1 Medicaid Rehabilitative Services Shawn Terrell Division of Coverage & Integration Disabled & Elderly Health Programs Group CMSO/CMS

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Medicaid Rehabilitative Medicaid Rehabilitative ServicesServices

Shawn TerrellShawn TerrellDivision of Coverage & IntegrationDivision of Coverage & Integration

Disabled & Elderly Health Disabled & Elderly Health Programs GroupPrograms Group

CMSO/CMSCMSO/CMS

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Intent of Rehabilitative Intent of Rehabilitative Services RuleServices Rule

In his 2007 budget proposal, the In his 2007 budget proposal, the President sought to clarify and refine President sought to clarify and refine the rehabilitation benefit through a the rehabilitation benefit through a regulation that will define allowable regulation that will define allowable services and exclude payment for services and exclude payment for services that are intrinsic to services that are intrinsic to programs other than Medicaid, such programs other than Medicaid, such as foster care, juvenile justice, and as foster care, juvenile justice, and education.education.

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Intent of Rehabilitative Intent of Rehabilitative Services Rule (cont.)Services Rule (cont.) The Rehabilitation rule is designed to The Rehabilitation rule is designed to

allow for State flexibility and growth in allow for State flexibility and growth in the field of rehabilitative services by the field of rehabilitative services by setting broad parameters for allowable setting broad parameters for allowable services rather than defining specific services rather than defining specific allowable services (e.g. assertive allowable services (e.g. assertive community treatment).community treatment).

The rule does not address payment The rule does not address payment methodologies.methodologies.

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Rehabilitative Services Rehabilitative Services

Proposed rule for Medicaid Coverage Proposed rule for Medicaid Coverage of Rehabilitative Services published of Rehabilitative Services published August 13, 2007 in Federal Register August 13, 2007 in Federal Register (CMS 2261-P)(CMS 2261-P)

Amends 42 CFR § 440.130 Diagnostic, Amends 42 CFR § 440.130 Diagnostic, screening, preventive and screening, preventive and rehabilitative servicesrehabilitative services

Creates new section: 42 CFR § 441.45 Creates new section: 42 CFR § 441.45 Rehabilitative ServicesRehabilitative Services

60 day public comment period through 60 day public comment period through October 12, 2007. October 12, 2007.

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Rehabilitative ServicesRehabilitative Services

HighlightsHighlights– Clarify definitions of restorative Clarify definitions of restorative

services, scope of services, and services, scope of services, and impairments that can be addressed impairments that can be addressed under rehabilitationunder rehabilitation

– Person-centered rehabilitative planPerson-centered rehabilitative plan– Case records requirementsCase records requirements– Exclusion of services that are intrinsic Exclusion of services that are intrinsic

elements of other programs. elements of other programs.

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Rehabilitative DefinitionRehabilitative Definition

Section 1905(a)(13) of the Act and 42 Section 1905(a)(13) of the Act and 42 CFR CFR §§ 440.130(d) provide that States 440.130(d) provide that States may cover rehabilitative services: may cover rehabilitative services: “including any medical or remedial “including any medical or remedial services services (provided in a facility, a home, (provided in a facility, a home, or other setting)or other setting) recommended by a recommended by a physician or other licensed practitioner of physician or other licensed practitioner of the healing arts within the scope of their the healing arts within the scope of their practice under State law, for the practice under State law, for the maximum reduction of physical or mental maximum reduction of physical or mental disability and restoration of an individual disability and restoration of an individual to the best possible functional level;”.to the best possible functional level;”.

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Key Definitions Key Definitions

– Restorative servicesRestorative services: Services that : Services that are provided to an individual who are provided to an individual who has had a functional loss and has a has had a functional loss and has a specific rehabilitative goal toward specific rehabilitative goal toward regaining that function. regaining that function.

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Key Definitions (cont.)Key Definitions (cont.)

