individual habilitative programming in a licensed childcare center. Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized. 

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year, Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized  for any combination of community networking, day supports, supported employment, Community Living and Supports.
• When school is not in session, up to 84 hours per week may be authorized.
• Adult beneficiary who lives in private homes: No more than 84 hours per week is authorized for any combination of community networking, day supports, supported employment, and/or Community Living and Supports.    
• Developmental Day: For school-aged or younger children. Developmental Day provides individual habilitative programming in a licensed childcare center. Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized. 

• Clinical Coverage Policy
• Clinical Coverage Policy

30 hours/week

• State Funded Policy

No Prior Authorization

• Medicaid Policy
• State Funded Policy

Per Plan Year, A beneficiary who chooses to self-direct via the Employer of Record model may require equipment necessary to carry out duties of Employer of Record and may access Employer Supplies.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

• Policy

Currently No Prior Auth (NPA) Level of care criteria for member 
May not exceed 45 days in a 12 month period

• Medicaid Policy
• State Funded Policy

Prior authorization required
Initial and concurrent: Up to 7 days
Billing limits of up to 24 units/day
Age 6-17 years
Within 24-hrs of admission, provider must contact the MCO to determine if the member is enrolled with another service provider or if the member is receiving care coordination. If the member is not already linked with a care coordinator, a referral must be made. 

• Medicaid Policy
• State Funded Policy

• No Prior Authorization is required for the initial length of stay is six months. 
• Any service delivered beyond six months requires authorization. 
• Eligibility for Outcome Payments dependent on the following criteria: 
  • Enrolled in Family Centered Treatment for at least 60 days 
  • No inpatient admissions 
  • No residential Level II or higher from discharge(planned or unplanned discharge) 
  • No return to Family Centered Treatment, admission to Intensive In-Home or Multisystemic Therapy

• Policy

• No Prior Authorization is required for the initial length of stay is six months. 
• Any service delivered beyond six months requires authorization. 
• Eligibility for Outcome Payments dependent on the following criteria: 
  • Enrolled in Family Centered Treatment for at least 60 days 
  • No inpatient admissions 
  • No residential Level II or higher from discharge(planned or unplanned discharge) 
  • No return to Family Centered Treatment, admission to Intensive In-Home or Multisystemic Therapy

• Policy

• No Prior Authorization is required for the initial length of stay is six months. 
• Any service delivered beyond six months requires authorization. 
• Eligibility for Outcome Payments dependent on the following criteria: 
  • Enrolled in Family Centered Treatment for at least 60 days 
  • No inpatient admissions 
  • No residential Level II or higher from discharge(planned or unplanned discharge) 
  • No return to Family Centered Treatment, admission to Intensive In-Home or Multisystemic Therapy

• Policy

Prior Authorization is required. Medicaid funded services may cover up to 60 days for the initial authorization. This service is limited to 40 units per month.

• Policy

Per Plan Year, Financial Support Services (FSS) is the umbrella service for the continuum of supports offered to NC Innovations individuals who elect the Individual and Family Directed Services Option, Employer of Record Model. A financial supports agency may be an Agency with Choice and provide Community Navigator.

• Clinical Coverage Policy
• Clinical Coverage Policy

No new admissions 

• State Funded Policy

State - no prior authorization               

Reauth after 90 days  (contract variations) 

State funded must apply for Medicaid   

• State Funded Policy

Due to the complex nature and urgency of admission, a Comprehensive Clinical Assessment or addendum with documentation of meeting the entrance criteria is acceptable for initiation of services with the submission of the PCP within 30 days of initial authorization. Before any service can be billed to Medicaid a written CCA and service order for medical necessity must be in place

• Policy

Due to the complex nature and urgency of admission, a Comprehensive Clinical Assessment or addendum with documentation of meeting the entrance criteria is acceptable for initiation of services with the submission of the PCP within 30 days of initial authorization. Before any service can be billed to Medicaid a written CCA and service order for medical necessity must be in place

• Policy

The service is limited to expenditures of $50,000 of supports (ATES, Home Modifications) over the duration of the waiver. HM covers purchases, installation, maintenance, and as necessary, the repair of home modifications required to enable individuals to increase, maintain or improve their functional capacity to perform daily life tasks. Medical necessity must be documented by the physician, physician assistant, or nurse practitioner, for every item provided/billed regardless of any requirements for approval.

