Currentintegrated_home_care_servicesPolicy N/A
Supported Employment - Individual (Scope of Service)
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Defines requirements, expectations, provider qualifications, service components, and reimbursement models for subcontracted Supported Employment - Individual services for members in the i Care Family Care and Family Care Partnership programs.
Policy Summary
Payerintegrated_home_care_services
PolicySupported Employment - Individual (Scope of Service)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateNov 21, 2025
Next Review DateN/A
Key ActionProviders must submit assessment and job development plan to the IDT before job placement and obtain authorization prior to billing.
SourceLink
POLICY UPDATE CHANGES
No material clinical or coverage changes in this revision.
6supported employment components described
1:1staff-to-member ratio
T2018/T2019procedure codes referenced
4SEOB tiers
24 hrsincident reporting timeframe
Key Definitions
Competitive Integrated Employment (CIE) — definition and intent
DefinitionCompetitive Integrated Employment (CIE) — employment consistent with the jointly approved CIE definition used by DHS-DMS and DVR; services aim to obtain and maintain CIE aligned with the member's person-centered employment goals (type of work, hours, income).
IntentSupport members to obtain and maintain CIE through individualized job development, job coaching, and other employment supports described in this Scope of Service.
Job development elementsWritten goals and preferences prior to service start; matching member's skills/interests to employers; direct and indirect business networking; job duty negotiation and accommodation assessment.
Supported employment - individual — six components summary
Components summarySupported employment — individual consists of six components to assist members to obtain and maintain competitive integrated employment, including job development, job coaching, work incentives counseling, Partners with Business, follow-along supports, and outcome-based supports.
Person-centered focusServices must be consistent with the member's person-centered employment goals (type of work, preferred hours, desired income).
Authorization constraintsJob development may not be authorized for members already in CIE except to augment existing employment, obtain promotion, or negotiate more hours as specified.
Partners with Business — arrangement description for employer supports
Arrangement descriptionPartners with Business (PwB) is an arrangement where provider and employer agree on supports, documentation, training, background checks, and reimbursement processes to support a member in employment; it can be used at hire or later to augment employer supports and fade to natural supports.
Employer responsibilitiesSupervisor(s)/co-worker(s) identified to provide support must pass background checks and receive orientation training covering Supported Employment basics, PwB expectations, member-specific supports, and provider contact/backup information.
Provider responsibilitiesProvider must retain written agreement, background check copies, proof of training, evidence of monthly check-ins, employer billing documentation, and records of reimbursements for MCO review.
Outlier — definition for individual outlier determination and fee-for-service unit basis
Outlier definitionAn individual member determined to be an outlier to SEOB model assumptions and reimbursed on a fee-for-service basis using a 15-minute unit rate established by MCO Family Care at time of authorization.
Authorization periodOutlier status applies for a specific period of time as determined at authorization and is outside the SEOB payment methodology.
Rate basis15-minute fee-for-service unit rate reflects job coach costs reported and verified during the most recently completed SEOB review.
SEOB review cycle — planned evaluation cadence starting CY2022, next review CY2025
Review cadenceSEOB review is planned every third year beginning CY2022; next review year is CY2025.
Provider participationProvider participation in the review process is required through the provider contract starting in CY2022.
Elements reviewedReview evaluates payments-per-hour-worked, provider job coaching costs, amount of job coaching provided, and member hours worked using prescribed data collection and cost worksheets.
Caregiver Background Checks — reference to background check requirement
RequirementCaregiver and criminal background checks must be completed in compliance with Wisconsin DHS Admin. Code Chapter 12 and 13; documentation must be maintained and available for review.
Provider responsibilityProvider is responsible for ensuring background checks are done timely for staff and for retaining copies on file.
PwB employer checksWhen PwB supervisor(s)/co-worker(s) provide supports, they must pass the same background checks required for Job Coach; provider is responsible for ensuring and retaining these checks.
Member Incidents — definition and reporting expectation
Reporting expectationProviders must report all incidents involving an i Care Enrollee to the IDT (Care Coach or Field Care Manager Nurse) within 24 hours via phone, fax, or email.
