CurrentBlue Cross Blue Shield - North DakotaPolicy N/A
1915(i) State Plan Home and Community-Based Services (HCBS) for Individuals with Behavioral Health Conditions
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Defines North Dakota's operation, administrative responsibilities, conflict-of-interest safeguards, covered service categories, eligibility rules, and projected enrollment for the 1915(i) State plan HCBS benefit for individuals with behavioral health conditions.
Policy Summary
PayerBlue Cross Blue Shield - North Dakota
Policy1915(i) State Plan Home and Community-Based Services (HCBS) for Individuals with Behavioral Health Conditions
Policy CodePolicy N/A
Change TypeNo material clinical or coverage changes in this revision.
Effective DateJun 1, 2024
Last ReviewAug 6, 2024
Next Review DateN/A
Key ActionComplete required HCBS settings compliance verification and document it in the person-centered plan of care prior to submission and service authorization.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
12service categories
11,150projected Year 1 participants
150% FPLincome eligibility
25+WHODAS threshold
≤5DLA-20 threshold
AnnualPOC review frequency
Coverage, Eligibility, and Settings Compliance
Coverage criteria and operational rules
Covered services and basic coverage rules
Covered HCBS service categories (must be documented in POC): Care Coordination; Training and Supports for Unpaid Caregivers; Peer Support; Family Peer Support; Respite; Non-Medical Transportation; Community Transition Services; Benefits Planning Services; Supported Education; Pre-Vocational Training; Supported Employment; Housing Supports.
Financial eligibility: individual must be Medicaid eligible and have income not exceeding 150% FPL.
Non-duplication: 1915(i) State plan HCBS will not be provided concurrently with another service that is the same in nature and scope regardless of funding source; when duplicate authorities exist the individual must access the service through the alternate authority rather than 1915(i).
Authorization and administration: The Department (Medical Services Division) is responsible for authorizing services and directly performs prior authorization and utilization management for State plan HCBS.
Participant protections: individuals have opportunities for fair hearings and appeals per 42 CFR 431 Subpart E; grievance and dispute resolution information and contacts are provided to individuals and families.
1915(i) eligibility and coverage criteria
Needs-based eligibility criteria and target population
Medicaid enrollment and income: individual must be Medicaid eligible and income must not exceed 150% FPL.
Functional assessment (ONE of)
- WHODAS 2.0 complex score ≥ 25 (complex scoring/IRT scoring used).
- DLA-20 score ≤ 5.
Service need: individual must require provision of at least one 1915(i) service; services must be provided at least monthly or the individual must have documented regular monthly monitoring when services are less frequent.
Target population by diagnosis: benefit targeted to individuals with qualifying diagnoses defined as behavioral health conditions, substance use disorders, or brain injury (targeting by diagnosis only).
Reevaluation: needs-based eligibility reevaluations are conducted at least every 12 months.
Pre-eligibility for institutional residents: pre-eligibility screening may be completed up to 90 days before an anticipated discharge, but final eligibility determination occurs upon discharge and referral/application cannot be submitted until discharge date is set and discharge plan includes qualifying information.
Assessment administration: assessments use WHODAS 2.0 (complex scoring via designated WHO spreadsheet/IRT) and DLA-20; assessors must be trained, qualified practitioners; WHODAS may be administered by Zone Eligibility Workers if needed.
HCBS settings compliance criteria
Required verification measures and ongoing monitoring for HCBS settings compliance.
Tier 1 verification: Care Coordinator completes site visit and the 1915(i) Initial HCBS Settings Review form for applicable residential settings prior to service start; Category 1 private residences presumed compliant unless concerns identified.
Tier 2 verification: When potential institutional qualities or other concerns exist, the Care Coordinator completes the 1915(i) Heightened Scrutiny visit form and process (onsite evaluation, provider policy review, observation, discussions).
Tier 3 verification: As part of person-centered planning, POC Attachment 1 Self-Assessment is completed initially and at least annually to capture the individual's experience and verify ongoing compliance with CMS HCBS Final Rule requirements.
Documentation requirement: Verification of HCBS settings compliance must be documented in the individual's Plan of Care and on POC forms prior to submission and authorization; care coordinators must continually assess and remediate non-compliance through face-to-face visits and the POC process.
Remediation and outcome: If remediation is possible the care coordinator initiates person-centered remediation; if setting cannot be remedied a denial is issued and the individual is given 30 days advance written notice and assistance to transition to a compliant setting. If no compliant setting allows services, 1915(i) eligibility will terminate.
Review and concurrence: When a setting refutes presumptions and evidence of full compliance is gathered, an evidence package is submitted for 30-day public comment then to CMS for concurrence via an internal HCBS settings committee review process.
Coverage criteria and operational requirements
Coverage and compliance conditions for delivering 1915(i) services in community settings and the requirements for POC content, submission, and approval.
Settings verification before authorization: Required HCBS settings compliance verification measures must be completed and documented prior to submission of the POC and approval of service authorizations; additional measures apply for individuals receiving services in their place of residence.
No reimbursement before compliance: Medicaid reimbursement will not occur for 1915(i) services delivered before initial required settings compliance measures are completed.
Heightened scrutiny process: When a setting is presumed institutional, the Heightened Scrutiny form is completed onsite; remediation evidence and an evidence package are reviewed by an internal HCBS settings committee to determine compliance, remediation needs, or denial.
POC content requirements: The POC must document a compliant community-based setting, participant choice of services and providers, identified assessed needs, frequency/duration/amount of services, risk factors and individualized crisis/back-up plan, required signatures, and must be uploaded into MMIS for authorization.
