1933 SUPPORTED EMPLOYMENT SERVICES - INDIVIDUAL AND SMALL GROUP SERVICES

1933.1 This section shall establish standards governing Medicaid eligibility for supported employment services for persons enrolled in the Home and Community-Based Services Waiver for Individuals with Intellectual and Developmental Disabilities (Waiver) and shall establish conditions of participation for providers of supported employment services.

1933.2 Medicaid reimbursable supported employment services are designed to provide opportunities for persons with disabilities to obtain competitive work in integrated work settings, at minimum wage or higher and at a rate comparable to workers without disabilities performing the same tasks. All Medicaid reimbursable supported employment services must fully comply with the requirements of the HCBS Settings Rule.

1933.3 Medicaid reimbursable supported employment services may be delivered individually or in a small group, based upon the recommendations of the person and his or her support team, as reflected in the person's Individual Support Plan (ISP) and Plan of Care. For persons enrolled in small group supported employment services, the provider must make every effort to match the person with another person or persons of his or her choosing, or with a person who has similar skills or interests.

1933.4 Medicaid reimbursable small group supported employment services are services and training activities that are provided in regular business, industry, or community setting for groups of two (2) to four (4) workers.

1933.5 Small group supported employment services is intended to enable the person to become part of a competitive, integrated work setting.

1933.6 In order to receive Medicaid reimbursement for supported employment services, the person receiving services shall:

1. (a) Be interested in obtaining full-time or part-time employment in an integrated work setting; and
2. (b) Demonstrate that a previous application for the District of Columbia Rehabilitation Services Administration (RSA) funded supported employment services was made, by the submission of a letter documenting either ineligibility for RSA services or the completion of RSA services with the recommendation for long-term employment support.

1933.7 Medicaid reimbursable supported employment services shall:

1. (a) Provide opportunities for persons with disabilities to achieve successful integrated employment consistent with the person's goals;
2. (b) Be recommended by the person's Support Team; and
3. (c) Be identified in the person's Individual Support Plan (ISP), Plan of Care, and Summary of Supports.1933.8 The three (3) models of supported employment services eligible for Medicaid reimbursement are as follows:- (a) An Individual Job Support Model, which evaluates the needs of the person and places the person into an integrated competitive or customized work environment through a job discovery process;
4. (b) A Small Group Supported Employment Model, which utilizes training activities for groups of two (2) to four (4) workers with disabilities to place persons in an integrated community based work setting; and
5. (c) An Entrepreneurial Model, which utilizes training techniques to develop on-going support for a small business that is owned and operated by the person.1933.9 Medicaid reimbursable supported employment services for the entrepreneurial model shall include the following activities:- (a) Assisting the person to identify potential business opportunities;
6. (b) Assisting the person in the development of a business and launching a business;
7. (c) Identification of the supports that are necessary in order for the person to operate the business; and
8. (d) Ongoing assistance, counseling and guidance once the business has been launched.1933.10 Medicaid reimbursable supported employment individual services shall consist of the following activities:- (a) Intake and assessment;

9. (b) Job placement and development;

10. (c) Job training and support; and

11. (d) Long-term follow-along services.1933.11 Medicaid reimbursable supported employment small group services shall consist of the following activities:- (a) Job placement and development;
12. (b) Job training and support; and
13. (c) Long-term follow-along services.1933.12 Intake and assessment services determine the interests, strengths, preferences, and skills of the person in order to ultimately obtain competitive employment and to further identify the necessary conditions for the person's successful participation in employment. The purpose of the intake and assessment is to facilitate and ensure a person's success in integrated competitive employment.1933.13 Medicaid reimbursable intake and assessment activities include, but are not limited to, the following:- (a) Conducting a person-centered vocational and situational assessment based upon what is important to and for the person as reflected in his or her Person-Centered Thinking and Discovery tools and related ISP goals;
14. (b) Developing a person-centered employment plan that includes the person's job preferences and desires, through a discovery process and the development of a Positive Personal Profile and Job Search and Community Participation Plan;
15. (c) Assessing person-centered employment information, including the person's interest in doing different jobs, transportation to and from work, family support, and financial issues;
16. (d) Engaging in community mapping to identify available community supports and assisting the person to establish a network for job development, placement and mentoring;
17. (e) Counseling an interested person on the tasks necessary to start a business, including referral to resources and nonprofit associations that provide information specific to owning and operating a business;
18. (f) Providing employment counseling, which includes, but is not limited to, the

