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Understanding the IO Waiver's Adult Family Living Service

Adult Family Living (AFL) is a service available to individuals who are enrolled on the Individual Options (IO) waiver that became effective on July 15, 2011. AFL is similar to the Homemaker/Personal Care (HPC) services provided through the IO waiver, but there are important differences such as the definition of who can provide you with services and how the services are billed. There is also a grandfather provision so that certain people can keep using HPC services instead of AFL services. However, there may be situations where this can change.

The Grandfather Provision and HPC services

The grandfather provision allowed people who were receiving HPC services from a relative who lived with them on July 15, 2011 and who would qualify to provide services under the AFL to continue using HPC services. People in this situation only changed to using AFL services if they and their county board of developmental disabilities agreed to the change.

It is not completely clear whether you can keep using HPC instead of AFL if there are certain changes to your services or situation, such as moving to a new residence, a different relative becoming a provider, or any other change to you or your provider. If a change occurs, your county board of developmental disabilities might deny your request to continue billing HPC services and instead require you to use AFL services.

Regardless of the grandfather provision, it is important to note that you may not have to use AFL services if the cost of your HPC services is less than 20% of the total cost of your waiver services. If so, you can continue to bill for HPC services.

How to appeal a denial of HPC services

If your county board of developmental disabilities denies your request to use HPC services instead of AFL services, then the board must notify you of the decision in writing, and must provide information about your right to appeal the decision. You can request a Medicaid appeal, which includes a hearing by an impartial hearing officer, and other appeal rights if you disagree with the hearing decision. If the county board is proposing to reduce, suspend, or terminate your benefits and you request a hearing within fifteen days of the notice, then your benefits will continue until the appeal is decided.

About AFL

AFL provides coverage for services similar to the HPC, including personal care and grooming; household tasks and errands; or supervision. Unlike HPC, AFL is only for services provided by a relative who lives with the adult on the IO waiver. AFL coverage does not include services provided by a non-relative (even if the person lives with the individual); a relative who does not live with the individual; a spouse; or services provided to a child or an individual who is not on the IO waiver.

Another difference between AFL and HPC is how AFL is billed. The billing for AFL is based on a daily rate and activities do not need to be broken down into 15 minute billing units as was with HPC. The daily rate is based on your county and IO waiver funding range, and varies from $38.93 per day to $165.84 per day. If more than one person is being served by the same AFL provider, then the daily rate for each person is reduced.

Although not required, you still have the option to bill AFL services into 15 minute billing units. This option is beneficial if you have different AFL providers and HPC providers, and if you use different providers on the same day. The fifteen-minute unit rate varies from $3.91 to $4.19 for one individual, and up to $5.45 for four individuals. If you choose to use the fifteen-minute billing rate, then the total cost of AFL and HPC services over the course of the waiver span cannot be more than the amount of the daily rate that would apply, multiplied by the number of days in the waiver span.

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This article is for informational purposes only and is not intended as legal advice.