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									                                                                  EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name           Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                        WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                     Reporting System
CARE MANAGEMENT SERVICES
603.01   CRM      HSRS COP ASSESSMENT                COP Assessment refers to the provision of services in a natural or supportive service setting to
                                                     persons who are or may become clients for the purposes of determining the existence of, and the
                                                     nature of, a specific problem or group of problems. Services may include, but are not limited to,
                                                     assessment/diagnosis and referral.

603.02   CRP       FC      COP PLAN                  COP Plan is the development of an initial case service or treatment plan based on the COP
                                                     assessment, including recipient goals, how needs are to be met, who will provide services, length
                                                     of each service, etc.
604      ZCM     HSRS/ **CASE                       Case Management Services (sometimes called support and service coordination) are provided
                  FC   MANAGEMENT/                  by an interdisciplinary care management team (IDT). The participant is the center of the IDT. The
                           CARE                     IDT consists of, at minimum, a registered nurse and a social services coordinator, and may also
                           MANAGEMENT: On include other professionals as appropriate to the needs of the participant and family or other
                           Service Capacity         informal supports requested by the participant. The IDT initiates and oversees the initial
                           Table of Provider        comprehensive assessment process and reassessment process, the results of which are used in
                           Application, in addition developing the individual’s participant-centered plan of care. The IDT identifies the participant’s
                           to number of             preferred outcomes and the services needed to achieve those outcomes and monitors the
                           consumers served,        participant’s health and welfare, the delivery of services, and progress in achieving identified
                           please list capacity     outcomes. The IDT also carries out activities that help participants and their families identify other
                           data on no. of Care      service needs and gain access to medical, social, rehabilitation, vocational, educational and other
                           Managers and             services identified.
                           Registered Nurses
                           Separately
COMMUNICATION
112.46    ZLF      FC      **LIFELINE**              Lifeline/PERS provides a direct telephonic or other electronic communications link between
                           (Personal emergency       someone living in the community and health professionals to secure immediate assistance in the
                           response system -         event of a physical, emotional or environmental emergency.
                           PERS)
112.47   ZCA       FC      **COMMUNICATION           Communication Aids are devices or services needed to assist with hearing, speech or vision
                           AIDS: On Service          impairments in order to access and deliver services. These services assist the individual to
                           Capacity Table of         effectively communicate with service providers, family, friends and the general public, decrease
                           Provider Application,     reliance on paid staff, increase personal safety, enhance independence, and improve social and
                           in lieu of number of      emotional well-being. Communication aids include: communicators, speech amplifiers, aids and
                           consumers served,         assertive devices, interpreters (as specified below), and cognitive retraining aids, (including repair)
                           please list capacity      and are items not covered under the Medicaid state plan. Interpreter services are usually
                           data on no. of orders     considered, and should be reported as, an administrative expense. Interpreter services may be
                           able to complete per      considered services under communication aids only when the interpreter service is needed to
                           mo/yr and no. of days     assist the individual to participate in community activities that are authorized by the
                           for delivery along with   interdisciplinary team as part of the member’s individualized service plan, and interpreter services
                           any other limiting        are not otherwise available (e.g., any public and private organizations provide interpreter services
                           factors                   upon request).
                                                     Communication aids does not include interpreter services needed to facilitate communication with
                                                     CMO staff.

112.47    ZIS      FC      **INTERPRETER             INTERPRETER SERVICES needed to facilitate communication with CMO staff, in which case the
                           SERVICES                  interpreter services needed to facilitate communication with CMO staff, in which case the
                                                     interpreter service is an administrative cost of the CMO; needed to facilitate communication with
                                                     any subcontracted service provider, in which case the interpreter service is an administrative cost
                                                     of the subcontracted service provider that may be included in the rate the CMO pays the provider;
                                                     or needed to facilitate communication with any Medicaid State Plan service provider, in which
                                                     case the Medicaid State Plan service provider is expected to provide the interpreter service as an
                                                     administrative cost under the rate paid by Medicaid. Communication aids does not include
                                                     interpreter services needed to facilitate communication with CMO staff.




                                                                     Page 1 of 12
                                                              EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name       Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                    WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                 Reporting System
509.00          HSRS      **COMMUNITY            Community Support Programs are non-institutionalized services designed to make medical
                HFS       SUPPORT                treatment and related care and rehabilitative services available to enable a recipient to better
                107.13(6) PROGRAMS               manage the symptoms of his or her illness, to increase the likelihood of the recipient's
                                                 independent, effective functioning in the community and to reduce the incidence and duration of
                                                 institutional treatment otherwise brought about by mental illness. Services include initial and in-
                                                 depth assessment by both a psychiatrist and treatment team personnel; development of a
                                                 treatment plan by the treatment team in conjunction with the recipient, recipient's guardian or
                                                 family, and signed off on by the psychiatrist; treatment services, psychological rehabilitation
                                                 services, and case management.


609.1     ZFS      FC      **FAMILY SUPPORT-     Consumer Directed Supports are services designed to build, strengthen or maintain informal
                           CONSUMER              networks of community support for the person. They include the following specific activities at the
                           DIRECTED              request and direction of the consumer or his/her legal representative: Provision of services and
                           SUPPORTS              supports which assist the person, family or friends to identify and access formal and informal
                                                 support systems, develop a meaningful consumer support plan, or increase and/or maintain the
                                                 capacity to direct formal and informal resources; completion of activities which assist the person,
                                                 his/her family, or his/her friends to determine his/her own future; development and implementation
                                                 of person centered support plans which provide the direction, assistance and support to allow the
                                                 consumer to live in the community, establish meaningful community associations, and make
                                                 valued contributions to his/her community; ongoing consultation, community support, training,
                                                 problem-solving, technical assistance and financial management assistance to assure successful
                                                 implementation of his/her person centered plan; development and implementation of community
                                                 supportstrategies which aid

                                                 and strengthen the involvement of community members who assist the person to live in the
                                                 community. Services provided under a plan for consumer directed supports may not duplicate any
                                                 other services provided to the person.

