CurrentBlue Cross Blue Shield - North DakotaPolicy BND-24-0855501 • 5-25

Benefits Planning (Work Incentives Counseling)

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Policy governing benefits planning services (work incentives counseling, PASS planning, benefits analysis) for members eligible for public benefits who want to seek employment; defines covered services, provider qualifications, telehealth limits, documentation, and billing for North Dakota Medicaid.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyBenefits Planning (Work Incentives Counseling)

Policy CodePolicy BND-24-0855501 • 5-25

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must provide a written monthly progress update to the member's care coordinator and document progress at each 1915(i) plan of care meeting.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8h/daydaily maximum service limit (32 units)

>=25%

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CurrentBlue Cross Blue Shield - North DakotaPolicy BND-24-0855501 • 5-25

Benefits Planning (Work Incentives Counseling)

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Sign up for Blue Cross Blue Shield - North Dakota Policy BND-24-0855501 • 5-25 alerts

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Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyBenefits Planning (Work Incentives Counseling)

Policy CodePolicy BND-24-0855501 • 5-25

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must provide a written monthly progress update to the member's care coordinator and document progress at each 1915(i) plan of care meeting.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

8h/daydaily maximum service limit (32 units)

>=25%

minimum in-person support per month

15-minbilling increment

≥8mminimum billable unit

Coverage and Eligibility Criteria

inv-01: Coverage Criteria

Covered when ALL of the following are met

Member eligibility: Member is eligible to receive public benefits (e.g., SSDI, SSI, Medicare, Medicaid) and wants to be employed

From Eligibility criteria.

Member presence: Member must be present for the service to occur

From Covered Services and Limits: 'Members must be present for this service to occur.'

Setting: Services must be rendered in a Home and Community-Based setting (not institutional)

See Service Requirements (policy restricts institutional settings).

Provider qualifications: Individual practitioner must meet required certification (CWIC, CPWIC, or SOAR), be ≥18 years, employed by an enrolled ND Medicaid provider, and have competency in person-centered plan implementation

From Individual provider qualifications in policy brief.

inv-02: Covered Services and Components

Covered service components include

Service Components: Development of an individualized assessment and benefits analysis (identifies projected financial goal or status, current public benefits, and plan to use work incentives); training and education on SSA work incentives and income reporting; assistance developing a Plan to Achieve Self Support (PASS) and other work incentives; assistance with budget development; assistance understanding health care coverage options (Medicaid, Medicaid Expansion, State Plan buy-in options); referrals to community resources and to PABSS; ongoing support and follow-up to manage benefit changes, negotiate with SSA, and coordinate with benefit program administrators.

Enumerated covered services from Covered Services and Limits.

The following services are not covered under this benefits planning policy: any services that are not listed under the enumerated Covered Services (this includes associated costs incurred to deliver those services, e.g., checking a member's eligibility), services provided to a member who is not eligible for public benefits under this policy, and services delivered by a provider who does not meet the policy's required qualifications. Providers and group agencies are responsible for confirming member eligibility before each service and for ensuring that individual and affiliated providers meet the required qualifications and training.

Benefits planning services must be delivered in a Home and Community-Based (HCBS) setting — for example, the member's private residence or another community-based, non-residential location. Services rendered in institutional settings are not allowed under this benefit and should be referred to the appropriate institutional service line or program.

Services provided to members who do not meet eligibility requirements or services provided by individuals who do not satisfy the policy's provider qualifications are considered non-covered / not medically necessary and are subject to denial. It is the provider's responsibility to verify eligibility and provider credentialing prior to delivering benefits planning services.

Billing Codes and Units

Covered HCPCS CodesHCPCSCovered

H2021	Benefits Planning (per 15 minutes)
Modifier = U3	Modifier associated with H2021 as specified

15 Minute Units — mapping of minutes to billable units (>=8 min = 1 unit, etc.)

Billing incrementProviders can bill a single 15-minute unit for services >= 8 minutes; sessions <8 minutes should not be billed.