Care Coordinator responsibilities: Care Coordinator develops and monitors the POC, conducts assessments, performs face-to-face monitoring at least every 90 days, develops a crisis plan within the first week of contact, ensures ongoing settings compliance verification, and submits all POCs for authorization.
Provider qualifications for POC development: Persons responsible for POC development must be ≥18, employed with an enrolled Medicaid Care Coordination provider, meet NDDHHS competencies, and meet specified education/experience (BA + 1 year supervised experience or 3 years supervised experience in lieu of degree).
Documentation retention: Service plans (written or electronic) must be maintained for a minimum of 3 years per 45 CFR §74.53; POCs uploaded into MMIS and available to the state for review.
Coverage criteria and operational requirements
Services covered when documented in the Person-Centered Plan of Care (POC) and when provider and participant requirements are met.
Crisis plan: A crisis plan must be developed within the first week of initial contact by the Care Coordinator in collaboration with the participant and POC team; the Care Coordination Agency has ultimate responsibility.
Monitoring and follow-up: Monitoring and follow-up activities must ensure services are furnished per the POC, reflect changes in needs/status, include adjustments and transitions, and document ongoing HCBS Settings Rule compliance; records must be available for NDDHHS review.
Remote support limits: Remote support permitted as real-time two-way check-ins and consultations, must be elected by the member, use a HIPAA-compliant platform, not block community access, not prohibit needed in-person services, and in-person support must be at least 25% of services per calendar month.
Provider enrollment and attestations: Providers must be ND Medicaid enrolled agencies or appropriately affiliated/enrolled practitioners; agencies must have ND Medicaid provider agreement, attest that individual practitioners meet qualifications and scope of practice, maintain 24/7 backup for crisis, conduct state-required training, and adhere to 1915(i) policies.
Staff qualifications: Individuals providing services must be ≥18 years old and have either a bachelor's degree plus one year supervised experience with special populations or three years supervised experience in lieu of degree; supervision by a qualified individual is required and verification records must be maintained.
Training & Support for Unpaid Caregivers scope: Covers practical living skills, parenting, home management, community resources, crisis de-escalation, suicide safety planning, systems advocacy, and assistance accessing services; caregiver must be unpaid and need must be documented in POC and functional assessment.
Billing and limits: Services billed in 15-minute units with a maximum daily limit of eight (8) hours (32 units); training purchase reimbursements procured through a third-party fiscal agent and identified in the POC; travel, meals, and overnight lodging are not reimbursable.
Duplication avoidance: Services must not duplicate services under Section 110 of the Rehabilitation Act or IDEA; justification that services are not otherwise available must be documented; care coordinators must check MMIS for C-waiver eligibility to avoid duplication.
Peer Support coverage criteria
Conditions and limits for coverage of Peer Support services
Age eligibility: Participant must be age 18 or older to receive Peer Support services.
Units and daily limit: Peer Support billed in 15-minute units; limited to eight (8) hours per day (32 units); service authorization required for additional hours to prevent imminent institutionalization, hospitalization, or out-of-home placement; such requests reviewed by NDDHHS.
Non-duplication: Peer Support cannot be provided at the same time as another service that is the same in nature and scope regardless of source; individuals eligible under multiple Medicaid authorities must access the service through the alternate authority rather than 1915(i).
Remote support requirements: Peer Support Specialists must meet in person with the participant before providing remote services and at least quarterly thereafter; remote support limited to real-time two-way check-ins and consultations (telephone or secure video), member-elected, must not block community access; providers must document each use met conditions.
Service scope: Peer Support includes engagement/transition support, coaching, self-advocacy, skill development, community connections, and peer relief services to avert crises; services must align with goals in the person-centered plan.
Provider requirements: Providers must be ND Medicaid enrolled agencies (or eligible OLPs enrolling independently where permitted), attest to practitioner qualifications and competencies, and revalidate enrollment at least once every five years; agencies must retain competency documentation for NDDHHS review.
Coverage criteria and rules
Coverage is available for family members/caregivers of participants under age 18 when documented as needed in the person-centered plan; services must be authorized and documented in the POC and functional needs assessment.
Eligibility: Family Peer Support Services are delivered to families/caregivers of 1915(i) participants under age 18; family defined broadly as primary caregiving unit.
Provider qualifications: Family Peer Support Specialists must be trained and certified with lived caregiver experience; agencies must verify and retain certification/competency evidence and complete attestations at enrollment and revalidation every five years.
Service scope: Includes engagement/bridging, self-advocacy and empowerment, parent skill development, community connections, and transition supports delivered trauma-informed, culturally responsive, person-centered, and recovery-oriented.
Limits: Billed in 15-minute units with maximum 32 units/day; service limited to families of participants under 18; additional hours to prevent imminent institutionalization/hospitalization/out-of-home placement require authorization review by NDDHHS.
Remote services: Must meet in-person before remote services and at least quarterly thereafter; remote support may not exceed 75% of services (implied by 25% minimum in-person), modalities include telephone or secure video, must be member-elected, HIPAA-compliant, not block community access, and not prohibit needed in-person services; documentation required for each use.
Exclusions: Non-reimbursable activities include peer-run 12-step programs, general outreach/education, recreational activities, academic instruction, child care, respite, services not on authorized treatment plan or not compliant with State Medicaid standards, and services to non-beneficiaries/not related to beneficiary's issues.
Duplication coordination: Services must not duplicate those under Section 110 of the Rehabilitation Act or IDEA; providers must coordinate with Department of Instruction/local Vocational Rehab and document justification; care coordinators must check MMIS to avoid C-waiver duplication.
