Individual Goods and Services allow individuals who choose to self direct their own budgets to purchase the goods and services they need to achieve their goals.
A Bridge Service is usually a Direct Provider Service- Com Hab/Respite/SEMP that can be implemented in a very timely fashion while the individual and planning team creates the Self-Direction budget/plan. This way they are not waiting for services until the plan is finalized. They can receive services up till the plan is approved and then decide to roll the services into the plan or cut them out and replace them with a more Self-Hired option.
From OPWDD Effective October 1, 2014
Individual Directed Goods and Services are available only for Home and Community Based Services (HCBS) Waiver authorized participants who self-direct their services with a self direction budget.
When an individual chooses to receive IDGS, the individual must choose a Fiscal Intermediary (FI) to bill and administer the service.
Individual Directed Goods and Services:
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, which includes improving and maintaining the participant’s opportunities for full membership in the community. IDGS, as part of a person-centered plan, allow an individual to receive services in the most integrated setting possible. IDGS items and services decrease the need for other Medicaid services, promote inclusion in the community, and/or increase the individual’s safety and independence in the home environment. Participants self-directing their services receive an individualized budget that they direct pursuant to an approved plan.
Participants manage their IDGS services, as described in their Individualized Service Plan and Self-Direction Budget, to fully purchase or put funds towards their personal fiscal resources to purchase items or services which meet the following criteria:
- Are related to a need or goal identified in the Individualized Service Plan;
- Are for the purpose of increasing independence or substituting for human assistance, to the extent the expenditures would otherwise be made for that human assistance;
- Promote opportunities for community living and inclusion;
- Are able to be accommodated without compromising the participant’s health or safety; and,
- Are provided to, or directed exclusively toward, the participant.
Qualifying expenses include, but are not limited to community classes, clinician services not otherwise funded through Medicaid, community membership dues, household appliances that assist a person to live independently, and staff management supports. Examples of expenses not allowed under IDGS include cell phones and telephones, leased vehicles, and experimental therapies. A full list of qualifying expenses are found in the “Individual Directed Goods and Services Definitions Chart.”
Individual Directed Goods and Services Billing Standard and Service Documentation:
The billing unit for Individual Directed Goods and Services is a ten-dollar increment. Providers must bill in $10 increments. Providers may not round up. To bill IDGS, the FI agency must ensure that the services, equipment and supplies are described in the participant’s Self-Direction budget.
A summary of expenses paid on behalf of the participant along with supporting receipts/documents must also be made maintained. This expense summary must include:
- Individual’s name and Medicaid number (CIN).
- Name of the FI agency paying for IDGS supports and services.
- Identification of the category of waiver service provided (e.g., Individual Directed
Goods and Services or IDGS).
- A list of expenses paid on behalf of the participant.
- The date(s) the expenses were paid.
- The amount paid for each expense.
FI Provider Billing Instructions:
IDGS is billed to Medicaid in $10 increments, with one unit equal to at least $10 in expenditures. Due to limitations within the eMedNY system, a maximum of 99 units may be billed to Medicaid on a given date of service. This system limit equates to $990 per date of service toward the statewide fee for IDGS. In regard to the $10 increment, each $10 threshold must be met to bill a unit of IDGS service and there will be no rounding up.
In instances where the FI has receipts and documentation substantiating allowable expenditures beyond the daily billing limit of $990, OPWDD suggests billing eMedNY using consecutive dates of service. For example, if receipts and documentation substantiate $1,500 in qualified IDGS reimbursement, OPWDD suggests submitting one claim for 99 units totaling $990 on a given date of service and submitting an additional claim for the remaining balance of 51 units totaling $510 on the next date of service. If the FI has incurred the total statewide IDGS fee for an individual, OPWDD suggests billing the full amount to eMedNY by using four consecutive dates of service as follows: Day 1 = 99 Units/ $990, Day 2 = 99 Units/ $990, Day 3 = 99 Units/ $990, and Day 4= 3 Units/ $30. The monthly FI fee associated with IDGS is to be billed to eMedNY on the first of the calendar month following the final IDGS claim for an individual. If IDGS is the only service provided to an individual by the FI, the FI is entitled to a single monthly FI fee for that individual even if the FI submitted IDGS claims using dates of service in different months.
ISP Documentation Requirements
In addition to the documentation described above for IDGS claims, the agency billing for these services must maintain a copy of the participant’s Individualized Service Plan (ISP), developed by the participant’s Medicaid Service Coordinator (MSC). For IDGS, the following elements must be included in the ISP:
- Identification of the IDGS category of waiver service (i.e., Individual Directed Goods and Services).
- Identification of the FI agency billing IDGS.
- Specification of an effective date for IDGS that is on or before the date of service for which the FI agency bills IDGS for the participant.
- Specification of the frequency for IDGS is “day.”
- Specification of the duration for IDGS is “ongoing.”
These services are not habilitative in nature, and therefore do not require a habilitation plan.
All documentation specified above, including the ISP and service documentation, must be retained for a period of at least six years from the date the service was delivered or when the service was billed, whichever is later.