Family Reimbursement Guidelines

OPWDD Region 1 Family Reimbursement Program Guidelines

Purpose:

The Family Reimbursement Program is to assist the family caring for the family member with the developmental disability with these increased expenses, and thereby enhance family stability and preserve family unity. The Goods and Services if provided would have a significant, definable, positive impact on the individual/family directly relating to health, safety, and emotional well-being, normalization of life, accessibility to needed services, personal growth and development of the individual. Priority will be given to those goods and services which directly address health and safety issues.

Eligibility

(Not Optional): Families (biological, adoptive, or extended) are eligible if they have a family member with a developmental disability who lives at home. A family is defined as more than one person. An individual living alone is not considered a family, and therefore not eligible for family reimbursement. Acceptable documentation to verify that eligibility has been determined with OPWDD is required.

Process:

All requests will be reviewed against established criteria, including how the request relates to the person’s developmental disability. Requests will be reviewed by a Committee which includes: individuals, advocates, and families. Applications may be submitted at any time to any of the Family Reimbursement Program Providers by individuals, families, case managers or advocates. The committee will meet as needed to review applications. Monies are for the calendar year (January 1-December 31) only and monies from one year cannot cover expenses in another year. Families must re-apply for funds every year. This is a reimbursement program and therefore it is the family’s responsibility to purchase the items/services needed and then submit the required documentation to be reviewed for reimbursement. Pre-approval for items/services will be considered on a case by case basis.

Funding Limits (Not Optional):

Families are eligible to receive up to $1,500.00 per Developmentally Disabled Individual

Annually, each Family Reimbursement Provider will set up a funding cap for the program year, which will identify the maximum amount that is available to a family per year with that provider. In addition, a process is in place with the OPWDD Regional Office for consideration of unique requests that are in excess of the annual cap. Families may access any of the Family Reimbursement Programs that provide funding in their county of residence. They may not be reimbursed for the same goods or service from more than one source at a time; for example, a request for $100 for a therapy ball cannot be submitted and paid by two agencies for the same item. This will be monitored by the agency and the local DDSO and duplicate claims will be disallowed. Applicants must provide all requested information to support their reimbursement request. Reimbursement for items that will be shared by others must directly relate to the needs of an individual with a developmental disability and may be pro-rated based on the number of family members in the household.

Supports available through natural or community resources, and normally funded through other echanisms, may be allowed on a short term basis as a result of a crisis or because the individual or family is in great need of specialized assistance. Some examples of these include:

Housing or Rent Subsidy, Utilities, Food Subsidy, Clothing Subsidy, Durable Medical Goods
Items not covered include: Taxes, fines, shipping fees
The outright purchase of homes, vehicles, luxury items.
Goods and Services, such as educational and health-related services, covered through other funding
mechanisms (e.g., state or federal sources, Medicaid, or insurances)
These lists are meant to be illustrative rather than exhaustive. Specific funding authorizations are made on an individually specific basis.

Reconsideration Process(Not Optional):

Each agency must have a written reconsideration process in place if the applicant disagrees with the decision made. The process must include one or more steps beyond the Family reimbursement Committee’s review. The reconsideration decision should include the review of someone of the agency administration.

Family Reimbursement Disclaimer:

Family reimbursement is intended to provide financial assistance to families for goods and services to support them in sustaining for a family member with a developmental disability in their home. Agencies processing reimbursements have a responsibility to ensure goods/services are necessary and appropriate and are sustained by the required documentation. Therefore, agencies providing reimbursement are
required to establish a system for monitoring and verifying receipt of goods and services and are subject to audits to ensure proper documentation and appropriate need and usage of the program. Agencies reserve the right to intercede and questions and suspect transactions.

In the event that acclaim for goods and services is discovered to be fraudulent by anyone involved in the reimbursement process, the agency to which that reimbursement application was submitted is to be notified (if not the discovering entity) and will investigate the request in question and all documentation provided with the reimbursement request. The agency will also notify the DDSO Family Support Services Coordinator and will provide a written summary of the investigation once completed.