If IDT unreachableIf unable to reach IDT, provider may leave a message for resolved/non-serious incidents; for unresolved or serious harm, the provider must attempt phone contact and follow specified escalation contacts for Family Care and Family Care Partnership.
Recordkeeping and follow-upAll reported incidents will be entered into the MCO Incident Management System and reported to DHS per contract; providers may be asked for additional information to complete investigations.
Coverage, Limitations, and Payment Rules
Coverage criteria and limitations
Service coverage requires documentation, exclusions, and provider qualifications; certain services cannot be billed concurrently and some expenses are excluded.
Service may not be provided in small-group format; ratio must be 1:1.
Before authorization, the member record must document that the service is not available under Vocational Rehabilitation (Rehabilitation Act §110) or, for ages 18-22, under IDEA.
Coverage excludes employer incentive payments, wage pass-throughs, and unrelated vocational training expenses.
Personal care may be included as a component but may not comprise the entirety of supported employment; if personal care is provided during supported employment it may be included in provider reimbursement or billed separately under supportive home care/self-directed personal care but not both; substantial personal care needs (e.g., when personal care exceeds amounts identified by IDT) must be authorized separately.
Transportation costs may be included in provider reimbursement or billed under specialized community transportation, but not both; when physical transport is required and no other option exists, transportation should be authorized separately.
Providers must conduct an assessment (not less than 80% in the community), complete a job development plan, and send both to IDT staff and the enrollee/guardian prior to job placement; placement cannot occur prior to review of assessment and plan.
Providers must maintain monthly contact with the member and employer and retain documentation required for SEOB and Partners with Business (PwB) arrangements, including agreements, background checks, trainings, and billing/reimbursement records.
Providers implementing Partners with Business (PwB) must ensure written agreements, background checks for supervisors/co-workers as indicated by PwB Support Analysis, orientation training, availability for backup supports, and retain records for MCO review; natural supports already negotiated with the employer are not reimbursable under PwB.
Individual job support staff must meet provider qualifications: CESP certification, ACRE Basic Employment Certificate, DVR-contracted supported/customized employment provider, or a minimum of two years' experience working with the target population. If personal care or transportation are provided, the provider must also meet the applicable training and qualification standards for those services.
Supported employment may be reimbursed on unit-of-service or outcome-based SEOB methods: one-time job development payments by acuity tier and ongoing monthly/hourly payments based on hours worked and member acuity tier; billing must use the specified procedure codes and modifiers per authorization.
Outlier criteria
Outlier determination and reimbursement criteria
An Outlier determination will only be considered if ALL conditions on the MCO Long Term Employment Support Outlier Checklist are met.
One of
- Member is required by court order to have 24-hour supervision (Protective Service Order indicated on LTCFS).
- Member has ongoing criminal behavior preventing fading of support without undue risk to others.
- LTCFS analysis results in a payment tier that provider, IDT, and DVR (if involved) consider insufficient to support the member in integrated employment.
- Member has unique support challenges, as determined by MCO in consultation with provider and IDT, that prevent or delay fading; outlier status may be temporary and subject to an approved plan to fade job coaching.
Outlier reimbursement is on a fee-for-service basis using the 15-minute unit rate established by MCO Family Care at authorization; these authorizations are outside the SEOB methodology and are excluded from SEOB review calculations.
Documentation retention criteria
Documentation and training requirements providers must meet and retain
Providers must retain proof that staff meet required qualifications, certification, or training standards and retain policies/procedures for supervision, complaints, and incident response.
Providers must maintain policies and evidence of verification and completion of criminal, caregiver, and licensing background checks and make documentation available for review by i Care.
Providers must maintain employee time sheets/visit records that support billing to the MCO and retain an individual enrollee file containing assessment, job development plan, training/coaching plan, copies of six‑month progress reports, and plan for long-term support.
Enrollee file must document that DVR services were denied, exhausted, or unavailable prior to providing supported employment services.