person’s rights as an employee with a disability; and

(g) Providing or coordinating access to benefits counseling, defined as analysis and advice to help the person understand the potential impact of employment on his or her public benefits, including, but not limited to Supplemental Security Income, Medicaid, Social Security Disability Insurance, Medicare, and Supplemental Nutrition Assistance Program (SNAP).

1933.14 After intake and completion of the assessments, each provider of Medicaid reimbursable supported employment services shall complete and deliver a comprehensive vocational assessment report prior to the end of the intake and assessment service authorization period, to the Department on Disability Services (DDS) Service Coordinator that includes the following information:

1. (a) Employment-related strengths and weaknesses of the person;
2. (b) Availability of family and community supports for the person;
3. (c) The assessor's concerns about the health, safety, and wellbeing of the person;
4. (d) Accommodations and supports that may be required for the person on the job; and
5. (e) If a specific job or entrepreneurial effort has been targeted:
6. (1) Individualized training needed by the person to acquire and maintain skills that are commensurate with the skills of other employees;
7. (2) Anticipated level of interventions that will be required for the person by the job coach;
8. (3) Type of integrated work environment in which the person can potentially succeed; and
9. (4) Activities and supports that are needed to improve the person's potential for employment, including whether the person has natural supports that may help him or her to be successful in the specific job or entrepreneurial effort.

1933.15 Medicaid reimbursable job placement and development includes activities to facilitate the person’s ability to work in a setting that is consistent with their strengths, abilities, priorities, and interests, as well as the identification of

potential employment options, as determined through the supported employment intake and assessment process.

1933.16 Job placement and development activities eligible for Medicaid reimbursement include, but are not limited to, the following:

1. (a) Conducting workshops or other activities designed to assist the person in completing employment applications or preparing for interviews;
2. (b) Conducting workshops or other activities to instruct the person on appropriate work attire, work ethic, attitude, and expectations;
3. (c) Assisting the person with the completion of job applications;
4. (d) Assisting the person with job exploration and placement, including assessing opportunities for the person's advancement and growth, with a consideration for customized employment, as needed;
5. (e) Visiting employment sites, participating in informational interviews, attending employment networking events, and job shadowing;
6. (f) Making telephone calls and conducting face-to-face informational interviews with prospective employers, individuals in the person's network, utilizing the internet, social media, magazines, newspapers, and other publications as prospective employment leads;
7. (g) Collecting descriptive data regarding various types of employment opportunities, for purposes of job matching and customized employment;
8. (h) Negotiating employment terms with or on behalf of the person;
9. (i) Working with the person to develop and implement a plan to start a business, including developing a business plan, developing investors or start-up capital, and other tasks necessary to starting a small business;
10. (j) Providing or coordinating access to benefits counseling; and
11. (k) Working with the person and employer to develop group placements.

1933.17 Job training and support activities are those activities designed to assist and support the person after he or she has obtained employment. The expectation is that the person’s reliance upon job training and support activities will decline as a result of job skills training and support from supervisors and co-workers in the existing work setting to maintain employment.

