Module 5. Support Services

Housing is not just about being able to afford rent or mortgage, or bricks and mortar. An essential part of a successful Long-Term housing solution is the creation of services that support the person and that can be sustained.

What do we Mean by Supports and Services?
In addition to the physical building that the person with I/DD will live in, the other aspect of housing that is equally or more important is securing the services and supports that the person will need to live independently. In the traditional group home, the provider agency will control the property and will also provide the services. In an independent setting the provision of residential support services is separate from the provision of property. Support services are required across a spectrum of need for people with I/DD.  Some persons require a nominal amount of support –an occasional visit to make sure that the person is safe and healthy and that they are sustaining themselves. Some require oversight of budgets, food shopping, home maintenance, and monitoring of medication, while others need round the clock support to ensure safety and provide health related care.  There are different routes through which to obtain these services.

IRA Certified Settings and Agency Operated Non-Certified Settings

In an IRA setting support services are funded by Medicaid Waiver funds. The person’s CM will develop their Lifeplan, which will set out what services are provided and how they will be delivered. The provider agency will create a Residential Habilitation Plan[1] based on the Life Plan, and a DSP employed by the agency will provide the services and the management of the property. The agency will typically become the representative payee for all SSI and SSDI funds and will administer the person’s SNAP and HEAP funds. They will also receive funding from the state to assist with establishing the home, any necessary conversions or modifications, and a letter known as a Prior Property Approval (PPA) which is an implicit state guarantee of funding that is critical in obtaining a commercial mortgage to purchase the property. A Supervised IRA (as described on page 37) is around the clock support setting while a Supportive IRA provides a more limited level of support depending on the person’s level of need.

In a non-certified setting support services can be provided for in a variety of ways. At the most simple level they can be provided in exactly the same way as they are in a certified setting, (i.e. by an agency that owns the property and employs all of the staff). The only distinction is that they are not certified, and thus will not receive the Congregate Care Supplement to the resident’s SSI payments. In addition they will also not receive the funding for start-up costs, or the PPA.

An agency may also provide services to a person or group of persons living in a home that is not owned by the agency. The property could be owned through any of the mechanisms described elsewhere in this guide. In this setting the agency may, for example, provide a full array of services as described above.  Funding for the services would be provided through the same mix of funding which is directed through the agency but which is “unbundled”. In such a setting the funding for services is derived from a person’s Self-Directed Services budget which can include Community Habilitation (the delivery of habilitation services in a non-certified setting, where the service delivery is recorded in 15-minute intervals), plus funding from  the OPWDD Housing Subsidy.

The plan may include funding for a Live In Caregiver (LIC) which in the past was only fundable through an ISS contract but which is now a Medicaid service. Per OPWDD the LIC “is an unrelated (by blood or marriage) care provider who resides in the same household as the waiver participant and provides as-needed supports to address the participant’s physical, social or emotional needs in order for the participant to live safely and successfully in his or her own home.” The LIC position requires an LIC agreement as set out with the person and their FI which will set out exactly what the LIC’s role is. The OPWDD housing subsidy will include the LIC based on the same rate. This person may have outside employment or they may be employed by a provider agency to provide CommHab services in addition to their LIC duties. In the event that the LIC provides CommHab to a person they live with their income is exempt from taxation per Section 131 of the IRS Code[2]. Agencies have to monitor the number of hours spent on both tasks carefully, in particular if the LIC is required to be awake for much of the night as the federal Department of Labor  (DOL) rules limit the number of hours that can be provided “in kind” and require overtime payments above a certain number of hours worked. These rules, designed to protect workers have the potential unintended consequence of pricing out people who are seeking self-directed services or non-congregate care.

Self-Directed resources also include SSI/SSDI, SNAP and HEAP funds which are controlled by the person. In some settings, these funds can be paid directly to the agency, or they can be paid through the person’s Fiscal Intermediary. One of the virtues of this latter approach is that if the person wishes to change the service provider they are able to do so. Such a change is a complex undertaking and would only be contemplated if the provider systematically failed to provide adequate services.

People who have a Self-Directed plan that includes funding for residential services and who want to be more independent may seek to purchase some of their services from an agency, but they may also seek to hire support personnel themselves. They may do this in one of two ways. They can typically work with their broker, or in some cases collaborate with their Fiscal Intermediary (FI),  to advertise for, interview, train and hire their staff, or they can do so personally, becoming the employer themselves. If they work with the FI, it will be the FI who becomes the employer of record and provides payroll, benefits, insurance, Workers Compensation, liability coverage, scheduling, training and background checks[3]. In exchange, the FI is paid a percentage of the person’s budget. If people choose to become the employer of record themselves they are required to fulfill all of the same requirements. While it is important that this latter option be available, the level of paperwork and knowledge required and the compliance risk involved make it inadvisable as currently formulated.

Individually Directed Goods and Services (IDGS)
IDGS is a waiver service under Self-Direction which provides funds that can be used to purchase equipment or supplies that are related to an identified plan-goal, will increase independence and can promote inclusion.  For example these funds can be used for staff training programs, service-related transportation, paid neighbor, interpretation and Self-Direction staff support. summer camp, employment related community classes, health club memberships, and assistive technology. The funding stream is still evolving and at present each expenditure is subject to individual capping with an overall annual cap of $32,000.

Other Than Personal Services (OTPS)
OTPS can fund items that are not eligible under Medicaid, for example internet, utilities, clothing, food that isn’t covered by SNAP, phone service, software and staff training. OTPS may not be used for any medical support. OTPS funds are capped at $3,000 annually.

Consumer Directed Personal Assistance Services (CDPAS)
Funding for support services can also be obtained through CDPAS. These funds require that the DSP work for an agency and that they be subject to a background check. The person is responsible for all aspects of hiring and employment and compliance.

One feature of CDPAS that fosters independence is that trained CDPAS employees may administer medication, while Direct Support Professionals employed under OPWDD’s 1915-C waiver may not, for the most part, administer medication outside of a certified setting.

While we commonly think of people with I/DD living in group homes the fact is that many of them would like to live alone or with other people who do not have I/DD. After all, a group home is primarily an economic construct rather than a social one.

Paid Neighbor Program
This is a Medicaid funded program that provides additional support to a person with a disability. The Paid Neighbor (PN) can be any person other than an immediate family member not residing at the same address, and they can be as far as 30 minutes away, although they should be available to respond on foot if needed.  The PN receives a monthly stipend of up to $800 per month to be "on call".  If they are needed to help the recipient, they may also provide Community Habilitation services. There must be an agreement between the PN and the FI, and there can be more than one PN within the monthly fee cap.

This program offers companionship and support to persons who want to live on their own but would benefit from having immediate access to 24-hour supports. Paid neighbors can provide 24-hour emergency supports. They are hired by the person they support and provide personal services depending on needs.  Employment and screening requirements are performed by the FI.

[1] “Community Habilitation” funding used to be known as “Residential Habilitation” funding. The term is still used when creating the plan.
[2] See  retrieved July 2020
[3] A state authorized criminal background check is required of any employee whose employment is funded through OPWDD funds, whether they work for an agency or for a person directly.