PA Lookup

Specialized Consultation Services provide expertise, training and technical assistance in a specialty area (psychology, behavior intervention, speech therapy, therapeutic recreation, augmentative communication, assistive technology equipment, occupational therapy, physical therapy, nutrition, nursing, and other licensed professionals who possess experience with individuals with Intellectual / Developmental Disabilities) to assist family members, support staff and other natural supports in assisting the member with developmental disabilities. Under this model, family members and other paid/unpaid caregivers are trained by a certified, licensed, and/or registered professional, or qualified assistive technology professional to carry out therapeutic interventions, consistent with the Individual Support Plan.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

This service may be used for evaluations for adults when the State Plan limits have been exceeded.

Exclusions

• • Specialized Consultative Services excludes services provided through Natural Supports Education and Crisis Services. This service may not duplicate services provided to family members through natural supports education
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Diagnosis Requirements

Coverage is limited to Medicaid beneficiaries with intellectual or developmental disabilities, or both, who meet NC Innovations waiver criteria. The beneficiary must meet ICF-IID level of care requirements, reside in an ICF-IID facility or be at high risk of placement in one, be able to maintain health, safety, and well-being in the community with NC Innovations services, require NC Innovations services identified through a person-centered planning process, and require at least one waiver service monthly as indicated in the ISP and Individual Budget.

Specific Diagnosis Codes Required

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Specialized Consultation Services provide expertise, training and technical assistance in a specialty area (psychology, behavior intervention, speech therapy, therapeutic recreation, augmentative communication, assistive technology equipment, occupational therapy, physical therapy, nutrition, nursing, and other licensed professionals who possess experience with individuals with Intellectual / Developmental Disabilities) to assist family members, support staff and other natural supports in assisting the member with developmental disabilities. Under this model, family members and other paid/unpaid caregivers are trained by a certified, licensed, and/or registered professional, or qualified assistive technology professional to carry out therapeutic interventions, consistent with the Individual Support Plan.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

This service may be used for evaluations for adults when the State Plan limits have been exceeded.

Exclusions

• • Specialized Consultative Services excludes services provided through Natural Supports Education and Crisis Services. This service may not duplicate services provided to family members through natural supports education
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Diagnosis Requirements

Coverage is limited to Medicaid beneficiaries with intellectual or developmental disabilities, or both, who meet NC Innovations waiver criteria. The beneficiary must meet ICF-IID level of care requirements, reside in an ICF-IID facility or be at high risk of placement in one, be able to maintain health, safety, and well-being in the community with NC Innovations services, require NC Innovations services identified through a person-centered planning process, and require at least one waiver service monthly as indicated in the ISP and Individual Budget.

Specific Diagnosis Codes Required

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Financial Support Services (FSS) is an umbrella service for the continuum of supports offered to NC Innovations individuals who elect the Individual and Family Directed Services Option, Employer of Record Model. Financial Support Services are provided to ensure that funds for self-directed services are managed and distributed as intended. The service also facilitates the employment of support staff by the Employer. A member who chooses to self-direct via the Employer of Record model may require equipment necessary to carry out duties of Employer of Record and may access this service.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

Available only to a beneficiary who chooses to self-direct via the Employer of Record model.

• - Intended only for equipment necessary to carry out Employer of Record duties.
• - Monthly internet/connectivity charges may be covered only when required for Employer of Record duties such as processing timesheets, using the Financial Support Services portal, or utilizing EHR software.
• - One laptop computer and one EHR software may be purchased over the life of the waiver.
• - EHR software may be upgraded more than once over the life of the waiver only if necessary to maintain functionality, and vendor documentation is required to show the software will not function without the upgrade.
• - Computer repair is covered only for equipment purchased through the waiver for the Employer of Record, only if repair cost does not exceed replacement cost, and only if the Employer of Record owns the equipment being repaired.

Exclusions

• • Items not coverable by Employer Supplies (this is not an all-inclusive list): a) Wireless keyboards; b) Mouse (unless the EOR is purchasing a desktop and the desktop does not include a mouse); c) Computer Protective Cases (outside of one laptop bag for EORs who utilize a laptop); d) Additional Computer Screens (a desktop computer should include one monitor); e) IT help desk service for support to operate the equipment; f) Office/Desk Chair.
• • The provider of financial support services may only additionally provide Community Navigator services. The financial support service may bill for the following services: community transition services, and individual goods and services under the NC Innovations waiver.
• • The financial supports agency may be an Agency with Choice and provide Community Navigator. They may bill for community transition and individual goods and services to the same member. Community Transition Services and Individual Goods and Services are not directly provided by the FMS.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Place of Service

Services generally can be provided at a location that best meets the beneficiary's needs. Services may be provided in a hotel, shelter, church or other setting based on the beneficiary's needs. However, some services must be provided at a specific location. Refer to the Attachment C, Service Definitions, for specific information about any limitations on where a service can be provided. Telehealth claims should be filed with the provider's usual place of service code(s). Home and Community Characteristics: HCB Settings requirements apply to Residential Supports, Day Supports and Supported Employment

Additional Service Specifics

U2. GT applies only when the service is telehealth billable and delivered by interactive audio-video.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Financial Support Services (FSS) is an umbrella service for the continuum of supports offered to NC Innovations individuals who elect the Individual and Family Directed Services Option, Employer of Record Model. Financial Support Services are provided to ensure that funds for self-directed services are managed and distributed as intended. The service also facilitates the employment of support staff by the Employer. A member who chooses to self-direct via the Employer of Record model may require equipment necessary to carry out duties of Employer of Record and may access this service.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

Available only to a beneficiary who chooses to self-direct via the Employer of Record model.

• - Intended only for equipment necessary to carry out Employer of Record duties.
• - Monthly internet/connectivity charges may be covered only when required for Employer of Record duties such as processing timesheets, using the Financial Support Services portal, or utilizing EHR software.
• - One laptop computer and one EHR software may be purchased over the life of the waiver.
• - EHR software may be upgraded more than once over the life of the waiver only if necessary to maintain functionality, and vendor documentation is required to show the software will not function without the upgrade.
• - Computer repair is covered only for equipment purchased through the waiver for the Employer of Record, only if repair cost does not exceed replacement cost, and only if the Employer of Record owns the equipment being repaired.