Respite Care coverage criteria
Respite Care service definition, allowable settings, activities, eligibility limitations, and documentation/coordination requirements.
Eligibility: Respite Care available to participants residing in family/home/foster/pre-adoptive/adoptive settings; available only to primary caregivers in family settings; not available to individuals residing in institutions or enrolled in specified waivers (Medically Fragile, Autism, Children's Hospice, Aged/Disabled Waiver).
Service activities: Respite activities may include assistance with ADLs, transportation to/from community activities, grooming/hygiene, meal preparation, medication administration, supervision, and recreational activities.
Limits: Reimbursed in 15-minute units with maximum 160 units/month (40 hours/month) and 480 hours/year; service authorization requests for additional hours to prevent imminent institutionalization/hospitalization/out-of-home placement will be reviewed by NDDHHS and approved exceptions cannot exceed 30 consecutive days.
Age restriction: Service available to individuals age 0 through 20; not available to individuals age 21 and older under 1915(i).
Duplication and prohibitions: Cannot be provided concurrently with another service of same nature and scope; not ongoing day care or before/after-school programs; not to be used to allow caregiver to work or attend school; cannot be provided by individuals living in the home; payments not made when routine family care expected or paid by other sources; providers/case managers must check MMIS and coordinate with C-waiver authority to avoid duplication.
Provider requirements: Providers/agencies must maintain records documenting provider knowledge and competency (e.g., person-centered plan implementation); agencies must attest that practitioners meet qualifications and provide services within scope; enrollment attestation and revalidation required at least every five years.
NMT and CTS coverage criteria and limits
Eligibility and service limitations for NMT and Community Transition Services
Non-Medical Transportation (NMT) scope: NMT enables participants to access authorized HCBS and community destinations tied to POC goals; cannot be used for medical appointments and is offered in addition to State plan medical transportation.
NMT limitations: NMT is for non-routine, time-limited trips (not ongoing routine transport to work/school); alternatives (family, public transport) must be explored prior to request; providers must be ND Medicaid enrolled and meet motor vehicle/licensing requirements.
Duplication rule: NMT cannot be provided simultaneously with another service of same nature/scope and is not available to individuals receiving NMT via certain 1915(c) waivers; Care Coordinator must check MMIS and coordinate with C-waiver authority to avoid duplication.
Community Transition Services (CTS) eligibility: Individual must have resided in an ND Medicaid institution ≥30 consecutive days, have an anticipated discharge to a private residence, be eligible for Medicaid upon discharge, have FPL ≤150%, a qualifying 1915(i) diagnosis, and WHODAS ≥25 or DLA ≤5; case manager must request State Medicaid Office approval.
CTS allowable expenses: One-time set-up expenses necessary to establish a basic household (security deposits, essential furnishings, moving expenses, utility setup fees, health/safety services, accessibility adaptations, assessment/arrangement activities); excludes monthly rent/mortgage, regular utilities, and recreational items; items become property of the individual.
CTS timing and billing: CTS may be authorized up to 90 days prior to eligibility/admission and up to 90 days after becoming eligible; purchases procured via third-party fiscal agent and costs billable when person leaves institution and enters 1915(i).
Provider qualifications: CTS providers must hold ND Medicaid provider agreement; individual providers must be employed by an enrolled billing group and be at least 18 years old; certain licensed practitioners may enroll independently as billing groups where permitted.
Coverage coordination: State identifies overlap with 1915(c) waivers for NMT and CTS and specifies processes to prevent duplicate funding/access including MMIS checks and coordination with C-waiver authorities.
Coverage criteria and operational rules
Conditions and limits for service coverage under the ND 1915(i) state plan.
Eligibility groups: Services available to categorically needy and medically needy as specified; Pre-vocational services available beginning 6 months prior to 18th birthday or upon receipt of HS diploma/GED as specified.
Unitization and daily limits: Services reimbursed in 15-minute units with a maximum of eight (8) hours per day (32 units/day); service authorization required for additional hours to prevent imminent institutionalization/hospitalization/out-of-community placement and reviewed by NDDHHS.
Remote support: Remote support permitted for check-ins and consultations via telephone or secure video; must be elected by the member, use HIPAA-compliant platform, not block community access, not prohibit needed in-person services, and in-person support must be at least 25% of services per calendar month (some services note specific 25% minimums).
Duplication avoidance: Services must not duplicate those funded under Section 110 of the Rehabilitation Act or IDEA or duplicative 1915(c) waiver services; Care Coordinator must coordinate with Department of Public Instruction/local VR and check MMIS for C-waiver spans and document justification when services are not otherwise available.
Provider enrollment and revalidation: Providers must have ND Medicaid provider agreement, attest to qualifications and scope, complete attestation at enrollment and revalidation; certain Other Licensed Practitioners may enroll independently; enrollments revalidated at least once every 5 years.
Federal exclusions: Federal financial participation is not claimed for incentive payments, subsidies, or unrelated vocational training expenses (e.g., employer incentive payments or passthrough payments).
Coverage criteria for Supported Education Services
Eligibility and non-duplication requirements
Eligibility: Supported Education Services available to categorically needy individuals age 5 and above; need must be documented in the person-centered POC and functional assessment.
Limits: Services limited to eight (8) hours per day (32 units/day) with 15-minute unit rate; service authorization requests for additional hours to prevent imminent institutionalization/hospitalization/out-of-community placement will be reviewed by NDDHHS.
