Attachment A Independent Supports Coordination Service Network180 Independent Supports Coordination Services: The Medicaid Provider Manual description of Supports Coordination includes: Independent Supports Coordination Core Requirements: Coordinate the following at least annually with NETWORK180 designee: o Social assessment o Pre-planning for person-center planning process o Individual plan of service through person-centered planning process o Completion of appropriate service profile(s) for eligibility process o Completion of individual service budget o Recommendation of services to be authorized o Completion of applicable self-direction documents Facilitate the person-centered planning process, including pre-planning and assuring PARTICIPANT S participation and resulting in an individual plan of service. Assure that the individual plan of service identifies the services that will be provided, who will provide them, and how SERVICE PROVIDER will monitor (i.e., interval of face-to-face contacts) the services and supports identified under each goal and objective. Oversee and monitor implementation of the individual plan of service. Assure the participation of the PARTICIPANT on an ongoing basis in discussions of plans, goals, and status and PARTICIPANT s ongoing satisfaction with the process and outcomes. Identify and address gaps in service provision. Assist in developing the required written emergency back-up/crisis plan for services provided through a self-direction arrangement. Coordinate the PARTICIPANT S services and supports with all providers and make referrals as needed. Assist PARTICIPANT to access programs that provide financial, medical, and other assistance such as Home Help, transportation services and entitlements.
Assure coordination with the PARTICIPANT S primary and other health care providers for continuity of care. Assist PARTICIPANT in filing out recipient rights complaints, appeals and grievances upon request using Network180 forms. Provide 24-hour crisis intervention for PARTICIPANT in the case of an emergency. Use supports strategies that will incorporate the principles of empowerment, community inclusion, health and safety assurances, and the use of natural supports as required by the Medicaid Provider Manual. Coordinate with Enhanced Health Care providers. Supports and Service Coordination shall maintain an open authorization to individuals in correctional facilities when there is a reasonable expectation that the individual will be returning to the community within six months. Consideration shall be given to transferring care to jail-based services during the incarceration. Individuals sentenced to prison shall be closed with the discharge date as the date of incarceration or the date the agency was made aware the individual was sentenced to prison. SERVICE PROVIDER must have the capacity to perform written comprehensive assessments addressing the PARTICIPANT S needs, barriers to needs being met, supports to address barriers, and health and welfare issues. The SERVICE PROVIDER must contact the Network180 designee and update their assessment when there is significant change in the condition or circumstances of the PARTICIPANT. The PARTICIPANT S record must contain sufficient information to meet the documentation requirements of the Medicaid Provider Manual. At a minimum, documentation must include the nature of service, the date, the start and stop times, and the location of contacts between the SERVICE PROVIDER and the PARTICIPANT, including whether the contacts were face-to-face. The frequency of contacts must be dependent on the PARTICIPANT s needs as reflected in the individual plan of service. The SERVICE PROVIDER must review services at intervals defined in the individual plan of service. The plan shall be kept current and modified through coordination with Network180 s designee when indicated by the PARTICIPANT S medical/clinical needs. The PARTICIPANT or his/her guardian or authorized representative may review the plan at any time. A formal review of the plan coordinated with the Network180 designee shall occur at least annually to review progress toward goals and objectives and to assess PARTICIPANT S satisfaction.
The SERVICE PROVIDER must determine, on an on-going basis, if the services and supports in the individual plan of service have been delivered, and if they are adequate to meet the clinical needs of the PARTICIPANT. Frequency and scope (face-to-face and telephone) of SERVICE PROVIDER monitoring activities must reflect the intensity of the PARTICIPANT S health and welfare needs identified in the individual plan of service. PARTICIPANT AND SERVICE PROVIDER acknowledge that the minimum qualifications for Independent Supports Coordinators are as follows: 1. Be at least 18 years of age; 2. Be able to prevent transmission of any communicable disease from self to others in the environment in which they are providing supports; 3. Be able to communicate expressively and receptively in order to follow PARTICIPANTS s individual plan requirements and PARTICIPANT-specific emergency procedures, and report on activities performed; 4. Be in good standing with the law according to the Medicaid Provider Manual; 5. Have a Recipient Rights Background Check completed; 6. A minimum of a Bachelor s degree in a human services field and one year of experience working with people with developmental disabilities if supporting that population, or 7. A minimum of a Bachelor s degree in a human services field and one year of experience with people with mental illness if supporting that population; PARTICIPANT and SERVICE PROVIDER will maintain documentation for all orientation and continuing education, which will include: 1. Person Centered Planning including safety/crisis planning; 2. Network180 Recipient Rights; 3. HIPAA/HITECH Act; 4. False Claims Act; 5. Grievance and Appeals;
6. Other areas as needed to provide high quality services (e.g., Mental Illnesses, Substance Use Disorders, Health Education, Culture of Gentleness, Positive Behavior Supports, Trauma Informed Services, Co-Occurring/Complex Needs, etc.) SERVICE PROVIDER acknowledges that PARTICIPANT requires the following additional credentials/training: 1. Driving record if employee is going to drive as a part of their job 2. Other SERVICE PROVIDER acknowledges that PARTICIPANT has the following rules pertaining to provision of service under this agreement: 1. (Smoking) 2. (Telephone usage) 3. (Other) PARTICIPANT/GUARDIAN/POA DATE SERVICE PROVIDER (Independent Supports Coordinator) DATE
Attachment A Independent Supports Coordination Assistant Service Network180 Independent Supports Coordination Assistant Service: The Medicaid Provider Manual description of Supports Coordination Assistant includes: Coordinate the following at least annually with NETWORK180 designee: o Social assessment o Pre-planning for person-center planning process o Individual plan of service through person-centered planning process o Completion of appropriate service profile(s) for eligibility process o Completion of individual service budget o Authorization of service o Completion of applicable self-direction documents Facilitate the person-centered planning process, including pre-planning and assuring PARTICIPANT participation. Assure that the individual plan of service identifies the services that will be provided, who will provide them, and how the SERVICE PROVIDER will monitor (i.e., interval of face-to-face contacts) the services and supports identified under each goal and objective. Oversee and monitor implementation of the individual plan of services. Assure the participation of PARTICIPANT on an ongoing basis in discussions of plans, goals, and status. Identify and address gaps in service provision. Assist in developing the required written emergency back-up/crisis plan for services provided through a self-direction arrangement. Coordinate PARTICIPANT S services and supports with all providers and make referrals as needed. Assist PARTICIPANT to access programs that provide financial, medical, and other assistance such as Home Help, transportation services and entitlements. Assure coordination with the PARTICIPANT S primary and other health care providers for continuity of care.
