Employment & Day Services FAQ's
The following Frequently Asked Questions are designed to assist in the implementation of the new Employment and Day Services changes. Since the training and implementation will include many stakeholders, it is expected that these FAQs will updated routinely as DIDD receives new questions and/or new information. To assist in identifying the most timely updates and new questions, each question below includes the date last updated.
Why is DIDD making changes to its Employment and Day Services? (Updated 1/16/19)
Tennessee’s intellectual and developmental service delivery system was the first to adopt an Employment First philosophy in 2002. The state committed further to competitive integrated employment as the first and preferred option for people with disabilities when Gov. Bill Haslam signed Executive Order No. 28 in 2013. Furthermore, the HCBS Final Settings Rule issued by the Centers for Medicare and Medicaid Services (CMS) mandated that Medicaid-funded home and community based services not isolate people in segregated settings.
The changes being made to Employment and Day Services in the state’s three 1915c waivers for people with intellectual disabilities (Statewide, CAC and Self-Determination) allow for increased flexibility in how and where services are provided and are designed to increase opportunities for employment and community participation. The changes better align reimbursement with employment and community outcomes, provide a path for people who want to explore employment, and give people more flexibility to choose how to spend their days.
How did DIDD develop the changes to Employment and Day Services? (Updated 1/16/19)
DIDD and TennCare worked in collaboration for two years with the provider community to develop the changes, and made several revisions based on feedback offered by stakeholders. The proposed changes were made available for public comment in May 2018, with the changes submitted to CMS in July 2018. CMS approved the changes in September 2018.
When are the changes being implemented? (Updated 11/20/19)
The changes are scheduled to take effect on January 1, 2020. People receiving employment and day services will receive official notice at least 30 days prior to implementation about the changes, and providers and ISCs have been encouraged to discuss the changes with persons supported during the months leading up to implementation.
Are there any changes to Personal Assistance Services? (Updated 1/25/19)
No. These waiver changes are limited to employment and day services. There are no changes to Personal Assistance at this time.
Where will the Employment and Day Services training be available? (Updated 1/25/19)
The training slides, appendix of resources, and a webinar recording of the training will all be housed on the DIDD website. There is a tab on the Employment First page called “Employment and Day Services.” Here is the link: https://www.tn.gov/didd/for-consumers/employment--first/employment-day-services.html
For FB day, what happens if a person is not making progress on their goal areas?
When a person receives FB day services, it is expected they make progress on their goal areas. This looks different for each person. If a person is no longer making progress on their FB goal areas, the provider should work with the person supported and COS to consider one or more of the following: 1) changing FB goals to something more appropriate for the person, 2) changing the method of measuring progress to capture incremental growth, 3) considering alternative services (e.g. community participation, supported employment, etc.) that may be more appropriate for the person to make progress in their personal goal areas.
When is a Circle of Support (COS) meeting required? When is a signature sheet required? (Updated 4/5/19)
A COS meeting can be required at any time the person or a COS member determines a meeting needs to be held to discuss services. If a COS meeting results in a request for a waiver-funded service, a signature sheet will be required. This applies to both annual and amended plans. The person-centered planning rule states that signatures are required for all those responsible in implementing the plan.
What are the new Pre-Employment Services? (Updated 11/20/19)
DIDD will have three different outcome-based pre-employment services: Exploration, Discovery and Job Development. These services can help a person and his or her family explore what working in the community would look like:
Exploration helps a person explore different jobs in the community based on a person’s interests, and existing skills. It can include business tours, job shadows and/or informational interviews with employers for people to fully understand what a job in the community could mean for them and how it could benefit them both financially and otherwise. It also includes education about work incentives for people receiving Social Security, Medicaid, food stamps, etc. It also includes information on how employment services work. After participating in Exploration, a person can make an informed choice whether or not they would like to pursue community employment or try Discovery to gain additional information on work opportunities and their own employment skills and interests.
Discovery assists people who want to work in the community, but who need more information on the best kinds of job matches for them, before they pursue a job. This service helps a person identify strong interests that relate to employment, strengths and skills that each person needs to be successful with employment.
Job Development supports a person in obtaining an individualized job in an integrated employment setting in the general workforce. This can include customized employment or self-employment start-up through the identification of business opportunities and assistance in business plan development.
Outcomes and expectations for payment will match those currently in place for TennCare’s Employment and Community First CHOICES program. Training for DIDD’s pre-employment services were held in spring 2019, and the presentation and templates can be found on the “Resources” page.
How can I tell if the person I support may be suitable for one of the pre-employment services? (Updated 1/16/19)
According to the National Core Indicators Adult Consumer Survey, more than one-third of people in DIDD services who do not have a job in the community are interested in working. Pre-employment services may assist those and others who are unsure how employment may benefit them to look at a variety of options. Consideration and discussion about the availability of each of the Employment support options is a required component of the Individual Support Planning process and will include the person and his or her Circle of Support.
How do I assist the person I support in determining whether they are interested in employment? (Updated 1/16/19)
It is important to start with the assumption that the person is capable of working and deserves the opportunity to consider employment. If a person knows right away he or she wants to work, the provider can help the person explore their preferences, interests, skills, gifts, and conditions for success. They can also help a person develop employment goals and a career profile. These activities may occur through the Discovery service, if the person is eligible, or through other conversations and activities at home and throughout the community.
If a person does not know right way if he or she wants to work, it is important to ensure they have access to the three E’s: education, exposure, and experience. A person should be educated about what it means to be employed, what different jobs look like, and how it would affect his or her lifestyle and financial situation. A person should also be exposed to various workplaces and other opportunities that demonstrate what working actually looks like. And a person should also be afforded plentiful opportunities to experience realistic work experiences, including, but not limited to: volunteering, work trials, job shadowing, informational interviews, business tours, etc.
If a person still does not express interest in employment, the conversation should focus on what the person sees as barriers. These may include, but are not limited to: low expectations from self or family, fear about benefits, concerns about safety, lack of confidence, no clear idea of skills/interests, etc. A person should never be forced to work, but their COS should maintain the belief that they are capable of working and should continue addressing the barriers the person faces; the person may change his or her mind over time through additional exposure to employment-related opportunities. In the meantime, they can focus on pursuing other socially valued roles such as volunteering and other community memberships.