Non-duplication: Services must not duplicate those funded under Section 110 of the Rehabilitation Act or IDEA; providers must coordinate with Department of Instruction/local Vocational Rehabilitation Agency and document justification that services are not otherwise available in the individual's record.
Authority choice: If member enrolled in multiple authorities offering same service (e.g., 1915(i) and 1915(c)), member must access service through alternate authority rather than 1915(i).
Remote support and documentation: Remote support (telephone, secure video) allowed but limited to check-ins and consultations; member must elect remote support; in-person support must be at least 25% of services per calendar month; providers must document member election, that remote support did not block community access or prohibit needed in-person services, use of HIPAA-compliant platform, and prioritization of community integration for each utilization.
Provider qualifications and recordkeeping: Billing group providers must meet licensure/accreditation requirements or ensure affiliated Individual Service Providers meet qualifications; agencies must retain records documenting provider competencies and adherence to 1915(i) policies for NDDHHS review.
SEP coverage criteria and restrictions
Eligibility and authorization criteria for SEP under 1915(i)
Participant need and election: Participant elects Supported Employment and demonstrates need; Care Coordinator documents need in the Person-Centered POC and functional needs assessment for initial and annual reevaluation.
Authorization process: Services are authorized during the person-centered planning process by the Care Coordinator; services must align with goals in the POC.
Duplication restrictions: Supported Employment must not duplicate services available under Section 110 of the Rehabilitation Act or IDEA; providers must coordinate with Department of Instruction/local Vocational Rehabilitation and document justification.
Remote support: Remote support allowed but limited to check-ins and consultations; in-person support must be at least 25% of services per calendar month; providers must document member election and that remote support did not block community access or prohibit needed in-person services and that a HIPAA-compliant platform was used.
Provider qualifications: Billing group providers must meet licensure/accreditation requirements or ensure affiliated Individual Service Providers meet required qualifications; Individual Service Providers must be employed by an enrolled billing group, be at least 18, have HS diploma/GED, complete Mental Health First Aid training (youth and/or adult as applicable), and supervisors require two or more years' experience.
Recordkeeping and exclusions: Agencies must maintain records for NDDHHS review documenting competencies and adherence to 1915(i) policies; federal FFP not claimed for employer incentive or passthrough payments.
Housing Support Coverage Criteria
Eligibility and service access criteria
Living setting requirement: To receive Housing Supports, individual must live in or plan to receive services in an HCBS-compliant setting that meets 42 CFR 441.301(c).
Targeted needs (ANY)
- Experiencing homelessness
- At risk of homelessness
- Living in a higher level of care than required
- At risk for institutional/segregated setting
Age rule: Services are available beginning six months prior to an individual's 18th birthday (for transition purposes) where applicable.
Service components: Housing Supports include Pre-tenancy and Tenancy services (assisting to secure housing, tenancy training, financial literacy, dispute resolution, coordination with landlords/property managers); Pre-tenancy may not be billed concurrently when Tenancy supports are being received.
Duplication rule: Services must not duplicate HCBS 1915(c), Section 110, or IDEA-funded services; providers must coordinate and document justification in the individual's record.
Remote support constraints and documentation: Remote support must be elected by the individual, not block community access, not prohibit needed in-person services, use a HIPAA-compliant platform, and prioritize integration; for each remote use document election, community access, in-person care not prohibited, HIPAA platform, and integration priority.
Authorization and limits: Care Coordinator must authorize Housing Supports in the POC prior to billing; maximum daily limit is eight (8) hours/day (32 units) billed in 15-minute units; in-person minimum when remote used = 25% per calendar month; requests for additional hours to prevent imminent institutionalization/hospitalization reviewed by NDDHHS.
Provider qualifications and enrollment: Individual providers must be employed by an enrolled billing group, be at least 18, complete Mental Health First Aid training as specified, supervisors must meet experience requirements (e.g., two+ years), and certain licensed practitioners may enroll independently as OLPs; providers revalidate enrollment at least every five years.
Authority choice: If individual eligible for multiple Medicaid authorities, they must access service through the alternate authority (e.g., 1915(c)) rather than 1915(i) when duplication exists.
Participant-direction availability
Participant-direction and authorities offered
State decision: The State does not offer participant-direction of State plan HCBS (no participant-employer, participant/common-law employer, or participant-budget authority is offered).
Quality measures and monitoring
Quality improvement measures and monitoring responsibilities for 1915(i) services
POC measures: (1a) POCs address assessed needs — measured as number/percent of POCs that identify and address assessed needs; data source: The Source; sample: representative sample at 95% confidence +/-5%.
POC timeliness: (1b) POCs are updated annually — measured as number/percent of POCs updated on or before required annual review date; monitored annually by NDDHHS Behavioral Health Division.
POC revision when warranted: (1c) POCs updated/revised when warranted by changes in participant needs — measured as number/percent revised when warranted; data source: The Source; annual sampling.
POC choice documentation: (1d) POCs document choice of services and providers — measured as number/percent of signed POCs containing Choice of Service and Provider Statement.
Eligibility measures: (2a/2b/2c) Evaluations for eligibility provided when indicated and eligibility reevaluated at least annually — measured as number/percent with evaluation prior to enrollment and number/percent whose eligibility reviewed within 365 days; data source: The Source; sample precision 95% +/-5%.
Provider qualifications measures: (3a initial, 3b ongoing) Number/percent of providers meeting required qualifications initially and at reauthorization; data source: The Source database; monitoring by NDDHHS Medical Services Division annually; sample precision 95% +/-5%; revalidation lookback = 5 years at reenrollment.