Assist PARTICIPANT in filing out recipient rights complaints, appeals and grievances upon request using NETWORK180 forms. Provide 24-hour crisis intervention for PARTICIPANT in the case of an emergency. Use supports strategies that will incorporate the principles of empowerment, community inclusion, health and safety assurances, and the use of natural supports as required by the Medicaid Provider Manual. Coordinate with Enhanced Health Care providers. Supports and Service Coordination shall maintain an open authorization to individuals in correctional facilities when there is a reasonable expectation that the individual will be returning to the community within six months. Consideration shall be given to transferring care to jail-based services during the incarceration. Individuals sentenced to prison shall be closed with the discharge date as the date of incarceration or the date the agency was made aware the individual was sentenced to prison. SERVICE PROVIDER will function under the supervision, guidance and oversight of a qualified supports coordinator who is a designee of Network180. SERVICE PROVIDER must have the capacity to perform written comprehensive assessments addressing the PARTICIPANT S needs, barriers to needs being met, supports to address barriers, and health and welfare issues. The SERVICE PROVIDER must contact the Network180 designee and update their assessment when there is significant change in the condition or circumstances of the PARTICIPANT. PARTICIPANT S record must contain sufficient information to meet the documentation requirements of the Medicaid Provider Manual. At a minimum, documentation must include the nature of service, the date, the start and stop times, and the location of contacts between the PARTICIPANT and SERVICE PROVIDER, including whether the contacts were face-to-face. The frequency of contacts must be dependent on the PARTICIPANT S needs as reflected in the individual plan of service. SERVICE PROVIDER must review services at intervals defined in the individual plan of service. The plan shall be kept current and modified through coordination with Network180 s designee when indicated by the PARTICIPANT S medical/clinical needs. The PARTICIPANT or his/her guardian or authorized representative may review the plan
at any time. A formal review of the plan coordinated with the Network180 designee shall occur at least annually to review progress toward goals and objectives and to assess PARTICIPANT satisfaction. The SERVICE PROVIDER must determine, on an on-going basis, if the services and supports in the individual plan of service have been delivered, and if they are adequate to meet the clinical needs of the PARTICIPANT. Frequency and scope (face-to-face and telephone) of SERVICE PROVIDER monitoring activities must reflect the intensity of the PARTICIPANT S health and welfare needs identified in the individual plan of service. PARTICIPANT AND SERVICE PROVIDER acknowledge that the minimum qualifications for Independent Supports Coordinators are as follows: 1. Be at least 18 years of age; 2. Be able to prevent transmission of any communicable disease from self to others in the environment in which they are providing supports; 3. Be able to communicate expressively and receptively in order to follow PARTICIPANTS s individual plan requirements and PARTICIPANT-specific emergency procedures, and report on activities performed; 4. Be in good standing with the law according to the Medicaid Provider Manual; 5. Have a Recipient Rights Background Check completed; 6. A minimum of a high school diploma and equivalent experience (i.e., possesses knowledge, skills and abilities similar to supports coordinator qualifications of Bachelor s degree in a human services field and one year of experience working with people with developmental disabilities) and, 7. Functions under the supervision, guidance and oversight of a qualified supports coordinator. PARTICIPANT and SERVICE PROVIDER will maintain documentation for all orientation and continuing education, which will include: 1. Person Centered Planning including safety/crisis planning; 2. Network180 Recipient Rights; 3. HIPAA/HITECH Act;
4. False Claims Act; 5. Grievance and Appeals; 6. Other areas as needed to provide high quality services (e.g., Mental Illnesses, Substance Use Disorders, Health Education, Culture of Gentleness, Positive Behavior Supports, Trauma Informed Services, Co-Occurring/Complex Needs, etc.) SERVICE PROVIDER acknowledges that PARTICIPANT requires the following additional credentials/training: 1. Driving record if employee is going to drive as a part of their job 2. Other SERVICE PROVIDER acknowledges that PARTICIPANT has the following rules pertaining to provision of service under this agreement: 1. (Smoking) 2. (Telephone usage) 3. (Other) PARTICIPANT/GUARDIAN/POA DATE SERVICE PROVIDER (ISCA) DATE