The Centers for Medicare & Medicaid Services has issued a bulletin that clarifies some of the expectations around employment in the 1915c waiver. This information is particularly important for advocates and states looking to explore employment services as a Medicaid service, and are seeking help with how to define services for CMS’ ultimate approval. See below and the link to the full CMS bulletin for more information.
Of particular importance is information on page five of this bulletin that outlines the restrictions on billing for sheltered workshops/work centers and pre-vocational settings:
“Waiver funding is not available for the provision of vocational services delivered in facility based or sheltered work settings, where individuals are supervised for the primary purpose of producing goods or performing services. The distinction between vocational and pre-vocational services is that pre-vocational services, regardless of setting, are delivered for the purpose of furthering habilitation goals such as attendance, task completion, problem solving, interpersonal relations and safety, as outlined in the individual’s person-centered services and supports plan. Prevocational services should be designed to create a path to integrated community based employment for which an individual is compensated at or above the minimum wage, but not less than the customary wage and level of benefits paid by the employer for the same or similar work performed by individuals without disabilities.”
CMS Guidance on Employment in 1915c Waiver
Updates to the §1915 (c) Waiver Instructions and Technical Guide regarding employment and employment related services
This Informational Bulletin is intended to provide clarification of existing CMS guidance on development and implementation of §1915 (c) Waivers regarding employment and employment related services. Specifically, this letter provides updates to several sections of the current Waiver Technical Guide Version 3.5, which was released in January of 2008, in advance of a future release of Technical Guide Version 3.6.
This guidance does not constitute new policy, but rather highlights the opportunities available to use waiver supports to increase employment opportunities for individuals with disabilities within current policy. Further, it underscores CMS’s commitment to the importance of work for waiver participants and provides further clarification of CMS guidance regarding several core service definitions.
While States have the flexibility to craft their own service definitions and modify CMS core service definitions, many States rely on CMS language for their waiver core service definitions. We hope that by emphasizing the importance of employment in the lives of people with disabilities, updating some of our core service definitions, and adding several new core service definitions to better reflect best and promising practices that it will support States’ efforts to increase employment opportunities and meaningful community integration for waiver participants.
The major changes in the Instructions and Technical Guide are summarized below:
• Highlights the importance of competitive work for people with and without disabilities and CMS’s goal to promote integrated employment options through the waiver program
• Acknowledges best and promising practices in employment support, including self direction and peer support options for employment support
• Clarifies that Ticket to Work Outcome and Milestone payments are not in conflict with payment for Medicaid services rendered because both Ticket to Work and Milestone payments are made for an outcome, not service delivery
• Adds a new core service definition- by splitting what had previously been supported employment into two definitions- individual and small group supported employment
• Includes a new service definition for career planning, that may be separate or rolled into the other employment related service definitions
• Emphasizes the critical role of person centered planning in achieving employment outcomes
• Modifies both the prevocational services and supported employment definitions to clarify that volunteer work and other activities that are not paid, integrated community employment are appropriately described in pre-vocational, not supported employment services
• Explains that pre-vocational services are not an end point, but a time limited (although no specific limit is given) service for the purpose of helping someone obtain competitive employment