Settings compliance measure: (4) Settings meet HCBS requirements — measured as number/percent of participants whose POC indicate a compliant setting prior to enrollment; monitored annually by NDDHHS Behavioral Health Division using representative sampling.
SMA oversight and financial accountability: (5/6) SMA retains oversight and maintains financial accountability — measured via timely annual reports to CMS and claims payment accuracy; monitoring by NDDHHS Medical Services Division annually using The Source database.
Participant rights and abuse prevention: (7) POCs must include participant signature indicating they were informed of rights regarding abuse/neglect/exploitation/restraints; monitored annually; electronic signatures acceptable in emergencies.
Provider qualifications (initial)
Performance measures and discovery activities for required sub-assurances include specific numerators/denominators and data sources.
Measure 3a (Providers meet required qualifications initially): numerator = number of service providers who initially met required licensure/authorization standards prior to furnishing 1915(i) services; denominator = total number of 1915(i) authorized service providers; data source = The Source database; sample precision = 95% confidence +/-5%; monitoring entity = NDDHHS Medical Services Division; frequency = annually.
Provider qualifications (ongoing)
Ongoing provider reauthorization monitoring.
Measure 3b (Providers meet required qualifications ongoing): numerator = number of reauthorized providers who met required qualifications prior to reauthorization; denominator = total number of 1915(i) providers reauthorized; data source = The Source database; sample precision = 95% confidence +/-5%; monitoring entity = NDDHHS Medical Services Division; frequency = annually; record retention/lookback = 5 years at reenrollment.
Home and community-based settings
Settings compliance with home and community-based setting requirements per 42 CFR 441.710.
Measure 4 (Settings meet HCBS requirements): numerator = number of participants whose POC indicate a setting for service delivery that meets HCBS requirements prior to enrollment; denominator = total POCs reviewed; data source = The Source database; monitoring entity = NDDHHS Behavioral Health Division; frequency = annually.
Oversight, financial accountability, and participant rights
SMA oversight, financial accountability, and participant rights monitoring.
Measure 5 (SMA authority/oversight): numerator = number of annual reports submitted to CMS timely; denominator = number of annual reports due; monitoring entity = NDDHHS Medical Services Division; frequency = annually.
Measure 6 (Financial accountability): numerator = number of claims paid during review period according to service rate; denominator = number of claims submitted during review period; data source = The Source database; monitoring entity = NDDHHS Medical Services Division; frequency = annually.
Measure 7 (Abuse/neglect prevention & participant rights): numerator = number of POCs with participant signature indicating they were informed of rights; denominator = total 1915(i) participant POCs reviewed; monitoring entity = NDDHHS Behavioral Health Division; frequency = annually; note = electronic signature acceptable in emergencies.
Billing Units, Codes, and Key Eligibility Values
Not specified in this excerptmixed
Related state SPA identifiermixed
| 23-0027 | Superseded SPA identifier |
Billing unit and daily maximummixedCovered
| Billed in 15-minute units; daily maximum eight (8) hours / 32 units |
Unit/billing rulesmixed
| Services billed in 15-minute units; max 8 hours (32 units) per day. |
Billing units and limitsmixedCovered
| Billed in 15-minute units; limited to 32 units daily (8 hours) |
respite_unitmixedCovered
| unit=15min | Respite reimbursed in 15-minute units |
Enrollment / billing groupmixed
| ND Medicaid billing group provider enrollment requirement; no specific CPT/HCPCS codes listed in this section |
Unitization and daily limitsmixedCovered
| Services reimbursed in 15-minute units; max 32 units (8 hours) per day |
Unit and daily limitsmixedCovered
| unit = 15 minutes | Service billed in 15-minute units; daily limit 32 units (8 hours). |
Supported EmploymentmixedCovered
| Supported Employment service (SEP) as defined in 1915(i) state plan |
Not specifiedmixed
| No explicit CPT/HCPCS/ICD codes provided in this excerpt. |
Income limit — eligibility
Income limitEligibility limited to individuals with income at or below 150% FPL
Needs-based eligibility thresholds
Needs-based thresholdsWHODAS 2.0 complex score ≥25 OR DLA-20 score ≤5
Financial eligibility income limit
Financial eligibility income limitIncome does not exceed 150% FPL
Pre-eligibility timing
Pre-eligibility screening windowMay complete pre-eligibility screening within 90 days prior to institution discharge; final eligibility determined upon discharge
Daily maximum units
Daily maximum units (general)32 units per day (8 hours)
Unit granularityBilled in 15-minute units
Authorization for extra hoursRequests for additional hours to prevent imminent institutionalization/hospitalization reviewed by NDDHHS
daily_unit_limit
Daily unit limit (billing)32 units per day (15-minute units) — equals 8 hours/day
Billing unit15-minute unit
Exception reviewService authorization required for additional hours beyond daily limit; reviewed by NDDHHS
Daily limit
Daily limit32 units (8 hours) per day
Unitization15-minute billing units
Extra hoursAdditional hours to prevent imminent institutionalization/hospitalization require NDDHHS review
Minimum in-person requirement
In-person minimum with remote supportAt least 25% of services must be in-person per calendar month; must meet in person before remote services and at least quarterly thereafter
Remote support safeguardsRemote support must be elected by member, use HIPAA-compliant platform, not block community access, and prioritize community integration
POC/care coordinator roleCare Coordinator develops crisis plan within first week and documents remote support election and conditions for each utilization
respite_limits
Monthly respite capMaximum 160 units/month (40 hours/month)
Annual respite capMaximum 480 hours/year
Consecutive days exceptionApproved exceptions for additional respite hours may not exceed 30 consecutive days and are reviewed by NDDHHS
Maximum allowable budget
Maximum allowable budget (CTS)See department fee schedule for maximum allowable budget per lifetime within 180 consecutive day window
CTS timingCTS may be authorized up to 90 days prior to eligibility/admission and up to 90 days after becoming eligible
