Page 19

(2) Tier D (extraordinary needs) -- Adults at this tier include persons with the most extensive/complex medical support needs that require nurse management to minimize medical risk factors. Maximum assistance with activities of daily living is required to meet their extensive physical support needs and personal hygiene; including lifting/transferring and positioning. Feeding tubes and other feeding supports (e.g., aspiration risk management), oxygen therapy or breathing treatments, suctioning, and seizure management are common as well. Persons at this needs level may be medically unstable or receiving hospice services. (3) Tier C (significant needs) -- Adults at this tier have profound medical/behavioral needs requiring significant supports. Some time may be spent alone, engaging independently in certain community activities and/or with natural supports. b. High level of needs. Tiers B and A: (1) Tier B (moderate needs) -- Adults at this level require more hours of daily support than those with needs at Tier A. Even though members of this tier have a broader scope of personal needs than those in Tier A, 24/7 supports are not required as their needs are still considered minimal in a significant number of life areas. (2) Tier A (mild needs) -- Adults at this level are assessed as having mild support needs. Persons at this tier are capable of managing many aspects of their lives with limited supports and services. They do not require 24/7 paid supports as they are able to spend a significant amount of time on their own and/or engaging in the community with limited supports and services. 5.7.4 Service Options

A. Services in an ICF/I-DD health institution are reserved for beneficiaries determined to have the highest level of "extraordinary need" (Tier E) on the SIS who require intensive 24/7 care and, due to extenuating circumstances, may only be served in a highly restricted setting. Generally, medical conditions requiring continuous on-site skilled, rather than custodial care, prohibit applicants at this level from obtaining care in an HCBS setting. Persons with this level of need are served in an NF or LTH offering the same or a more robust service array. B. The HCBS service options available to beneficiaries with the needs levels at each service classification provide the appropriate care and supports in the least