1 unit>= 8 minutes through 22 minutes

2 units>= 23 minutes through 37 minutes

3 units>= 38 minutes through 52 minutes

4 units>= 53 minutes through 67 minutes

5 units>= 68 minutes through 82 minutes

Provider Requirements and Authorization

Prior Authorization

Authorization for Exceeding Daily Maximum

Daily maximum of eight (8) hours (32 units). Service authorization requests exceeding the maximum limit which are deemed necessary to prevent the member's imminent institutionalization, hospitalization, or out of home/out of community placement will be reviewed. All requests to exceed limits must initiate with the member's care coordinator.

Daily maximum = 8 hours (32 units)
Requests > daily maximum require review and must be initiated by the member's care coordinator
Exceeding authorization considered only when needed to prevent imminent institutionalization, hospitalization, or out-of-home placement

Billing Rule

Avoid Duplicative Services

Key Definitions

Telehealth — definition

DefinitionTelehealth means the use of telecommunications and information technology to provide access to physical, mental, and behavioral health care across distance; services must occur in real-time with the member present via telecommunications or information technology.

Real-time requirementServices must occur in real-time with the member present.

ScopeIncludes physical, mental, and behavioral health care delivered across distance.

Home and Community Based Setting (HCBS)

DefinitionHome and Community Based Setting (HCBS) means a member's own home or community location rather than an institution or other isolated setting.

Examples of HCBS locationsMember's residence, community locations outside institutions.

Background and Scope

Benefits planning (also called work incentives counseling) supports members who are eligible for public benefits and who want to pursue employment. The service helps members understand and use Social Security work incentives, develop individualized plans such as a Plan to Achieve Self-Support (PASS), manage budgets and income reporting to avoid unintended loss of benefits, and navigate health coverage options. These services may include a benefits analysis, education and training on work incentives, PASS development, budget planning, referrals to community resources, and ongoing follow-up to support sustained employment efforts.

Policy Summary

PayerBlue Cross Blue Shield - North Dakota

PolicyBenefits Planning (Work Incentives Counseling)

Policy CodePolicy BND-24-0855501 • 5-25

Change TypeNo material changes

Effective Date

Next Review Date

Key ActionProviders must provide a written monthly progress update to the member's care coordinator and document progress at each 1915(i) plan of care meeting.

SourceLink

On This Page

Care coordinators are responsible for ensuring there is no duplication of services prior to authorization or provision.

Confirm services are not duplicative of other paid supports or programs before authorizing or delivering services

Documentation Required

Provider Documentation Requirements

Benefits planning providers must provide a written monthly progress update to the member's care coordinator to ensure progress toward goals and to evaluate ongoing service necessity. The member's progress must also be discussed and documented at each 1915(i) plan of care review.

Monthly written progress update to care coordinator required
Progress discussion and documentation required at each 1915(i) plan of care meeting
See 'Documentation Guidelines' in Provider Requirements policy for Medicaid documentation standards

Denial Risk

Denial Risk — Non‑eligible Members or Non‑qualified Providers

Services provided to a non-eligible member or by a non-qualified provider are not covered and may be denied. Providers are responsible for confirming member eligibility prior to each service and ensuring group and affiliated individual providers meet qualifications and training requirements.

Confirm member eligibility before delivering services
Ensure provider and affiliated individuals meet qualification and training requirements

Denial Risk

Denial Risk — Institutional Setting

Services must be rendered in a Home and Community-Based setting (member's private residence or community‑based non‑residential setting). Services rendered in an institutional setting are noncompliant and risk denial.

Do not provide these services in institutional settings
If not provided in a private residence or community-based non-residential setting, refer to Home and Community guidance to ensure compliance

ImplicationServices must be rendered in HCBS (not in institutional settings) to meet this policy's setting requirement.

Institutional setting — examples

DefinitionInstitutional setting means nursing facilities (NF), intermediate care facilities for individuals with intellectual disabilities (ICF/IID), Qualified Residential Treatment Programs (QRTPs), Psychiatric Residential Treatment Facilities (PRTF), hospitals, and jails/prisons.

ExamplesNursing facilities; ICF/IID; QRTPs; PRTFs; hospitals; jails/prisons.

Policy impactServices provided in institutional settings are not allowed under this service and should be referred elsewhere.