ProcurementCommunity Transition purchases procured through a third-party fiscal agent; costs billable when person leaves institution and enters 1915(i)
Daily unit cap
Daily unit cap32 units per day (8 hours)
Billing increment15-minute unit rate
Extra hours reviewRequests for additional hours to prevent imminent institutionalization/hospitalization will be reviewed by NDDHHS
daily_unit_limit
Daily unit limit (per-day)32 units per day (15-minute units) — equals 8 hours/day
Unit rate15-minute unit
Eligibility age noteApplies to specified services with stated age eligibility in service sections
In-person service minimum
In-person service minimumAt least 25% of services per calendar month must be provided in-person when remote support is used
Initial in-person requirementMust meet in person before initiating remote services and at least quarterly thereafter
DocumentationFor each remote use, providers must document member election, community access not blocked, and HIPAA-compliant platform use
Daily limit
Daily limit per service8 hours/day (32 units); billed at 15-minute rate
Unitization15-minute units; 32 units equals 8 hours
Authorization for exceptionsAdditional hours to prevent imminent institutionalization/hospitalization reviewed by NDDHHS
Quality review sample confidence
Quality review sample precisionRepresentative sample at 95% confidence level with +/-5% margin of error
Data sourceThe Source database and/or reports used for data collection
FrequencyRepresentative samples reviewed as specified in performance measures (annual aggregation)
Performance trigger for Quality Improvement Strategies
Performance trigger for QISMeasures trending near or below 85% prompt Quality Improvement Strategies (QIS)
QIS monitoring cadenceAfter QIS implementation, performance measure data reviewed quarterly to assess improvement
Remediation methodsRemediation may include training, policy clarification, system changes, or sanctions as appropriate
Provider Responsibilities, Authorization, and Documentation
Prior Authorization
Minimum service and monitoring requirements
The minimum requirement to determine 1915(i) needs-based eligibility is that the person requires at least one 1915(i) service. Services must be provided at least monthly, or if less than monthly, the Plan of Care must document regular monthly monitoring by the Care Coordinator. Specify and document the minimum service (one or more) and the required frequency or monitoring in the person-centered Plan of Care prior to authorization.
- Minimum number of 1915(i) services required: 1
- If services furnished less than monthly: monthly monitoring must be documented in the POC
- Quarterly minimum face-to-face contact requirement applies to select services per service-specific sections
Prior Authorization
1915(i) pre-eligibility for institutional residents
Individuals living in institutions are not eligible to receive HCBS while institutionalized, but may undergo a 1915(i) pre-eligibility screening within 90 days of an identified discharge date. The institutional case manager must provide qualifying diagnosis, WHODAS or DLA score, FPL at or below 150%, and identified need for 1915(i) services. Zone Eligibility Workers place the individual in pending status until final eligibility is determined the day after discharge.
- Pre-eligibility window: within 90 days of identified discharge date
- Required pre-eligibility documentation from institutional case manager: diagnosis, WHODAS/DLA score, FPL ≤150%, identified need for services
- Zone Eligibility Worker completes screening and marks pending until day after discharge when final eligibility is set
Documentation Required
Duplication check and approval
Care Coordinators and providers must check for and document that services are not duplicative of other Medicaid-funded authorities, Section 110 Rehabilitation Act services, or IDEA services. Before authorizing services the Care Coordinator must query MMIS for C‑waiver eligibility and, if spans exist, contact the C‑waiver authority to confirm no duplication. Justification that services are not otherwise available through Department of Instruction or Vocational Rehabilitation must be kept in the individual's record.
- Care Coordinator will contact State Medicaid Office/MMIS to check for C‑waiver spans
- If C‑waiver spans exist, Care Coordinator contacts C‑waiver authority to ensure POC has no duplicative services
- Document coordination with Department of Instruction and/or local Vocational Rehabilitation Agency and retain justification in the record
Documentation Required
Documentation requirements for remote support
Remote support is allowed only when elected by the individual and must not replace or block community access or required in-person services. Remote support must use a HIPAA-compliant platform, prioritize community integration, and be limited to real-time two-way check-ins and consultations. For each occurrence providers must document the member's election and that the use met all remote-support safeguards.
- Remote support must be elected by the individual
- Remote support must not block community access or prohibit needed in-person services
- Platform used must be HIPAA-compliant
- Document for each use: member election; did not block community access; did not prohibit needed in-person services; HIPAA-compliant platform used; prioritized community integration
Prior Authorization
Authorization and Plan Documentation
All services must be authorized in the person-centered Plan of Care by the Care Coordinator before billing. The Care Coordinator must document the need for the service within the POC, include applicable HCBS settings compliance verification, and ensure required POC attachments (e.g., HCBS Settings Review, Self-Assessment) are completed and uploaded to MMIS as part of the authorization submission.
- Services must be authorized in the person-centered POC by the Care Coordinator prior to billing
- Document clinical need and goals for each authorized service in the POC
- Complete required HCBS settings compliance verification measures and include them in the POC before submission to MMIS
Documentation Required
Provider qualification discovery and remediation
The state will monitor provider qualification at initial enrollment and at revalidation. The NDDHHS Medical Services Division (Provider Enrollment) will perform discovery using The Source and related reports with representative sampling (95% confidence, ±5%). Providers must complete enrollment, attest during provider agreement and at revalidation, and revalidate at least every five years. NDDHHS will aggregate results, require remediation when deficiencies are found, and perform ongoing annual analysis of provider qualification metrics.