619.00   ZMN      HSRS **MONEY                   See Consumer Directed Supports
                           MANAGEMENT


COUNSELING

507.00    ZCT     WAC      **COUNSELING/         Counseling and Therapeutic Resources are services that are needed to treat a personal, social,
                           THERAPEUTIC           behavioral, cognitive, mental or alcohol or drug abuse disorder. Services are usually provided in a
                           RESOURCES             natural setting or service office. Services include: counseling to assist in understanding
                                                 capabilities and limitations or assist in the alleviation of problems of adjustment and interpersonal
                                                 relationships, recreational therapy, music therapy, nutritional counseling, medical and legal
                                                 counseling, and grief counseling.


507.17            WAC **MENTAL HEALTH            Mental Health - Day Treatment are services prescribed by a physician and must be planned for
                  HFS SERVICES-DAY               and directed by designated members of an interdisciplinary team that includes a social worker,
                 107.13 TREATMENT                psychologist, occupational therapist and a registered nurse or physician, physician's assistant or
                                                 another appropriate health care professional. Day treatment does not include services which are
                                                 primarily social, recreation-oriented and which are provided in non-medically supervised settings
                                                 such as 24 hour day camps or other social service programs. This includes sports activities,
                                                 exercise groups, activities such as craft hours, leisure time, social hours, meal or snack time, trips
                                                 to community activities, tours, or treatment provided in the recipient's home.



507.18             FC   **AODA-DAY               AODA-Day Treatment and Other Services are performed by a certified provider according to the
                  HFS TREATMENT AND              recipient's treatment program in a non-residential, medically supervised setting. The following
                 107.13 OTHER SERVICES           elements need to be present: initial assessment by a qualified medical professional, a treatment
                                                 plan based on the intial assessment and developed by an interdisciplinary team in consultation
                                                 with both the medical professional and the recipient, approval of the plan by the supervising
                                                 physician or psychologist, and monitoring of the recipient's progress by the interdisciplinary team
                                                 to inlcude modifications to the plan as needed.

                                                                Page 2 of 12
                                                              EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name       Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                    WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                 Reporting System
507.99            WAC      **ALTERNATE           See Counseling/Therapeutic Resources
                           THERAPIES


DAY CARE - CHILDREN AND ADULT

101                FC      **DAY SERVICES        Day Services for Children are the provision of services that provide children with regularly
                           FOR CHILDREN          scheduled activities for part of the day. Services include training, coordination and intervention
                                                 directed at skill development and maintenance, physical health promotion and maintenance,
                                                 language development, cognitive development, socialization, social and community integration
                                                 and domestic and economic management. This includes services not otherwise available through
                                                 public education programs that provide after school supervision, daytime services when school is
                                                 not in session, and services to pre-school age children. Services are typically provided up to five
                                                 days per week in a non-residential setting and may occur in a single physical environment or in
                                                 multiple environments, including natural settings in the community. Training activities may involve
                                                 children and their families. Coordination activities may involve the implementation of components
                                                 of the child’s family-centered and individualized service plans and may involve family,
                                                 professionals, and others involved with the child as directed by the child’s

                                                 plan. Day Services for children also include the provision of supplementary staffing necessary to
                                                 meet the child’s exceptional care needs. Excludes any services available through public
                                                 education programs. Excludes the basic cost of day care unrelated to a child’s disability (i.e., the
                                                 rate paid for children who do not have special needs). Excludes any service that falls under the
                                                 definition of daily living skills training, prevocational services, or respite care. Excludes services
                                                 provided to children under the age of 17 years and 9 months. For children with physical or
                                                 personal care needs, the types of activities that may be applied include direct personal care
                                                 provision beyond those age activities expected for a child, skilled tasks such as tube or gavage
                                                 feedings, catheterization, close supervision and monitoring of a child with complex medical needs,
                                                 follow through on specific therapeutic interventions, and frequent positioning or specialized skin
                                                 care. Providers are required to have criminal background checks and specialized training related
                                                 to the child’s unique needs in order to effectively address the needs and to

                                                 ensure the health, safety and welfare of each child served. If these unique needs are generally
                                                 related to physical, medical and personal care the provider is responsible for implementing
                                                 specificactivities or treatments as outlined in a medical plan of care.
102.00   ZDC       FC      **ADULT DAY CARE      Adult Day Care Services are the provision of services for part of a day in a nonresidential group
                                                 setting to adults who need an enriched social or health-supportive experience or who need
                                                 assistance with activities of daily living, supervision and/or protection. Services may include
                                                 personal care and supervision, light meals, medical care, transportation to and from the day care
                                                 site. Transportation between the individual's place of residence and the adult day health center
                                                 may be provided as a component part of adult day health services. The cost of this transportation
                                                 is included in the rate paid to providers of adult day health services.



HOUSING

106.00   ZHA      HSRS **HOUSING/                Housing/Emergency Assistance is for individuals in jeopardy of losing their living situation due to
                           EMERGENCY             inablility or unavailability of the primary caregiver, and no alternative resources are available.
                           ASSISTANCE            Services are short term, for up to 120 days, provided to or on behalf of, an adult to prevent civil
                                                 commitment to an institution or to prevent a permanent out of home placement. Services to
                                                 maintain the individual in the community and stabilize the situation include short term residential
                                                 placement or additional support services. This service requires prior authorization in accordance
                                                 with State Administrative Rules.