– Scope of ServicesScope of Services: Rehabilitative : Rehabilitative services may include assistive services may include assistive devices, medical equipment and devices, medical equipment and supplies, not otherwise covered supplies, not otherwise covered under the plan, which are determined under the plan, which are determined necessary to the achievement of the necessary to the achievement of the individual’s rehabilitation goals. individual’s rehabilitation goals. Rehabilitative services do not include Rehabilitative services do not include room and board in an institutional or room and board in an institutional or community setting. community setting.

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Impairments to be addressedImpairments to be addressed: : Services provided to the Medicaid Services provided to the Medicaid eligible individual to address the eligible individual to address the individual’s physical impairments, individual’s physical impairments, mental heath impairments, and or mental heath impairments, and or substance-related disorder substance-related disorder treatment needs.treatment needs.

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Medical servicesMedical services: Services specified : Services specified in the rehabilitation plan that are in the rehabilitation plan that are required for the diagnosis, treatment, required for the diagnosis, treatment, or care of a physical or mental or care of a physical or mental disorder and are recommended by a disorder and are recommended by a physician or other licensed physician or other licensed practitioner of the healing arts within practitioner of the healing arts within the scope of his or her practice under the scope of his or her practice under State law. State law.

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Remedial servicesRemedial services:: Services that Services that are intended to correct a physical are intended to correct a physical or mental disorder and are or mental disorder and are necessary to achieve a specific necessary to achieve a specific rehabilitative goal specified in the rehabilitative goal specified in the individual’s rehabilitation plan. individual’s rehabilitation plan.

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Under the Direction ofUnder the Direction of: For physical : For physical therapy, occupational therapy, and therapy, occupational therapy, and services for individuals with speech, services for individuals with speech, hearing and language disorders, the hearing and language disorders, the Medicaid qualified therapist meets Medicaid qualified therapist meets qualifications based on 42 CFR § qualifications based on 42 CFR § 440.110. 440.110.

– Please note: This definition only applies to Please note: This definition only applies to the specific services listed above. the specific services listed above.

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Under the Direction ofUnder the Direction of: The : The supervision must include face-to-supervision must include face-to-face contact with the beneficiary, face contact with the beneficiary, prescription of services, reviewing prescription of services, reviewing the need for continued services, the need for continued services, and acceptance of professional and acceptance of professional responsibility for the services responsibility for the services provided.provided.

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Written rehabilitation planWritten rehabilitation plan: The : The written rehabilitation plan shall be written rehabilitation plan shall be reasonable and based on the reasonable and based on the individual’s condition(s) and on individual’s condition(s) and on the standards of practice for the the standards of practice for the provision of rehabilitative services provision of rehabilitative services to an individual with the to an individual with the individual’s condition(s). individual’s condition(s).

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Written Rehabilitation Written Rehabilitation PlanPlan The written rehabilitation plan must The written rehabilitation plan must

meet the following requirements:meet the following requirements:

– Be developed by a qualified provider, with Be developed by a qualified provider, with input from the individual and others who input from the individual and others who are important to the individual. CMS are important to the individual. CMS recommends a person-centered planning recommends a person-centered planning process.process.

– Follow guidance obtained through the Follow guidance obtained through the active participation of the individual, active participation of the individual, and/or persons of the individual’s and/or persons of the individual’s choosing, in the development, review, and choosing, in the development, review, and modification of plan goals and services modification of plan goals and services

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Written Rehabilitation Written Rehabilitation Plan (cont.)Plan (cont.) Specify the individual’s rehabilitation Specify the individual’s rehabilitation

goals to be achieved, including recovery goals to be achieved, including recovery goals for persons with mental health goals for persons with mental health and/or substance use disordersand/or substance use disorders

Identify the medical and remedial Identify the medical and remedial services intended to reduce the services intended to reduce the identified physical impairment, mental identified physical impairment, mental health and/or substance related disorderhealth and/or substance related disorder

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Written Rehabilitation Written Rehabilitation Plan (cont.)Plan (cont.) Identify the methods that will be Identify the methods that will be

used to deliver services (e.g. used to deliver services (e.g. Cognitive Behavioral Therapy, Cognitive Behavioral Therapy, Occupational Therapy)Occupational Therapy)