- Entity responsible: NDDHHS Medical Services Division – Provider Enrollment
- Discovery data source: The Source database and reports; sample at 95% confidence ±5%
- Frequency: initial verification at enrollment and reauthorization at revalidation (providers revalidate at least every 5 years); ongoing annual analysis
- Remediation: NDDHHS Provider Enrollment manages remediation activities and timeframes when providers fail to meet qualification standards
Key Terms and Role Definitions
SMA authority and oversight
SMA and line authorityMedical Services Division retains line authority and oversight for operation of the 1915(i) benefit; NDDHHS is the Single State Medicaid Agency (SMA)
Shared responsibilitiesMedical Services Division and Behavioral Health Division share operational functions (e.g., provider enrollment, POC review)
Delegation requirementAny functions not performed directly by the SMA must be delegated in writing and monitored by the Medicaid division
Human Service Zones — enrollment and eligibility
Human Service Zones roleHuman Service Zones perform individual enrollment and eligibility evaluation/reevaluation and maintain county offices for access
Eligibility workers dutiesZone Eligibility Workers enroll individuals in 1915(i), verify proof of diagnosis and needs-based assessment scores, may assist applicants or administer WHODAS if needed
AccessHuman Service Zones have offices in every county for ease of access
WHODAS 2.0 (complex scoring)
WHODAS 2.0 useWHODAS 2.0 used to assess level of need across 6 domains; complex score ≥25 required for 1915(i) eligibility
Administration modesWHODAS may be administered by interview or proxy; interviewers must be independent and qualified
Scoring guidanceWHODAS administrators must follow WHO instructions and state qualification requirements
DLA-20 (Daily Living Activities)
DLA-20 purposeDLA-20 assesses 20 daily living activities affected by mental health and disability
Eligibility thresholdA DLA-20 score of 5 or lower indicates eligibility for 1915(i)
Use in POCDLA scores are documented and considered in person-centered POC planning
Human Service Zone Eligibility Worker
Zone Eligibility WorkerHuman Service Zone Eligibility Worker — responsible for enrollment, verification of diagnosis and needs-based scores, and entering eligibility into web-based system
WHODAS administrationZone Eligibility Worker may administer WHODAS if the individual lacks a trained practitioner's score
DocumentationEligibility information entered into web-based system as proof of 1915(i) eligibility
Category 1 — Private Residence
Category 1 — Private ResidencePrivate home or apartment owned or rented by the individual or guardian; presumed compliant unless concerns identified
Tier 1 verificationTier 1 settings review/site visit not required for Category 1 absent concerns; person-centered compliance measures still required
ExamplesIncludes participant's private residence and Respite Care Homes
Category 2 — Provider Owned/Controlled Residential Setting
Category 2 — Provider owned/controlled residential settingIncludes sober living, group homes, foster homes, treatment foster homes, transitional living homes, and private homes of unrelated paid caregivers; requires Tier 1 initial site visit and review
Verification stepsCare Coordinator completes Tier 1 Initial HCBS Settings Review form and site visit; may require Heightened Scrutiny (Tier 2) and Tier 3 person-centered verification
POC documentationEach HCBS settings requirement must be addressed in the individual's POC
Category 3 — Presumed Institutional Qualities
Category 3 — Presumed institutional qualitiesSettings with presumed institutional characteristics requiring full verification including Tier 1 site visit, Heightened Scrutiny (Tier 2), and Tier 3 person-centered assessments
Heightened ScrutinyHeightened Scrutiny form completed onsite by Care Coordinator; evidence reviewed for compliance, remediation, or denial
ExamplesSettings located adjacent to institutions or that restrict community access/choice
Category 4 — Institutions
Category 4 — InstitutionsInstitutions (e.g., NF, ICF/IID, IMD, QRTP, PRTF, hospitals). Individuals residing in these settings are not eligible for 1915(i) services
Community Transition exceptionException: Community Transition Services may be available under certain circumstances for individuals transitioning from institutions
No HCBS in institutionsInstitutional residents should receive care under institutional Medicaid authorities rather than 1915(i)
Heightened Scrutiny Process
Heightened Scrutiny ProcessWhen presumed institutional qualities exist, Care Coordinator completes Heightened Scrutiny form onsite and documents noncompliance, remediation efforts, and timelines
Evidence review and CMS concurrenceIf a setting refutes presumption and demonstrates full compliance, evidence package submitted for 30-day public comment then to CMS for concurrence
Remediation and denialCare Coordinator implements remediation; if not remedied, denial issued and 30-day advance notice provided for relocation
Person-Centered POC
Person-Centered POC requirementsPOC must meet federal requirements (42 CFR §§441.720, 441.725), incorporate independent assessment results, participant choice, signatures, and required documentation
POC developers qualificationsPersons developing POC must be ≥18, employed by enrolled Medicaid Care Coordination provider, and meet specified education/experience competencies
Care Coordinator responsibilitiesCare Coordinator develops and monitors POC, conducts assessments, face-to-face monitoring at least every 90 days, and develops crisis plan within first week
Unpaid caregiver
Unpaid caregiver definitionAny person (e.g., parent, relative, foster parent, grandparent, legal guardian, adoptive parent, neighbor, spouse, friend, companion, co-worker) who provides uncompensated care, training, guidance, companionship or support to a 1915(i) participant
Role in Training & SupportUnpaid caregivers may receive Training and Support services when documented in the POC
ExclusionCaregivers who are paid to care for the participant are not eligible for Training and Support services
Crisis plan
Crisis plan timelineCrisis plan developed by Care Coordinator in collaboration with participant and POC team within the first week of initial contact
Care Coordination responsibilityCare Coordination Agency has ultimate responsibility for development, implementation, and monitoring
Peer Support
Peer Support definitionPeer Support delivered to participants age 18+ by trained/certified individuals with lived experience, providing engagement, coaching, advocacy, skill development and peer relief services
Service settingsDelivered in home and community-based settings including participant's home, community centers, peer recovery centers, parks, etc.