In the event that the fraudulent claim is confirmed, the individual/family will be required to pay the amount of reimbursement back to the agency (if the services was already reimbursed) and will be suspended from any future reimbursement for goods and services for a period of time determined by the agency and DDSO. The recipient of the reimbursement may also subject to legal actions as determined by the agency and DDSO.

Guidelines for the Reimbursement of Goods & Services

1) Family Reimbursement is not intended for goods and services covered through other funding sources, e.g., county, state, federal or private sources, etc., and for goods and services not reasonably related to the care of the family member with a developmental disability. Family Reimbursement Dollars are 100% state
dollars and funding of last resort to be accessed only after all other sources of funding have been
eliminated/exhausted.

2) Requests for medical or clinical services or equipment must be supported by statements from an appropriate physician or clinician. There must be documentation that the medical/clinical services will be provided by an appropriately licensed or certified practitioner.

Adaptive Equipment

1) Supportive documentation is provided from an appropriate physician or clinician (OT, PT, Speech Pathologist) stating that the specific item requested is needed and would be beneficial for the
individual.

2) Funding is not the responsibility of another provider such as State Education or an Early Intervention Program.

3) Item is NOT covered by another funding source such as another Family Reimbursement Program, health insurance, HCBS waiver and/or Medicaid. Documentation of denial is required.

Items of Specific Guidelines

These are overall guidelines to follow for specific items/services; this is not an all inclusive list and any additional items/services can be considered by the agency on a case by case basis.

Clothing

Requests for the extra cost for specialized clothing or extra clothing which may be adaptive in nature or necessary for the health and safety due to the individual’s developmental disability. If health and safety are an issue, request will require documentation to verify. Documentation will be needed from an MD or Clinician.

Dental

Families are responsible for providing documentation showing the link between the individual’s developmental disability and the need for oral or dental intervention. i.e. provide documentation
on Williams Syndrome.

Diapers/Pull-Ups/Wipes

1) Parents are responsible for the purchase of diapers/pull-ups for children ages 0 to 3yrs. old.

2) Families need to apply to Medicaid first to receive a denial from them before a reimbursement request will be considered for individuals 3yrs old and older. Wipes will then also be considered for approval with the request.

3) Families who do receive diapers/pull-ups via Medicaid and need more are required to justify why.

4) Families who are choosing to not to use Medicaid provided diapers/pull-ups are required to justify why.

Diet (including Gluten Free/Casein Free Dietary Expenses)

Reimbursement requests for special diet purchases may be considered for approval under the following conditions:

* a recommendation or prescription by a physician for such a diet accompanies the request.

* a physician’s recommendation must be provided EACH year.

* diet items, even though listed as allowable under the specific diet regimen, should only be covered if they are considered “special foods”.

*All diet items will be reimbursed at 75% of the cost of the it

Examples of Foods Allowable

gluten free breads, rolls, flours
xanthan gum
other food specially prepared for gluten-free
casein-free diets (check with Family Reimbursement Coordinator for specific approval)
non-dairy substitutes (rice or soy milk products)

Examples of Foods Not Allowable Reimbursement

fresh fruits/vegetables
off the shelf cereals, taco shells etc
some juices
spring water (unless ordered with justification for its use)
other “off the shelf” typical food items)
meats/eggs

Eyeglasses/Hearing Aid Devices

1) If the 1st pair/device breaks and there is sufficient documentation that shows the individual has a
hard time maintaining the proper care for the initial pair, then a request can be submitted for a 2nd pair if not covered by insurance.

2) Families are responsible for providing documentation to show the link between the individual’s developmental disability and the need for eyeglasses/hearing aid devices.

Fences (If not approved through your OPWDD agency’s E-Mod process

1) If the family lives in a rental property, the request will require written approval by the landlord and could be considered if there are health and safety issues, which must be documented.

2) If the family owns their own home, the request could be considered if there is a health and safety issues, which must be documented. If the family moves within 5 years, a pay back provision will be expected unless there are extenuating circumstances for the cause of the move.