                                                                Page 3 of 12
                                                                  EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name           Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                        WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                     Reporting System
106.30    ZHZ     HSRS HOUSING START-UP Housing Start-Up includes the payment of certain costs associated with the relocating from an
                                                     institution. Costs may include the initial fees to establish utility service and the purchase of
                                                     essential items and services needed to establish a community living arrangement. Relocation
                                                     related housing start up services includes person-specific services, supports or goods that may be
                                                     arranged, scheduled, contracted or purchased, and that will be put in place in preparation for the
                                                     participant’s relocation to a safe, accessible community living arrangement. There is no
                                                     institutional length of stay requirement that must be met in order to access this service. Services
                                                     may be provided up to 180 days prior to discharge. May include payment of initial utility (heating,
                                                     electric, water and telephone) connection costs and or fees; the purchase of essential home
                                                     furnishings, such as necessary basic furniture and kitchen appliances not furnished in the housing
                                                     arrangement; telephone(s), cooking/ serving utensils, basic cleaning equipment and household
                                                     supplies as well as basic bathroom and bed-room furnishings; payment

                                                     of a security deposit; services to move personal belongings and to prepare the selected
                                                     community living arrangement, including general cleaning and the organization of household
                                                     supplies and furnishings. Excludes purchase of food, the payment of rent, or the purchase of
                                                     leisure or recreational devices or services (e.g., television or video equipment, cable or satellite
                                                     service, etc); and excludes the use of waiver funds to purchase service agreements or extended
                                                     warranties for appliances or any other home furnishings. Criminal, caregiver and licensing
                                                     background checks are required for providers of relocation services who meet the definition of a
                                                     caregiver.
112.00    ZAA      FC      **ACCESSIBILITY/          Accessibility/Adaptation refers to ramps, lifts, modifications or additions to bathroom or kitchen
                           ADAPTATION: On            facilities; specialized accessibility or safety adaptations/additions.
                           Service Capacity
                           Table of Provider
                           Application, in lieu of
                           number of consumers
                           served, please list
                           capacity data on no. of
                           Projects able to
                           complete per mo/yr
                           and no. of days
                           backlog with any other
                           limiting factors
112.99    ZAP      FC      **ADAPTIVE AIDS:          Adaptive Aids are controls or appliances that cannot be obtained through Wisconsin's approved
                           On Service Capacity       MA State Plan. They are aids that enable persons to increase their abilities to perform activities of
                           Table of Provider         daily living or control the environment in which they live (including patient lifts, control switches,
                           Application, in lieu of   etc.). Adaptive aids are also services and material benefits that enable individuals to access,
                           number of consumers       participate and function in their community. These include the purchase of vehicle modifications
                           served, please list       (such as van lifts, hand controls, equipment modifications etc. that allow the vehicle to be used by
                           capacity data on no. of   the participant to access the community), or those costs associated with the maintenance of these
                           orders able to            items.
                           complete per mo/yr
                           and no. of days for
                           delivery along with any
                           other limiting factors
112.56   ZAM       FC      **MODIFICATION -          Home Modifications are services and items that assess the need for, arrange for and provide
                           ARCHITECTURE OF           modifications and or improvements to a participant's living quarters to allow for community living,
                           HOME: On Service          provide safe access to and within the home, reduce the risk of injury, facilitate independence and
                           Capacity Table of         self-reliance, allow the individual to perform more ADLs or IADLs with less assistance and
                           Provider Application,     decrease reliance on paid staff. Home modifications must be necessary to increase self-reliance
                           in lieu of number of      and independence, or to ensure safe, accessible means of ingress/ egress to a participant's living
                           consumers served,         quarters, or to otherwise provide safe access to rooms, facilities or equipment within the
                           please list capacity      participant’s living quarters, or adjacent buildings that are part of the residence. Home
                           data on no. of Projects   modifications may include ramps; stair lifts, wheelchair lifts, or other mechanical devices to lift
                           able to complete per      persons with impaired mobility from one vertical level to another; kitchen/bathroom modifications;
                           mo/yr and no. of days     specialized accessibility/safety adaptations; voice activated, light-activated, motion-activated and
                           backlog with any other    electronic devices that increase the participant’s self-reliance and capacity to function
                           limiting factors          independently.



                                                                    Page 4 of 12
                                                               EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name        Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                     WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                  Reporting System
                                                  Modifications which increase the square footage, or that enhance the general livability and value,
                                                  of a privately owned residence are excluded.
610.00   ZHX       FC      **HOUSING              Housing Counseling is a service which provides assistance to a recipient when acquiring
                           COUNSELING             housing in the community, where ownership or rental of housing is separate from service
                                                  provision. The purpose of the housing counseling is to promote consumer choice and control of
                                                  housing and access to housing that is affordable and promotes community inclusion. Housing
                                                  counseling includes exploring both home ownership and rental options, and both individual and
                                                  shared housing situations, including situations where the individual lives with his or her family.
                                                  Services include counseling and assistance in identifying housing options, identifying financial
                                                  resources and determining affordability, identifying preferences of location and type of housing,
                                                  identifying accessibility and modification needs, locating available housing, identifying and
                                                  assisting in access to housing financing, and planning for ongoing management and maintenance.
                                                  A qualified provider must be an agency or unit of an agency that provides Housing Counseling as
                                                  a regular part of its mission. Counseling must be provided by staff with specialized training

                                                  and experience in housing issues and shall be available to anyone in the general public who
                                                  needs assistance with housing. Waiver funds may not be used to purchase this service if it is
                                                  otherwise provided free to the general public. Excludes reimbursement if this service is provided
                                                  by an agency that also provides residential support services or support/service coordination to the
                                                  waiver participant. Excludes funding for physical alterations of a person’s home to address
                                                  accessibility, which are included under Home Modifications. Excludes funds to pay for items
                                                  necessary for housing start up expenses, which are included under Relocation Services.