Unit and daily limitsBilled in 15-minute units; max 32 units/day (8 hours); additional hours require NDDHHS review
Remote support
Remote support definitionRemote support includes real-time, two-way communication (telephone or secure video) for check-ins and consultations
Member safeguardsMust be elected by the member, not block community access, not prohibit needed in-person services, use HIPAA-compliant platform, and prioritize community integration
Documentation requirementsFor each remote use, providers must document member election, that it did not block community access or prohibit needed in-person services, and HIPAA platform use
Remote support — election and safeguards
Remote support election & safeguardsRemote support must be elected by the member, use a HIPAA-compliant platform, not block community access, and prioritize community integration
Initial in-person meetingPeer Support Specialist must meet in person before providing remote services and at least quarterly thereafter
Permitted modalitiesTelephone and secure video conferencing
Billing group provider / OLP
Billing group providerBilling group provider: enrollable individual or entity able to provide 1915(i) services; some practitioners may enroll independently as Other Licensed Practitioners (OLP)
OLP examplesExamples: Licensed Professional Clinical Counselor, Licensed Clinical Social Worker, Licensed Marriage and Family Therapist, Psychologist, Nurse Practitioner, Physician
Enrollment requirementIf not an OLP, provider must affiliate with a clinic/hospital/agency to enroll; providers revalidate enrollment at least every five years
Non-Medical Transportation (NMT)
Non-Medical Transportation (NMT)NMT enables access to community services/resources tied to the person-centered POC; not for medical appointments and offered in addition to state plan medical transportation
Use conditionsMust be cost-effective; family/neighbors/community resources should be used when available
Provider requirementsNMT providers must be enrolled in ND Medicaid and meet motor vehicle/licensing requirements
Community Transition Services (CTS)
Community Transition Services (CTS)CTS are time-limited, non-recurring set-up expenses to help individuals transition from certain institutions to private residences
CTS timingMay be authorized up to 90 days prior to eligibility/admission and up to 90 days after becoming eligible; purchases procured via third-party fiscal agent
CTS eligibility functional requirementRequires institutional residency ≥30 days, anticipated discharge to private residence, Medicaid upon discharge, FPL ≤150%, qualifying diagnosis, and WHODAS ≥25 or DLA ≤5
billing group provider
Billing group provider (definition)Billing group provider: an individual or entity able to enroll to provide 1915(i) services; OLPs may enroll independently
Provider enrollment rulesNon-OLP providers must affiliate with a clinic/hospital/agency to enroll and must meet qualifications specified in SPA
OLP — Other Licensed Practitioners
Other Licensed Practitioners (OLP)Examples: LPC, LCSW, LMFT, Psychologist, NP, Physician — may enroll independently as billing group providers if within scope of practice
Scope requirementOLPs may provide state plan services within their professional scope when enrolled as billing group providers
Benefits Planning Services
Benefits Planning ServicesIndividualized assessment and benefits analysis, training on SSA work incentives, PASS assistance, budgeting, healthcare coverage education, referrals and ongoing follow-up
Target purposeSupports individuals considering or seeking competitive employment to make informed choices about public benefits
Pre-vocational Services
Pre-vocational ServicesTime-limited community-based services to develop general soft skills and work-related experiences (volunteer, internships, job shadowing); limited to 8 hours/day
Eligibility timingAvailable beginning 6 months prior to 18th birthday or receipt of HS diploma/GED, whichever comes first
Remote support — service rules
Remote support (service-level)Remote support is real-time, two-way communication limited to check-ins and consultations via telephone or secure video
LimitsRemote support limited in scope (check-ins/consultations) and cannot replace required in-person minimums (≥25% in-person/month)
DocumentationProviders must document member election and compliance with safeguards for each remote use
Supported Employment (SEP)
Supported Employment (SEP)Individualized services to obtain and maintain competitive employment including assessment, job development, coaching, benefits planning, and ongoing follow-along
AuthorizationServices authorized during person-centered planning by Care Coordinator; need documented in POC and functional assessment
Duplication avoidanceMust not duplicate services under Section 110 of Rehab Act or IDEA; providers coordinate with Dept of Instruction/VR and document justification
Participant-direction
Participant-directionParticipant-direction means self-direction of services per §1915(i)(1)(G)(iii); State does not offer participant-direction for State plan HCBS
No employer/budget authorityState does not offer participant-employer, participant-budget, or participant-direction authorities for this SPA
Policy Summary
PayerBlue Cross Blue Shield - North Dakota
Policy1915(i) State Plan Home and Community-Based Services (HCBS) for Individuals with Behavioral Health Conditions
Policy CodePolicy N/A
Change TypeNo material clinical or coverage changes in this revision.
Effective DateJun 1, 2024
Last ReviewAug 6, 2024
Next Review DateN/A
Key ActionComplete required HCBS settings compliance verification and document it in the person-centered plan of care prior to submission and service authorization.
SourceLink
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