(b)(3) Supported Employment Adolescents and Adults with Intellectual Developmental Disabilities (IDD) Medicaid Billable Service Effective 04-01-07 Revised 12-20-10 Revised 5-1-14 Revised 11-20-15 Revised 03-01-2021
CODES: H2023 U4 = Initial Individual Supported Employment H2023 HQ U4 = Initial Group Supported Employment H2026 U4 = Maintenance Individual Supported Employment H2026 HQ U4 = Maintenance Group Supported Employment
Supported Employment Services provide assistance with choosing, acquiring and maintaining a job for members ages 16 and older for whom competitive, integrated employment has not been achieved and/or has been interrupted or intermittent. Competitive integrated employment is an individual job in competitive or customized employment, or self-employment, in an integrated work setting in the general workforce for which an individual is compensated at or above the minimum wage.
Initial Supported Employment-Individual services may include any of the following, based on individual beneficiary circumstances and needs: • Services that support a beneficiary to explore, and make an informed choice about pursuing, competitive integrated employment. When this service is used to assist a beneficiary to explore, and make an informed choice about pursuing, competitive integrated employment, this service includes, at minimum: o Sufficient but time-limited job and career exploration activities to identify a person’s specific interests and aptitudes for paid work, including experience and skills transferable to competitive integrated employment; o Uniquely arranged business tours, informational interviews and/or job shadows, that are specifically related to the person’s identified interests, experiences and/or skills, to explore potential opportunities for competitive integrated employment in the person’s local area; o Introductory, basic education on the numerous work incentives for individuals receiving publicly funded benefits (e.g. SSI, SSDI, Medicaid, etc.); o Introductory education on how Supported Employment-Individual services work (including Vocational Rehabilitation services). Educational information is provided to the person and the legal guardian and/or most involved family member(s), if applicable, to ensure legal guardian and/or family support for the person’s choice to pursue competitive integrated employment. The educational aspects of this service shall include addressing any concerns, hesitations or objections of the person and the legal guardian and/or most involved family member(s), if applicable. • Targeted and time-limited employment navigation assistance that is designed to assist a beneficiary who wants to pursue and obtain competitive integrated employment to access needed employment services and supports from non- Medicaid sources [e.g. Vocational Rehabilitation; NC Works programs and services; Special Education; Ticket to Work; Work Incentives Planning and Assistance (WIPA) program]. • Services to support an individual to successfully seek, choose, acquire, increase and/or advance in competitive integrated employment which may include career/educational counseling, discovery, job shadowing, job development/ placement, customized job development, training or assistance in resume preparation, job interview skills and/or learning other skills necessary for success, and assistance in the use of educational resources and development of study skills. When this service is used to assist a beneficiary to seek, choose, acquire or advance in competitive integrated employment, the employment or self-employment outcome must be consistent with the individual’s interests, preferences, strengths, skills and conditions identified as necessary for success, in order to maximize the likelihood of sustained and satisfying work. Job finding is not based on a pool of jobs that are available or set aside specifically for individuals with disabilities. • Initial coaching and employment support activities that enable an individual to complete initial job training, develop skills necessary to maintain employment, and transition successfully to long term follow-up. These activities typically include but are not limited to assistance in: learning job tasks (e.g. systematic instruction); learning company policies and expectations, developing skills for traveling to/from work, and getting to know/interacting effectively with supervisors and co-workers. Initial coaching and employment support activities should be expected to continue the person successfully completes any probation period that the employer may impose. • Fading of initial coaching and employment support activities should begin at some level within the first month of employment and incremental fading gains should be expected to continue over time, as the person becomes more independent on the job and can rely on natural supervisors and co-workers for needed supports, until fading has been maximized and/or the person completes their probation period, at which point the person should transition to long term follow-up. Feedback regarding the performance and integration of the individual into their workplace should be obtained from the employer, through employee evaluations or other means that provide information on the level and type of coaching and support that the individual requires. The transition to Long term follow-up should typically occur within one year of the individual starting competitive integrated employment. • As part of initial coaching employment support activities, consultation, technical assistance and education for the employer, including supervisors and co-workers as needed. This can include education on reasonable accommodations and other strategies that can contribute to long-term success of the competitive integrated employment situation and the satisfaction of the employer.
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• Services to assist an individual to achieve self-employment or ownership of a micro-enterprise. This assistance consists of: o Aiding the individual to identify potential business opportunities; o Assistance in the development of a business plan, including potential sources of business financing and other assistance; o Assistance, based on needs related to disability, in launching the self- employment or micro-enterprise venture; o Identification of the long-term follow-along supports that are necessary in order for the individual to maintain self-employment or operate the micro- enterprise.
