Rule 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 (SRSP) 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;
(c) General consultation, including advocacy and building and maintaining relationships with employers;
(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; or
(b) Transportation.
(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, 42 U.S.C. 12101 et. seq. (January 1, 2024);
(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 5160-27-03 of the Administrative Code;
(c) Be certified by the Ohio department of mental health and addiction 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 service 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 service 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 of 1973, 29 U.S.C. 701 et. seq. (July 1, 2023), relating to vocational rehabilitation services, or the Individuals with Disabilities Education Act (1990), set forth in 20 U.S.C. section 1400 et. seq. (January 1, 2024), relating to special education.
(C) Recovery management is the coordination of all SRSP 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 or have a minimum of one year post degree experience working with individuals with diagnosed chronic conditions;
(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 (SPMI) or diagnosed chronic conditions (DCC) and community-based interventions/resources for those individuals;
(e) Attend training activities including, but not limited to:
(i) Person-centered service planning;
(ii) Administering the "Adult Needs and Strengths Assessment (ANSA)" (8/2021);
(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 (October 1, 2023);
(v) 42 C.F.R. part 2 (October 1, 2023), confidentiality of alcohol and drug abuse patient records; and
(vi) Incident management as described in rule 5160-44-05 of the Administrative Code.
(f) Be supervised by clinical staff who possess 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" (8/2021);
(ii) Verification of the individual's residence in an HCBS setting;
(iii) Verification of the individual's qualifying behavioral health diagnoses or diagnosed chronic conditions as described in the qualifying diagnosis appendix which is available on the ODM website at https://medicaid.ohio.gov/resources-for-providers/special-programs-and-initiatives/srs; and
(iv) Evaluation of all other eligibility criteria as described in paragraph (A) of rule 5160-43-02 of the Administrative Code.
(v) At the discretion of ODM or its designee, evaluations may be conducted by video conference or telephonically at the request of the individual, unless the individual's needs require a face-to-face visit.
(b) Person-centered care planning and updating the individual's service plan;
(c) Facilitation of transitioning to the community for individuals who receive medicaid-funded institutional services. Recovery management activities for individuals leaving institutions shall be coordinated with, and shall not duplicate, institutional, mycare and managed care plan discharge planning, and other community resources.
(d) Informing the individual about SRSP services, person centered planning, resources for recovery, and individual rights and responsibilities;
(e) Supporting the review and approval of the individual's person-centered service plan in accordance with rule 5160-44-02 of the Administrative Code;
(f) Monitoring the individual's service plan;
(g) Identifying and resolving issues that impede access to needed SRSP services;
(h) Identifying resources in the person-centered service plan to support the individual's recovery goals, including non-HCBS medicaid, medicare, private insurance, and community resources;
(i) Coordinating with other service providers and systems;
(j) Assisting with accessing resources necessary to complete medicaid redetermination and retain HCBS and medicaid eligibility;
(k) Responding to and assessing emergency situations and incidents and assuring that appropriate actions are taken to protect the health, welfare, wellness, and safety of the individual in accordance with rule 5160-44-05 of the Administrative Code and assist in meeting the needs of the individual in those situations;
(l) Evaluating the individual's progress in meeting his or her goals;
(m) Participating in quality oversight activities and reporting activities as described in rule 5160-43-07 of the Administrative Code;
(n) Participating in case consultations regarding an individual's progress with a trans-disciplinary care team, as defined in rule 5160-43-01 of the Administrative Code. When an individual is assigned to or enrolled in a comprehensive care management program operated by an accountable entity (e.g. patient centered medical home or managed care plan), the recovery manager will support access to the individual's full set of medicaid and medicare benefits and community resources across the continuum of care, including behavioral, medical, LTSS and social services;
(o) Updating the assessment at least annually, making revisions to the individual's service plan, and making recommendations to the accountable care management entity, as appropriate;
(p) Educating the individual about hearing and appeal rights; and
(q) Assisting the individual with preparing and submitting a hearing request, as needed.
(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;
(c) Representative payee functions; and
(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 shall 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;
(c) Not be the individual's legally responsible family member;
(d) Be identified as the provider and have specified on the individual's person-centered service 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 shall 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 shall contain:
(a) A copy of the current person-centered service plan;
(b) Documentation of each service interaction including the duration recovery management was provided; and
(c) Documentation that the service is not available under a program funded under section 110 of the Rehabilitation Act of 1973, 29 U.S.C. 701 et. seq. (January 1, 2024) relating to vocational rehabilitation services, or the Individuals with Disabilities Education Act, of 1990 set forth in 20 U.S.C. 1400 et. seq. (January 1, 2024), relating to special education.
Last updated September 3, 2024 at 9:10 AM
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