Exclusions

• • Items not coverable by Employer Supplies (this is not an all-inclusive list): a) Wireless keyboards; b) Mouse (unless the EOR is purchasing a desktop and the desktop does not include a mouse); c) Computer Protective Cases (outside of one laptop bag for EORs who utilize a laptop); d) Additional Computer Screens (a desktop computer should include one monitor); e) IT help desk service for support to operate the equipment; f) Office/Desk Chair.
• • The provider of financial support services may only additionally provide Community Navigator services. The financial support service may bill for the following services: community transition services, and individual goods and services under the NC Innovations waiver.
• • The financial supports agency may be an Agency with Choice and provide Community Navigator. They may bill for community transition and individual goods and services to the same member. Community Transition Services and Individual Goods and Services are not directly provided by the FMS.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Place of Service

Services generally can be provided at a location that best meets the beneficiary's needs. Services may be provided in a hotel, shelter, church or other setting based on the beneficiary's needs. However, some services must be provided at a specific location. Refer to the Attachment C, Service Definitions, for specific information about any limitations on where a service can be provided. Telehealth claims should be filed with the provider's usual place of service code(s). Home and Community Characteristics: HCB Settings requirements apply to Residential Supports, Day Supports and Supported Employment

Additional Service Specifics

U2. GT applies only when the service is telehealth billable and delivered by interactive audio-video.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Crisis Supports provide intervention and stabilization for a member experiencing a crisis. Crisis Supports are for a member who experiences acute crises and who presents a threat to the member’s health and safety or the health and safety of others. These behaviors may result in the member losing his or her home, job, or access to activities and community involvement. Crisis Supports promote prevention of crises as well as assistance in stabilizing the member when a behavioral crisis occurs. Crisis Supports are an immediate intervention available 24 hours per day, 7 days per week, to support the individual.

Out-of-home crisis is a short-term service for an individual experiencing a crisis and requiring a period of structured support and/or programming. The service takes place in a licensed facility. Out of-home crisis may be used when an individual cannot be safely supported in the home, due to his/her behavior, and implementation of formal behavior interventions have failed to stabilize the behaviors, and all other approaches to ensure health and safety have failed. In addition, the service may be used as a planned respite stay for waiver members who have heightened behavioral needs.

Crisis consultation is for individuals that have significant, intensive, or challenging behaviors or medical conditions that have resulted or have the potential to result in a crisis. Consultation is provided by staff that meets the minimum staffing requirements of a Qualified Professional and who have crisis experience.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. Following service auth, any needed modifications to the ISP and individual budget will occur within five working days of the date of verbal service authorization.
• 2. Out-of-Home Crisis services are authorized in increments of up to 30 calendar days.
• 3. Crisis Intervention & Stabilization Supports may be authorized for periods of up to 14 calendar day increments per event.

Exclusions

• • This service may not duplicate services provided under Specialized Consultation Services.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Crisis Supports provide intervention and stabilization for a member experiencing a crisis. Crisis Supports are for a member who experiences acute crises and who presents a threat to the member’s health and safety or the health and safety of others. These behaviors may result in the member losing his or her home, job, or access to activities and community involvement. Crisis Supports promote prevention of crises as well as assistance in stabilizing the member when a behavioral crisis occurs. Crisis Supports are an immediate intervention available 24 hours per day, 7 days per week, to support the individual.

Out-of-home crisis is a short-term service for an individual experiencing a crisis and requiring a period of structured support and/or programming. The service takes place in a licensed facility. Out of-home crisis may be used when an individual cannot be safely supported in the home, due to his/her behavior, and implementation of formal behavior interventions have failed to stabilize the behaviors, and all other approaches to ensure health and safety have failed. In addition, the service may be used as a planned respite stay for waiver members who have heightened behavioral needs.

Crisis consultation is for individuals that have significant, intensive, or challenging behaviors or medical conditions that have resulted or have the potential to result in a crisis. Consultation is provided by staff that meets the minimum staffing requirements of a Qualified Professional and who have crisis experience.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. Following service auth, any needed modifications to the ISP and individual budget will occur within five working days of the date of verbal service authorization.
• 2. Out-of-Home Crisis services are authorized in increments of up to 30 calendar days.
• 3. Crisis Intervention & Stabilization Supports may be authorized for periods of up to 14 calendar day increments per event.

Exclusions

• • This service may not duplicate services provided under Specialized Consultation Services.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Day Supports is a group, facility-based service that helps the member with acquisition, retention, or improvement in socialization and daily living skills and is one option for a meaningful day. Day Supports emphasizes inclusion and independence with a focus on enabling the individual to attain or maintain his/her maximum self-sufficiency, increase self-determination and enhance the person’s opportunity to have a meaningful day.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Unit Value

Day Supports is billed in 1-hour unit increments.

Limits

• • The amount of Day Supports is subject to the Limits on Sets of services.
• • For individuals who are eligible for educational services under the Individuals with Disability Educational Act, Day Supports is the payer of last resort for Developmental Day.
• • Day Supports are furnished in a non-residential setting, separate from the home or residential setting where the member resides.
• • Transportation to/from the member’s home, the day supports facility and travel within the community is included in the payment rate. Transportation to and from the licensed day program is the responsibility of the Day Supports provider.
• • This service may not duplicate services, nor can they be furnished or billed at the same time of day as services, provided under Community Networking, In-Home Intensive Supports, Community Living and Supports, Supported Living, Residential Supports, Supported Employment and/or one of the State Plan Medicaid Services that works directly with the member.
• • Waiver funding is not available for vocational services delivered in facility based, sheltered work settings, or Adult Developmental Vocational Program.
• • Individuals are provided opportunities to seek employment and work in competitive integrated settings, engage in community life and control personal resources.
• • Each individual’s rights of privacy, dignity, respect and freedom from coercion and restraint are protected.
• • Settings optimize, but do not regiment, individual initiative, autonomy and independence in making life choices.
• • Settings facilitate individual choice regarding services and support, and who provides these.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Length of Stay

Billed in 1-hour unit increments; at least 15 minutes of service must be provided before one 1-hour unit may be billed. Subject to limits on sets of services: with residential supports, adults max 40 hours/week and children max 20 hours/week during school year or 40 when school is not in session; in private homes, adults max 84 hours/week and children max 54 hours/week during school year or 84 when school is not in session, for the applicable combined service sets.

Age Group Details

Day Supports is a group, facility-based service; Developmental Day is for school-aged or younger children in a licensed childcare center.

• - Individuals new to the service who are age 16 or older must receive education during the planning meeting on available meaningful-day options.

Place of Service

Day Supports must be furnished in a non-residential setting separate from the home or residential setting where the beneficiary resides, though it may occur outside the facility if consistent with ISP goals.