What type of certification and/or training is necessary for an agency to provide these services? (Updated 1/16/19)
For Discovery and Job Development, an agency staff person must qualify as a Job Developer by obtaining the one of the following:
- Association of People Supporting Employment (APSE) Certified Employment Support Professional (CESP) Certificate received through passing an exam
- ACRE Basic Employment Certificate – The Supported Employment Online Certificate Series earned through Virginia Commonwealth University
- ACRE Basic Employment Certificate in Community Employment with Emphasis on Customized Employment offered by Griffin-Hammis Associates
- ACRE Basic Employment Certificate – College of Employment Services (CES) Plus offered by University of Massachusetts Institute for Community Inclusion
- ACRE National Certificate of Achievement in Employment Services earned through University of Tennessee
- ACRE Professional Employment Certificate earned through completion of “Work Works” online course offered by University of Georgia Institute on Human Development and Disability.
For agency employment staff delivery Exploration and Job Coaching, the staff must be a qualified job coach by successfully completing a competency-based training course covering best practices in job coaching and consultation, pre-approved by DIDD and covering, at a minimum, specific content prescribed in policy by DIDD. This includes the job coaching curriculum in Relias. A person who is a qualified job developer as listed above may also provide these services.
What determines whether a person should start with Exploration or move on to Discovery? (Updated 1/16/19)
Exploration may be a suitable service for people who are unsure they want a job in the community or want to learn more about what community employment could look like.
Discovery may be a suitable service for people who have expressed a desire to have a job in the community but are unsure about the options that may be the best fit for their strengths and interests
A person will start with Exploration or Discovery, depending on their level of interest and their specific support needs.
Does a person need to apply for Vocational Rehabilitation before this service is available with DIDD waiver funding?
DIDD works closely with the Vocational Rehabilitation (VR) program to ensure a seamless delivery of employment services to people with disabilities. As the payer of last resort, the DIDD waiver is the last option for payment of pre-employment supports only when all other federally-funded resources have been exhausted. The Exploration process should educate people about VR services and help address any concerns or objections.
The Discovery process, if waiver-funded, should include assistance for the person to apply for VR services to obtain individualized integrated employment or self-employment.
Exploration and Discovery can be provided before VR funding is accessed. Job Development should only be provided with waiver funding if the person is not eligible for job development or job placement through VR. Documentation of contact with VR should be provided in order for DIDD to approve waiver funding for this service.
After a job placement has occurred, before accessing ongoing job coach support through Supported Employment-Individual, a provider must demonstrate they have helped the person supported with contacting VR and attempting to access available VR funding.
Can these services be provided to a person on Day 1 of the waiver changes? (Updated 1/16/19)
Yes. If a provider agency has staff that meets the qualifications for Job Developer and/or Job Coach, then the Circle of Support can discuss the utilization of these services at any time and a request to utilize these services can be submitted as early as 21 days before the implementation date of the Employment and Day Services changes.
How does an agency get paid for providing these services? (Updated 11/20/19)
DIDD will utilize an outcome-based reimbursement approach, similar to that in the Employment and Community First CHOICES program for these services. For Exploration and Discovery, providers will document the date and services provided and submit a report, utilizing templates provided by DIDD, summarizing the process and outcomes. This report is due no later than fourteen (14) days after the last date of service has concluded. DIDD will review the report and documentation of the service provided and authorize payment upon approval. For Job Development, the service will be paid once the person has completed two calendar weeks of individualized integrated employment or self-employment. These outcome payments are tiered based on the assessed level of need for the person being served. For more information, please refer to the pre-employment services training slides on the “Resources” page.
Is there a limit on how many times a person can receive each service if obtaining employment is not successful? (Updated 1/16/19)
Once a person has received the Exploration service for the first time, it can only be reauthorized once a year with a minimum 365-day interval between services. This can only be reapproved if the person is not already engaged in employment or other services to obtain employment.
Discovery can only be reauthorized once every three years after the person has received the service for the first time. This can only be reauthorized if the person is not already employed or receiving other employment services AND the person has a goal of obtaining integrated employment within twelve (12) months.
The Job Development service can only be reauthorized once a year after a person has received it for the first time. At the time of reauthorization, a person cannot have employment or be engaged in other employment services AND the person has a goal to achieve individualized integrated employment or self-employment within nine (9) months.
Will these services count against a person’s expense cap? (Updated 1/16/19)
Yes. The outcome-based payments for the above services will be included in a person’s cap.
Who will approve if the outcomes of each pre-employment service have been met in order to obtain payment? (Updated 11/20/19)
Each pre-employment service (Discovery, Exploration, and Job Development) has a required report template for providers to complete, as well as an optional “Recommended Steps and Timeframes” document that may be a useful tool for providers while delivering the service. These templates and documents can all be found on the “Resources” page. Providers will submit report templates to their applicable regional Administrative Services unit for review, approval, and payment.
Can Discovery and Exploration still be used on a day-to-day basis and billed as Community Participation? (Updated 1/16/19)
The Discovery and Exploration services should be utilized whenever available and when deemed appropriate for the person. They are specifically designed to help a person assess his or her attitude toward work and develop personalized employment goals. Please note, no other day or employment services can be billed during the same units of time during which pre-employment services are being provided.
Is Training Resource Network (TRN) part of the training requirement for Exploration? (Updated 4/5/19)
No, TRN is not part of the staff training requirement for Exploration under DIDD’s services. Staff providing Exploration must complete the “Job Coach” training curriculum in Relias.
What does the time frame look like between Exploration and Discovery? (Updated 11/20/19)
A provider has up to 30 days to complete Exploration from the date of service initiation, and up to 14 days from the last date of service to submit the required report template. After review and approval, a person supported can decide if he or she would like to continue on to Discovery, at which point the provider/ISC/CM can follow the process to request that service.
What is the process for submitting reports for the pre-employment services (Discovery, Exploration, Job Development)? (Updated 11/20/19)
Providers will submit reports to their applicable regional Administrative Services unit for review and approval.