Long term follow-up supports include: • Coaching and employment support activities necessary to enable an individual to maintain competitive integrated employment, such as on-the-job supports that do not supplant or discourage natural supports, services necessary to maintain and improve skills needed to complete job tasks, supports to manage impact of disability in relation to employment. Feedback regarding the performance and integration of the individual into their workplace should be obtained from the employer at regular intervals, through employee evaluations or other means that provide information on the level and type of coaching and support that the individual requires. A focus on identifying and implementing strategies for fading should continue in long term follow-up. • Ongoing assistance, counseling and guidance for an individual who is self- employed or operates a microenterprise • Ongoing employer consultation, technical assistance and education, including supervisors and co-workers as needed, with the objective of ensuring long-term success of the competitive integrated employment situation and the satisfaction of the employer and supported employee. This includes proactively identifying issues and offering assistance to resolve these issues in order to prevent the supported employee’s loss of employment, and advising the employer regarding reasonable accommodations and other legal requirements.
Documentation will be maintained in the file of each provider agency specifying that this service is not otherwise available under a program funded under section 110 of the Rehabilitation Act of 1973, or Individuals with Disabilities Education Act (20 U.S.C. 1401 et seq.) for this member.
Medicaid shall cover procedures, products, and services when they are medically necessary, and • the procedure, product, or service is individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the beneficiary’s needs; • the procedure, product, or service can be safely furnished, and no equally effective and more conservative or less costly treatment is available statewide; and
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• the procedure, product, or service is furnished in a manner not primarily intended for the convenience of the beneficiary, the beneficiary’s caretaker, or the provider.
Exclusions Medicaid funding is not to be claimed for incentive payments, subsidies or unrelated vocational training expenses such as the following: • Incentive payments made to an employer to encourage or subsidize the employer’s participation in a supported employment program; • Payments that are passed through to users of supported employment programs; or • Payments for training that are not directly related to a member’s supported employment program.
For members who are eligible for educational services under the Individual’s with Disability Educational Act, Supported Employment does not include transportation to/from school settings. This includes transportation to/from the member’s home, provider home where the member is receiving services before/after school or any community location where the member may be receiving services before or after school. Transportation cannot start or end at a school setting.
Provider Requirements Supported Employment services must be delivered by staff employed by an IDD provider organization that meets the provider qualification policies, procedures, and standards established by the Division of Mental Health, Developmental Disabilities and Substance Abuse Services and the requirements of 10A NCAC 27G as well as agencies endorsed to provide Supported Employment services through the NC Innovations waiver. These policies and procedures set forth the administrative, financial, clinical, quality improvement, and information services infrastructure necessary to provide services. Provider organizations must demonstrate that they meet these standards by being endorsed by Cardinal Innovations Healthcare Solutions and demonstrate competency through experience with employment supports, including programs such as PASS, IRWE and/or Ticket to Work. The organization must be established as a legally recognized entity in the United States and qualified/registered to do business as a corporate entity in the State of North Carolina.
Providers must meet all NC Innovations waiver provider requirements and be enrolled 1915(c) waiver providers.
Tribal providers do not need to meet licensure or accreditation requirements.
Staffing Requirements Staff who provide Supported Employment services will have a high school diploma or high school equivalency (GED) and must be qualified in CPR and First Aid with three (3)
4 Revised 03-01-2021 years of experience in the general workforce, one of which is working directly with members that have intellectual or developmental disabilities. A Qualified Professional will supervise all staff. All staff providing Supported Employment services must complete the below training within ninety (90) ninety days of employment. The competency-based training should include but not be limited to the following: • Diagnosis and clinical issues regarding the population served • Client Rights • Confidentiality/HIPPA • Crisis Intervention and Response • Infectious/Communicable Diseases • CPR • First AidIndividual Support Planning to include goals/strategies • Approved training on alternatives/restrictive interventions by a certified instructor prior to being alone with a member as appropriate for the member • Protective Devices/Usage as appropriate for the member • Cultural Diversity/Awareness • Knowledge of the Service Delivery System • Medication Administration as appropriate for the member • Vocational Skills and Training to include successful interviewing strategies and relevant employment laws such as wage and hour laws
Service Type/Setting Supported Employment is a day/night service as specified under NC Administrative Code T10:14V.5800. Supported Employment Services occur in integrated environments with non-disabled persons or in a business owned by the member. The service may not be provided in licensed facilities, including residential facilities in which the member lives, or licensed vocational facilities for people with disabilities.
Program Requirements • Providers are to follow NC Employment First principles. • Providers are encouraged to use Best Practice Models to achieve Supported Employment success. • Supported Employment services must be available in a variety of locations and employment settings. All services should be provided in locations agreeable to the member employed. Access to staff to provide Supported Employment should be available at all times when members are on the job. • Staff who provide Supported Employment will canvas the community, seeking and/or creating the appropriate job opportunity for each unique member.