LEGAL

301.00    ZLS     HSRS **LEGAL                    Legal Assistance/Court Intake & Studies is the provision of services essential to the provision
                           ASSISTANCE             of reports and recommendations to the court. Services may include but are not limited to:
                           (COURT                 assessment/diagnosis; and case planning, monitoring, and review. Includes custody studies,
                           INTAKE/STUDIES)        mediation and monitoring pursuant to divorce actions. Includes Chapter 51 commitment
                                                  evaluations other than those done by inpatient facilities. (Primary focus is upon reports to the
                                                  court required under Chapters 48, 51, 55 Wisconsin Statutes.)


301.00   ZRW       FC      **WATTS REVIEW         See Legal Assistance (Court Intake and Studies)

406.00   ZCG       FC      **CORPORATE            Corporate Guardianship services include recruitment and development of families and interested
                           GUARDIANSHIP           citizens who may serve as guardians for mentally incompetent individuals. Excludes services
                                                  designed primarily to teach money management skills and guardianship services for purposes of
                                                  adoption.

MEDICAL/NURSING

107.24            WAC **DURABLE           Durable Medical Equipment refers to occupational therapy assistive or adaptive equipment,
                  HFS MEDICAL             orthopedic or corrective shoes, orthoses, other home health care durable medical equipment such
                 107.24 EQUIPMENT (except as patient lifts, hospital beds and traction equipment, oxygen therapy equipment, physical therapy
                           hearing aids and        splinting or adaptive equipment, protheses, and wheelchairs.
                           prosthetics): On
                           Service Capacity
                           Table of Provider
                           Application, in lieu of
                           number of consumers
                           served, please list
                           capacity data on no. of
                           orders able to
                           complete per mo/yr
                           and no. of days for
                           delivery along with any


                                                                 Page 5 of 12
                                                                  EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name           Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                        WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                     Reporting System
107.24             FC   **MEDICAL                    Medical Supplies means disposable, consumable, expendable or nondurable medically
                  HFS SUPPLIES: For                  necessary supplies which have a very limited life expectancy. Examples include plastic bed
                 107.24 capacity data, see           pans, catheters, electric pads, hypodermic needles, syringes, continence pads and oxygen
                           Durable Medical           administration circuits.
                           Equipment above
112.55    ZSS      FC      **SPECIALIZED             Specialized Medical Equipment and Supplies are those items necessary to maintain the
                           MEDICAL                   participant’s health, manage a medical or physical condition, improve functioning or enhance
                           EQUIPMENT &               independence. Items or devices provided may be in excess of the quantity of medical equipment
                           SUPPLIES: On              or supplies covered under the Medicaid state plan when coverage of the additional items or
                           Service Capacity          devices has been denied. Items or devices provided must be of direct medical or remedial benefit
                           Table of Provider         to the participant. Allowable items devices or supplies may include incontinence supplies, wound
                           Application, in lieu of   dressings, IV or life support equipment, orthotics, nutritional supplements, vitamins, over the
                           number of consumers       counter medications and skin conditioning lotions/lubricants. Additionally allowable items may
                           served, please list       include books and other therapy aids that are designed to augment a professional therapy or
                           capacity data on no. of   treatment plan. Room air conditioners, humidifiers and water treatment systems may be allowable
                           orders able to            when needed to support a participant’s health and safety outcomes. Excludes separate additional
                           complete per mo/yr        charges for shipping, handling, mailing or delivery of items.
                           and no. of days for
                           delivery along with any
                           other limiting factors
112.55   ZEM      FC/      **EQUIPMENT -             See Specialized Medical Equipment and Supplies
                  WAC      MEDICAL: For
                           capacity data, see
                           Specialized Medical
                           Equipment above
507             FC HFS **NURSING FACILITY Nursing Facility refers to medically necessary services provided by a certified nursing home to
                 107.09 - including       an inpatient and prescribed by a physician in a written plan of care. This does not include
                           Intermediate Care         services of private duty nurses when provided in a nursing home, custodial care and rest and
                           Facilities (ICF) and      study in Christian Science sanatoria, ICF-level services provided to a developmentally disabled
                           Institutions for Mental   person admitted after September 12, 1986, to an ICF facility other than to a facility certified under
                           Diseases (IMD)            s.HFS 105.12 as an intermediate care facility for the mentally retarded unless the provisions of
                                                     s.HFS 132.51(2)(d) 1. have been waived for that person;and inpatient services for IMD residents
                                                     between the ages of 21 years and 64 years of age, except that services may be provided to a 21
                                                     year old resident of an IMD if the person was a resident immediately prior to turning 21 and
                                                     continues to be a resident after turning 21.


507.11            WAC **PHYSICAL         Physical Therapy Services (other than home health care) are those medically necessary
                  HFS THERAPY/           modalities, procedures and evaluations prescribed by a physician and performed by a qualified
                 107.16 MASSAGE THERAPY- physical therapist or certified physical therapy assistant under the direct, immediate, on-premises
                           OTHER THAN HOME supervision of a physical therapist. Services shall be furnished to a recipient under a written plan
                           HEALTH          of care established, signed, and periodically reviewed by a physician. Physical Therapy Services
                                           do not include activities for the general good and welfare of recipients, such as general exercises
                                           to promote overall fitness and flexibility and activities to provide diversion or general motivation.