Why is DIDD changing the way it pays for Supported Employment Services? (Updated 1/16/19)
To better support the increasing the number of waiver participants who have clearly expressed their desire to work in individualized supported employment, it is necessary to ensure that the vast majority of Waiver funding for Supported Employment is going to the provision of Supported Employment Services, including services to help people obtain employment and job coaching reimbursement rates that are adequate to cover the cost of job coaching services when they are needed.
Supported Employment has been a per diem rate, and has been billed regardless of whether a job coach is on-site for the duration of a person’s employment hours. Under the waiver changes, a provider can bill for Supported Employment when the service is being directly provided, utilizing 15-minute units. This allows for funding to be directed towards providing Exploration, Discovery, and Job Development and also provides for a higher reimbursement rate for individual job coaching services. Furthermore, the funding changes align with desired outcomes, incentivizing fading of a job coach and providing for quality incentive payments for providers if a person is working an increased number of hours.
What circumstances will allow for billing for Supported Employment? (Updated 1/16/19)
In order to bill for job coaching, a provider must be actively engage in the process of helping a person maintain competitive, integrated employment during the times the service is billed. This can include direct (face-to-face) or indirect (not face-to-face) contact with the person and also include supports provided to a person’s supervisor and/or co-workers.
If a person’s job support needs are one hour per week or less, Stabilization and Monitoring can be authorized.
Can a provider bill for Supported Employment if there is no job coach present at the worksite? (Updated 1/16/19)
Yes, but only if a job coach is working during the time period billed to support the specific person to maintain employment in an indirect capacity. Service documentation must support billing consistent with these expectations. However, if a person does not have a job coach, then it cannot be billed.
Does a person need to go through VR to receive Supported Employment through the waiver? (Updated 1/16/19)
If a person is eligible for job development or job placement services offered through Vocational Rehabilitation, these must be utilized prior to approval for Employment Services from DIDD. A person who has achieved “job stabilization” (Status 22) through VR can request Supported Employment through DIDD. Evidence of stabilization can be provided from a phone call, email, letter, and/or other document that clearly indicates the VR staff and provider are in agreement that the person has achieved stabilization. Additionally, if a person already has a job or gets a new job but has not opened a case with VR, the person can request Supported Employment from DIDD right away if there is a risk of losing their job without immediate support. This is in accordance with memo 210, issued by Commissioner Debra K. Payne in 2016.
More information about stabilization and other VR requirements can be found in VR’s Program User Guide.
How does the new billing incentivize fading of a job coach? (Updated 1/16/19)
A person should always be supported to live life as independently as possible, including at their workplace. Therefore, there are three job coaching rate levels available depending on the person’s level of need, the number of months a person has been in his or her current job, and the amount of fading achieved.
What if a person is unable to work without a job coach the entire work day? (Updated 1/16/19)
While the rates incentivize best practice job coaching for meeting appropriate fading targets, people are placed in an acuity tier based on an objective level of need assessment and fading expectations for the acuity level. For persons who have been approved for job coaching but are unable to work without a job coach, there is a rate available based on acuity level.
Can a provider bill for Supported Employment while transporting a person to and from his or her job? (Updated 1/16/19)
Yes. Transportation of the person to and from his or her workplace can be counted as billable time when such transportation is needed by the person and is 1:1. The expectation is that the job coach will use this time with the person to engage in conversation to identify or address employment-related issues and questions and to provide support, guidance, and positive reinforcement that contributes to the person maintaining competitive integrated employment.
How does the billing period limit work for a person who works a full-time job? (Updated 1/16/19)
As with all other employment and day services, a provider can bill no more than 240 quarter hour units per person in a fourteen day billing period.
What is a fading plan and what should one look like? (Updated 1/16/19)
A fading plan is a tool to help a person work as independently as possible. There are many types of fading plans; persons supported and job coaches should decide on a format that best meets their needs. Common elements of a fading plan include, but are not limited to:
· Information about a person’s strengths, needs, preferences, and conditions for success
· Roles and responsibilities of staff (e.g. job coach, residential staff, PA, etc.)
· Information about how the person would like to increase independence, both in type and level of support
· Strategies to increase independence (e.g. family, coworkers, enabling technology, simple accommodations, assistive technology, checklists, etc.)
· Benchmarks/milestones to measure success
How does a provider request different levels of job coaching? (Updated 1/16/19)
Since fading is expected, multiple levels of job coaching are provided to accommodate this process and can be requested and approved for up to one year ahead.
When can a provider receive the stabilization and monitoring rate? (Updated 1/16/19)
A provider can receive the stabilization and monitoring rate when his or her support needs are one hour or less per week. This requires a minimum of one monthly face-to-face contact with the person, one monthly contact with the employer, and the ability of the provider to respond as needed to prevent loss of employment and where necessary, pursue a change in service authorization as needed to address longer-term challenges to avoiding job loss.
How many hours does a person need to work to qualify for the quality incentive payments for Supported Employment? (Updated 1/16/19)
There are two quality payment levels available and can be earned by the provider up to twice a year. A provider is eligible for the base tier payment of $1,500 when a person has worked in competitive integrated employment between 15-19 hours a week during the prior six (6) month calendar period (between 390 and 519 hours total). The top tier of $2,000 per person is available for persons who worked twenty (20) or more hours a week during the prior six (6) month calendar period (at least 520 hours total).
Will the quality incentive payments go against the person’s expense cap? (Updated 1/16/19)
No. These quality incentive payments for hours worked will not count against a person’s annual individual expense cap in the Statewide and Self-Determination Waivers.
How will DIDD verify a person’s hours to trigger the quality incentive payments? (Updated 11/20/19)
DIDD will pay the quality incentive payment for hours worked twice a year—in February and August. The first payment is estimated to be in August 2020, utilizing provider supplied data supporting hours worked from January-June. Providers will use a DIDD supplied Invoicing Template and be asked to submit documentation indicating a person has worked enough hours to qualify for the payment:
· For the $1,500 payment: between 390 and 519 hours in the prior six calendar month period.
· For the $2,000 payment: 520 hours or more in the prior six calendar month period.
Providers will be asked to submit documentation to be validated from hours worked in January-June in July, with payments made in August. For hours worked from July-December, providers will submit documentation in January, with payments made in February.
