Family Reimbursement Guidelines

Family reimbursement through the FSS program is provided to help families by easing the expenses of providing care for family members with intellectual or developmental disabilities. For certain children, FSS may be the only service needed to support a child residing at home. Additionally, similar community and private services should be explored to support children residing at home. When an individual has Medicaid and is enrolled in HCBS Waiver the use of Family Support Services must not be duplicative. FSS goods and services must be:

     1. Related to the individual’s intellectual or developmental disability; and
     2. Deemed appropriate and necessary to meet the needs of the individual by the FSS provider.

The family must provide the FSS provider with a justification that indicates 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/or development of the individual.

FSS cannot be used to supplement an individual’s services funded through the HCBS Waiver. For example, if an individual is receiving camp waiver services, they cannot also receive FSS reimbursement to supplement the costs associated with camp.

Eligibility

To be eligible for consideration for FSS reimbursement, individuals must:
     1. Have established eligibility for OPWDD services; and
     2. Reside with one or more non-paid family member (i.e., biological, adoptive, or extended family or non-paid caregiver in the absence of biological, adoptive or extended family).

FSS providers must confirm and document an individual’s eligibility for FSS before approving or providing reimbursements.

Process:

Reimbursement applications may be submitted by individuals, families, care managers, or advocates. The individual’s life plan must also be submitted along with the reimbursement application in order to verify all services the individual is receiving to prevent duplication of services. For those that are enrolled in a Care Management Service (FSS) should be listed in Section V of the Life Plan. When applicable, care Managers must help individuals and families complete and submit applications. Applications must be submitted to the FSS provider in their district. In cases where FSS providers within the same district only provide certain services (e.g., family reimbursed respite vs. other goods and services), the DDRO does not need to give prior approval to the individual or family. If there are no FSS providers in the individual’s district, or the providers in district cannot reimburse the individual due to lack of funds, the individual may seek written approval from the DDRO to apply to a different FSS provider for reimbursement. Individuals can receive services outside of their district of residence.

Incomplete or incorrect applications for reimbursement may be returned to be corrected, which could cause a delayed payment. Applications for reimbursement must be submitted no later than ninety (90) days after the purchase of goods or provision of services. Applications submitted more than ninety (90) days after the purchase of goods or provision of services will only be reimbursed at the discretion of FSS provider.
FSS reimbursement applications must include:
     i. Completed application;
     ii. Verification of OPWDD eligibility;
     iii. Verification that the individual resides with a non-paid family member or non-paid caregiver;
     iv. Receipts for the items/services to be reimbursed (see Section M);
     v. Medicaid denial letters (for items that can be funded by Medicaid) (see attachment D);
     vi. Additional documentation if requesting reimbursement for emergency items/services (see Section (e)(1)(b)), respite (see Section G), camp (see section H), electronic devices (see Section K) or medical/clinical devices or services (see section N); and
     vii. Any other relevant information.