507.12            WAC **OCUPATIONAL                  Occupational Therapy Services (other than home health care) are medically necessary services
                  HFS THERAPY- OTHER                 prescribed by a physician and performed by a certified occupational therapist or certified
                 107.17 THAN HOME                    occupational therapist assistant under the direct, immediate, on-premises supervision of a certified
                           HEALTH                    occupational therapist. Services shall be furnished to a recipient under a written plan of care
                                                     established, signed, and periodically reviewed by a physician. Occupational Therapy Services
                                                     do not include activities for the general good and welfare of recipients, such as general exercises
                                                     to promote overall fitness and flexibility and activities to provide diversion or general motiviation.




                                                                    Page 6 of 12
                                                              EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name       Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                    WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                 Reporting System
507.13            WAC **SPEECH AND               Speech and Language Therapy Services (other than home health care) include those medically
                  HFS LANGUAGE                   necessary diagnostic, screening, preventive or corrective speech and language pathology
                 107.18 THERAPY - OTHER          services prescribed by a physician and provided by a certified sppech and language pathologist or
                           THAN HOME             under the direct, immediate on-premises supervision of a certified speech and language
                           HEALTH                pathologist. Services shall be furnished to a recipient under a written plan of care established,
                                                 signed, and periodically reviewed by a physician. Speech and Language Therapy services do not
                                                 include services which are of questionable therapeutic value, such as "language development-
                                                 facial physical," "voice therapy - facial physical" or "appropriate outlets for reducing stress."



606.00   ZMD       FC      **MEDICAL/ DENTAL     Medical/Dental Health Screening & Accessibilty is the provision of services in a natural or
                           (HEALTH               supportive service setting to persons at risk for health problems for the purpose of early
                           SCREENING &           identification of health care needs and improved accessibility to needed health care services.
                           ACCESSIBILITY)        Services may included, but are not limited to: case finding; assessment/diagnosis; case planning,
                                                 monitoring and review; referral; and advocacy.


704.00   ZDM       FC      **DAY TREATMENT       Day Treatment-Medical is a nonresidential program in a medically supervised setting that
                           MEDICAL               provides case management, counseling, medical care and therapies on a routine basis for a
                                                 scheduled portion of a 24 hour day and a scheduled number of days per week to alleviate those
                                                 problems. Services include individual, family and group counseling but not aftercare services as
                                                 defined under s.HFS 61.51(1).
710      ZNC               **SKILLED NURSING Skilled Nursing Services covers services listed in the plan of care which are within the scope of
                           SERVICES - general Wisconsin's Nurse Practice Act. Services will be provided by an Advanced Practice Nurse, a
                                              Registered Nurse, or a Licensed Practical Nurse under the supervision of a Registered Nurse,
                                              licensed to practice in the state.


RESIDENTIAL CARE

202.10    ZFH      FC      ADULT FAMILY          Adult Family Homes for 1-2 beds are residences in which the owner of the residence provides
                           HOME : 1-2 BEDS       care and maintenance above the level of room and board, but not including nursing care to one or
                                                 two residents.
202.10    ZPX      FC      PERSONAL &            See Adult Family Homes
                           CLOTHING,
                           ALLOWANCE
202.20    ZFZ     HSRS **ADULT FAMILY            Adult Family Homes for 3-4 beds are small congregate care settings where 3-4 adults who are
                           HOME : 3-4 BEDS       not related to the operator reside and receive care, treatment, support, supervision and training
                                                 that is provided as needed for support in one or more aspects of living such as: health care,
                                                 personal care, supervision, behavior and social supports, daily living skills training and
                                                 transportation when transportation is part of providing the services and that may include several
                                                 hours per week of nursing care per resident. Room and board costs are not included in the
                                                 services the person receives.


506.61   ZCB       FC      **CBRF                Community-Based Residential Facilities (CBRF) are larger congregate care settings where 5 or
                                                 more adults who are not related to the operator or administrator reside and receive care,
                                                 treatment, support, supervision and training that is provided as needed for support in one or more
                                                 aspects of living such as: health care, personal care, supervision, behavior and social supports,
                                                 daily living skills training and transportation when transportation is part of providing the services
                                                 and that may include several hours per week of nursing care per resident. Room and board costs
                                                 are not included in the services the person receives. For persons with developmental disabilities,
                                                 a variance must be obtained from the Department of Health and Family Services for the
                                                 individuals on the waiver to live in a CBRF. Variances will be granted only for facilities with 5 to 8
                                                 beds. For elders and persons with physical disabilities no bed size limit is imposed because DHFS
                                                 has determined that, although bed size has historically been used as a proxy for whether a facility
                                                 is really “community-based,” the interdisciplinary case management team




                                                                Page 7 of 12
                                                              EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name       Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                    WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                 Reporting System
506.61   ZCR      HSRS CBRF                      which includes the consumer, can more effectively monitor the nature and quality of facilities,
                           SUPPLEMENTAL          rather than continuing to administratively impose bed size limits. Among the factors to be
                           RATE                  considered in such monitoring is the importance of privacy to the individual consumer and in larger
                                                 facilities the extent to which the consumer’s “residence” is physically separated from that of others
                                                 (e.g. separate lockable door, bathroom, kitchen facilities etc.). Each CMO network is required to
                                                 include facilities that offer such physical separateness in various residential service settings
                                                 including CBRFs, adult family homes, RCACs and nursing homes.


711.00             FC      **RESIDENTIAL         Residential Care Apartment Complexes (RCAC) are services provided in a homelike,
                           SERVICES - RCAC       community-based setting where 5 or more adults reside in their own living units that are separate
                                                 and distinct from each other. Persons who reside in the facility also receive the following services:
                                                 supportive services, personal assistance, nursing services, and assistance in the event of an
                                                 emergency.


