Provider Requirements and Service Limitations
From The May 2010 Florida Medicaid Provider Handbook
Information highlighted in yellow indicates a change since the July 2007 version of this handbook.
Supported Employment- Requirements To Receive
Supported employment services provide training and assistance in a variety of activities to support recipients in sustaining paid employment at or above minimum wage unless the recipient is operating a small business. The supported employment provider assists with the acquisition, retention or improvement of skills related to accessing and maintaining such employment or developing and operating a small business. With the assistance of the supported employment provider, the recipient is assisted in securing employment according to their desired outcomes, including the type of work environment, activities, hours of work, level of pay and supports needed. Supported employment is conducted in a variety of settings, to include work sites in which individuals, without disabilities, are employed.
Supported employment includes activities needed to sustain paid work at or above minimum wage for recipients receiving waiver services, including supervision and training. This training can focus on both the recipient’s needs, as well as providing consultation to the employer to enhance supports natural to the workplace rather than imposing paid supports. Supported employment providers will immediately notify the recipient’s waiver support coordinator of any changes affecting the recipient’s income. The service provider shall work with both the recipient and the respective support coordinator to maintain eligibility under the DD waiver, as well as health and income benefits through the Social Security Administration and other resources. Models of supported employment services include:
Individual Model - One person at a time approach to obtaining competitive employment through the support of a job coach, employment specialist, or consultant for job development, intensive training (Phase I) and systematic follow-along supports (Phase 2). The individual model can apply to either employment in the general work force or in development and operation of establishing a business to be operated by the recipient.
Phase I is defined as time-limited supports needed to obtain a job and reach stabilization. These billable support activities include:
(a) A situational assessment to determine a person’s employment goals, preferences and skills;
(b) Job development for a specific recipient, matching the person with a job that fits personal expectations; and
(c) Intensive, systematic on-the-job training and consultation focused on building skills needed to meet employer productivity requirements, learning behaviors and acceptance in the social environment of the job setting, building job related supports with the employer from those naturally occurring at that work site and other job related supports.
The number of hours of intervention is intended to diminish over the first few weeks of employment as the supported employee becomes more productive and less dependent on paid supports. Phase I ends after demonstration that the supported employee has established job stability. The stabilization period begins when the person has achieved satisfactory job performance as judged by the employer, provider, Vocational Rehabilitation counselor (if applicable) and the supported employee or when the need for paid supports diminishes to fewer than 20 percent of weekly hours of employment. The stabilization period is a minimum of 90 days following the onset of stabilization. If the supported employee continues to perform the job satisfactorily the service moves into extended, ongoing support services (Phase 2).
Staff is expected to provide varying intensities of services to each supported employee, beginning with high intensity and fading to achieve stabilization. Given the nature of this wide variation in level of support intensity and duration needed per person, usual and typical staff to service recipient ratios demonstrate that one staff person can support up to two to three supported employees who are in Phase I at any given point in time. Phase I services typically average 6-8 hours a day per recipient during the first week of services. Average hours of service should fade to 1-2 hours a week in preparation for transition to Phase 2. The average time period for Phase I is 24 to 25 weeks, but is different for each recipient depending upon need.
Phase 2 is defined as long-term, ongoing supports needed to maintain employment indefinitely. These billable support activities include:
(a) Ongoing, systematic contacts with supported employees to determine the need, intensity and frequency of supports needed to maintain productivity, social inclusion and maintain employment;
(b) Remedial on-the-job training to meet productivity expectations, consultation and refinement of natural supports or other elements important to maintaining employment; and
(c) Related work supports such as accessing transportation and other supports necessary for the recipient to maintain a job, or consultation to family members or other members of a recipient’s support network including employers and coworkers.
Phase 2 supports assume periodic life changes and personal tensions that will cause job instability. Supports and services are designed to be dynamic and to change in intensity and duration consistent with the needs of each supported employee during periods of job instability and possibly during job loss and re-employment activities. When supports needed to maintain employment for a given person become too great in intensity or duration, it may be necessary to move back to Phase I services to access a better job match or seek employment alternatives. Moving to Phase I supports must include a referral to Vocational Rehabilitation or the local school system (as applicable) to seek required funding. Medicaid waiver funding shall be used only if these alternative resources are not available.
During Phase 2 the service levels needed per supported employee vary according to individual needs but typically average 1-2 hours a week per recipient. Usual and typical demonstration of Phase 2 services assert an expectation of a staff to service recipient ratio of one staff person supporting up to twenty supported employees.
Group Models – Including:
- Enclave - A group approach to employment where up to eight recipients with disabilities work either as a group or dispersed individually throughout an integrated work setting with supervision by the provider.
- Mobile Crew - A group approach to employment where a crew, such as lawn maintenance or janitorial, of up to eight recipients with disabilities are in the community in businesses or other community settings with supervision by the provider.
- Entrepreneurial - A group approach to employment where up to eight recipients with disabilities work in a small business created specifically by or for the recipients.
Providers of supported employment services shall comply with requirements found in the Medicaid Waiver Services Agreement, Core Assurances, and those specified in this handbook.
Supported employment services are limited to the amount, duration and scope of the services described in the recipient’s support plan and current approved cost plan. The provider shall render services at a time mutually agreed to by the recipient and the provider. Off-hours support may occur as an alternative or supplement to the on-thejob contacts.