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Carolina Complete Health through Availity

• https://network.carolinacompletehealth.com/resources/availity-essentials.html

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Assistive Technology, Equipment and Supplies (ATES) are necessary for the proper functioning of items and systems, whether acquired commercially, modified, or customized, that are used to increase, maintain, or improve functional capabilities of individuals. This service covers purchases, leasing, trial periods and shipping costs, and as necessary, repair/modification of equipment required to enable individuals to increase, maintain or improve their functional capacity to perform daily life tasks that would not be possible otherwise. Cost of Monthly monitoring, connectivity, and internet charges may be covered when it is required for the functioning of the item and system.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year. for each plan year.
• 2. SIS
• 3. Individual Budget: shipping costs must be itemized. Taxes are not coverable.
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures, e) a plan for training the individual, the natural support system, and paid caregivers on the use of the requested equipment and supplies, f) Long-range outcomes related to training needs associated with the member’s or family’s utilization and procurement of the requested equipment or adaptations. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Assessment or Written Recommendation: by an appropriate professional identifying:
• a. the equipment and supplies being requested in the amounts needed
• b. Must be less than one calendar year old from requested date.
• 7. Certificate of Medical Necessity/Prescription: completed by the physician, PA, or NP. MN must be documented for every item requested.
• 8. MN Letter: written & signed by an MD/ DO, PA, NP, or applicable professional for every item requested. This meets the prescription requirement when created by an MD/ DO, PA, or NP.
• 9. When an assessment is completed by another professional recommending the MN of specific items, then an MD/ DO, PA, or NP must write a letter of MN OR sign off on the letter of MN prepared by professional AND write a prescription.10. The estimated life of the equipment and the length of time the member is expected to benefit from the equipment.
• 11. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

For Assistive Technology Equipment

• 1. Training Plan: how the person and family will be trained on the use of the equipment
• 2. Two quotes for the requested item(s)

For Supplies

• 1. Statement of Medical Necessity: completed by an appropriate professional, to include the amount and type of item(s)
• 2. Supplies that continue to be needed at the time of the Annual Plan must be recommended by an annual re-assessment. The assessment or recommendation must be updated if the amount needs change.
• 3. Two quotes for the requested item(s)

For Adaptive Car Seats

• 1. A documented chronic health condition or DD which requires the use of an adaptive car seat for positioning.
• 2. The following information in the assessment must be included:
• a. Member’s weight;
• b. Weight limits of the car seat currently used to transport;
• c. Measurements showing the member has a seat to crown height that is longer than the back height of the largest child car safety seat if the member weighs less than the upper weight limit of the current car seat;
• d. Reasons why the member cannot be safely transported in a car seat belt or convertible or booster seat for individual weighing 30 pounds and up;
• e. Two quotes for the requested item(s)

Exclusions

• • Limited to expenditures of $50,000 (ATES and Home Modifications) over the life of the waiver (excluding nutritional supplements and monthly alert monitoring / connectivity system charges).
• • Assistive Technology and Supplies can be requested when the item will belong to the individual.
• • Excluded Items include:
• o Recreational items normally purchased by a family
• o Non-Adaptive Computer desks and other furniture items.
• o Service, maintenance contracts and extended warranties
• o Equipment or supplies purchased for exclusive use at the school/home school
• o Computer hardware solely to improve socialization or educational skills, to provide recreation or diversion activities, or to be used by any person other than the member.
• o Hot tubs, Jacuzzis, and pools.
• o Items utilized as restraints.
• o Items that are coverable under the Medicaid DME benefit should not be covered by NC Innovations ATES.
• • Remote support technology may only be used with consent of the individual and guardian, indicated in the ISP (including preference for the location of any monitoring equipment)
• • Service contracts and extended warranties may be covered for a one-year time frame.
• • All items must meet applicable standards of manufacture, design, and installation.
• • Car seats are not approved for behavioral restraint.
• • See the CCP for all covered items and categories
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Living provides a flexible partnership that enables a NC Innovations member to live in their own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the member. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the member, budget management, attending appointments, and interpersonal and social skills building to enable the member to live in a home in the community. Training activities, supervision, and assistance may be provided to allow the member to participate in home life or community activities. Other activities include assistance with monitoring health status and physical condition, and assistance with transferring, ambulation and use of special mobility devices.

The purpose of Supported Living Transition is to provide members with the support that they need to facilitate their transition to Supported Living.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) risk assessment, e) back-up, relief staff, and in the case of emergency or crisis details, f) specific plan for addressing health and safety needs for unsupervised times, g) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. The Supported Living Periodic service is available for a member who uses four or less hours of Supported Living per day.
• 2. A member’s own home is defined as the place the person lives and in which the person has all of the ownership or tenancy rights afforded under the law. This home must have a separate address from any other residence located on the same property.
• 3. A member receiving Supported Living has the right to manage personal funds as specified in the ISP.
• 4. A formal roommate agreement, separate from the landlord lease agreement, is established and signed by individuals whose name is on the lease.

Exclusions

• • The amount of Supported Living is subject to the Limits on Sets of Services.
• • Supported Living Transition is only available during the six-month period in advance of the member’s move to a Supported Living setting.
• • Supported Living is not provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIFD) or residential group homes.
• • Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents.
• • A member who receives Supported Living may not receive: Community Living and Supports or State Plan Personal Care Services. Respite may only be provided for participation in non- integrated camps or for participation in non-integrated Support Groups.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the person.
• • A member receiving Supported Living may only receive Home Modifications if the home is owned by the member or the member’s family. If the home is rented, only Home Modifications that are portable and can be removed once the member no longer leases the residence may be used.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
• • Relatives who own provider agencies may not provide Supportive Living services to family members. Other staff employed by the provider agency may provide services to the individual.
• • The provider of Supported Living services shall not: a) Own the person/s’ home or have any authority to require the member to move if the member changes service providers; b) Own, be owned by, or be affiliated with any entity that leases or rents a place of residence to a member if such entity requires, as a condition of renting or leasing, the member to move if the Supported Living provider changes.
• • Supported Living must not be provided in a home where a member lives with family members unless such family members are a member receiving Supported Living, a spouse, or a minor child. All members receiving Supported Living services who live in the same household must be on the lease unless the person is a live-in caregiver.
• • Reimbursement for Supported Living must not include payment for services provided by the spouse of a person or to family members as defined in this service definition or legal guardian. The Supported Living provider and provider staff shall not be a member of the member’s immediate family as defined in this service definition and reimbursement must not include payment for Supported Living provided by such persons.
• • A Supported Living home must have no more than three residents including any live-in caregiver providing support.
• • Reimbursement for Supported Living shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver.
• • Reimbursement cannot include the cost of maintenance of the dwelling.
• • Transportation is an inclusive component of Supported Living to achieve goals and objectives related to these activities with the exception of transportation to and from medical services covered through the Medicaid State Plan.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Age Group Details

Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents

Level of Care

Supported Living levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A & B Level 2: SIS Level C & D Level 3: SIS Level E, F, & G

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Living provides a flexible partnership that enables a NC Innovations member to live in their own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the member. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the member, budget management, attending appointments, and interpersonal and social skills building to enable the member to live in a home in the community. Training activities, supervision, and assistance may be provided to allow the member to participate in home life or community activities. Other activities include assistance with monitoring health status and physical condition, and assistance with transferring, ambulation and use of special mobility devices.

