Peer Support Services State Plan Amendment and Policy Update

Tuesday, November 5, 2019

The NC Medicaid State Plan Amendment (SPA) for Peer Support Services (PSS) was approved by the Centers for Medicare & Medicaid Services on Oct. 23, 2019, with an effective date of July 1, 2019.  The clinical coverage policy will be posted with an effective date of Nov. 1, 2019. 

Peer Support Services policy requirements are as follows:

  • Program is under the direction of a full-time qualified professional (QP). 
  • Maximum program staff ratios: QP to certified peer support specialist (CPSS) is 1:8; CPSS to beneficiary is 1:12; and CPSS group facilitator to beneficiaries is 1:12 for peer support group.
  • Peer support specialist must be a NC certified peer support specialist (NCPSS).
  • There are 24 unmanaged units available once per episode of care in a state fiscal year.
  • Prior approval is required for PSS beyond the unmanaged unit limitation. 
  • A service order must be signed prior to or on the first day service is rendered. 
  • Comprehensive clinical assessment is required to determine medical necessity of service.
  • Clinical information must be obtained and documented in the beneficiary’s person-centered plan.
  • PSS may be provided in the beneficiary’s place of residence, community, in an emergency department or in an office setting. 
  • PSS is not a “first responder” service. PSS providers shall coordinate with other service providers to ensure first responder coverage and crisis response.
GDIT, (800) 688-6696