• Clinical Coverage Policy
• Clinical Coverage Policy

40 hours/plan year

• State Funded Policy

The cost of individual directed goods and services for each beneficiary cannot exceed $2,000.00 per beneficiary plan year annually.

• Clinical Coverage Policy
• Clinical Coverage Policy

Initial: No Prior Authorization first 72 hours. Concurrent: 3 days (State Facilties can request 7 days)

• Medicaid Policy

Initial: 60 days; Concurrent: 60 days State Funded Limited to 6 months per calendar year

• Medicaid Policy
• State Funded Policy

Authrorization may be up to one year. LOC must be submitted every 180 days

• Medicaid Policy

Authorization required within 48 hours after 32 unmanaged units have been exhausted. Clinical documents required if TAR is for more than 8 additional units.

• Medicaid Policy
• State Funded Policy

Initial: 5 months; NPA for Mediciad. 

State Funded limited to 1 treatment episode per lifetime. 

• Medicaid Policy
• State Funded Policy

Initial: 5 months; Currently NPA for Mediciad. State Funded limited to 1 treatment episode per lifetime. 

• Medicaid Policy
• State Funded Policy

• Natural Supports Education provides education and training which must have outcomes directly related to the needs of the beneficiary or the natural support network’s ability to provide care and support to the beneficiary.
• Training and education, including reimbursement for conferences, are excluded for family members and natural support networks when those members are employed to provide supervision and care to the beneficiary.
• Reimbursement for conference and class attendance will be limited to $1,000 per year.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Natural Supports Education provides education and training which must have outcomes directly related to the needs of the beneficiary or the natural support network’s ability to provide care and support to the beneficiary.
• Training and education, including reimbursement for conferences, are excluded for family members and natural support networks when those members are employed to provide supervision and care to the beneficiary.
• Reimbursement for conference and class attendance will be limited to $1,000 per year.

• Clinical Coverage Policy
• Clinical Coverage Policy

No Prior Authorization.

• Medicaid Policy
• State Funded Policy

Per Plan Year, Crisis Supports are an immediate intervention available 24 hours per day, 7 days per week, to support the individual. Following Authorization any modification to the ISP and budget must occur within 5 working days of the verbal service Authorization. Crisis Intervention & Stabilization Supports may be Authrorizationorized for periods of up to 30 calendar day increments per event.

• Clinical Policy Coverage
• Clinical Coverage Policy

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

• Policy

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

• Policy

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

• Policy

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

• Policy

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

• Policy

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

• Policy

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

• Policy

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

• Policy

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

• Policy

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

• Policy

Medicaid: 24 unmanaged visits. Authorization Required beyond 24 unmanaged. State: 12 Unmanaged For Adults. 24 Unmanaged for Children

• Policy

• Policy

• Policy

Initial Authorization 7 days. Concurrent Authorization 7 days. State Funded No More than 30 days in 12 month period.

• Medicaid Policy
• State Funded Policy

All authorizations 270 units of Individual and/or Group. 90 day authorization period

• State Funded Policy

All authorizations 270 units of Individual and/or Group. 90 day authorization period

• State Funded Policy

Intial 5 days. Concurrent: 3 days Maximum  8 days 

• Medicaid Policy
• State Funded Policy

Initial: 30 days; Concurrent: 30 days

• Medicaid Policy

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Authorization required after 9 hours

Initial : 90 days Concurrent: 180 days  

Servicel imited to 6 months of authorization per rolling year.

Must apply for Medicaid within first 30 days

All members must have step-down plan. 