1933.18 Medicaid reimbursable job training and support activities include, but are not limited to, the following:

1. (a) On-the-job training in work and work-related skills required to perform the job;
2. (b) Work site support that is intervention-oriented and designed to enhance work performance and support the development of appropriate workplace etiquette
3. (c) Supervision and monitoring of the person in the workplace;
4. (d) Training in related skills essential to obtaining and maintaining employment, such as the effective use of community resources, break or lunch rooms, attendance and punctuality, mobility training, re-training as job responsibilities change, and attaining new jobs; including, where appropriate, the use of assistive technology, i.e. calendar alerts, timers, alarm clocks and other devices that assist a person with meeting employment requirements;
5. (e) Monitoring and providing information and assistance regarding wage and hour requirements, appropriateness of job placement, integration into the work environment, and need for functional adaptation modifications at the job site;
6. (f) Providing or coordinating access to ongoing benefits counseling, including but not limited to prior to the person reaching the end of his or her Trial Work period and/or attaining Substantive Gainful Activity (SGA);
7. (g) Consulting with other professionals and the person's family, as necessary;
8. (h) Providing support and training to the person's employer, co-workers, or supervisors so that they can provide workplace support, as necessary; and
9. (i) Working with the person and his or her support network to identify a plan to develop his or her skills that facilitate workplace independence and confidence so that the person is less reliant upon job training and support activities.

1933.19 Medicaid reimbursable long-term follow-along activities are stabilization services needed to support and maintain a person in an integrated competitive employment site or in their own business.

1933.20 Medicaid reimbursable long-term follow-along activities include, but are not limited to, the following:- (a) Periodic monitoring of job stability with a minimum of two (2) visits per month;

- (b) Intervening to address issues that threaten job stability;

- (c) Providing re-training, cross-training, and additional supports as needed, when job duties change;

- (d) Facilitating integration and natural supports at the job site;

- (e) Providing or coordinating access to benefits counseling prior to and after the person reaching the end of his or her Trial Work period and/or attaining SGA, and to ensure a person maintains eligibility for benefits and that earnings are being properly reported;

- (f) Working with the person and his or her support network to identify a plan to develop his or her skills that facilitate workplace independence and confidence so that the person is less reliant upon job training and support activities; and

- (g) Facilitating job advancement, professional growth, and job mobility.1933.21 Each provider of Medicaid reimbursable supported employment services shall be responsible for delivering ongoing supports to the person to promote job stability after they become employed.- (a) Once the person exhibits confidence to perform the job without a job coach present, the provider shall make a minimum of two (2) visits to the job site per month for the purpose of monitoring job stability.

- (b) On the job coaching supported employment services may be provided in person, or by phone or by any other technology device that supports the use of Skype, FaceTime, etc., where approved by the person and his or her support team and documented in the ISP. Supported employment services by phone or other technology to communicate cannot exceed twenty (20) percent of the total hours of supported employment services that the person receives each week.1933.22 When applicable, each provider of Medicaid reimbursable supported employment services shall coordinate with DDS and the employer to provide functional adaptive modifications for each person to accomplish basic work related tasks at

the work site.

1933.23 When applicable, each provider of Medicaid reimbursable supported employment services shall coordinate with the employer to ensure that each person has an emergency back-up plan for job training and support.

1933.24 Each provider of Medicaid reimbursable supported employment services shall be a Waiver provider agency and shall comply with the following requirements:

(a) Participate in the person's support team meetings, at the person's preference;

(b) Be certified by the U.S. Department of Labor, if applicable;

(c) Comply with the requirements described under Section 1904 (Provider Qualifications) and Section 1905 (Provider Enrollment Process) of Chapter 19 of Title 29 DCMR; and

(d) Enroll as a supported employment provider for the District of Columbia Rehabilitation Services Administration by September 23, 2016, for current providers, or, for new Medicaid waiver supported employment provider agencies, within one year after enrollment as a waiver provider.

1933.25 Each professional or paraprofessional providing Medicaid reimbursable supported employment services for a Waiver provider shall meet the requirements in Section 1906 (Requirements for Direct Support Professionals) of Chapter 19 of Title 29 DCMR.

1933.26 Professionals authorized to provide Medicaid reimbursable supported employment activities without supervision shall include the following:

(a) A Vocational Rehabilitation Counselor;

(b) An individual with a Master's degree and a minimum of one (1) year of experience working with persons with intellectual and developmental disabilities in supported employment;

(c) An individual with a bachelor's degree and two years of experience working with persons with intellectual and developmental disabilities in supported employment; or

(d) A Rehabilitation Specialist.