The purpose of Supported Living Transition is to provide members with the support that they need to facilitate their transition to Supported Living.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) risk assessment, e) back-up, relief staff, and in the case of emergency or crisis details, f) specific plan for addressing health and safety needs for unsupervised times, g) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. The Supported Living Periodic service is available for a member who uses four or less hours of Supported Living per day.
• 2. A member’s own home is defined as the place the person lives and in which the person has all of the ownership or tenancy rights afforded under the law. This home must have a separate address from any other residence located on the same property.
• 3. A member receiving Supported Living has the right to manage personal funds as specified in the ISP.
• 4. A formal roommate agreement, separate from the landlord lease agreement, is established and signed by individuals whose name is on the lease.

Exclusions

• • The amount of Supported Living is subject to the Limits on Sets of Services.
• • Supported Living Transition is only available during the six-month period in advance of the member’s move to a Supported Living setting.
• • Supported Living is not provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIFD) or residential group homes.
• • Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents.
• • A member who receives Supported Living may not receive: Community Living and Supports or State Plan Personal Care Services. Respite may only be provided for participation in non- integrated camps or for participation in non-integrated Support Groups.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the person.
• • A member receiving Supported Living may only receive Home Modifications if the home is owned by the member or the member’s family. If the home is rented, only Home Modifications that are portable and can be removed once the member no longer leases the residence may be used.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
• • Relatives who own provider agencies may not provide Supportive Living services to family members. Other staff employed by the provider agency may provide services to the individual.
• • The provider of Supported Living services shall not: a) Own the person/s’ home or have any authority to require the member to move if the member changes service providers; b) Own, be owned by, or be affiliated with any entity that leases or rents a place of residence to a member if such entity requires, as a condition of renting or leasing, the member to move if the Supported Living provider changes.
• • Supported Living must not be provided in a home where a member lives with family members unless such family members are a member receiving Supported Living, a spouse, or a minor child. All members receiving Supported Living services who live in the same household must be on the lease unless the person is a live-in caregiver.
• • Reimbursement for Supported Living must not include payment for services provided by the spouse of a person or to family members as defined in this service definition or legal guardian. The Supported Living provider and provider staff shall not be a member of the member’s immediate family as defined in this service definition and reimbursement must not include payment for Supported Living provided by such persons.
• • A Supported Living home must have no more than three residents including any live-in caregiver providing support.
• • Reimbursement for Supported Living shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver.
• • Reimbursement cannot include the cost of maintenance of the dwelling.
• • Transportation is an inclusive component of Supported Living to achieve goals and objectives related to these activities with the exception of transportation to and from medical services covered through the Medicaid State Plan.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Age Group Details

Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents

Level of Care

Supported Living levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A & B Level 2: SIS Level C & D Level 3: SIS Level E, F, & G

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Living provides a flexible partnership that enables a NC Innovations member to live in their own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the member. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the member, budget management, attending appointments, and interpersonal and social skills building to enable the member to live in a home in the community. Training activities, supervision, and assistance may be provided to allow the member to participate in home life or community activities. Other activities include assistance with monitoring health status and physical condition, and assistance with transferring, ambulation and use of special mobility devices.

The purpose of Supported Living Transition is to provide members with the support that they need to facilitate their transition to Supported Living.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) risk assessment, e) back-up, relief staff, and in the case of emergency or crisis details, f) specific plan for addressing health and safety needs for unsupervised times, g) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. The Supported Living Periodic service is available for a member who uses four or less hours of Supported Living per day.
• 2. A member’s own home is defined as the place the person lives and in which the person has all of the ownership or tenancy rights afforded under the law. This home must have a separate address from any other residence located on the same property.
• 3. A member receiving Supported Living has the right to manage personal funds as specified in the ISP.
• 4. A formal roommate agreement, separate from the landlord lease agreement, is established and signed by individuals whose name is on the lease.

Exclusions

• • The amount of Supported Living is subject to the Limits on Sets of Services.
• • Supported Living Transition is only available during the six-month period in advance of the member’s move to a Supported Living setting.
• • Supported Living is not provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIFD) or residential group homes.
• • Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents.
• • A member who receives Supported Living may not receive: Community Living and Supports or State Plan Personal Care Services. Respite may only be provided for participation in non- integrated camps or for participation in non-integrated Support Groups.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the person.
• • A member receiving Supported Living may only receive Home Modifications if the home is owned by the member or the member’s family. If the home is rented, only Home Modifications that are portable and can be removed once the member no longer leases the residence may be used.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
• • Relatives who own provider agencies may not provide Supportive Living services to family members. Other staff employed by the provider agency may provide services to the individual.
• • The provider of Supported Living services shall not: a) Own the person/s’ home or have any authority to require the member to move if the member changes service providers; b) Own, be owned by, or be affiliated with any entity that leases or rents a place of residence to a member if such entity requires, as a condition of renting or leasing, the member to move if the Supported Living provider changes.
• • Supported Living must not be provided in a home where a member lives with family members unless such family members are a member receiving Supported Living, a spouse, or a minor child. All members receiving Supported Living services who live in the same household must be on the lease unless the person is a live-in caregiver.
• • Reimbursement for Supported Living must not include payment for services provided by the spouse of a person or to family members as defined in this service definition or legal guardian. The Supported Living provider and provider staff shall not be a member of the member’s immediate family as defined in this service definition and reimbursement must not include payment for Supported Living provided by such persons.
• • A Supported Living home must have no more than three residents including any live-in caregiver providing support.
• • Reimbursement for Supported Living shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver.
• • Reimbursement cannot include the cost of maintenance of the dwelling.
• • Transportation is an inclusive component of Supported Living to achieve goals and objectives related to these activities with the exception of transportation to and from medical services covered through the Medicaid State Plan.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Age Group Details

Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents

Level of Care

Supported Living levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A & B Level 2: SIS Level C & D Level 3: SIS Level E, F, & G

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Living provides a flexible partnership that enables a NC Innovations member to live in their own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the member. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the member, budget management, attending appointments, and interpersonal and social skills building to enable the member to live in a home in the community. Training activities, supervision, and assistance may be provided to allow the member to participate in home life or community activities. Other activities include assistance with monitoring health status and physical condition, and assistance with transferring, ambulation and use of special mobility devices.

