1915(i) Operational FAQs (Billing, Providers, etc.)

Once a member has been deemed eligible for 1915(i) services, the member’s Health Plan or Carelon will inform the care manager/care coordinator of the member’s eligibility determination. After the individual is deemed eligible, the care manager/care coordinator should work to complete the following steps:

Care Plan/ISP Development:

• The member’s care manager/care coordinator should work with the beneficiary to identify a 1915(i) service provider for their 1915(i) services.
  • If the 1915(i) service provider had already been identified, the care manager/care coordinator should notify the 1915(i) service provider that the member has been deemed eligible for 1915(i) services.
  • The 1915(i) service provider must comply with conflict free case management (so the 1915(i) service provider cannot be a provider affiliated with the same organization as the member’s care manager).
     
• Then the care manager/care coordinator works to develop the Care Plan/ISP with the beneficiary, service provider and any other individuals identified by the beneficiary.
  • Refer to the 1915(i) Independent Assessment & Care Plan/ISP Requirements section above )NOTE: consider inserting jumplink here) for more information on the Care Plan/ISP development).
     
• The care manager/care coordinator shall submit the completed Care Plan/ISP to the Health Plan and the 1915(i) service provider.

Prior Approval Submission:

• The care manager/care coordinator submits the completed Care Plan/ISP along with the prior approval request, when applicable, to the member’s Health Plan for review.
  • A member’s eligibility for 1915(i) services does not imply approval of/authorization of a particular 1915(i) service. The member’s Health Plan will review the prior authorization (PA) request to complete a utilization review of the service(s).
  • Care managers shall follow utilization management guidance from Health Plans.
     
• The Health Plan will complete the review of the prior approval, when applicable, and return a decision to the member’s care manager/care coordinator.

Service Delivery & Care Coordination:

• After the prior approval has been approved by the member’s Health Plan, the care manager/care coordinator works with the 1915(i) service provider to implement the authorized 1915(i) service(s) according to the Care Plan/ISP.
   
• Throughout the delivery of the 1915(i) services, the care manager/care coordinator provides ongoing care coordination and HCBS monitoring for the 1915(i) services.

1915(i) Service providers should not bill 1915(i) services until a member has been deemed eligible for 1915(i) services (which happens after the 1915(i) assessment has been completed) and the member’s 1915(i) services have been authorized by the member’s Tailored Plan or LME/MCO if prior approval is required.

The following codes can be leveraged after the member has been authorized for 1915(i) services:

The following NC CORE Model billing codes can be leveraged for Supported Employment-Individual Placement and Support (IPS) for Mental Health and Substance Use Disorder:

NC CORE is a value-based payment model for IPS that reimburses providers when designated milestones are reached in the delivery of the services. The milestone information should be reported by the 1915(i) IPS providers in the Demonstration Project Identifier segment on the claim form.

This information is captured in the REF*P4 segment in the Loop 2300 of an 837 professional claim. The 1915(i) IPS provider will submit the procedure code H2023-Supported Employment with the U4 modifier, but will designate the milestone through the REF*P4 segment. The format of the REF-P4 segment will also contain an indication of the program, in addition to the milestone being reported.

The 1915(i) add-on payment is for the coordination services which are required for 1915(i) services under federal regulations. The 1915(i) care management add-on rate cannot be leveraged until after the member has been deemed eligible for 1915(i) services.

This means that care management providers cannot bill the 1915(i) add-on payment for completion of the assessment. The 1915(i) add-on payment is not available for billing prior to a member being deemed eligible for 1915(i) services.

For example, if a member is deemed eligible for 1915(i) services on Oct. 1, 2023, then the 1915(i) add-on payment cannot be billed prior to Oct. 2, 2023. The 1915(i) add-on payment is only intended to be billed monthly.

The 1915(i) care management Add-On rate is $78.94, which mirrors the Innovations add-on payment rate.

Yes, members currently on the Innovations waitlist will keep their spot on the Innovations waitlist and continue to use 1915(i) services.

Members who are enrolled in the Innovations or TBI waiver will no longer be eligible for 1915(i) services, as they will have access to similar services through the Innovations or TBI waiver.

NC Medicaid expects Health Plans to pay 1915(i) services at a rate which is no less than the rate which the service was paid under 1915(b)(3) or Innovations (for Community Living and Supports). Each Health Plan has established their own fee schedules for these rates, therefore NC Medicaid will not establish a fee schedule for 1915(i) services.

For ongoing monitoring for the 1915(i) services, the care manager/care coordinator are responsible for completing the following activities monthly:

• Monitoring Care Plan/ISP goals.
• Maintaining close contact with the beneficiary, providers and other members of the care team.
• Promoting the delivery of services and supports in the most integrated setting that is clinically appropriate for the beneficiary inclusive of HCBS requirements.
• Updating the independent assessment at least annually or as significant changes occur.
  • Note: For beneficiaries receiving TCM and 1915(i) services, the care manager must complete the independent assessment as part of the annual care management comprehensive reassessment.
• Notifying the appropriate Health Plan of updates to 1915(i) service eligibility.
• Monitoring of 1915(i) service delivery.

As a requirement of monitoring, the care manager must meet with the member face-to-face at least once per quarter (this can be in person or with two-way audio-visual communication) and conduct telephonic follow-up with the member for the other months in the quarter.

Please also review the HCBS Monitoring Tool Training deck.