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Utilization Management Prior-authorization by Cardinal Innovations Healthcare Solutions is required. The amount, duration and frequency of service must be included in a member’s Service Plan or Person-Centered Plan and authorized on or before the day services are to be provided. Initial authorization for services may not exceed a ninety (90) day period. Re- authorization must be conducted every ninety (90) days.
Initial job development, training and support: a maximum of eighty-six (86) hours or 344 units per month for the first ninety (90) days Intermediate training and support: a maximum of forty-three (43) hours or172 units per month for the second ninety (90) days Long Term support: a maximum of ten (10) hours or forty (40) units per month unless specific authorization for exceeding this limit is approved
Specific authorization must be obtained to exceed these limits.
This service may be provided in a group setting. The minimum number to constitute a group is three (3) and the minimum Staff-to-Member ratio is one to nine (1:9).
Entrance Criteria
GS 122C defines a developmental disability as a severe, chronic disability of a person that satisfies all of the following: a. Is attributable to a mental or physical impairment or combination of mental and physical impairments. b. Is manifested before the person attains age 22, unless the disability is caused by a traumatic head injury and is manifested after age 22. c. Is likely to continue indefinitely. d. Results in substantial functional limitations in three or more of the following areas of major life activity: self-care, receptive and expressive language, capacity for independent living, learning, mobility, self-direction, and economic self- sufficiency. e. Reflects the person's need for a combination and sequence of special interdisciplinary, or generic care, treatment, or other services which are of a lifelong or extended duration and are individually planned and coordinated.
Medical necessity for the service must be documented in a treatment plan such as an Individual Support Plan unless otherwise noted.
Continued Stay Criteria • The member continues to meet the entrance criteria listed above and requires this service to maintain employment within the community.
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• The member has obtained employment and needs additional support in skill building, developing work habits and/or improving social workplace skills. • The member needs support or training in order to change jobs or increase hours of employment. • The member needs support in managing benefits (Social Security, Ticket to Work, etc.).
Discharge Criteria • The member can maintain employment without assistance. OR • The individual has made no progress during the past six months in developing a micro-enterprise, securing a job or maintaining a job, despite efforts to provide Supported Employment training and support; and the individual is not experiencing any type of personal or family crisis that would prelude at least minimal progress toward the individual’s employment goals. OR • The member expresses the decision not to work.
Expected Outcomes The member will have increased ability to function in all major role areas related to employment without ongoing assistance from the program and without significant relapse when services are withdrawn. Gainful employment has been correlated with improved levels of functioning including ability to meet basic needs such as food, clothing and housing. Stability in work, home and social roles has been associated with recovery.
Service Orders A Qualified Professional in IDD orders this service.
Documentation Requirements Provider must have psychological testing with adaptive functioning for IDD, and Medical documentation to support that health condition and Adaptive Testing for other Developmental disabilities that support admission criteria prior to initiation of services.
A valid Individual Support Plan, Person-Centered Plan or Service plan.
Minimum standard is a daily full service note that meets the criteria specified in the DMH/DD/SAS Records Management and Documentation Manual (APSM 45-2) and includes, but not limited to: • the member’s name, • Medicaid identification number • date of service • name of the service provided • duration of the service
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• purpose of contact • the provider’s interventions, including the time spent performing the interventions • effectiveness of the intervention • the signature, credentials and job title of the staff providing the service
All documentation must relate directly to the goal(s) listed in the member’s current plan. Refer to DMH/DD/SAS Records Management and Documentation Manual (APSM 45-2) for a complete listing of documentation requirements.
Service Exclusions/Limitations Supported Employment will not be claimed in incentive payments, subsidies, or unrelated vocational training expenses such as the following: • Incentive payments made to an employer to encourage or subsidize the employer’s participation in a Supported Employment program; • Payments that are passed through to users of Supported Employment programs; or • Payments for vocational training that are not directly related to a member’s Supported Employment program.
Supported Employment Services do not occur in a licensed community day program.
The member may not work for the member’s provider of Supported Employment services.
This service may not be provided to members who are actively funded by Vocational Rehabilitation to meet their Support Employment needs under the Rehabilitation Act of 1973, or P.L. 94-142.
Supported Employment may not be provided at the same time of day as the following services: • (b)(3) or state-funded Respite • (b)(3) or state-funded Supported Employment • Other 1915(b)(3) services or alternative services • Other State Plan Medicaid services that work directly with the person
Supported Employment may not be provided during the same Authorization period as ACTT, Community Support Team, SAIOP, SACOT or ICF/IID.
(b)(3) services, with the exception of Psychiatric Consultation, are not available to participants of all state 1915(c) waivers. (b)(3) services are only available up to the capitation amount provided to fund these services by NC DHHS.
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This service may not be provided by a legally responsible person, a relative or legal guardian.
This service cannot duplicate services currently being provided by educational institutions or Vocational Rehabilitation.
Administrative activities such as writing service notes and Person-Center Plans (PCPs) or completing Treatment Authorization Requests (TARs) are not billable activities.
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