The purpose of Supported Living Transition is to provide members with the support that they need to facilitate their transition to Supported Living.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) risk assessment, e) back-up, relief staff, and in the case of emergency or crisis details, f) specific plan for addressing health and safety needs for unsupervised times, g) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. The Supported Living Periodic service is available for a member who uses four or less hours of Supported Living per day.
• 2. A member’s own home is defined as the place the person lives and in which the person has all of the ownership or tenancy rights afforded under the law. This home must have a separate address from any other residence located on the same property.
• 3. A member receiving Supported Living has the right to manage personal funds as specified in the ISP.
• 4. A formal roommate agreement, separate from the landlord lease agreement, is established and signed by individuals whose name is on the lease.

Exclusions

• • The amount of Supported Living is subject to the Limits on Sets of Services.
• • Supported Living Transition is only available during the six-month period in advance of the member’s move to a Supported Living setting.
• • Supported Living is not provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIFD) or residential group homes.
• • Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents.
• • A member who receives Supported Living may not receive: Community Living and Supports or State Plan Personal Care Services. Respite may only be provided for participation in non- integrated camps or for participation in non-integrated Support Groups.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the person.
• • A member receiving Supported Living may only receive Home Modifications if the home is owned by the member or the member’s family. If the home is rented, only Home Modifications that are portable and can be removed once the member no longer leases the residence may be used.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
• • Relatives who own provider agencies may not provide Supportive Living services to family members. Other staff employed by the provider agency may provide services to the individual.
• • The provider of Supported Living services shall not: a) Own the person/s’ home or have any authority to require the member to move if the member changes service providers; b) Own, be owned by, or be affiliated with any entity that leases or rents a place of residence to a member if such entity requires, as a condition of renting or leasing, the member to move if the Supported Living provider changes.
• • Supported Living must not be provided in a home where a member lives with family members unless such family members are a member receiving Supported Living, a spouse, or a minor child. All members receiving Supported Living services who live in the same household must be on the lease unless the person is a live-in caregiver.
• • Reimbursement for Supported Living must not include payment for services provided by the spouse of a person or to family members as defined in this service definition or legal guardian. The Supported Living provider and provider staff shall not be a member of the member’s immediate family as defined in this service definition and reimbursement must not include payment for Supported Living provided by such persons.
• • A Supported Living home must have no more than three residents including any live-in caregiver providing support.
• • Reimbursement for Supported Living shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver.
• • Reimbursement cannot include the cost of maintenance of the dwelling.
• • Transportation is an inclusive component of Supported Living to achieve goals and objectives related to these activities with the exception of transportation to and from medical services covered through the Medicaid State Plan.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Age Group Details

Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents

Level of Care

Supported Living levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A & B Level 2: SIS Level C & D Level 3: SIS Level E, F, & G

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Living provides a flexible partnership that enables a NC Innovations member to live in their own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the member. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the member, budget management, attending appointments, and interpersonal and social skills building to enable the member to live in a home in the community. Training activities, supervision, and assistance may be provided to allow the member to participate in home life or community activities. Other activities include assistance with monitoring health status and physical condition, and assistance with transferring, ambulation and use of special mobility devices.

The purpose of Supported Living Transition is to provide members with the support that they need to facilitate their transition to Supported Living.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) risk assessment, e) back-up, relief staff, and in the case of emergency or crisis details, f) specific plan for addressing health and safety needs for unsupervised times, g) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. The Supported Living Periodic service is available for a member who uses four or less hours of Supported Living per day.
• 2. A member’s own home is defined as the place the person lives and in which the person has all of the ownership or tenancy rights afforded under the law. This home must have a separate address from any other residence located on the same property.
• 3. A member receiving Supported Living has the right to manage personal funds as specified in the ISP.
• 4. A formal roommate agreement, separate from the landlord lease agreement, is established and signed by individuals whose name is on the lease.

Exclusions

• • The amount of Supported Living is subject to the Limits on Sets of Services.
• • Supported Living Transition is only available during the six-month period in advance of the member’s move to a Supported Living setting.
• • Supported Living is not provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIFD) or residential group homes.
• • Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents.
• • A member who receives Supported Living may not receive: Community Living and Supports or State Plan Personal Care Services. Respite may only be provided for participation in non- integrated camps or for participation in non-integrated Support Groups.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the person.
• • A member receiving Supported Living may only receive Home Modifications if the home is owned by the member or the member’s family. If the home is rented, only Home Modifications that are portable and can be removed once the member no longer leases the residence may be used.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
• • Relatives who own provider agencies may not provide Supportive Living services to family members. Other staff employed by the provider agency may provide services to the individual.
• • The provider of Supported Living services shall not: a) Own the person/s’ home or have any authority to require the member to move if the member changes service providers; b) Own, be owned by, or be affiliated with any entity that leases or rents a place of residence to a member if such entity requires, as a condition of renting or leasing, the member to move if the Supported Living provider changes.
• • Supported Living must not be provided in a home where a member lives with family members unless such family members are a member receiving Supported Living, a spouse, or a minor child. All members receiving Supported Living services who live in the same household must be on the lease unless the person is a live-in caregiver.
• • Reimbursement for Supported Living must not include payment for services provided by the spouse of a person or to family members as defined in this service definition or legal guardian. The Supported Living provider and provider staff shall not be a member of the member’s immediate family as defined in this service definition and reimbursement must not include payment for Supported Living provided by such persons.
• • A Supported Living home must have no more than three residents including any live-in caregiver providing support.
• • Reimbursement for Supported Living shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver.
• • Reimbursement cannot include the cost of maintenance of the dwelling.
• • Transportation is an inclusive component of Supported Living to achieve goals and objectives related to these activities with the exception of transportation to and from medical services covered through the Medicaid State Plan.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Age Group Details

Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents

Level of Care

Supported Living levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A & B Level 2: SIS Level C & D Level 3: SIS Level E, F, & G

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Living provides a flexible partnership that enables a NC Innovations member to live in their own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the member. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the member, budget management, attending appointments, and interpersonal and social skills building to enable the member to live in a home in the community. Training activities, supervision, and assistance may be provided to allow the member to participate in home life or community activities. Other activities include assistance with monitoring health status and physical condition, and assistance with transferring, ambulation and use of special mobility devices.

The purpose of Supported Living Transition is to provide members with the support that they need to facilitate their transition to Supported Living.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) risk assessment, e) back-up, relief staff, and in the case of emergency or crisis details, f) specific plan for addressing health and safety needs for unsupervised times, g) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. The Supported Living Periodic service is available for a member who uses four or less hours of Supported Living per day.
• 2. A member’s own home is defined as the place the person lives and in which the person has all of the ownership or tenancy rights afforded under the law. This home must have a separate address from any other residence located on the same property.
• 3. A member receiving Supported Living has the right to manage personal funds as specified in the ISP.
• 4. A formal roommate agreement, separate from the landlord lease agreement, is established and signed by individuals whose name is on the lease.