Specify the anticipated outcomes Specify the anticipated outcomes Indicate the frequency, amount and Indicate the frequency, amount and

duration of the services duration of the services Be signed by the individual Be signed by the individual

responsible for developing the responsible for developing the rehabilitation plan rehabilitation plan

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Written Rehabilitation Written Rehabilitation Plan (cont.)Plan (cont.) Indicate the provider(s) of the Indicate the provider(s) of the

service(s).service(s). Specify a timeline for reevaluation Specify a timeline for reevaluation

of the plan, based on the of the plan, based on the individual's assessed needs and individual's assessed needs and anticipated progress, but not anticipated progress, but not longer than one yearlonger than one year

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Written Rehabilitation Written Rehabilitation Plan (cont.)Plan (cont.) Be reevaluated with the involvement Be reevaluated with the involvement

of the individual, family or other of the individual, family or other responsible individuals. responsible individuals.

Be reevaluated including a review of Be reevaluated including a review of whether the goals set forth in the plan whether the goals set forth in the plan are being met and whether each of the are being met and whether each of the services described in the plan has services described in the plan has contributed to meeting the stated contributed to meeting the stated goalsgoals

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Written Rehabilitation Written Rehabilitation Plan (cont.)Plan (cont.) If it is determined that there has If it is determined that there has

been no measurable reduction of been no measurable reduction of disability and restoration of disability and restoration of functional level, any new plan functional level, any new plan would need to pursue a different would need to pursue a different rehabilitation strategy including rehabilitation strategy including revision of the rehabilitative revision of the rehabilitative goals, services and/or methods. goals, services and/or methods.

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Case Record Case Record RequirementsRequirements Providers of rehabilitative services must Providers of rehabilitative services must

maintain case records that include:maintain case records that include:– A copy of the rehabilitative planA copy of the rehabilitative plan– The name of the individualThe name of the individual– The date of the rehabilitative services The date of the rehabilitative services

providedprovided– The nature, content, and units of the The nature, content, and units of the

rehabilitative servicesrehabilitative services– The progress made toward the functional The progress made toward the functional

improvement and attainment of the improvement and attainment of the individual's goals as identified in the individual's goals as identified in the rehabilitative plan and case recordrehabilitative plan and case record

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Excluded ServicesExcluded Services

Rehabilitation services do not include services Rehabilitation services do not include services that are intrinsic elements of programs other that are intrinsic elements of programs other than Medicaid including, but not limited to:than Medicaid including, but not limited to:– Foster careFoster care– Child WelfareChild Welfare– EducationEducation– Child Care Child Care – Vocational and prevocational trainingVocational and prevocational training– HousingHousing– Parole and probation Parole and probation – Juvenile justiceJuvenile justice– Public guardianshipPublic guardianship

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Excluded Services Excluded Services (cont.)(cont.) ExamplesExamples

– Therapeutic Foster Care: Services Therapeutic Foster Care: Services furnished by foster care providers to furnished by foster care providers to children, except for medically children, except for medically necessary rehabilitation services for an necessary rehabilitation services for an eligible child that are clearly distinct eligible child that are clearly distinct from packaged therapeutic foster care from packaged therapeutic foster care services and that are provided by services and that are provided by qualified Medicaid providersqualified Medicaid providers

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Excluded Services Excluded Services (cont.)(cont.) Habilitation Services: Including Habilitation Services: Including

services for which FFP was services for which FFP was formally permitted under the formally permitted under the Omnibus Budget Reconciliation Omnibus Budget Reconciliation Act of 1989. Habilitation services Act of 1989. Habilitation services include services provided to include services provided to individuals with mental individuals with mental retardation or related conditions. retardation or related conditions.

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Statutory ExclusionsStatutory Exclusions

Services provided to inmates living in Services provided to inmates living in the secure custody of law enforcement the secure custody of law enforcement and residing in a public institution. and residing in a public institution.