Why is DIDD eliminating group employment for groups larger than four? (Updated 1/16/19)
One goal of the waiver changes is to help persons supported experience the most natural and integrated settings possible. This means persons supported should have opportunities to interact with community members, including people without disabilities. Large groups—in facility, community, and employment settings—limit a person’s ability to interact with people without disabilities. Large groups also make it difficult for employment and community activities to be truly person-centered because more people’s desires must be taken into account. It is also important to ensure that all services and settings adhere to the HCBS Final Settings Rule, which requires people to have access to integrated settings. For these and other reasons, DIDD is eliminating group employment for groups larger than four. Small group employment will still be an available service for groups up to four people (see below).
All persons who are currently in groups larger than four will have an individualized plan developed to transition them to another appropriate waiver service.
What justifies small group employment instead of individual supported employment? (Updated 1/16/19)
Small group employment is approved when the person needs or continues to need services and training activities to support the successful transition to individualized integrated employment or self-employment or to supplement such employment when it is only part-time. In order to reauthorize this service, the Individual Service Plan (ISP) must document that such opportunities are being provided through this service, to the person, on an on-going basis. The ISP shall also document and address any barriers to the person transitioning to individualized integrated employment or self-employment if the person is not already participating in individualized integrated employment or self-employment. Any person using this service to supplement part-time individualized integrated employment or self-employment shall be offered assistance to increase hours in individualized integrated employment and/or self-employment as an alternative or partial alternative to continuing this service.
Can Facility-Based Day Supports be billed on the same day as Supported Employment-Individual? (Updated 4/5/19)
Yes, Facility-Based Day Supports can be billed on the same day as Supported Employment-Individual. Please see slide 63 of this training presentation for more information about which services cannot be billed on the same day.
Can people who work at the provider agency bill for supported employment? (Updated 4/5/19)
No, if a provider supports someone who works in any facility or building owned, operated, or leased by any provider agency, this cannot be billed as supported employment.
Can job development and job coaching be provided at the same time? (Updated 4/5/19)
No, because in order to qualify for job development, a person cannot already be engaged in competitive integrated employment. Therefore, these two services cannot be provided at the same time.
Can small group employment and discovery be provided at the same time? (Updated 4/5/19)
Yes, small group employment and Discovery can be provided at the same time. They can occur on the same day, but direct (face-to-face) Discovery cannot overlap time units with small group employment.
How do you determine the wage for self-employment to meet the requirements for job coaching? (Updated 4/5/19)
To determine the hourly wage for self-employment, divide the total income earned by the total number of hours worked during a specified time period. There is a one-year start-up period for self-employment, during which time someone may earn less than minimum wage. However, after the one-year start-up period, a person must earn at least minimum wage in order for the provider to bill supported employment (job coaching).
Do the quality incentive payments for hours worked apply to those in small group employment? (Updated 4/5/19)
No, the quality incentive payments only apply to people engaged in individual competitive integrated employment.
If a person works in an integrated community business but is paid by the provider (the business has a contract with the provider) can this be billed as SE-individual or SE-group. (Updated 12/20/19)
Effective January 1, 2020 new and approved waiver service definitions will go t into effect that prohibit a provider agency from billing for Employment Services for a person for whom they are also the employer of record (EOR).
While a person supported may be employed by a provider, reimbursement for Supported Employment services cannot be provided if the employer of record is the provider supporting the person in the workplace.
Supported Employment services do not include supporting paid employment or training in a business enterprise owned or operated by a provider of these services.
In order to assist those people currently being supported in an employment arrangement where the agency is also the employer of record, DIDD is allowing a transition period of no more than 6 months in which providers can work to bring services into compliance. Providers accessing this transition period will be required to track and report progress to the applicable Regional Employment Coordinator on a monthly basis.
Please note, Tennessee Department of Transportation rest areas, operated by a provider as part of State Use Program, where individuals employed are earning at least minimum wage and not working in a group, are excluded from this requirement on a limited basis as indicated in the excerpt provided below. Excerpt represents language submitted to, but pending final approval from, CMS.
“those individuals who are currently employed by a provider to fulfill a contract authorized pursuant to TCA 71-4-701 et seq. may continue to receive supported employment services for paid employment or training until the contract expires or the person loses the employment for any other reason. At that point, any supported employment services the person receives must fully align with best practices in competitive integrated employment and the State’s commitment to Employment First, and will no longer be used to support employment or training in a business enterprise owned or operated by or affiliated with a provider of these services. In limited circumstances where the person is working in an integrated employment arrangement, but the provider agency is serving as the EOR, providers will be permitted to bill for Employment Supports while EOR responsibilities are transitioned from the provider to the business/entity offering the integrated employment opportunity, in order to ensure that employment is not disrupted.”
If a provider has activities or parties in a licensed facility would the individual be able to attend these types of events and bill for community participation? (Updated 12/20/19)
A person may attend those types of events. However, the provider would not be able to bill for Community Participation during the time spent at a facility owned, leased, or operated by a provider of this service.
Appendix C:
“All settings where Community Participation Supports are provided must be non-disability specific and meet all federal standards for HCBS settings. This service is provided separate and apart from the person’s place of residence. This service does not take place in licensed facilities, sheltered workshops or any type of facility owned, leased or operated by a provider of this service.”
Do fading plans need to be established prior to billing for job coaching? (12/20/19)
Yes, a fading plan should be established prior to billing for Job Coaching.
Per Appendix C, “Supports during each phase of employment must be guided by a Job Coaching Fading Plan which incorporates an appropriate mix of best practices for the individual to achieve fading goals as identified in the Plan…..”
Is the six-hour rule being eliminated? (Updated 1/16/19)
Yes. Employment and Day Services will now be billed using quarter-hours without a daily minimum or maximum, which will provide flexibility to change their plans during the day, and allow them to use their home as a base. Employment and Day Services can be provided at any time during the day or night, for any length of time, as long as they do not exceed the allowable limit within a 14-day billing period.
What types of activities count as Community Participation? (Updated 1/16/19)
Community Participation supports provide assistance for active and positive participation in a broad range of integrated community settings that allow the person to engage with the broader community, including people who do not have disabilities and who are not paid staff. These services cannot be provided in a person’s home, a licensed facility or a facility owner, leased or operated by a provider. Community Participation can include, but is not limited to, the following: age-appropriate community activities, groups, associations and clubs, health and wellness classes or activities that relate to a person’s skills and interests, volunteer opportunities, and participation in self-advocacy training opportunities.
