5160-43-04 Specialized recovery services program covered services and provider requirements.

5160-43-04 Specialized recovery services program covered services and provider requirements.

(A)This rule sets forth the covered services available to an individual enrolled in the specialized recovery services program and the requirements for providers of those services.

(B)Individualized placement and support - supported employment (IPS-SE) is the implementation of evidence-based practices allowing individuals to obtain and maintain meaningful employment by providing training, ongoing individualized support, and skill development to promote recovery. IPS-SE is an evidence based practice which is integrated and coordinated with mental health treatment and rehabilitation designed to provide individualized placement and support to assist individuals with a severe and persistent mental illness obtain, maintain, and advance within competitive community integrated employment positions.

(1)IPS-SE activities include:

(a) Benefits planning;

(b) Development of a vocational plan;

(d)Individualized job supports, including regular contact with the individual's employer(s), family members, guardians, advocates, treatment providers, and other community supports;

(e) Job coaching;

(f)Job development and placement;

(g) Job seeking skills training;

(h) On-the-job training and skill development;

(i) Vocational rehabilitation guidance and counseling;

(j) Time unlimited vocational support; and

(k) Vocational assessment.

(2)IPS-SE activities may include the following when provided in conjunction with an IPS-SE activity listed in paragraph (B)(1) of this rule:

(a) Facilitation of natural supports;

(b) Peer services; and/or

(3) The following activities are not payable under IPS-SE:

(a) Adaptations, assistance and training used to meet the employer's responsibility to fulfill requirements for reasonable accommodations under the Americans with Disabilities Act (2008);

(b) Job placements paying below minimum wage;

(c) Supervision, training, support and adaptations typically available to the general workforce filling similar positions in the business;

(d)Supervisory activities rendered as the normal part of business setting;

(e) Unpaid internships, unless they are considered crucial for job placement and such experience is vital to the individual achieving his or her vocational goal(s);

(f)Services which are not provided in integrated settings including sheltered work or other types of vocational services in specialized facilities, or incentive payments, subsidies, or unrelated vocational training expenses such as the following:

(i) Incentive payments made to an employer to encourage hiring the individual;

(ii) Payments that are passed through to the individual; or

(iii) Payments for supervision, training, support and adaptations typically available to other workers without disabilities filling similar positions in the business; or payments used to defray the expenses associated with starting up or operating a business.

(4) To be a provider and submit a claim for payment of IPS-SE services, the provider delivering the service must meet all of the following requirements:

(a) Comply with all rules set forth in this chapter and Chapter 5160-27 of the Administrative Code;

(b) Request payment for the provision of services in accordance with rule 5160-27-05 of the Administrative Code;

services (OhioMHAS) under section 5119.36 of the Revised Code;

(d)Not be the individual's legally responsible family member, as defined in rule 5160-43-01 of the Administrative Code;

(e) Be identified as the provider and have specified on the individual's person-centered care plan, that is prior approved by the Ohio department of medicaid (ODM) or its designee, the number of hours the provider is authorized to furnish program services to the individual;

(f)Provide services that are supported by an identified need or recovery goal in a manner that supports and respects the individual's communication needs including translation services, and/or assistance with communication devices; and

(g) Not provide IPS-SE services simultaneously with other rehabilitation services available under the medicaid state plan.

(5) IPS-SE providers must maintain a record for each individual served in a manner that protects the confidentiality of those records. At a minimum, the record must contain:

(a) A copy of the current person-centered care plan;

(b) Documentation of each service interaction including the duration IPS-SE was provided; and

(c) Documentation that the service is not available under a program funded under section 110 of the Rehabilitation Act (1973), relating to vocational rehabilitation services, or the Individuals with Disabilities Education Act (1990), set forth in 20 U.S.C. section 1400 et. seq. (as in effect on February 1, 2016), relating to special education.

(C) Peer recovery support provides community-based supports to an individual with a mental illness with individualized activities that promote recovery, self-determination, self-advocacy, well-being and independence through a relationship that supports the person's ability to promote his or her own recovery. Peer recovery supporters use their own experiences with mental illness to help individuals reach their recovery goals.

(1) Peer recovery support activities include:

(a) Assisting the individual with accessing and developing natural support systems in the community;

(b) Attending and participating in care team meetings;

(d)Coordinating and/or assisting in crisis interventions and stabilization as needed;

(e) Developing and working toward achievement of the individual's personal recovery goals;

(f)Facilitating development of daily living skills;

(g) Modeling personal responsibility for recovery;

(h) Promoting coordination among similar providers;

(i) Providing group facilitation that addresses symptoms, behaviors, and thought processes to assist an individual in eliminating barriers to seeking and maintaining recovery, employment, education, and housing;

(j) Supporting individuals in achieving personal independence as identified by the individual; and

(k) Teaching skills to effectively navigate the health care delivery system to utilize services.