1933.27 Paraprofessionals shall be authorized to perform Medicaid reimbursable supported employment activities under the supervision of a professional. Supervision is not intended

to mean that the paraprofessional performs supported employment activities in the presence of the professional, but rather that the paraprofessional has a supervisor who meets the qualifications of a professional as set forth in § 1933.26.

1933.28 Paraprofessionals authorized to perform Medicaid reimbursable supported employment activities are as follows:

(a) A Job Coach; or

(b) An Employment Specialist.

1933.29 Services shall be authorized for Medicaid reimbursement in accordance with the following Waiver provider requirements:

(a) DDS provides a written service authorization before the commencement of services;

(b) The provider conducts a comprehensive vocational assessment, at minimum consisting of a Positive Personal Profile and Job Search and Community Participation Plan, if the person does not already have a comprehensive assessment. If the person does have a comprehensive vocational assessment, this must be reviewed to ensure that it is current and reflects what is important to and for the person, and updated as needed;

(c) The provider develops an individualized employment plan with training goals and techniques within the first two (2) hours of service delivery;

(d) The service name and provider delivering services are identified in the ISP and Plan of Care;

(e) The ISP, Plan of Care, and Summary of Supports and Services document the amount and frequency of services to be received;

(f) The provider completes an employment progress plan, using the template required by DDS, and submits it as an attachment to the required quarterly report; and

(g) Services shall not conflict with the service limitations described under Subsections 1933.31-1933.42.

1933.30 If extended services are required, the provider shall submit a supported employment extension request. The request is a written justification that must be submitted to the Service Coordinator at least fifteen (15) calendar days before the exhaustion of Supported Employment hours. Failure to submit all required documents may result in a delay of the approval of services. Any failure on the part of the provider to submit

required documents to approve service authorizations will result in sanctions by DDS up to and including a ban on authorizations for new service recipients. Service interruptions to the waiver participant due to the service provider's failure to submit required documentation will initiate referrals to a choice of a new service provider to ensure a continuation of services for the waiver participant.

1933.31 Supported employment services are not available to people who are eligible to participate and are fully supported in programs funded under Title I of the Rehabilitation Act of 1973, Section 110, enacted September 26, 1973 (Pub. L. 93-112; 29 USC §§ 720 et seq.), or Section 602(16) and (17) of the Individuals with Disabilities Education Act, 20 USC §§ 1401(16) and (71), enacted October 30, 1990 (Pub. L. 91-230; 20 USC §§ 1400 et seq.). However, supported employment services may be used to provide additional supports for employment for persons eligible for and participating in those programs.

1933.32 Court-ordered vocational assessments authorizing intake and assessment services qualify for Medicaid reimbursement under the Waiver if services provided through programs funded under the Acts referenced in Subsection 1933.31 cannot be provided in the timeframe set forth in the Court's Order.

1933.33 Medicaid reimbursement is available for supported employment services that are provided either exclusively as a vocational service or in combination with individualized day supports, employment readiness, or day habilitation services if provided during different periods of time, including during the same day.

1933.34 Medicaid reimbursement is not available if supported employment services are provided in specialized sheltered workshop or other similar type facilities that are not part of the general workforce. Medicaid reimbursement is not available for volunteer work.

1933.35 Medicaid reimbursable supported employment services shall not include payment for supervision, training, support, adaptations, or equipment typically available to other workers without disabilities in similar positions.

1933.36 Medicaid reimbursable supported employment services shall be provided for a maximum of eight (8) hours per day, five (5) days per week.

1933.37 Medicaid reimbursement is not available for incentive payments, subsidies, or unrelated vocational training expenses such as the following:

(a) Incentive payments made to an employer to encourage or subsidize the employer's participation in a supported employment services program;

(b) Payments that are processed and paid to users of supported employment service programs; and

(c) Payment for vocational training that is not directly related to the person's success in the supported employment services program.

1933.38 Supported employment providers may not pay a stipend to a person for attendance or participation in activities at the day habilitation program.

1933.39 A supported employment provider may not concurrently employ a person and be his or her provider of Medicaid supported employment services.