How many hours must a person be involved in Community Participation and/or Employment in order to bill for the Intermittent Employment and Community Participation Wraparound? (Updated 12/20/19)
Intermittent Employment and Community Participation Wraparound services can be billed for up to four (4) hours on the same day that a person spends at least two (2) hours in Community Participation or working in the community. Please note that these two hours do not have to be consecutive.
What does it mean to use a person’s home as a base? (Updated 1/16/19)
With the flexibility to bill for different services throughout the day using the quarter-hour rates, a person is able to use their home, rather than a facility, to start and end their day, or come home as needed in between participating in the community utilizing the Intermittent Employment and Community Participation Wraparound service.
Can a person use another person’s home as a base and receive the Wraparound Service? (Updated 1/16/19)
No. The Intermittent Employment and Community Participation Wraparound service can only be paid when the person is using their own residence as a base.
Can a person who receives Supported Employment also receive the Wraparound Service when they are not working? (Updated 1/16/19)
Yes. The Intermittent Employment and Community Participation Wraparound service is available to people on days when they spend at least two hours working in the community, regardless of whether a job coach is being provided at the time.
Why can a person not receive Facility-Based Day and the Wraparound Service on the same day? (Updated 1/16/19)
The Intermittent Employment and Community Wraparound supports are expressly designed to support people in engaging in integrated community participation and employment when sustained, all-day participation in these opportunities outside the home is not possible. A person will use the facility as their base on days when they receive facility-based day services and therefore cannot bill for Wraparound Services on that same day.
Can a doctor’s visit count as Community Participation? (Updated 4/5/19)
Yes, if a person needs support to attend medical appointments, this can be billed as Community Participation Supports.
What should documentation include for the wraparound period? (Updated 12/20/19)
Documentation supporting the wraparound benefit should be consistent with the reason for accessing the benefit as applied to Employment and/or Community Participation outcomes. Sometimes this benefit will be simply an opportunity for someone to rest and that is fine. Please note, this is a service that can only be accessed and billed when at least two hours of Supported Employment and/or Community Participation are billed on any given day.
As described within the approved definition of the Wraparound service, these supports are designed to support the community participation and integrated employment benefit when all-day participation in these opportunities is not possible due to intermittent needs related to personal care, personal assistance with preparing and eating a meal, and/or regaining stamina. The goal of the Wraparound service is, quite simply, to facilitate continued involvement in Employment and Community Participation services and is, therefore, a support that enables the goals for those services.
Will Intermittent Employment and Community Integration Wraparound require separate outcomes? (Updated 12/20/19)
As described within the approved definition of the Wraparound service, these supports are designed to support the community participation and integrated employment benefit when all-day participation in these opportunities is not possible due to intermittent needs related to personal care, personal assistance with preparing and eating a meal, and/or regaining stamina. The goal of the Wraparound service is, quite simply, to facilitate continued involvement in Employment and Community Participation services and is, therefore, an support that enables the goals for those services. A standalone goal for this Wrapround benefit is not required. Rather, the body of the ISP should indicate that, as needed, the person supported will access the Wraparound service in order to achieve the individualized and intended benefit consistent with the definition.
Why is DIDD eliminating In Home Day? (Updated 1/16/19)
With the elimination of the six hour rule, people will have more flexibility to come and go from their house during the day. By adding the Intermittent Employment and Community Participation Wraparound service, people who currently receive In Home Day will have access to this service as long as they spend two hours in Community Participation or Supported Employment. Data indicates most people who receive In Home Day do leave the home for some period of time, just not the six hours currently required to bill for Community-Based Day Services.
For people with qualifying significant medical or behavioral needs who are unable to leave their homes for any portion of the day, the Residential Special Needs Adjustment—Homebound or Non-Residential Homebound Support Service is available.
What needs to be done if a person has In Home Day in their ISP? (Updated 11/20/19)
Persons who receive In-Home Day will receive termination notices at least 30 days prior to the scheduled implementation date of January 1, 2020. An ISC or SD Case Manager must revise the person’s ISP to reflect the discontinued service and alternative service, where applicable, no later than 21 days prior to implementation.
What if the person is retired and does not want to leave the home? (Updated 1/16/19)
Retirement is not a criterion for a person to receive the Homebound Special Needs Adjustment. If a person does not qualify through exceptional medical and/or behavioral needs for the Homebound Special Needs Adjustment, approval for those supports cannot be attained.
It should be noted that many people who are retired ARE able to spend at least a few hours outside of their homes participating in their communities. In those cases, if a person spends two hours during the day in Community Participation, then the Intermittent Employment and Community Wraparound will be available.
What are some alternatives for people who receive In Home Day because they are retired? (Updated 1/16/19)
As mentioned above, many people who are retired are able to spend time in the community. For people who spend two hours or more outside of the home participating in the community, the Intermittent Employment and Community Wraparound will be available.
For those who are retired and do not want to leave the home, the Circle of Support may want to discuss whether the person is able to spend time alone, and whether this is an opportunity for the person to be more independent. People who choose to stay at home may also be able to do so with the support of Enabling Technology. For those interested in exploring Enabling Technology as a support option, please contact your Regional Office and ask to speak to one of the Department’s Technology Champions.
What if the person does not want to leave the home and requires support staff to be present? (Updated 1/16/19)
A person has the choice as to whether or not they want to leave the home on any given day. However, a provider will not be able to bill for day services on those days if the person does not qualify for the Residential Special Needs Adjustment—Homebound or Non-Residential Homebound Support Service.
Also, if employment may be something the person is interested in, the new pre-employment services are available to assist that person in understanding what employment could look like and how he or she may be able to utilize their skills and interests through working in the community.
What qualifies a person to receive the Homebound Supports? (Updated 1/16/19)
“Homebound” means that a person is unable (not unwilling) to participate in any employment or day service or leave their home for a sustained period of time except for medical treatment or medical appointments. Due to extreme medical or behavioral needs or circumstances, the persons is not capable (even with supports) of leaving their home for at least 2 hours per day and only when such inability to leave the home is for a sustained period of time—at least 5 days in a 14 day billing period.