(2) The following activities are not payable under peer recovery support:

(a) Assistance with activities of daily living as defined in rule 5160-3-05 of the Administrative Code;

(b) Management of medications; and

(3) To be a provider and submit a claim for payment of peer recovery support services, the provider delivering the service must meet all of the following requirements:

(a) Comply with all rules set forth in this chapter and Chapter 5160-27 of the Administrative Code;

(b) Request payment for the provision of services in accordance with rule 5160-27-05 of the Administrative Code;

(d)Not be the individual's legally responsible family member, as defined in rule 5160-43-01 of the Administrative Code;

(e) Be identified as the provider and have specified on the individual's person-centered care plan, that is prior approved by ODM or its designee, the number of hours the provider is authorized to furnish services to the individual;

(g) Not provide peer recovery support activities simultaneously with other rehabilitation services available under the state plan; and

(h) Be supervised by other senior peers or non-peer staff that have been certified to supervise peers and receive regularly scheduled clinical supervision from a person meeting the qualifications of a behavioral health professional with experience regarding this specialized behavioral health service.

(4) All peer recovery support providers must maintain a record for each individual served in a manner that protects the confidentiality of those records. At a minimum, the record must contain:

(a) A copy of the current person-centered care plan;

(b) Documentation of each service interaction including the duration peer recovery support was provided; and

(c) Documentation that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973, relating to vocational rehabilitation services, or the Individuals with Disabilities Education Act (1990) set forth in 20 U.S.C. section 1400 et. seq. (as in effect on February 1, 2016), relating to special education.

(D) Recovery management is the coordination of all specialized recovery services program services received by an individual and assisting him or her in gaining access to needed medicaid services, as well as medical, social, educational, and other resources, regardless of funding source.

(1) Recovery managers shall:

(a) Be a registered nurse, or hold at least a bachelor's degree in social work, counseling, psychology, or related field;

(b) Have a minimum of three years post degree experience working with individuals with severe and persistent mental illness;

(c) Possess an active medicaid provider agreement or be employed by an entity that has an active medicaid provider agreement;

(d)Demonstrate knowledge of issues affecting people with severe and persistent mental illness and community-based interventions/resources for those individuals;

(e) Attend training activities including, but not limited to:

(i) Person-centered care planning;

(ii) Administering the "Adult Needs and Strengths Assessment (ANSA)" (7/2016);

(iii) Home and community-based services (HCBS) settings;

(iv) "Health Insurance Portability and Accountability Act of 1996" (HIPAA) regulations set forth in 45 C.F.R. parts 160 and 164 (as in effect on February 1, 2016);

(v) 42 C.F.R. part 2 (as in effect on February 1, 2016), confidentiality of alcohol and drug abuse patient records; and

(vi) Incident management as described in rule 5160-43-06 of the Administrative Code.

(f)Be supervised by clinical staff who posses a current, valid and unrestricted license with the appropriate licensure board from the fields of nursing, social work, psychology, or psychiatry.

(2) Recovery management activities include:

(a) Face-to-face eligibility evaluation, including:

(i) Administration of the "ANSA" (7/2016);

(ii) Verification of the individual's residence in an HCBS setting as described in rule 5160-44-01 of the Administrative Code,

(iii) Verification of the individual's qualifying behavioral health diagnoses as described in the appendix to rule 5160-43-02 of the Administrative Code; and

(iv) Evaluation of all other eligibility criteria as described in paragraph (A) of rule 5160-43-02 of the Administrative Code.

(b) Person-centered care planning, monitoring and updating the care plan.

(c) Facilitation of community transition for individuals who receive Medicaid-funded institutional services. Recovery management activities for individuals leaving institutions must be coordinated with, and must not duplicate, institutional and managed care plan discharge planning and other community transition programs. This service may be provided up to one hundred eighty days in advance of anticipated movement to the community.

(3) Recovery management activities do not include:

(a) Travel time incurred by the recovery manager billed as a discrete unit of service;

(b) Services that constitute the administration of another program such as child welfare, child protective services, foster care, parole and probation functions, legal services, public guardianship, and special education;

(d)Other activities identified by ODM.

(4) To be a provider and submit a claim for payment of recovery management services, the provider delivering the service must meet all of the following requirements:

(a) Comply with all rules set forth in this chapter of the Administrative Code;

(b) Request payment for the provision of services in accordance with rule 5160-43-08 of the Administrative Code;

(d)Be identified as the provider and have specified on the individual's person-centered care plan, that is prior approved by ODM or its designee, the number of hours the provider is authorized to furnish services to the individual;

(e) Provide services that are supported by an identified need or recovery goal in a manner that supports and respects the individual's communication

needs including translation services, and/or assistance with communication devices.

(5) All recovery management activities must be documented in a record using the process prescribed by ODM for each individual served in a manner that protects the confidentiality of these records. At a minimum, the record must contain:

(a) A copy of the current person-centered care plan;

(b) Documentation of each service interaction including the duration recovery management was provided; and

Effective:	08/01/2016
Five Year Review (FYR) Dates:	08/01/2021
CERTIFIED ELECTRONICALLY
Certification
07/15/2016
Date
Promulgated Under:	119.03
Statutory Authority:	5164.02
Rule Amplifies:	5164.02, 5162.03

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Document Information

Effective Date:: 8/1/2016
File Date:: 2016-07-15
Last Day in Effect:: 2016-08-01
Rule File:: 5160-43-04_PH_FF_N_RU_20160715_0934.pdf
Related Chapter/Rule NO.: (1): Ill. Adm. Code 5160-43-04. [Effective 8/1/2016] Specialized recovery services program covered services and provider requirements