Members with Medicaid are determined eligible for 1915(i) services through an independent assessment.
| Service | I/DD | SED | SMI | SUD | TBI | NEEDS -Based Criteria | |
|---|---|---|---|---|---|---|---|
| Community Living and Support | ✔ | ✔ | · Have a functional deficit · Can benefit from skill acquisition (e.g.,self-determination, independent living) or · Can benefit from assistance in monitoring a health condition/living skills |
||||
| Community Transition | ✔ | ✔ | ✔ | · Moving to own community living arrangement and need initial set-up expenses/items. | |||
| Individual and Transitional Support | ✔ Age 16-21 | ✔ Age 18+ | ➕ | · At least on deficit in an instrumental activity of daily living (e.g., meal preparation) | |||
| Respite | ✔ | ✔ Age 3-20 | ✔ Age 3-20 | · Unable to care for themselves in the absence of their primary caregiver | |||
| Supported Employment | ✔ 16+ | ✔ 16+ | ✔ 16+ | ✔ 16+ | ✔ 16+ | · Express the desire to work · Has a pattern of under/unemployment or · Have educational goals that relate to employment goals |
Assessments
- Following the completion of an initial 1915(i) independent assessment, an individual must obtain a 1915(i) independent assessment at least annually or when their circumstances or needs change significantly. Care managers will use the same 1915(i) independent assessment standardized template issued by the NCDHHS when conducting reassessments.
Why is it important?
- Federal rules require that individuals obtain an independent assessment and independent evaluation to use 1915(i) services.
- If a member has not been assessed and determined 1915(i) eligible, the member is not eligible to receive the services.
ISP and Prior Authorizations
- A care manager will work with the member AND the service provider to develop an ISP.
- A care manager will then submit a prior authorization request for the service through Jiva.
- The service provider can view the prior authorization request through the Jiva Provider Portal and access any documents attached.
- The member’s initial care plan/ISP must be reviewed and approved/denied within 45 days of 1915(i) independent evaluation eligibility determination from the state.
- The care plan/ISP should end on the last day of the member’s birth month.
- Every annual care plan/ISP will start, the first day of the month following the birth month and end, the last day of the birth month. This will ensure all plans are not due at the same time.
Monitoring of Services
- The care manager must meet with the member in person at least quarterly to monitor delivery of services.
- Monitoring includes assessing plan implementation, quality of care, health, safety, and well-being, and the appropriateness of services.
- Monitoring includes monitoring that progress is being made and/or short term goals are adjusted when progress is not being made.
Service Provider and Care Manager Collaboration
- Ongoing communication is key.
- Service providers can support member engagement with the care manager by explaining the process for 1915(i) services.
- To find the members assigned care manager:
- Contact Member and Recipient Services
- NC Tracks
- Email [email protected]
| Care Manager | Service Provider | Collaborative |
|---|---|---|
| Eligibility assessments | Reviewing referral for member to confirm referral is appropriate (i.e, diagnosis for the service) Assist with CM and member communication if needed | Monitoring of service delivery and goal progress Tracking eligibility and authorization |
| Develop/author the ISP in collaboration with member and provider, submit the PAR | Participation in ISP meeting and plan development | Developing progress updates for PAR submissions |
| Monitor service delivery | Short term goals and monitoring for progress | Communication to the member on the process/requirements of 1915i services. |
1915(i) Services Quick Reference
This table services as a quick reference only. All 1915(i) service eligibility criteria, limitations and requirements, unit/hours request limits, and exclusions are detailed in the Clinical Coverage Policy. Review each policy in the Alliance Clinical Coverage Policy Reference Tool.
| Service | Code and Modifier | Units | CCP | Prior Authorization Required? |
|---|---|---|---|---|
| Community Transition | H0043 U4 | 1 | 8H-6 | Yes |
| Respite Child | H0045 U4 | 1 unit = 15 minutes | 8H-4 | Yes |
| Respite Adult | H0045HB U4 | 1 unit = 15 minutes | 8H-4 | Yes |
| Respite Child Group | H0045HQ U4 | 1 unit = 15 minutes | 8H-4 | Yes |
| Respite Adult Group | H0045 HQ HB U4 | 1 unit = 15 minutes | 8H-4 | Yes |
| Supported Employment Initial | H2023 U4 | 1 unit = 15 minutes | 8H-1 | Yes |
| SE Maintenance | H2026 U4 | 1 unit = 15 minutes | 8H-1 | Yes |
| Individual and Transitional Support | T1019 U4 | 1 unit = 15 minutes | 8H-3 | Yes |
| Individual and Transitional Support (non- EVV, Community only) | T1019 U4 TS | 1 unit = 15 minutes | 8H-3 | Yes |
| Community Living and Supports (non-EVV, community only) | T2012 U4 | 1 unit = 15 minutes | 8H-5 | Yes |
| Community Living and Supports Group- Community Only | T2012 HQ U4 | 1 unit = 15 minutes | 8H-5 | Yes |
| Community Living and Supports Relative as provider lives in home (non-EVV) | T2012 GC U4 | 1 unit = 15 minutes | 8H-5 | Yes |
| Community Living and Supports Individual, In home | T2013 TF U4 | 1 unit = 15 minutes | 8H-5 | Yes |
| Community Living and Supports Group, In Home | T2013 TF HQ U4 | 1 unit = 15 minutes | 8H-5 | Yes |
| Individual Placement and Support (IPS) for Mental Health and Substance abuse. | 2023 U4 | See SOW for all milestone information | 8H-2 | No |