RESPITE CARE

103.99   ZRC       FC      **RESPITE CARE        Respite Care Services are services provided to a waiver eligible participant on a short-term basis
                                                 to relieve the participant’s family or other primary caregiver(s) from daily stress and care
                                                 demands. Respite care may be provided in an institution such as a certified Medicaid setting
                                                 (hospital, nursing home) or other licensed facility. Respite care may also be provided in a
                                                 residential facility such as a certified or licensed Adult Family Home, licensed CBRF, Child Care
                                                 Institution, children's foster home, children's treatment foster home, children's group home,
                                                 certified Residential Care Apartment Complex, in the participant’s own home or the home of a
                                                 certified respite care provider. FFP will not be claimed for the cost of room and board except when
                                                 provided as part of respite care furnished in a facility approved by the State that is not a private
                                                 residence or a residential care apartment complex.


103.22   ZRR       FC      **RESPITE CARE-       Same as above.
                           RESIDENTIAL

103.24    ZRI      FC      **RESPITE CARE-       Same as above.
                           INSTITUTIONAL

103.26   ZRH       FC      **RESPITE CARE-       Same as above.
                           HOME BASED


SUPPORTIVE HOME CARE

104.10    ZSJ      FC      **SUPPORTIVE          Supportive Home Care (SHC) services are services to provide necessary assistance for eligible
                           HOME CARE             persons in order to meet their daily living needs and to insure adequate functioning at home, in
                                                 small integrated alternate care settings and in the community. Services include intermittent major
                                                 household tasks that must be performed seasonally or in response to some natural or other
                                                 periodic event. They inlcude: outdoor activities such as yard work and snow shoveling; indoor
                                                 activities such as window washing, cleaning of attics and basements, cleaning of carpets, rugs
                                                 and drapery, and refrigerator/freezer defrosting; and the necessary cleaning of vehicles,
                                                 wheelchairs and other adaptive equipment and home modifications such as ramps. Excludes
                                                 nonemergency twenty-four hour care in an adult's or child's own home for the purpose of respite.



104.00    ZAS      WM      **ATTENDANT           Attendant Care Services include hands-on care, of both a supportive and health-related nature,
                           SERVICES              specific to the needs of a medically stable, physically handicapped individual. Housekeeping
                                                 activities which are incidental to the performance of care may also be furnished as part of this
                                                 activity.
104.1    ZSR       FC      **SUPERVISED          See Supportive Home Care
                           APARTMENT
104.1     ZSK      WM      **SUPPORTIVE     See Supportive Home Care
                           HOME CARE - DAYS

                                                                Page 8 of 12
                                                              EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name       Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                    WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                 Reporting System
104.2     ZSL     WAC      **SUPPORTIVE          See Supportive Home Care
                           HOME CARE -
                           HOURS
506.61   ZRB       FC      ROOM & BOARD          Room and Board refers to the cost incurred by a supportive home care worker who "lives in" with
                                                 the recipient.
104               WAC **PERSONAL CARE            Personal Care Services are medically oriented activities related to assisting a recipient with
                  HFS                            activities of daily living necessary to maintain the recipient in his or her place of residence in the
                 107.112                         community. The personal care worker shall be assigned by the supervising RN to specific
                                                 recipients to do specific tasks for those recipients for which the personal care worker has been
                                                 trained. The personal care worker's training for these specific tasks shall be assured by the
                                                 supervising RN. The personal care worker is limited to performing only those tasks and services
                                                 as assigned for each recipient and for which he or she has been specifically trained.


104.00   ZSLF      FC      **FISCAL AGENT-       Fiscal Agent services are the provision of services to assist waiver participants and their families
                           INTERMEDIARY/         to manage service dollars or manage their personal finances. This service includes a person or
                           FINANCIAL             agency paying service providers after the participant, guardian or family authorizes payment to be
                           MANAGEMENT            made for services included in the participant’s approved individualized service plan. Financial
                           SERVICES -            Management Services providers/fiscal intermediaries, are organizations or individuals that write
                           SUPPORTIVE HOME       checks to pay bills for personnel costs, tax withholding, worker’s compensation, health insurance
                           CARE                  and other taxes and benefits appropriate for the specific provider consistent with the individual’s
                                                 ISP or budget for services. Financial management services are purchased directly by the CMO
                                                 and made available to the participant/family to insure that appropriate compensation is paid to
                                                 providers of services. Also includes the provision of assistance to waiver participants who are
                                                 unable to manage their own personal funds to assist them manage their personal resources.
                                                 Includes assistance to the participant to effectively budget the

                                                 participant’s personal funds to ensure sufficient resources are available for housing, board and
                                                 other essential costs. The costs of the housing and board are not covered by the waiver. Includes
                                                 paying bills authorized by the participant or their guardian, keeping an account of disbursements
                                                 and assisting the participant ensure that sufficient funds are available for needs. This service is
                                                 necessary to prevent institutionalization. Excludes payments to court appointed guardians or court
                                                 appointed protective payees if the court has directed them to perform any of these functions.