1933.40 Medicaid reimbursement is not available for time spent in transportation to and from the employment program and shall not be included in the total amount of services provided per day. Time spent in transportation to and from the program for the purpose of training the person on the use of transportation services is Medicaid reimbursable and may be included in the number of hours of services provided per day for a period of time specified in the person's ISP and Plan of Care.

1933.41 Medicaid reimbursement shall only be available for adaptations, supervision and training for supported employment services provided at the work site in which persons without disabilities are employed. Medicaid reimbursement shall not be available for supervisory activities, which are rendered as a normal part of the business setting.

1933.42 Medicaid reimbursable intake and assessment activities shall be billed at the unit rate. This service shall not exceed three-hundred and twenty (320) units or eighty (80) hours annually. A standard unit of service is fifteen (15) minutes and the provider shall provide at least eight (8) continuous minutes of service to bill one (1) unit of service. There shall be a Medicaid reimbursement rate for individual supported employment intake and assessment activities (a) if performed by a professional listed in Subsection 1933.26; and (b) if performed by a paraprofessional listed in Section 1933.28 under the supervision of a professional.

1933.43 Medicaid reimbursable job preparation, developmental and placement activities shall be billed at the unit rate. This service shall not exceed nine hundred and sixty (960) units or two-hundred and forty (240) hours annually for both individual and group services, combined. A standard unit of service is fifteen (15) minutes and the provider shall provide at least eight (8) continuous minutes of service to bill for one (1) unit of service. There shall be a Medicaid reimbursement rate for individual supported employment job preparation, developmental and placement activities (a) if performed by a professional listed in Section 1933.26; and (b) if performed by a paraprofessional listed in Subsection 1933.28 under the supervision of a professional. For small group supported employment job preparation, developmental and placement activities, there shall

be a Medicaid reimbursement rate for each person in a group of two (2) to four (4) people enrolled in the Waiver.

1933.44 Medicaid reimbursable on the job training and support activities shall not exceed three hundred and sixty hours (360) or one thousand, four hundred and forty (1,440) units per ISP year, unless additional hours are prior authorized by DDS. A standard unit of service is fifteen (15) minutes and the provider shall provide at least eight (8) continuous minutes of service to bill one (1) unit of service. There shall be a Medicaid reimbursement rate for individual supported employment job training and support activities (a) if performed by a professional listed in Subsection 1933.26; and (b) if performed by a paraprofessional listed in Subsection 1933.28 under the supervision of a professional. For small group supported employment on the job training and support activities, there shall be a Medicaid reimbursement rate for each person in a group of two (2) to four (4) people enrolled in the Waiver.

1933.45 Medicaid reimbursable long-term follow-along activities shall not exceed one thousand four hundred eight (1,408) units per ISP year. A standard unit of service is fifteen (15) minutes and the provider shall provide at least eight (8) continuous minutes of service to bill one (1) unit of service. There shall be a Medicaid reimbursement rate for both professionals and paraprofessionals for individual supported employment long-term follow-along activities. For small group supported employment long-term follow-along activities, there shall be a Medicaid reimbursement rate for each person in a group of two (2) to four (4) people enrolled in the Waiver.

1933.46 DDS shall only approve an extension for Job Training and Supports when there is documentation in the employment progress plan that the person continues to demonstrate progress on the job, including but not limited to: learning the job and related tasks, following directions, interaction with others, following supervision, reluctance or reliance on the job coach, etc. However, if recommended by the person and/or his or her support team and reflected in the ISP, DDS would authorize long-term follow-along supported employment services as needed to support the person on an ongoing basis.

1933.47 In order to be eligible for Medicaid reimbursement, each Waiver provider of supported employment services shall comply with Section 1908 (Reporting Requirements); Section 1909 (Records and Confidentiality of Information); and Section 1911 (Individual Rights) of Chapter 19 of Title 29 DCMR.

SOURCE: Final Rulemaking published at 61 DCR 3563 (April 4, 2014); as amended by Final Rulemaking published at 63 DCR 9678 (July 22, 2016); as amended by Final Rulemaking published at 64 DCR 7469 (August 4, 2017); as amended by Final Rulemaking published at 65 DCR 2190 (March 2, 2018).