• Medicaid Policy
• State Funded Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 180 days; Concurrent: 180 days

• Medicaid Policy

Initial: 60 days; Concurrent: 60 days

• Medicaid Policy

Initial Authorization: 60 days

Concurrent 60 days

• Policy

Initial: 60 days; Concurrent: 60 days

• Medicaid Policy

Initial: 60 days; Concurrent: 60 days

• Medicaid Policy

Initial: 60 days; Concurrent: 60 days

• Medicaid Policy

Initial: 60 days; Concurrent: 30 days

• Medicaid Policy

• Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized. 
• Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.

• Clinical Policy Coverage
• Clinical Coverage Policy

• Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized. 
• Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized. 
• Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized.
• Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized.
• Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized. 
• Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized.
• Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year. Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services. When school is not in session, up to 40 hours per week may be authorized.
• Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year, Respite is periodic or scheduled support and relief to the primary caregiver(s); temporary relief to a beneficiary who resides in Licensed or Unlicensed AFL.                                                                                                                                             Respite is not available to beneficiaries who reside in licensed facilities that are licensed as 5600B or 5600C.  
• The cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID Facility.                                                  
• Respite may not be used  for a beneficiary who is living alone or with a roommate and not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year, Respite is periodic or scheduled support and relief to the primary caregiver(s); temporary relief to a beneficiary who resides in Licensed or Unlicensed AFL.                                                                                                                                             Respite is not available to beneficiaries who reside in licensed facilities that are licensed as 5600B or 5600C.  
• The cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID Facility.                                                  
• Respite may not be used  for a beneficiary who is living alone or with a roommate and not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year, Respite is periodic or scheduled support and relief to the primary caregiver(s); temporary relief to a beneficiary who resides in Licensed or Unlicensed AFL.                                                                                                                                             Respite is not available to beneficiaries who reside in licensed facilities that are licensed as 5600B or 5600C.  
• The cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID Facility.                                                  
• Respite may not be used  for a beneficiary who is living alone or with a roommate and not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year, Respite is periodic or scheduled support and relief to the primary caregiver(s); temporary relief to a beneficiary who resides in Licensed or Unlicensed AFL.                                                                                                                                             Respite is not available to beneficiaries who reside in licensed facilities that are licensed as 5600B or 5600C.  
• The cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID Facility.                                                  
• Respite may not be used  for a beneficiary who is living alone or with a roommate and not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year, Respite is periodic or scheduled support and relief to the primary caregiver(s); temporary relief to a beneficiary who resides in Licensed or Unlicensed AFL.                                                                                                                                             Respite is not available to beneficiaries who reside in licensed facilities that are licensed as 5600B or 5600C.  
• The cost of 24 hours of respite care cannot exceed the per diem rate for the average community ICF-IID Facility.                                                  
• Respite may not be used  for a beneficiary who is living alone or with a roommate and not available at the same time of day as Community Networking, Day Supports, Community Living and Supports, Supported Employment or one of the State Plan Medicaid Services that works directly with the person such as Private Duty Nursing.

• Clinical Coverage Policy
• Clinical Coverage Policy

No more than 1,536 units (384 hours) can be provided to a recipient in a plan year. This service is a periodic service.

• State Funded Policy

No more than 1,536 units (384 hours) can be provided to a recipient in a plan year. This service is a periodic service.

• State Funded Policy

No more than 1,536 units (384 hours) can be provided to a recipient in a plan year. This service is a periodic service.

• State Funded Policy

No more than 1,536 units (384 hours) can be provided to a recipient in a plan year. This service is a periodic service.

• State Funded Policy

Initial authorization shall not exceed 10 days. Reauthorization shall not exceed 10 days. All utilization review activity shall be documented in the Provider’s Service Plan. This is a short-term service that may not exceed more than 45 days in a 12-month period.