Extreme medical or behavioral needs or circumstances include only the following:
End of life – issues related to someone’s death and the time just before it, when it is known that the person is likely to die within 6 months from a terminal illness or similar condition; person is receiving support and medical care (i.e., hospice or other palliative care)
Recovery from hospitalization – recovery due to being admitted to hospital or ICU, emergency illness requiring extended stay, surgical procedure and/or complication related to surgical procedure or accident resulting in need for rehabilitative therapy and recovery period before activities can resume
Significantly health compromised – a debilitating chronic health issue, supported by current medical records that restricts the person from leaving their home under certain pre-determined circumstances, including environmental issues (extreme heat or cold, high pollen, air quality, exposure to high incidences of communicable diseases ) that would further and significantly compromise the individual’s health and physical well-being
Sustained behavioral crisis- involves behaviors not otherwise typical for the individual. Behaviors are considered unsafe and/or would be sufficiently disruptive if displayed in the community or place of employment so as to cause issues that would place the person or others at significant risk of harm and interfere with successful participation in the community or employment.
All Homebound requests will be reviewed by an Interagency Review Committee.
How early can a person apply from the Homebound Supports prior to the January 1, 2020 implementation date? (Updated 11/20/19)
The Circle of Support can discuss the Residential Special Needs Adjustment-Homebound or the Non-Residential Homebound Support Service at any time prior to implementation. Requests can be submitted as early as 21 days before the “go live” date.
What will the Homebound approval process look like? (Updated 1/16/19)
Homebound requests must be appropriate based on the living arrangement, the criteria from homebound criteria are met, and one or more of the specific extreme medical or behavioral circumstances is met and supported by documentation. For the Non-Residential Homebound Supports, the person also must require paid support beyond that provided by a PA or others at least six hours a day.
All requests will be subject to review by an Interagency Committee made up of DIDD and TennCare staff. Requests will be submitted to the DIDD regional office on a specified form. The Regional Office will ensure all required documentation is in order before submitting for Interagency Review, who will either approve or deny the request.
How often will Homebound supports need to be reauthorized? (Updated 1/16/19)
Both the Residential Homebound Special Needs Adjustment and the Non-Residential Homebound Support Service must be reviewed and reauthorized every 90 days.
What type of documentation is necessary to prove Homebound Supports are needed? (Updated 12/20/19)
Documentation is based on each specific circumstance:
1. End of life issues -a hospice or physician attestation will be required (within the last 90 days) that death is expected within 6 months and which specifies the person’s terminal illness or similar condition. Documentation will also need to be provided which specifies the support and medical care the person is currently receiving, including the provider and payor of such, which should be provided in the person’s ISP and additional supporting documentation as applicable, such as nursing or other clinical notes.
2. Sustained behavioral crisis- person is currently in a sustained behavioral crisis, engaging in behaviors which are not typical for the person and which pose significant risk of harm to self or others or would be sufficiently disruptive to others.
Documentation is based on 3 main parts:
a. Documentation from a BA or other licensed BH clinician within the past 30 days which provides:
i. specifics on the atypical behaviors which resulted in the behavioral crisis
ii. start date of such behaviors, including the frequency, intensity and duration of such behaviors
iii. specifics on how these behaviors place the person or others at imminent risk of harm
iv. specific measures that have been attempted but failed to remedy the person’s atypical behaviors.
b. Person must have a current BSP which includes an intervention for limiting community outings following incidents of unsafe behavior, and also includes interventions for restricting community activities or engagement following incidents of unsafe behavior. The BSP also must contain interventions that will help address behavior support needs and allow future opportunities for employment and community participation.
c. Documentation will need to be provided which shows that either the implementation of the BSP or the person’s rate of challenging behavior may result in the person not spending 2 hours per day in a community setting for at least 5 days in a 14-day billing period. Since this requirement is based on a 2-week pattern, the plans reviewer will need consistent and ample documentation to show that this pattern is most likely to continue. A minimum of 2 months of this documentation will be needed in order for the plans reviewer to make this determination.
3. Person is recovering after hospitalization due to surgery, illness, accident or surgical complication – documentation regarding hospital stay, such as nurse’s notes, discharge summary or op notes. This documentation will need to include the hospital admit date and release date (which must have occurred within the last 30 days), diagnosis (reason for admittance), course of treatment, restrictions and follow-up as required after discharge and as applicable, specifics regarding rehabilitative therapy before normal activities can resume (i.e., surgical procedure or accident which results in the need for rehabilitative therapy).
4. Person is significantly health compromised (debilitating chronic health issue) – documentation from a licensed medical professional within the last 90 days which includes the debilitating condition and the specific circumstances which restricts the person from leaving their home for at least 2 hours per day and only when such inability to leave the home is for a sustained period of time which is at least 5 days in a 14 day billing period. In addition, documentation will need to be provided which supports serious adverse consequences for the person upon leaving their home, which includes less restrictive alternatives which have been attempted but failed and the duration needed for such.
The specific requirements are included in the IOG linked on the DIDD Website on the Employment and Day Services Resources Page.
Why is it necessary that these requests be reviewed by an Interagency Review Committee? (Updated 1/16/19)
An interagency review process will provide another layer of accountability to ensure that people who are able to participate in their community have the opportunity to do so. With the elimination of the six-hour rule, people have the option to utilize the Intermittent Employment and Community Wraparound, which will provide flexibility to use their home as a base. Only those who cannot participate in employment or their community based on specific extreme medical and/or behavioral needs should receive Homebound.
Is there an appeal process if a person is not approved for Homebound Supports? (Updated 1/16/19)
Yes. Upon any denial of this service, a Grier notice will be issued to the person which provides the specific reasons that the service has been denied and will also provide information on how the person can file an appeal with TennCare if desired. The appeal process is the same as with any other waiver-funded service that DIDD has denied.
Can nursing and/or therapy services be provided at the same time as Homebound Supports? (Updated 1/16/19)
Therapy and Behavioral services may be provided at the same time as the Homebound supports where appropriate. Nursing may be provided at the same time, but only on an intermittent basis: limited to one hour to address specific skilled nursing tasks.