Decisions to change the duration or intensity of the service to less than twice monthly contacts, in the individual model of service delivery, or to terminate supported employment services, shall only be made through consensus among the recipient receiving services and his guardian; the Vocational Rehabilitation counselor, if applicable; the APD Area Office or waiver support coordinator; and the provider. If for any reason a recipient has terminated services and requests reinstatement due to the need for ongoing supports, he will be given priority for restoration of services.
Recipients working an average of less than 20 hours per week must have at least a quarterly review. Documented attempts to increase work hours or secure an appropriate job must be summarized quarterly, in the monthly summary notes. Recipients should not remain in job development status for more than a two month period. For recipients who remain in job development status for more than two months, the supported employment coach will justify monthly the reason(s) why employment has not been obtained and the strategies planned for securing employment.
Phase I supported employment services are limited to eight hours, or 32-quarter hour units per recipient a day. Phase 2 supported employment services are limited to eight hours, or 32-quarter hour units per recipient per week. Group model services are limited to eight hours, or 32-quarter hour units per recipient a day.
Transportation of recipients to and from their job is not a component of supported employment services but may be funded under transportation services when no other community, natural, or generic support is available.
Separate payment for transportation services furnished by the supported employment provider will not be made when rendered as a component of this service.
Note: Refer to the transportation section description in this handbook for additional information.
Reimbursement* and monitoring documentation to be maintained by the provider:
- *Copy of claim(s) submitted for payment;
- *Service log
- *Quarterly summary, the third quarterly summary which includes a summary of the activities of the current and previous quarters of the support plan and shall be considered the annual report.
- Documentation, in the form of a letter from Vocational Rehabilitation (VR) Services or a case note detailing contact with a named VR representative, the date, summary of conversation, etc., indicating a lack of available VR funding for supported employment.
- *Individual employment plan must be completed within 30 days of the initiation of a new service or within 30 days of the support plan effective date for continuation services and at any time updates and changes are made before they are implemented and annually thereafter.
In addition to the minimum required components of the individual plan for employment described in the definitions section of this handbook, the plan must also contain the following:
Documented review by the provider to furnish information and supports for the recipient to make an informed choice in the type of work preferred, job changes or career advancement opportunities.
- Copy of service log, monthly;
- Individual plan for employment; and
- Third quarterly summary which summarizes the current and previous quarters of the activities of the support plan and will count as the annual report.
If the provider plans to transport recipients in his private vehicle, at the time of enrollment, the provider must be able to show proof of: 1) a valid driver’s license, 2) car registration, and, 3) insurance. Subsequent to enrollment, the provider is responsible for keeping this documentation up-to-date.
*Indicates reimbursement documentation.
Place of Service:
Supported employment services are provided in the recipient’s place of employment in the community or in a setting mutually agreed to by the supported employee, the employment coach or consultant and the employer.
Should the employment location of a recipient change, the provider shall notify the recipient’s waiver support coordinator within five working days.
Supported employment services furnished under the waiver are not available through programs funded by the Rehabilitation Act of 1973 or Public Law 94-142. Documentation to this effect will be maintained in the file of each recipient receiving this service.
When the supervisor of a mobile crew or enclave does not meet the qualifications for a supported employment coach, although the recipient meets the criteria for supported employment, the support service must be billed as adult day training off-site, rather than supported employment.
Supported employment services are defined as competitive employment, which may be performed on a full-time or part-time basis, in an integrated setting, for which an individual is compensated at or above minimum wage but not less than the customary wage, and at a level of benefits paid by the employer for the same or similar work that is performed by trained, non-disabled individuals.
Providers of supported employment – group model services will bill for each recipient based on the published stepped rate for the service. The group rate shall be determined based on from two to eight recipients receiving the service.
Providers of supported employment – individual model services will bill, based on a one to one ratio, the rate established for the service in the published rate system.
Payment will not be made for incentives, subsidies, or unrelated vocational training. The supported employment vendor will not bill for supports provided by the employer.
Supported Employment Services Provider Requirements
Providers of supported employment services may be either independent vendors, solo providers or agency vendors.
Independent vendors, employees of agencies and solo providers who render these services shall have a bachelor’s degree from an accredited college or university with a major in nursing; education; or a social, behavioral or rehabilitative science. In lieu of a bachelor’s degree, a person rendering these services shall have an associate’s degree from an accredited college or university with a major in nursing; education; or a social, behavioral or rehabilitative science and two years of experience. Experience in one of the previously mentioned fields shall substitute on a year-for-year basis for the required college education.
Agency employees, independent providers and solo providers are required to attend 12 hours of pre-service training prior to assuming job responsibilities, and eight hours of annual in-service training. Agency employees and independent providers enrolled after October 2003 are required to attend eighteen hours of pre-service training prior to assuming job responsibilities, and eight hours of annual in-service training. Training will consist of a curriculum provided by APD, an overview of affordable housing options and home modifications, and Chapter 65G-5, F.A.C. The pre-service training content must be approved by APD’s Central Office to ensure statewide uniformity.
Providers of supported living coaching services must, at a minimum, also complete training covering CPR, infection control, HIV/AIDS, maintaining current certification.
Proof of annual or required updated training shall be maintained on file for review. The provider is responsible for all training requirements outlined in the Core Assurances.
Note: Refer to the Core Assurances in Appendix A for the provider training requirements