• Medicaid Policy
• State Funded Policy

• Clinical Coverage Policy

• Clinical Coverage Policy

No Prior Authorization for first 60 days (“Pass-through” available once per fiscal year, July 1-June 30); Concurrent for 60 days (contract variations) 

• Medicaid Policy
• State Funded Policy

State/Medicaid members: NPA for first 30 days (“Pass-through” available once per fiscal year, July 1-June 30) Concurrent: 60 days (contract variations) 

• Medicaid Policy
• State Funded Policy

No new admissions 

• State Funded Policy

• Per Plan Year, Supported Employment is available to any beneficiary ages 16 and older for whom individualized, competitive integrated employment has not been achieved, and/or has been interrupted or intermittent.                                                                                  
• Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services.  
• Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized.  
• Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.  

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year, Supported Employment is available to any beneficiary ages 16 and older for whom individualized, competitive integrated employment has not been achieved, and/or has been interrupted or intermittent.                                                                                  
• Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services.  
• Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized.  
• Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.  

• Clinical Coverage Policy
• Clinical Coverage Policy

• Per Plan Year, Supported Employment is available to any beneficiary ages 16 and older for whom individualized, competitive integrated employment has not been achieved, and/or has been interrupted or intermittent.                                                                                  
• Child beneficiary (through age 21) who receives residential supports: during the school year, no more than 20 hours per week authorized for any combination of community networking, day supports and supported employment services.  
• Child beneficiary who lives in private homes: During the school year, no more than 54 hours per week authorized for any combination of community networking, day supports, supported employment, Community Living and Supports. When school is not in session, up to 84 hours per week may be authorized.  
• Adult beneficiary (age 22 and over) who receives residential supports: no more than 40 hours per week is authorized for any combination of community networking, day supports and supported employment services.  

• Clinical Coverage Policy
• Clinical Coverage Policy

• Supported Employment Individual- 30 hours per week 
• Supported Employment Group- 40 hours per plan year 

• State Funded Policy

• Supported Employment Individual- 30 hours per week
• Supported Employment Group- 40 hours per plan year

• State Funded Policy

• The amount of Supported Living is subject to the Limits on Sets of Services. Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents. 
• Supported Living Periodic service is available for a beneficiary who uses four or less hours of Supported Living per day. 
• Supported Living Transition is only available only during the six-month period in advance of the beneficiary’s move to a Supported Living setting.

• Clinical Coverage Policy
• Clinical Coverage Policy

• The amount of Supported Living is subject to the Limits on Sets of Services. Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents. 
• Supported Living Periodic service is available for a beneficiary who uses four or less hours of Supported Living per day. 
• Supported Living Transition is only available only during the six-month period in advance of the beneficiary’s move to a Supported Living setting.

• Clinical Coverage Policy
• Clinical Coverage Policy

• The amount of Supported Living is subject to the Limits on Sets of Services. Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents. 
• Supported Living Periodic service is available for a beneficiary who uses four or less hours of Supported Living per day. 
• Supported Living Transition is only available only during the six-month period in advance of the beneficiary’s move to a Supported Living setting.

• Clinical Coverage Policy
• Clinical Coverage Policy

• The amount of Supported Living is subject to the Limits on Sets of Services. Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents. 
• Supported Living Periodic service is available for a beneficiary who uses four or less hours of Supported Living per day. 
• Supported Living Transition is only available only during the six-month period in advance of the beneficiary’s move to a Supported Living setting.

• Clinical Coverage Policy
• Clinical Coverage Policy

• The amount of Supported Living is subject to the Limits on Sets of Services. Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents. 
• Supported Living Periodic service is available for a beneficiary who uses four or less hours of Supported Living per day. 
• Supported Living Transition is only available only during the six-month period in advance of the beneficiary’s move to a Supported Living setting.

• Clinical Coverage Policy
• Clinical Coverage Policy

• Medicaid Policy
• Medicaid Policy

Limited to expenditures of $20,000 over the life of the waiver. Vehicle Modifications can only be used on a vehicle that you already have and the vehicle must be insured. Medical necessity must be documented by the physician, physician assistant, or nurse practitioner, for every item provided/billed regardless of any requirements for approval.

• Clinical Coverage Policy
• Clinical Coverage Policy