How many days can a person receive Homebound Supports in a billing cycle? (Updated 12/20/19)
A person can receive homebound supports no more than 5 days per calendar week and 10 days in a *static 14-day billing period
*Static, meaning that the 14-day periods have a scheduled start and end date.
- The 1st period is a short one (less than 14 days) and runs from 1/1/20 – 1/11/20.
- The 2nd period runs from 1/12/20 – 1/25/20
- 3rd is from 1/26/20 – 2/8/20
- 4th is from 2/9/20 – 2/22/20 and so forth
Is a Behavior Support Plan (BSP) required to meet the exceptional circumstance criteria for Sustained Behavioral Crisis under the Non-Residential Homebound Support Service or Residential Special Needs Adjustment-Homebound? (Updated 12/20/19)
Yes. A BSP is required for approval for exceptional circumstance criteria. For listing of full requirements please see the approved definition and IOG for approval of this service linked on the DIDD Website on the Employment and Day Services Resources Page.
Can the Non-Residential Homebound Support Service or Residential Special Needs Adjustment-Homebound and other Employment and Day Services be billed in the same billing cycle? (Updated 1/25/19)
Yes. However, on a day when a person receives one of the homebound services, a provider cannot bill any other employment and day service on that particular day.
While receiving the Non-Residential Homebound Support Service or Residential Special Needs Adjustment-Homebound, can a person leave the home for doctor’s appointments? (Updated 1/25/19)
Yes. To meet the definition of “homebound”, a person is unable (not unwilling) to participate in any employment or day service or leave their home for a sustained period of time except for medical treatment or medical appointments.”
What if a person does not meet Homebound criteria but is unwilling to leave the home and participate in community activities? (Updated 1/25/19)
Consistent with person-centered practices, a person may choose to stay home and not participate in any employment or community participation activities. When this occurs, if a person is not eligible to receive the Non-Residential Homebound Support Service or Residential Special Needs Adjustment-Homebound, the provider is unable to bill for the time the person spends at home—apart from residential services, if applicable. It may present an opportunity to discuss whether or not the person desires to be more independent, which may include spending more time without staff at home. If so, the COS may discuss options such as Enabling Technology and other strategies to help the person spend time without staff at home, while also ensuring they are safe and their needs are being met.
Do I have to get a new doctor’s note every 90 days to be reapproved for Homebound? (Updated 1/25/19)
No. If a doctor’s note is still valid and not expired, the same note can be resubmitted for the subsequent reauthorization request.
If someone has a BSP or documentation with an approved restriction for staying at home for a period of hours after a behavioral incident, would Homebound meet that need? (Updated 1/25/19)
Yes, if the behavioral incident is the result of atypical behaviors and the time the person stays at home following such incidents results in the person not spending 2 hours per day in a community setting for at least 5 days in a 14-day billing period.
Does the addition of the Homebound Residential Special Needs Adjustment impact or replace the current Residential Special Needs Adjustment? (Updated 4/5/19)
No. It is possible for a person to be approved for one or both of the adjustments if he or she meets the criteria.
How early should homebound reauthorizations be submitted to ensure no interruption in the service? (Updated 4/5/19)
Reauthorizations should be requested with the start date being the day after the currently authorized service end date and should be submitted 21 days prior to the start date.
If a person refuses to sign a Behavior Support Plan (BSP), are you able to request homebound for behavioral? (Updated 4/5/19)
The person must sign if they have no conservator. If there is a conservator, the conservator’s signature will be required. The BSP cannot be initiated without the person’s or conservator’s consent, which is demonstrated by their signature.
For Homebound support services, what are examples of "additional paid support outside of the PA services"? (Updated 12/20/19)
Non-Residential Homebound Support Services can be utilized when someone has needs above and beyond what the PA can give them for at least 6 hours a day. For example, if a PA works from 8:00 a.m.-4:00 p.m., Homebound, if approved, would be utilized outside of the PA hours.
What if Homebound is approved within the last four days of the billing cycle? (Updated 12/20/19)
The intent behind approval for these services is to provide for the Homebound option of support during times of critical need. In these circumstances, we would use a “rolling period,” looking at whether the person is homebound for at least 5 days (even if some of those days occur in the subsequent billing period) before allowing the provider to bill.
What services will be automatically converted on a person’s cost plan? (Updated 1/16/19)
DIDD will conduct automatic internal conversions for the following services, and will not require a Cost Plan/ISP amendment:
Community Based Day > Community Participation
Facility Based Day > Facility Based Day
Supported Employment > SE-Individual (1:1) or SE-Group (2-4)
Intermittent Employment and Community Participation Wraparound will be included on cost plans for people who are currently receiving Community Based Day and/or Supported Employment services.
What services will require an amendment to the ISP? (Updated 12/20/19)
All requests for services will follow DIDD Authorization for Services Policy 80.3.4. Any of the three pre-employment services (Exploration, Discovery, Job Development), the Residential Homebound Special Needs Adjustment and the Non-Residential Homebound Support Service will need to have a request submitted. These requests can be submitted as early as 21 days before the “go live” date. In addition, people who currently have In-Home Day or Supported Employment for groups of 5-8 will have their approved service plan automatically adjusted to remove these services. Their ISP should be revised to reflect the discontinued service with the next submission, be that amendment or annual ISP.
Will there be any resources to assist ISCs and the Circle of Support in determining whether pre-employment services might be suitable for a person? (Updated 1/16/19)
There are several resources available for ISCs and the COS to help a person determine which pre-employment or employment services may be appropriate. These include, but are not limited to:
· Materials from training on pre-employment services (see above)
· ISP Guidance Tool
· DIDD Employment First website: https://www.tn.gov/didd/for-consumers/employment--first.html
· Regional employment coordinators:
· West TN- Ashley Sanders: ashley.sanders@tn.gov
· Middle TN- Michael Barbour: michael.barbour@tn.gov
· East TN- Angella Broussard: angella.broussard-chrisman@tn.gov
What happens if a person has a discontinued service on his or her cost plan and an amendment is not submitted prior to January 1, 2020? (Updated 11/20/19)
The termination of that day service will be effective January 1, 2020, regardless of whether or not an amendment has been submitted prior to that date. There is no waiver funding for those discontinued services beyond December 31, 2019
What happens if a person’s request for a service is denied? (Updated 1/16/19)
It depends on the funding source of the denied service. If the service is state-funded, the person will receive a notice as to why the service is denied, but the person cannot file an appeal. For waiver-funded services, the person will receive a notice and has the right to file an appeal.