104.00    ZCL      WM      **SUPPORTED           Supported Living Service refers to assistance with daily living, personal adjustment, household
                           LIVING SERVICE        maintenance, attendant care, medication assistance, supervision, exercies, therapy (ROM),
                                                 personal maintenance, etc.
104.10   ZCP       WM      **COMPANION           Companion Services include socialization (reading, conversation, assistance with mail and other
                           SERVICE               interaction with recipient as appropriate); assistance with or supervision of meal/snack
                                                 preparation, laundry, and shopping; incidental light housekeeping, and sitting service focusing on
                                                 the recipient inlcuding supervision, orientation, and making appropriate contact in case of
                                                 emergency.
104.10   ZHS       WM      **HOMEMAKER           Homemaker Services consist of general household activities (meal preparation and routine
                           SERVICES              household care)provided by a trained homemaker, when the individual regularly responsible for
                                                 these activities is temporarily absent or unable to manage the home and care for him/herself or
                                                 others in the home or to allow the caregiver more time to care for the individual. Homemakers
                                                 shall meet such standards of education and training as are established by the State for the
                                                 provision of these activities.
104.14   ZCH       FC      **HOUSEHOLD/          Household/Chore Services include routine indoor housekeeping chores, such as general house
                           CHORE SERVICE         cleaning tasks, laundry, changing bedding and meal preparation as well as tasks related to
                                                 managing the home such as shopping and errands. Household/chore service also includes
                                                 routine outdoor chores related to exterior upkeep, as well as lawn mowing and snow removal.


105               WAC **HOME HEALTH              Home Health Aide Services are primarily medically oriented tasks, as determined by the
                  HFS AIDE                       delegating RN, when the instability of the recipient's condition as documentedin the medical
                 107.11                          record is such that the recipient's care cannot be safely delegated to a personal care worker.


                                                                 Page 9 of 12
                                                               EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name        Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                     WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                  Reporting System
105.11            WAC **HOME HEALTH               Physical Therapy Services are services provided in the recipient's home which can only be
                  HFS CARE - PHYSICAL             safely and effectively performed by a skilled physical therapist or by a certified therapy assistant
                 107.11 THERAPY                   who receives supervision by the certified therapist for a recipient confined to his or her home.
                                                  Skilled physical therapy services do not include activities provided for the general welfare of the
                                                  recipient or activities to provide diversion for the recipient or to motivate the recipient.


105.12            WAC **HOME HEALTH               Occupational Therapy Services are services provided in the recipient's home which can only be
                  HFS CARE -                      safely and effectively performed by a skilled occupational therapist or by a certified therapy
                 107.11 OCCUPATIONAL              assistant who receives supervision by the certified therapist for a recipient confined to his or her
                           THERAPY                home. Skilled occupational therapy services do not include activities provided for the general
                                                  welfare of the recipient or activities to provide diversion for the recipient or to motivate the
                                                  recipient.
105.13            WAC **HOME HEALTH               Speech Therapy Services are services provided in the recipient's home which can only be safely
                  HFS CARE - SPEECH               and effectively performed by a skilled speech pathologist for a recipient confined to his or her
                 107.11 THERAPY                   home. Skilled speech pathology services do not include activities provided for the general
                                                  welfare of the recipient or activities to provide diversion for the recipient or to motivate the
                                                  recipient.
105.20            WM       **HOME HEALTH          Skilled Nursing Services are services which, due to the recipient's medical condition, may be
                  HFS      CARE-SKILLED           only safely and effectively provided by an RN or LPN.
                 107.11    NURSING
402.00   ZHM     HSRS      **HOME DELIVERED Home Delivered Meals or "meals on wheels" include the costs associated with the purchase and
                           MEALS            planning of food, supplies, equipment, labor and transportation to deliver one or two meals a day
                                            to recipients who are unable to prepare or obtain nourishing meals without assistance. This
                                            service will be provided to persons in natural or supportive service settings to promote
                                            socialization and adequate nutrition.

TRAINING

108.00    ZPV      FC      **PRE-VOCATIONAL Prevocational Services is the provision of services intended to prepare an individual for paid or
                           SERVICES         unpaid employment but which are not job task oriented. Services include teaching an individual
                                            such concepts as following directions, attending to tasks, task completion problem solving, safety
                                            and mobility training. Prevocational services furnished under the waiver are not available under a
                                            program funded under section 110 of the Rehabilitation Act of 1973 or section 602(16) and (17) of
                                            the Individuals with Disabilities Education Act (20 U.S.C. 1401(16 and 17). Prevocational services
                                            may be provided to supplement, but may not duplicate services provided under vocational futures
                                            planning provided under the waiver. Transportation may be provided between the individual's
                                            place of residence and the site of the habilitation services or between habilitation sites (in cases
                                            where the individual receives habilitation services in more than one place) as a component part of
                                            habilitation services. The cost of this transportation is included in the rate paid to providers of the
                                            appropriate type of habilitation services.



110.00    ZDL      WM      **DAILY LIVING         Daily Living Skills Training is the provision of training in activities of daily living such as child-
                           SKILLS TRAINING        rearing skills, money management, home care maintenance, food preparation and accessing and
                                                  using community resources. Daily living skills training are provided in a residential setting and are
                                                  intended to improve the participant’s ability to perform routine daily living tasks, improve ability to
                                                  utilize greater independence by either training the participant or the caregiver to perform activities
                                                  with greater independence.




                                                                 Page 10 of 12
                                                               EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name        Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                     WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                  Reporting System
113.00    ZET      FC      **EDUCATION &          Consumer Education and Training is designed to help a person with a disability develop self
                           TRAINING               advocacy skills, exercise civil rights, and acquire skills needed to exercise control and
                                                  responsibility over other support services. Includes education and training for participants, their
                                                  caregivers and/or legal representatives that is directly related to building or acquiring the skills
                                                  described above. Excludes educationally related services available under IDEA or other relevant
                                                  funding sources. Excludes education/training costs exceeding $2500 per participant annually.
                                                  Excludes payment for hotel and meal expenses while participants, or their legal representatives
                                                  attend allowable training/education events. Local agencies will assure that information about
                                                  educational and/or training opportunities is made available to participants and their caregivers and
                                                  legal representatives.



