Community Transition Services 525-05-30-22

(New 7/1/18 ML #3543)

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Purpose

The purpose of Community Transition Services is to assist eligible individuals transitioning from an institution or another provider-operated living arrangement (to include skilled nursing facility, adult residential, adult foster care, basic care, and assisted living) to a living arrangement in a private residence where the client is directly responsible for his/her own living expenses and needs non-recurring set-up expenses.

 

Service Eligibility, Criteria for

The individual receiving Community Transition Services will meet the following criteria:

  1. Must be on Medicaid;
  2. Must be eligible for the Medicaid Waiver for Home and Community Based Services;
  3. Must be at least age 18;
  4. The care needs of the client must fall within the scope of Community Transition Services as described in this service chapter;
  5. The client must be transitioning from an institution or another provider-operated living arrangement to a living arrangement in a private family dwelling where the client is directly responsible for his/her own living expenses; and
  6. Prior approval from a HCBS Program Administrator is required before this service may be authorized.

Service Activities

Community Transition Services include one-time set-up expenses and transition coordination.

  1. Transition coordination assists an individual to procure one-time moving costs and/or arrange for all non-Medicaid services necessary to assist the individual with the actual coordination and implementation of their individualized plan to move back to the community. The non-Medicaid services may include:
  1. assisting with finding housing to include searching, coordinating deposits, and/or utility set-up;
  2. helping participants set up their households by identifying needs, help with shopping, and/or selection of household goods;
  3. arrange the actual move by getting things out of storage, and/or finding movers;
  4. identifying the community in which the participant wants to live;
  5. identifying and coordinating transportation options for the move; and
  6. assisting with community orientation to locate and learn how to access community resources.

Individual Program Plans

Once an individual begins Community Transition Services, an Individual Program Plan (IPP) must be completed by the interdisciplinary team (to at least include the service provider, the individual and/or their legal representative) and the case manager.

 

This IPP must be completed within 30 days of the beginning effective date of the services. The IPP must include how the provider will meet the needs of the client and must also identify the goal or goals of the individual and how the goals will be accomplished.

 

This IPP will be subject to review by the HCBS Case Manager during the initial plan implementation period. At the team meeting, the team will review the goals and progress, and strategies for accomplishing the plan goal or goals.

 

Preliminary Care Plan

Community Transition Services may be authorized up to 180 consecutive days prior to admission to the waiver of an institutionalized person. A preliminary care plan must be completed by the HCBS Case Manager. The Person Centered Plan of Care (SFN 404) and Authorization to Provide Medicaid Waiver Services (SFN 410), must be completed and noted “preliminary care plan” at the top. The HCBS Case Manager is responsible to send the completed documents to the HCBS line.

 

Services Activities, Authorized and Limits

  1. Community Transition Services do not include expenses that constitute room and board; monthly rental or mortgage expense; escrow; specials; insurance; food; regular utility charges; and/or household appliances or items that are intended for purely diversional/recreational purposes.
  2. Community Transition Services may be authorized up to 180 consecutive days prior to admission to the waiver of an institutionalized person and 90 days from the date the client became eligible for the waiver.
  3. Transition coordination is limited to 300 hours or 1200 units per recipient.
  4. One-time set-up expenses are limited to $3000 per recipient.
  5. Community Transition Services will require prior approval from the HCBC Program Administrator to prevent any duplication of services.
  6. When Community Transition Services are furnished to individuals returning to the community from a Medicaid institutional setting through entrance to the waiver, the costs of such services are considered to be incurred and billable when the person leaves the institutional setting and enters the waiver. The individual must be reasonably expected to be eligible for and to enroll in the waiver. If for any unseen reason, the individual does not enroll in the waiver (e.g., due to death or a significant change in condition), Community Transition Services may be billed to Medicaid as an administrative cost.

Authorization of Services

The service activities within the scope of this service chapter must be identified on the Authorization to Provide Service, SFN 410.

  1. One-time set-up expenses
  1. One-time set-up expenses are limited to $3000 per recipient.
  2. On the preliminary care plan and preliminary authorization, case managers will authorize the estimated amount of one-time expenses, not to exceed $3000.
  3. A copy of all receipts from purchases must be retained in client’s file.
  4. QSP will bill based on actual expenses.
  1. Transition coordination
  1. Transition coordination is limited to 300 hours or 1200 units per recipient.
  2. On the preliminary care plan and preliminary authorization, case managers will authorize the estimated number of units, not to exceed 1200 units.
  3. QSP must document every interaction with recipient. Documentation will include the task and number of units.
  4. QSP will bill based on actual number of units of Transition Coordination provided to recipient.
  1. These services cannot be billed until the recipient has transitioned to a living arrangement in a private family dwelling and
  2. The recipient has been admitted to the waiver and a Person Centered Plan of Care (SFN 404) and Authorization to Provide Medicaid Waiver Services (SFN 410) have been signed.

Standards for Providers

Enrolled agency or individual QSPs, authorized to provide Community Transition Services.

 

Agency QSP staff: Completion of an associate or bachelor’s degree in sociology, social services, social work, nursing, or a field related to programmatic needs from an accredited university. Staff with an associate degree must also have at least one year of progressively responsible experience in programs related to the task.

 

Individual QSPs: Completion of a bachelor’s degree in sociology, social services, social work, nursing, or a field related to programmatic needs from an accredited university.