Exclusions

• • The amount of Supported Living is subject to the Limits on Sets of Services.
• • Supported Living Transition is only available during the six-month period in advance of the member’s move to a Supported Living setting.
• • Supported Living is not provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIFD) or residential group homes.
• • Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents.
• • A member who receives Supported Living may not receive: Community Living and Supports or State Plan Personal Care Services. Respite may only be provided for participation in non- integrated camps or for participation in non-integrated Support Groups.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the person.
• • A member receiving Supported Living may only receive Home Modifications if the home is owned by the member or the member’s family. If the home is rented, only Home Modifications that are portable and can be removed once the member no longer leases the residence may be used.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
• • Relatives who own provider agencies may not provide Supportive Living services to family members. Other staff employed by the provider agency may provide services to the individual.
• • The provider of Supported Living services shall not: a) Own the person/s’ home or have any authority to require the member to move if the member changes service providers; b) Own, be owned by, or be affiliated with any entity that leases or rents a place of residence to a member if such entity requires, as a condition of renting or leasing, the member to move if the Supported Living provider changes.
• • Supported Living must not be provided in a home where a member lives with family members unless such family members are a member receiving Supported Living, a spouse, or a minor child. All members receiving Supported Living services who live in the same household must be on the lease unless the person is a live-in caregiver.
• • Reimbursement for Supported Living must not include payment for services provided by the spouse of a person or to family members as defined in this service definition or legal guardian. The Supported Living provider and provider staff shall not be a member of the member’s immediate family as defined in this service definition and reimbursement must not include payment for Supported Living provided by such persons.
• • A Supported Living home must have no more than three residents including any live-in caregiver providing support.
• • Reimbursement for Supported Living shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver.
• • Reimbursement cannot include the cost of maintenance of the dwelling.
• • Transportation is an inclusive component of Supported Living to achieve goals and objectives related to these activities with the exception of transportation to and from medical services covered through the Medicaid State Plan.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Age Group Details

Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents

Level of Care

Supported Living levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A & B Level 2: SIS Level C & D Level 3: SIS Level E, F, & G

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Living provides a flexible partnership that enables a NC Innovations member to live in their own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the member. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the member, budget management, attending appointments, and interpersonal and social skills building to enable the member to live in a home in the community. Training activities, supervision, and assistance may be provided to allow the member to participate in home life or community activities. Other activities include assistance with monitoring health status and physical condition, and assistance with transferring, ambulation and use of special mobility devices.

The purpose of Supported Living Transition is to provide members with the support that they need to facilitate their transition to Supported Living.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) risk assessment, e) back-up, relief staff, and in the case of emergency or crisis details, f) specific plan for addressing health and safety needs for unsupervised times, g) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. The Supported Living Periodic service is available for a member who uses four or less hours of Supported Living per day.
• 2. A member’s own home is defined as the place the person lives and in which the person has all of the ownership or tenancy rights afforded under the law. This home must have a separate address from any other residence located on the same property.
• 3. A member receiving Supported Living has the right to manage personal funds as specified in the ISP.
• 4. A formal roommate agreement, separate from the landlord lease agreement, is established and signed by individuals whose name is on the lease.

Exclusions

• • The amount of Supported Living is subject to the Limits on Sets of Services.
• • Supported Living Transition is only available during the six-month period in advance of the member’s move to a Supported Living setting.
• • Supported Living is not provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIFD) or residential group homes.
• • Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents.
• • A member who receives Supported Living may not receive: Community Living and Supports or State Plan Personal Care Services. Respite may only be provided for participation in non- integrated camps or for participation in non-integrated Support Groups.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the person.
• • A member receiving Supported Living may only receive Home Modifications if the home is owned by the member or the member’s family. If the home is rented, only Home Modifications that are portable and can be removed once the member no longer leases the residence may be used.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
• • Relatives who own provider agencies may not provide Supportive Living services to family members. Other staff employed by the provider agency may provide services to the individual.
• • The provider of Supported Living services shall not: a) Own the person/s’ home or have any authority to require the member to move if the member changes service providers; b) Own, be owned by, or be affiliated with any entity that leases or rents a place of residence to a member if such entity requires, as a condition of renting or leasing, the member to move if the Supported Living provider changes.
• • Supported Living must not be provided in a home where a member lives with family members unless such family members are a member receiving Supported Living, a spouse, or a minor child. All members receiving Supported Living services who live in the same household must be on the lease unless the person is a live-in caregiver.
• • Reimbursement for Supported Living must not include payment for services provided by the spouse of a person or to family members as defined in this service definition or legal guardian. The Supported Living provider and provider staff shall not be a member of the member’s immediate family as defined in this service definition and reimbursement must not include payment for Supported Living provided by such persons.
• • A Supported Living home must have no more than three residents including any live-in caregiver providing support.
• • Reimbursement for Supported Living shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver.
• • Reimbursement cannot include the cost of maintenance of the dwelling.
• • Transportation is an inclusive component of Supported Living to achieve goals and objectives related to these activities with the exception of transportation to and from medical services covered through the Medicaid State Plan.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Age Group Details

Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents

Level of Care

Supported Living levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A & B Level 2: SIS Level C & D Level 3: SIS Level E, F, & G

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Living provides a flexible partnership that enables a NC Innovations member to live in their own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the member. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the member, budget management, attending appointments, and interpersonal and social skills building to enable the member to live in a home in the community. Training activities, supervision, and assistance may be provided to allow the member to participate in home life or community activities. Other activities include assistance with monitoring health status and physical condition, and assistance with transferring, ambulation and use of special mobility devices.

The purpose of Supported Living Transition is to provide members with the support that they need to facilitate their transition to Supported Living.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) risk assessment, e) back-up, relief staff, and in the case of emergency or crisis details, f) specific plan for addressing health and safety needs for unsupervised times, g) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. The Supported Living Periodic service is available for a member who uses four or less hours of Supported Living per day.
• 2. A member’s own home is defined as the place the person lives and in which the person has all of the ownership or tenancy rights afforded under the law. This home must have a separate address from any other residence located on the same property.
• 3. A member receiving Supported Living has the right to manage personal funds as specified in the ISP.
• 4. A formal roommate agreement, separate from the landlord lease agreement, is established and signed by individuals whose name is on the lease.