TRANSPORTATION

107.3     ZTS     WAC   **SPECIALIZED             Specialized Transportation Services assist in improving an individual's general mobility and
                        TRANSPORTATION            ability to perform tasks independently and to gain access to waiver and other community services,
                        SERVICES-                 activities and resources. Services can consist of material benefits such as tickets or other fare
                        GENERAL: On               medium needed as well as direct conveyance of participants and their attendants to destinations.
                        Service Capacity
                        Table of Provider
                        Application, in lieu of
                        number of consumers
                        served, please list
                        capacity data on no. of
                        Trips able to complete
                        per mo/yr along with
                        any other limiting
107.40             FC   **TRANSPORTATION          SMV Transportation refers to use of a vehicle equipped with a lift or ramp for loading wheelchairs
                  HFS - SPECIALIZED               by recipients who are either legally blind or indefinitely or temporarily disabled. The driver of a
                 107.23 MEDICAL VEHICLE           SMV must have first aid training and CPR certification. The need for SMV transportation must be
                        (SMV): On Service         documented in writing by a physician, physician assistant, nurse midwife, or nurse practitioner.
                        Capacity Table of         The documentation must include why the person's condition prevents him/her from using a
                        Provider Application,     common carrier or private vehicle. In the case of a temporary disability, the documentation must
                        in lieu of number of      indicate the expected length of time SMV services will be necessary, as well as why the person
                        consumers served,         cannot use common carrier transportation. A recipient's age, place of residence, lack of parental
                        please list capacity      supervision, or lack of a driver's license are not qualifying criteria for SMV services. SMV
                        data on no. of Trips      transportation must be to and from a location at which the recipient receives an MA-covered
                        able to complete per      service on that day.
                        mo/yr along with any
                        other limiting factors


VOCATIONAL/EMPLOYMENT

114.01    ZFP      FC      **VOCATIONAL     Vocational Futures Planning (VFP) is a consumer-directed, team based comprehensive
                           FUTURES PLANNING employment service that supports waiver program participants to obtain, maintain or advance in
                                            employment. The agency providing vocational futures planning services will ensure that it
                                            includes: identification of the barriers to work, including an assistive technology pre-screen and, if
                                            required, an in-depth comprehensive assessment; benefits analysis; resource team coordination;
                                            career exploration; job seeking support; and ongoing support. Vocational futures planning must be
                                            done by a team of qualified professionals that includes, at a minimum, an employment specialist, a
                                            benefits counselor and an assistive technology consultant. Vocational futures planning furnished
                                            under the waiver are not available under a program funded under section 110 of the Rehabilitation
                                            Act of 1973 or section 602 (61) and (17) of the Individuals with Disabilities Education Act (20
                                            U.S.C. 1401 (16 and 17). When this service is provided the member record must contain activity
                                            reports, completed by the VFP Team and filed within thirty (30) days of

                                                  completing each of the six required activities, and monthly ongoing support reports from the VFP
                                                  Team. Vocational futures planning excludesservices that could be provided as supported
                                                  employment or prevocational sheltered employment and work activity services.

                                                                Page 11 of 12
                                                              EXHIBIT A
                  DSD/FAMILY CARE LIST OF SERVICE NAMES and DESCRIPTIONS
Capacity Data on Provider Application is only required for services identified with double asterisk (**) before Service Name.
SPC #     Z      Source       Service Name       Service Descriptions based on source code abbreviations: FC = Family Care
         Code                                    WAC = WI Admin. Code WM = Waivers Manual HSRS = Human Services
                                                 Reporting System
615.00   ZSW       FC      **SUPPORTED           Supported Employment Services is the provision of support to maintain paid, competitive
                           EMPLOYMENT            employment in an integrated work setting to individuals who, because of their disabilities, need
                                                 intensive on-going support to perform in a work setting. Supported employment services include
                                                 supervision, training, transportation services needed to provide intensive ongoing support, and any
                                                 activity needed to sustain paid work by the participant, i.e., supported employment assessment
                                                 supported employment job placement, supported employment training, and supported employment
                                                 follow-up. Supported employment services furnished under the waiver are not available under a
                                                 program funded by either the Rehabilitation Act of 1973 or P.L. 94-142. Supported employment
                                                 services may be provided to supplement, but may not duplicate services provided under
                                                 vocational futures planning provided under the waiver.



615.00    ZES      FC      **EMPLOYMENT          Same as Supported Employment Services. Excludes welfare and employment programs.
                           SERVICES
706.10   ZCN      HSRS **DAY CENTER              Day Center Service/Treatment is the provision of regularly scheduled activities in a non-
                           SERVICES - NON-       residential setting (day center) to enhance social development and to develop skills in performing
                           MEDICAL               activities of daily living and community living. Day services include services primarily intended for
                                                 disabled adults. Transportation may be provided between the individual's place of residence and
                                                 the site of the habilitation services or between habilitation sites (in cases where the individual
                                                 receives habilitation services in more than one place) as a component part of habilitation services.
                                                 The cost of this transportation is included in the rate paid to providers of the appropriate type of
                                                 habilitation services. Day center services may be provided to supplement, but may not duplicate
                                                 services provided under vocational futures planning provided under the waiver.




OTHER

403.01   ZRA      HSRS **RECREATION/             Recreational/Alternative activities are services in a natural or supportive setting to persons who
                           ALTERNATIVE           are socially or physically inactive, or whose activities are socially inappropriate, for the purpose of
                           ACTIVITIES            increasing their participation in constructive leisure time activities which enhance their dignity,
                                                 support their independence, and /or encourage their involvement in and with the community.
                                                 Excludes recreational services provided as an integral part of a day services center/treatment
                                                 program.




                                                                Page 12 of 12

								
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