3) It is suggested that the purchase of fences be on a one time only basis for a 5 year period unless there are extenuating circumstances, which must be documented.

4) Each family will be responsible to obtain and purchase the necessary permit(s).

*Caution: Fences do not necessarily ensure safety and should not be used in lieu of supervision.

Furniture

Request could be considered if primarily for the benefit of the individual with the developmental disability, adaptive in nature, or necessary for the health and safety of the individual with the developmental disability. If for health and safety issue, request will require documentation to verify.

Purchasing Guidelines:

-Bed (which would include, mattress, frame and box spring)

Financial and Life Planning

Families may submit for reimbursement for financial and life planning for things such as guardianship, special needs trusts, wills, etc. For those that wish to utilize the Future Cares program in Monroe county, the cost of the program can be reimbursed which is $280.

iPad

(If not approved through your OPWDD agency’s E-Mod/Adaptive Tech. process)

Purchasing guidelines:

1) If being used for communication purposes, submit a communication assessment no more than one year old completed by a Speech Pathologist specifying the program/application to be used and how it relates to the individual’s developmental disability in the area of communication; must indicate that the individual has the necessary communication prerequisites and ability to use the iPad and its software (Each Family Reimbursement program that funds an iPad should keep the required documentation in their files.)

2) iPad’s are not eligible for reimbursement if the primary use is for educational purposes; in this case it
would be the responsibility of the school district to purchase the device. If the device is utilized outside of school for other purposes then this could be considered for reimbursement and documentation must be provided that indicates how the device will be used (ie: applications or programs used and for what
purpose) and how it relates to their disability.

3) iPad’s lost, stolen, or damaged will not be replaced by Family Reimbursement. Protective cases/covers can also be considered.

4) Family Reimbursement will reimburse the 16GB Wi-Fi version only. If another version is purchased it will be considered that the iPad’s use will not be solely for the individual with developmental disability’s communication needs and use, therefore if funded the cost for the iPad will be prorated by the number of people in the home.

Medication and Dr. co-pays

1) All medications must be FDA approved in order to consider eligible for reimbursement.

2) All medication must be identified by MD as to how it relates to the individual’s DD.

3) All medical and therapy professionals that provide service are to be licensed in the state of New York.

Out of State Travel

1) All requests will be reviewed on a case by case basis by the agency the request is
submitted to.

2) All requests must be accompanied by a written justification for going out of state, e.g., for research, treatment and conferences (Health and Safety).

3) Each travel request for reimbursement will be approved for the individual with the developmental disability and one family member.

4) Reimbursable expenses can include hotel cost, mileage, tolls, conference registration fees, airline costs, etc.

Rent (crisis only)

Rent is considered as a reimbursable expense on a one time only basis if the individual receives a notice of eviction and the situation is considered a crisis or health/safety concern. Rent subsidy may be allowed for a maximum of one month’s rent. The individual/family cannot be more than 2 months behind in rent and there needs to be a plan in place to prevent reoccurrence. This payment will be made out directly to the landlord. It is imperative that the agency obtain a receipt for this payment directly from the landlord. Each program coordinator is responsible to tract all rental subsidies.

Respite

Respite is intended to provide temporary relief from the demands of care giving, which helps reduce overall family stress. The following guidelines apply to respite reimbursement:

1) Respite service costs must be reasonable based upon the needs of the individual and established rates for similar services. As a guideline, respite services should be not exceed the range of $10.00 per hour, unless the individual has intensive medical or behavioral needs. Final amount is to be determined by family. The $1,500.00 cap remains the same even when higher rates are paid. Anyone requesting respite during hours of sleep will need to justify the rate of pay; the respite rate could be decreased or denied if not determined to be appropriate for reimbursement.

2) Normal child care costs, such as day care for working parents, will not be considered for reimbursement. Extra expenses incurred due to the child’s disability, and child care for persons over the age of 13, may be considered for reimbursement.

3) Respite may be provided by anyone with whom the primary caregiver is comfortable. HOWEVER, this excludes anyone living in the family household.