Exclusions

• • The amount of Supported Living is subject to the Limits on Sets of Services.
• • Supported Living Transition is only available during the six-month period in advance of the member’s move to a Supported Living setting.
• • Supported Living is not provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIFD) or residential group homes.
• • Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents.
• • A member who receives Supported Living may not receive: Community Living and Supports or State Plan Personal Care Services. Respite may only be provided for participation in non- integrated camps or for participation in non-integrated Support Groups.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the person.
• • A member receiving Supported Living may only receive Home Modifications if the home is owned by the member or the member’s family. If the home is rented, only Home Modifications that are portable and can be removed once the member no longer leases the residence may be used.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
• • Relatives who own provider agencies may not provide Supportive Living services to family members. Other staff employed by the provider agency may provide services to the individual.
• • The provider of Supported Living services shall not: a) Own the person/s’ home or have any authority to require the member to move if the member changes service providers; b) Own, be owned by, or be affiliated with any entity that leases or rents a place of residence to a member if such entity requires, as a condition of renting or leasing, the member to move if the Supported Living provider changes.
• • Supported Living must not be provided in a home where a member lives with family members unless such family members are a member receiving Supported Living, a spouse, or a minor child. All members receiving Supported Living services who live in the same household must be on the lease unless the person is a live-in caregiver.
• • Reimbursement for Supported Living must not include payment for services provided by the spouse of a person or to family members as defined in this service definition or legal guardian. The Supported Living provider and provider staff shall not be a member of the member’s immediate family as defined in this service definition and reimbursement must not include payment for Supported Living provided by such persons.
• • A Supported Living home must have no more than three residents including any live-in caregiver providing support.
• • Reimbursement for Supported Living shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver.
• • Reimbursement cannot include the cost of maintenance of the dwelling.
• • Transportation is an inclusive component of Supported Living to achieve goals and objectives related to these activities with the exception of transportation to and from medical services covered through the Medicaid State Plan.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Age Group Details

Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents

Level of Care

Supported Living levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A & B Level 2: SIS Level C & D Level 3: SIS Level E, F, & G

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Living provides a flexible partnership that enables a NC Innovations member to live in their own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the member. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the member, budget management, attending appointments, and interpersonal and social skills building to enable the member to live in a home in the community. Training activities, supervision, and assistance may be provided to allow the member to participate in home life or community activities. Other activities include assistance with monitoring health status and physical condition, and assistance with transferring, ambulation and use of special mobility devices.

The purpose of Supported Living Transition is to provide members with the support that they need to facilitate their transition to Supported Living.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) risk assessment, e) back-up, relief staff, and in the case of emergency or crisis details, f) specific plan for addressing health and safety needs for unsupervised times, g) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. The Supported Living Periodic service is available for a member who uses four or less hours of Supported Living per day.
• 2. A member’s own home is defined as the place the person lives and in which the person has all of the ownership or tenancy rights afforded under the law. This home must have a separate address from any other residence located on the same property.
• 3. A member receiving Supported Living has the right to manage personal funds as specified in the ISP.
• 4. A formal roommate agreement, separate from the landlord lease agreement, is established and signed by individuals whose name is on the lease.

Exclusions

• • The amount of Supported Living is subject to the Limits on Sets of Services.
• • Supported Living Transition is only available during the six-month period in advance of the member’s move to a Supported Living setting.
• • Supported Living is not provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIFD) or residential group homes.
• • Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents.
• • A member who receives Supported Living may not receive: Community Living and Supports or State Plan Personal Care Services. Respite may only be provided for participation in non- integrated camps or for participation in non-integrated Support Groups.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the person.
• • A member receiving Supported Living may only receive Home Modifications if the home is owned by the member or the member’s family. If the home is rented, only Home Modifications that are portable and can be removed once the member no longer leases the residence may be used.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
• • Relatives who own provider agencies may not provide Supportive Living services to family members. Other staff employed by the provider agency may provide services to the individual.
• • The provider of Supported Living services shall not: a) Own the person/s’ home or have any authority to require the member to move if the member changes service providers; b) Own, be owned by, or be affiliated with any entity that leases or rents a place of residence to a member if such entity requires, as a condition of renting or leasing, the member to move if the Supported Living provider changes.
• • Supported Living must not be provided in a home where a member lives with family members unless such family members are a member receiving Supported Living, a spouse, or a minor child. All members receiving Supported Living services who live in the same household must be on the lease unless the person is a live-in caregiver.
• • Reimbursement for Supported Living must not include payment for services provided by the spouse of a person or to family members as defined in this service definition or legal guardian. The Supported Living provider and provider staff shall not be a member of the member’s immediate family as defined in this service definition and reimbursement must not include payment for Supported Living provided by such persons.
• • A Supported Living home must have no more than three residents including any live-in caregiver providing support.
• • Reimbursement for Supported Living shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver.
• • Reimbursement cannot include the cost of maintenance of the dwelling.
• • Transportation is an inclusive component of Supported Living to achieve goals and objectives related to these activities with the exception of transportation to and from medical services covered through the Medicaid State Plan.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Age Group Details

Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents

Level of Care

Supported Living levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A & B Level 2: SIS Level C & D Level 3: SIS Level E, F, & G

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Supported Living provides a flexible partnership that enables a NC Innovations member to live in their own home with support from an agency that provides individualized assistance in a home that is under the control and responsibility of the member. The service includes direct assistance as needed with activities of daily living, household chores essential to the health and safety of the member, budget management, attending appointments, and interpersonal and social skills building to enable the member to live in a home in the community. Training activities, supervision, and assistance may be provided to allow the member to participate in home life or community activities. Other activities include assistance with monitoring health status and physical condition, and assistance with transferring, ambulation and use of special mobility devices.

The purpose of Supported Living Transition is to provide members with the support that they need to facilitate their transition to Supported Living.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) risk assessment, e) back-up, relief staff, and in the case of emergency or crisis details, f) specific plan for addressing health and safety needs for unsupervised times, g) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. The Supported Living Periodic service is available for a member who uses four or less hours of Supported Living per day.
• 2. A member’s own home is defined as the place the person lives and in which the person has all of the ownership or tenancy rights afforded under the law. This home must have a separate address from any other residence located on the same property.
• 3. A member receiving Supported Living has the right to manage personal funds as specified in the ISP.
• 4. A formal roommate agreement, separate from the landlord lease agreement, is established and signed by individuals whose name is on the lease.

