PROS AND EMPLOYMENT RELATED SERVICES: What We Know Now

Updated: August 3, 2004

The New York Work Exchange has obtained this information from a number of sources including: informational meetings with SOMH personnel; informational meeting with DOHMH personnel; the SOMH website; personal correspondence with SOMH staff; and other written documents pertaining to PROS. Given that SOMH continues to refine the PROS initiative, this information may change or become dated or inaccurate. We understand that many issues still remain unclear; we will continue to seek answers to questions in order to keep you informed. Should you have any questions or comments regarding the following information please do not hesitate to contact us.

Comments are not intended to address the full range of issues pertaining to PROS programs, standards or services.

Affirmative Businesses and Client Worker Programs

• These program are being surveyed by LGUs to assess effectiveness. The assessment process may delay the mandatory conversion of these programs — they will most likely NOT have to convert during the current implementation process.

CRS employment-related

• Many CRS services can be used to help a consumer attain and sustain employment — they can be utilized in preparing someone for work (before) as well as helping someone sustain work (after), even when ORS off-site services are billed. CRS services can be delivered both on and off site. Delineated below are some examples of how CRS services can include employment-related activities consistent with the existing definitions:
• Engagement: initial contact with recipient; activities used to help engage the person in receiving employment-related services.
• Assessment: initial and ongoing process needed to assess the effects of health/illness on ability to function as an employee/worker.
• Individual Recovery Planning: assistance to modify the IRP when decisions affecting employment outcomes change.
• Community Living Exploration: helping someone determine the type of activity they want to participate in eg. career development activities, individualized job development-related activities eg. visits to employment or other career-type settings
• Basic Living Skills Training: to support someone before or after they have attained employment in: eg. personal hygiene, transportation training (getting to and from work), developing supports on or off the job, social skills/interactions that may be needed for successful employment. These may be considered job coaching activities.
• Benefits and financial management: counseling/support providing assistance with income, benefits, financial planning and other fiscal issues while obtaining or keeping work.
• Crisis intervention: (self-explanatory).
• Information and Education Regarding Self-Help: assisting someone in connecting with and participating in self-help/mutual aid groups that may help a consumer in attaining or keeping work.
• Structured Skill Development and Support: assistance with helping prospective workers to develop skills "for performing normative life roles" This service is primarily thought of as being delivered on-site at the Clubhouse (eg. work-ordered day) or similar setting (psychosocial clubs). Supportive counseling techniques are designed to help individuals complete essential tasks.
• Wellness Self-Management: a range of services are listed under this category. Job coaching and related support activities may be included in the following services: coping skills training — strategies to address symptoms and manage stress; disability education - providing practical and other information (to the person or collateral/employer) on facts concerning mental illness, prevention, and related issues that will aid in the achievement of work goals; medication education and self-management — providing information (to the person or collateral/employer) on medication, efficacy, side effects etc.; problem solving skills training — helping (the person or collateral/ employer) to develop solutions for stressful situations that may interfere with job attainment or maintenance; relapse-prevention planning — helping someone (individual or collateral) understand what triggers recurrence of symptoms that may interfere with work, and how to cope with recurrence.Coping Skills Training, Problem Solving Skills Training, and Relapse-Prevention Planning may be considered job coaching-related services, on or off site.

Enclaves and ORS

• Enclaves can meet the minimum requirements to bill ORS — someone needs to be working at least 15 hours per week, the setting must be integrated (among non-disabled co-workers or assisting customers from the general public) and competitive (interviewed for the job).

IR employment-related services

• For the purpose of employment-related services, IR includes Intensive Rehabilitation Goal Acquisition (Comprehensive or Limited licensed PROS).Intensive Rehabilitation Goal Acquisition services are intended to assist consumers in attaining goals, including employment. They can also be used to assist someone who is working less than 15 hours per week to increase their hours worked. (See note regarding CRS services).
• Employment-related Intensive Rehabilitation Goal Acquisition activities include services associated with: choosing and obtaining an employment goal; and individualized job development and placement activities that are part of locating, selecting, interviewing for, and acquiring a job.
• Providers considering comprehensive licenses need to be aware that Medicaid will reimburse IR for up to 50% of total # of CRS bills submitted annually. This limit is a concern for some providers: to minimize IR billing, providers can consider using CRS services (for individuals working<15 hours per week) and ensure that ORS services are provided as soon as individuals are working at least 15 hours per week.