Services provided to residents of an Services provided to residents of an institution for mental disease (IMD) who institution for mental disease (IMD) who are under the age of 65, including are under the age of 65, including residents of community residential residents of community residential treatment facilities with more than 16 treatment facilities with more than 16 beds that do not meet the requirement beds that do not meet the requirement of inpatient psychiatric service for of inpatient psychiatric service for individuals under age 21. individuals under age 21.

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Example: Peer Support Example: Peer Support ServicesServices States are increasingly interested in covering States are increasingly interested in covering

peer support providers as a distinct provider peer support providers as a distinct provider type for the delivery of counseling and other type for the delivery of counseling and other support services to Medicaid eligible adults with support services to Medicaid eligible adults with mental illnesses and/or substance use mental illnesses and/or substance use disorders. disorders.

CMS issued a State Medicaid Directors Letter on CMS issued a State Medicaid Directors Letter on 8/15/2007 providing guidance to states 8/15/2007 providing guidance to states interested in providing peer support services interested in providing peer support services under the Medicaid program. (SMD#07-011)under the Medicaid program. (SMD#07-011)

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Peer Support Services Peer Support Services (cont.)(cont.)

Peer support services are an Peer support services are an evidence-based mental health evidence-based mental health model of care which consists of model of care which consists of a qualified peer support a qualified peer support provider who assists individuals provider who assists individuals with their recovery from mental with their recovery from mental illness and substance use illness and substance use disorders.disorders.

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Peer Support Services Peer Support Services (cont.)(cont.) Peer support providers should be self-Peer support providers should be self-

identified consumers who are in identified consumers who are in recovery from mental illness and/or recovery from mental illness and/or substance use disorders. substance use disorders.

Supervision and care coordination are Supervision and care coordination are core components of peer support core components of peer support services. Additionally, peer support services. Additionally, peer support providers must be sufficiently trained providers must be sufficiently trained to deliver services. to deliver services.

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Peer Support Services Peer Support Services (cont.)(cont.)SupervisionSupervision Supervision must be provided by a Supervision must be provided by a

competent mental health professional (as competent mental health professional (as defined by the State). defined by the State).

The amount, duration and scope of The amount, duration and scope of supervision will vary depending on State supervision will vary depending on State Practice Acts, the demonstrated Practice Acts, the demonstrated competency and experience of the peer competency and experience of the peer support provider, as well as the service support provider, as well as the service mix, and may range from direct oversight mix, and may range from direct oversight to periodic care consultation. to periodic care consultation.

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Care CoordinationCare Coordination Peer support services must be Peer support services must be

coordinated within the context of a coordinated within the context of a comprehensive, individualized plan of comprehensive, individualized plan of care that includes specific individualized care that includes specific individualized goals. goals.

States should use a person-centered States should use a person-centered planning process to help promote planning process to help promote participant ownership of the plan of care. participant ownership of the plan of care.

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Training and CredentialingTraining and Credentialing Peer support providers must Peer support providers must

complete training and certification as complete training and certification as defined by the State. defined by the State.

Training must provide peer support Training must provide peer support providers with a basic set of providers with a basic set of competencies necessary to perform competencies necessary to perform the peer support function. the peer support function.

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Peer Support Services Peer Support Services (cont.)(cont.)Training and Credentialing (cont)Training and Credentialing (cont) The peer must demonstrate the ability The peer must demonstrate the ability

to support the recovery of others from to support the recovery of others from mental illness and/or substance use mental illness and/or substance use disorders.disorders.

Similar to other provider types, ongoing Similar to other provider types, ongoing

continuing educational requirements for continuing educational requirements for peer support providers must be in place. peer support providers must be in place.

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Contact InformationContact Information

Shawn Terrell Shawn Terrell

[email protected]@cms.hhs.gov

410-786-0672410-786-0672

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Discussion and Discussion and QuestionsQuestions

Documents

1 Medicaid Rehabilitative Services Shawn Terrell Division of Coverage & Integration Disabled & Elderly Health Programs Group CMSO/CMS