Supplements

All families must have documentation that the use of a supplement is approved by the individual’s clinician with its treatment goal(s) and how it is related to the individual’s developmental disability. This is to be provided to the Family Reimbursement Program Coordinator to keep in their files. For the purposes of clarification supplements will be defined by the following categories:

1) Primary Nutrition Source: the supplement is the only means of nutritional intake for the individual. It can be administered orally or by a tube feeding.

2) Supplemental Feeding: boost the food intake of the individual in order to provide additional calories and nutrients. Includes such items as Ensure or Boost.

3) Vitamin or Mineral supplements: taken to enhance a person’s food intake but has a specific benefit to the person’s disability.

Therapies

Reimbursement requests for therapy services may be considered under the following conditions:

1) Specific therapy requested is recommended by an appropriate physician or clinical therapist – documented need should be submitted with the request and should be no more than 3 years old.

2) Provision of therapy is not the responsibility of another provider/agency such as State Education Department.

3) Therapy is not covered by health insurance and/or Medicaid. – FSS is funding source of last resort.

4) Therapist is a recognized, credentialed professional in that specific therapy area

Transportation

For cases that families must take extraordinary measure to get an individual to a physician’s appointment or therapies will be covered at the current federal rate of mileage. Any other requests for transportation reimbursement will be considered on a case by case basis (ie. volunteer or job related).

Utilities (crisis only)

Utilities are considered as a reimbursable expense on a one time only basis with a maximum of 2 months, if notice of shut off of utility is received by individual and situation is considered a crisis. Utility would include gas, electric, oil, and telephone. The individual/family cannot be more than 2 months behind in utilities and there needs to be a plan in place to prevent reoccurrence. Each program coordinator is responsible to tract all utility subsidies.

Process:

Application (available from Medicaid Service Coordinator (MSC) or Agency providing reimbursement must be filled out in FULL and submitted to the agency you are asking for reimbursement. If they are not filled out in full, the application will be returned and payment delayed.

The family reimbursement provider’s responsibility to ensure that records are maintained as follows:

1) Verification forms must be completed in full (as appropriate).

2) ORIGINAL receipts must be submitted in order to receive reimbursement for goods and services. Forms for goods and services must also be completed in full. How receipts are submitted and filed will be according to the agency on who you are receiving reimbursement from. Families will need to submit anything from the previous fiscal year for approval by no later than January 31 of the following fiscal year. For example, on January 31, 2013 would be the last day to submit verification forms for anything in 2012 to be reimbursed. A receipt must have the name of the vendor (store, recreation program etc.) on it and be dated. A hand written receipt must be signed and will be verified by the reimbursement agency. Grocery receipts should be stapled to the diet/goods and services forms. Do NOT highlight purchases on receipts as this may degrade what is written on the tape.

3) Requests for diets, adaptive equipment etc., REQUIRE submission of a physician’s order and/or a clinical
rationale/justification letter.

***ALL respite forms and receipts are to be submitted within 90 days. Receipts cannot be accepted to cover the cost of an item(s) or service(s) of a previous year or an upcoming calendar year. ***

Anything submitted more than 90 days after purchase/occurrence, will be up to the discretion of the reimbursement agency. Funding is for the calendar year only (January 1 through December 31). Reapplying is necessary for each year if continued services are needed. Approval in one year does NOT mean you will automatically be approved in the following years, although we will make every effort per agency discretion to meet your family’s needs to the fullest extent of our resources.

In some instances the applicant may ask that FR pay the Vendor directly for the good(s) or service(s). In that case an explanation will be required with the request for a reason as to why the family can not pay for the service or item first. Along with the explanation the family will be required to provide documentation of the household income and the number of persons living in the home. Documentation of income may vary from DSS, SSI, SSD, or Pay Stub etc. Once the income information has been received it will then be compared against the Federal Lower Level Income Guidelines for their family size to ensure that their family meets the income guidelines warranting Family Reimbursement to pay the vendor for them. Final decision will be up to the discretion of the reimbursement agency.