Job Coaching

• Medicaid will reimburse job coaching that helps an individual perform in a job by: addressing functional limitations; helping someone adjust to a setting; assisting with developing supports (eg. people, things etc.); managing anxiety; problem-solving, ameliorating symptoms, etc.
• Medicaid will not simply reimburse job coaching activities that help an individual learn job-specific tasks, eg. "How to" use a photocopier, or "How to" use a cash register. The services must be linked back to and described in the context of functional disabilities. (See above)
• Job coaching activities that address symptoms interfering with task accomplishment can be billed as: CRS (See Section) - Basic Living Skills Training; Wellness Self-Management (coping skills training, problem solving skills training); and as ORS — counseling, mentoring or ‘coaching’, advocacy

Job Development

• Activities related to job development can be reimbursed if they are individualized and undertaken with the individual present. These activities can be billed to: CRS - Community Living Exploration; IR - Intensive Rehabilitation Goal Acquisition.

Limited Licenses

• Proposed Limited Licenses are for the delivery of IR and ORS services specific to employment and education-related goals.
• In NYC, T2 submissions for 12 Limited Licenses were received by DOHMH. Because an initial scan of these T2s has identified significant areas of concern, these programs are being reviewed by OMH from a policy perspective.

Non-Reimbursable Activities

• Clearly, the following employment-related items are not reimbursable under Medicaid: i) client wages, ii) unattached job development; activities that do not directly involve an individual in the process iii) specific job-skills training.

NYC's Plan for PROS Implementation

• DOHMH Staff in collaboration with SOMH staff from Albany and the NYC Field Office have begun meeting with providers to review T2 submissions. A total of 55 (provider) meetings are planned. 11 meetings have occurred. Key issues pertain to gaging utilization and projecting staffing of proposed PROS programs.
• Following meetings to review T2s and agree upon revisions, data from NYC will be aggregated and analyzed by DOHMH at a Borough and city-wide level. The analysis will be reviewed for service and system access and capacity. DOHMH will then reconvene with providers to ensure that there is no loss of access, cultural diversity etc.
• NYC will not undergo a phase system (Phase 1 and Phase 2) like the other counties but will be converted to PROS during a single process. Due to the number, diversity and complexity of NYC agencies, the timeframe for inclusion in PROS has been extended, thereby insuring that a greater number of providers will be afforded incentives.
• Conversions will commence sometime in 2005 and continue through the year of 2005. Implementations will be staggered throughout this period, making moot the idea of "phases" in New York City.

NYISER Data

• A few additions to the existing SE NYISER data will be requested: information related to the individual’s employer’s name, eligibility for Medicaid Buy-In, referrals to VESID, and length of time to become eligible for VESID

ORS services

• The ORS add-on is billed for individuals working 15 hours per week — or scheduled to work this number of hours per week and have worked at least one week during a month - in an integrated and competitive job.
• ORS services include any relevant billable activities that are required to "assist individuals in managing symptoms and overcoming functional barriers" to sustain employment.
• ORS must be delivered off site — or not at the site where PROS services are delivered. This may mean at the job site or wherever else is appropriate.
• When a consumer requires limited support to sustain employment of at least 15 hours per week, AND the support is desired at the PROS site, appropriate CRS services can be delivered and billed for in place of ORS services. For example: a consumer wishes to meet with a staff person in the privacy of an office to talk about problems at work; a Job Club Meeting for working consumers on employment retention issues is held in a room at the agency location; a TE dinner meeting in the Clubhouse dining room is designed to help working consumers enhance strategies needed to keep their jobs. (see CRS employment-related)
• Exceptional situations may exist where ORS support is delivered at an agency-related location — eg. if a consumer’s employment happens to be associated with the agency.
• ORS should be used once someone works for the minimum of 15 hours per week (to ‘transfer’ someone out of IR services and lower agency average utilization rate, capped at 50% - see IR)

Recipient Employees

• Recipient-employees must be on the provider’s staffing plan. (Staffing plans cannot include non-paid functions of PROS participants.)

Replacement -related activities

• Although these services are not distinctly identified, it appears that the following services could be billed: Intensive Rehabilitation Goal Acquisition- defined as assisting in "identifying, attaining and retaining a goal over time"; CRS (see section on Job Development); or ORS.

Supported Education Activities

• PROS services reimbursable off site to support the role of a student: community living exploration, basic living skills training, structured skill and support development, wellness self-management, and goal acquisition
• Academic accommodations -- the responsibility is for the institution to make accomodations -- not the provider

Ticket to Work and Employment Networks (EN)

• At this time, there appears to be no conflict — fiscal or otherwise - between an agency being both an EN and a PROS entity

Transitional Employment and ORS

• ORS services now apply to Transitional Employment (TE). Providers can bill ORS for the relevant billable support services needed to help a consumer sustain a TE placement.

VESID

• Because Medicaid is the payor of last resort, if an employment-related service is provided to a VESID-sponsored consumer, VESID should pay for the service.
• A PROS staff person can work with both non-VESID and VESID consumers
• PROS services are designed to help individuals deal with personal issues that may interfere with employment that are a result of a psychiatric illness; this is not a primary intent of VESID services
• VESID and PROS can not be billed for the same person at the same time

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