Exclusions

• • The amount of Supported Living is subject to the Limits on Sets of Services.
• • Supported Living Transition is only available during the six-month period in advance of the member’s move to a Supported Living setting.
• • Supported Living is not provided in inpatient hospitals, nursing facilities, and Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IIFD) or residential group homes.
• • Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents.
• • A member who receives Supported Living may not receive: Community Living and Supports or State Plan Personal Care Services. Respite may only be provided for participation in non- integrated camps or for participation in non-integrated Support Groups.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the person.
• • A member receiving Supported Living may only receive Home Modifications if the home is owned by the member or the member’s family. If the home is rented, only Home Modifications that are portable and can be removed once the member no longer leases the residence may be used.
• • This service is not available at the same time of day as Community Networking, Day Supports, Supported Employment or one of the State Plan Medicaid services that works directly with the member.
• • Relatives who own provider agencies may not provide Supportive Living services to family members. Other staff employed by the provider agency may provide services to the individual.
• • The provider of Supported Living services shall not: a) Own the person/s’ home or have any authority to require the member to move if the member changes service providers; b) Own, be owned by, or be affiliated with any entity that leases or rents a place of residence to a member if such entity requires, as a condition of renting or leasing, the member to move if the Supported Living provider changes.
• • Supported Living must not be provided in a home where a member lives with family members unless such family members are a member receiving Supported Living, a spouse, or a minor child. All members receiving Supported Living services who live in the same household must be on the lease unless the person is a live-in caregiver.
• • Reimbursement for Supported Living must not include payment for services provided by the spouse of a person or to family members as defined in this service definition or legal guardian. The Supported Living provider and provider staff shall not be a member of the member’s immediate family as defined in this service definition and reimbursement must not include payment for Supported Living provided by such persons.
• • A Supported Living home must have no more than three residents including any live-in caregiver providing support.
• • Reimbursement for Supported Living shall not be made for room and board with the exception of a reasonable portion that is attributed to a live-in caregiver.
• • Reimbursement cannot include the cost of maintenance of the dwelling.
• • Transportation is an inclusive component of Supported Living to achieve goals and objectives related to these activities with the exception of transportation to and from medical services covered through the Medicaid State Plan.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Age Group Details

Supported Living is not covered for persons under age 18 since the home must be under the control and responsibility of the residents

Level of Care

Supported Living levels are determined by the IBT and other evidence of support need. The SIS Level is only one piece of evidence that may be considered.

Level 1: SIS Level A & B Level 2: SIS Level C & D Level 3: SIS Level E, F, & G

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

Crisis Supports provide intervention and stabilization for a member experiencing a crisis. Crisis Supports are for a member who experiences acute crises and who presents a threat to the member’s health and safety or the health and safety of others. These behaviors may result in the member losing his or her home, job, or access to activities and community involvement. Crisis Supports promote prevention of crises as well as assistance in stabilizing the member when a behavioral crisis occurs. Crisis Supports are an immediate intervention available 24 hours per day, 7 days per week, to support the individual.

Out-of-home crisis is a short-term service for an individual experiencing a crisis and requiring a period of structured support and/or programming. The service takes place in a licensed facility. Out of-home crisis may be used when an individual cannot be safely supported in the home, due to his/her behavior, and implementation of formal behavior interventions have failed to stabilize the behaviors, and all other approaches to ensure health and safety have failed. In addition, the service may be used as a planned respite stay for waiver members who have heightened behavioral needs.

Crisis consultation is for individuals that have significant, intensive, or challenging behaviors or medical conditions that have resulted or have the potential to result in a crisis. Consultation is provided by staff that meets the minimum staffing requirements of a Qualified Professional and who have crisis experience.

Authorization Guidelines

• 1. TAR: Prior approval is required for each plan year.
• 2. SIS
• 3. Individual Budget
• 4. Care Management Comprehensive Assessment
• 5. ISP: to include a) the service/ support, b) projected frequency, c) provider, d) required signatures. See CCP 8P, section 5.3, for all general ISP requirements.
• 6. Submission of applicable records that support the member has met the medical necessity criteria.

Limits

• 1. Following service auth, any needed modifications to the ISP and individual budget will occur within five working days of the date of verbal service authorization.
• 2. Out-of-Home Crisis services are authorized in increments of up to 30 calendar days.
• 3. Crisis Intervention & Stabilization Supports may be authorized for periods of up to 14 calendar day increments per event.

Exclusions

• • This service may not duplicate services provided under Specialized Consultation Services.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

Additional Service Specifics

Requesting the core service automatically includes the use of the telehealth (GT) code when approved. A separate request is not needed, and the GT service code should not be requested separate from the non-telehealth service code.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• Clinical Coverage Policy No 8P: North Carolina Innovations
• Records Management and Documentation Manual
• Innovations Waiver

The purpose of Community Transition is to provide initial set-up expenses for adults to facilitate their transition from a Developmental Center (institution), community ICF-IID Group Home, nursing facility or another licensed living arrangement (group home, foster home, Psychiatric Residential Treatment Facility, alternative family living arrangement), a family home or one person AFL(Alternative Family Living) to a living arrangement where the individual is directly responsible for his or her own living expenses. This service may be provided only in a private home or apartment with a lease in the member’s, legal guardian’s, representative’s name or a home owned by the member.

Authorization Guidelines

Maintained in the Record (not all inclusive):

• 1. Service Note(s): Required
• 2. ASAM: If applicable, the ASAM Score must be supported with detailed clinical documentation on each of the six ASAM dimensions.
• 3. Person Centered Plan (PCP) Revision Recommendations: Required for those already receiving services, Mobile Crisis Management (MCM) must recommend revisions to existing crisis plan components in PCPs.
• 4. Submission of applicable records that support the member has met the medical necessity criteria.

Unit Value

One unit per episode

Limits

The cost of Community Transition has a life of the waiver limit of $5,000.00 per beneficiary. Community Transition includes the actual cost of services and does not cover provider overhead charges.

Length of Stay

These services are available only during the three-month period that commences one calendar month in advance of the member’s move to an integrated living arrangement.

Exclusions

• • Community Transition does not cover monthly rental or mortgage expense; regular utility charges; and/or household appliances or diversional/recreational items such as televisions, streaming devices, VCR players and components and DVD players and components. Service and maintenance contracts and extended warranties are not covered.
• • Community Transition services can be accessed only one time from either the 1915b or 1915c waiver over the life of the waiver.
• • In situations when a member lives with a roommate, Community Transition cannot duplicate items that are currently available.
• • Community Transition expenses are furnished only to the extent that the member is unable to meet such expense or when the support cannot be obtained from other sources.
• • Exclusions, limitations & exceptions detailed in the Eligibility Requirements, Terms of Service, Limits on Sets of Services, General Limitations on Coverage, Relative as Provider, Individual and Family Directed Services, and Claims sections of this Benefit Plan apply.
• • See the CCP for all applicable exclusions, limitations & exceptions.

How to Submit

Please submit your request to Trillium Health Resources (iTransact for TP Medicaid members and Provider Direct for MCD Direct members)

• https://provider.trilliumitransact.com/HSP/iTransact/logon/logon.aspx
• Trillium Provider Direct Portal

Resources

• 8P, North Carolina Innovations
• Records Management and Documentation Manual