Do ISCs need to revise ISPs that have been submitted already? (Updated 1/25/19)
If the person wishes to make a change in their current day services, or they are currently getting a day service which will be discontinued (i.e., IHD and SE-Group 5+), an ISP amendment will be required. ISP Amendments which contain service-related changes should be submitted to the regional office no later than 21 days prior to date of service initiation including alternative services as applicable.
ISP amendments which regard administrative changes only [referred to as “Amd with no change”] will also need to be submitted (e.g., change in billing code or the person is receiving the same day service but the service name or service code of the day service has changed). These ISP amendments are not bound to the 21-day submission timeframe since they do not regard a change in the person’s services.
For plans submitted after the January 1 implementation date, will Intermittent Employment and Community Wraparound need to be submitted as a service? (Updated 11/20/19)
Yes. Current plans containing community-based day and/or supported employment will automatically include the wraparound service as an additional support option. However, if a plan does not contain community-based day and/or supported employment prior to implementation, the wraparound service will have to be requested after implementation. Likewise, upon expiration of services automatically converted, all new service requests containing community-based day and/or supported employment will also require a request for intermittent employment and community participation wraparound benefit if that support is desired.
What are the billing limits for employment and day services? (Updated 1/16/19)
The benefits of the new employment and day services include flexibility in billing: there is no longer a requirement for six hours of participation to bill on a particular day, and providers can now bill for services delivered on days currently considered unbillable.
With the changes, a person can receive up to 60 hours (or 240 15-minute units) within each 14-day billing period.
While there is increased flexibility in how and when services are delivered, billing of two face-to-face employment or day services at the same time is prohibited. QA and FAR surveys will look to ensure no overlap occurs.
Can a person bill for therapy services at the same time that intermittent employment and community wraparound is being billed? (Updated 1/16/19)
Yes. While no other employment and day services may be billed at the same time, a person is able to receive therapy services at the same time as intermittent employment and community wraparound is billed.
Can the new employment and day services be billed on the same day as respite? (Updated 1/16/19)
The new employment and day services may be billed on the same date as respite level 4 only. None of the new services may be provided on the same date as respite level 3 or with behavioral respite.
Why is there an order for payment of hours billed? (Updated 1/16/19)
One of the primary goals of the waiver changes is to increase employment and community participation opportunities for persons supported. Therefore, DIDD established a payment order that prioritizes the delivery of employment and community participation services. If a person receives employment/day services from multiple providers, the providers need to reach an agreement about how and when services are billed. Services will be paid in the following order, up to 60 hours (240 units) in a 14-day billing period.
1. SE-Individual;
2. SE-Small Group;
3. Community Participation Supports;
4. Intermittent Employment & Community Participation Wraparound;
5. FB Day;
6. Residential Special Needs Adjustment – Homebound or Non-Residential Homebound Support Service (day billed will be counted as 6 hours).
When will quality incentive payments for hours worked be paid? (Updated 11/20/19)
Documentation that shows the person worked enough hours to qualify for the incentive payment must be submitted in July and January. The payments are estimated to be made by DIDD to providers per qualifying person supported in August 2020 and February 2021, and then each August and February thereafter.
Is separate documentation required for each 15-minute billing increment? (Updated 1/16/19)
No. Documentation and notes can reflect the entire duration of a service. For instance, if you spent three hours from 1:00 p.m. to 4:00 p.m. in Community Participation, the documentation should reflect the activities of the entire time span, not each specific 15-minute increment within the three hours. Please refer to the Employment and Day Services training for specific examples.
How should I document for each service provided during the day? (Updated 1/16/19)
Documentation requirements will not be unlike those that currently exist for Day Services in the 1915c waiver, with the exception that if more than one service is utilized during the day, the documentation should reflect activities conducted during each service. Please see the training materials for documentation examples.
What documentation is required to bill for stabilization and monitoring? (Updated 1/16/19)
One monthly contact note documenting a face-to-face meeting with the person and the employer is required for Stabilization and Monitoring.
Can a person qualify for the quality incentive payment for number of hours worked while also receiving a homebound service? (Updated 1/16/19)
Yes. If a person works the minimum number of hours during a six month period and also meets the criteria for the homebound service, both may be billed.
How will the 60-hour (240-unit) billing period limit be enforced? (Updated 1/25/19)
There is a feature in PCP (the DIDD billing system) that will ensure the 60-hour (240-unit) limit is not exceeded. Once the limit is reached within a two-week billing period, billing can no longer occur.
Will the billing continue to be Monthly from the 1st to the 14th, 14th thru 28, etc. or change to strictly Sunday thru Saturday for 14 days? Which could include 2 months during that same period. (Updated 12/20/19)
· Billing will continue with calendars in PCP.
· It is very important that the providers understand that the 14 day period referenced throughout this document is a static period.
· The first period is a bit shorter and runs from 1/1/20 – 1/11/20.
· Providers will bill the current services up through 12/31/19
· The 1st 240 unit period runs from 1/1/20 – 1/11/20
The annual limit will be 5,832 quarter hour units per waiver/calendar year and a maximum of 240 quarter hour units in the 14-day billing period**. This includes any combination of the following:
· Community Participation Supports
· Facility Day Based Day Services
· Supported Employment Small Group
· Job Coach
· Residential Homebound Support
· Non-Residential Homebound Support
Within this limit of 5,832 - the maximum for Intermittent Employment and Community Participation Wraparound is 3,888 quarter hours
· The 14-day limit is 240 units.
o Within this 240 units – the maximum for Intermittent Employment and Community Participation Wraparound is 160 quarter hours
**The 14-day billing periods are static and have a scheduled start and end date.
· The 1st period is a short one (less than 14 days) and runs from 1/1/20 – 1/11/20. The limit within this shorter period = 240 units
· The 2nd period runs from 1/12/20 – 1/25/20
· 3rd is from 1/26/20 – 2/8/20
· 4th is from 2/9/20 – 2/22/20 and so forth.