Providers must comply with licensing/certification training requirements or ensure staff are fully trained for assigned tasks; orient and train staff on Family Care/Family Care Partnership programs and on recognizing/reporting abuse and neglect, emergency response, confidentiality, cultural competence, communication, and grievance processes.
SEOB data submission criteria
Data and financial submission requirements for SEOB review years
Provider participation in SEOB review years is required by contract beginning CY2022; reviews occur on a three-year cycle (next review CY2025).
Providers must submit job coach cost worksheets in the fourth quarter of the review year in the format prescribed by the MCO.
In each targeted review year, providers must collect job coaching time and mileage and member hours worked during a designated two-week period each quarter (four two-week samples per review year) and report cumulative quarterly data to the MCO.
MCO will pull member tier data for members reported in Quarter 4 cumulative reports, conduct analysis of all data, and determine any adjustments to payments-per-hour-worked in the year following the review year; timeline examples and data collection/reporting deadlines will be provided to providers at the start of the review year.
Payment adjustment criteria
Payment adjustment rules based on organization-wide financial results and thresholds
If Organization-Wide net income is no more than 10% (or Organization-Wide net loss is no more than 10%), payments-per-hour-worked will not be adjusted in the year following the review; providers showing net loss will be offered technical assistance.
If Organization-Wide net income exceeds 10%, target job coaching percentages and/or the job coaching fee‑for‑service rate will be adjusted down the following year to bring Organization‑Wide net income to no more than 10%. If Organization‑Wide net loss exceeds 10%, adjustments will be made up to bring net loss to no more than 5%.
Provider obligations for staffing, reporting, incidents, and quality
Provider obligations and expectations for staffing, training, supervision, reporting, incident management, and quality assurance.
Background checks: Caregiver and criminal background checks must be completed in compliance with Wisconsin DHS Admin. Code Chapter 12 and 13 and documentation maintained for review.
Staff training and orientation: Providers must comply with licensing/certification training requirements or otherwise ensure staff are fully trained for assigned tasks; orient and train staff on Family Care/Family Care Partnership programs and on recognizing and reporting abuse/neglect, emergency response, confidentiality, cultural competence, communication, and complaint/grievance processes.
Supervision and staffing adequacy: Maintain adequate staffing to meet enrollee needs; provide on-site supervision, address performance issues promptly, involve supervisory staff in assessment and goal planning, and ensure collaborative communication with MCO staff.
Communication and reporting: Ensure MCO has accurate contact information; report changes in service provider and changes in enrollee needs; report missed scheduled services within 24 hours (unless alternate date scheduled); notify IDT of formal complaints/grievances within 48 hours; send written reports to IDT at least once every six months; notify enrollee and IDT when contracted services cannot be rendered.
Incident reporting and escalation: Report all incidents involving an i Care enrollee to the IDT (Care Coach or Field Care Manager Nurse) within 24 hours via phone, fax, or email; if IDT is unreachable, leave message for resolved/non-serious incidents; attempt phone contact if incident unresolved or resulted in serious harm; follow specified Family Care and Family Care Partnership escalation phone contacts when IDT is not reachable; all incidents entered into MCO Incident Management System and reported to DHS per contract.
Quality program monitoring: MCO will monitor provider compliance through quality assurance activities including legal/regulatory compliance, staff education/training, performance records (including incident tracking), contract compliance, availability/responsiveness, and collaborative quality improvement efforts focused on enrollee-centered solutions.
Payment/authorization caution: IDT must be notified if a service level modification is indicated; i Care will not pay for services that have not been authorized.
Provider notice when unable to provide services: Provider agency shall give at least 30 days' advance notice to the IDT when unable to provide authorized services; IDT will attempt to provide 30 days' notice when discontinuing services.
Codes and Modifiers
Referenced service and SEOB codesmixedCovered
| T2018 | Supported employment, integrated. Per Day / Each |
| T2019 | Supported employment, integrated. Per 15 minutes |
| Y1000 | SEOB Tier 1 outcome/payment code |
| Y2000 | SEOB Tier 2 outcome/payment code |
| Y3000 | SEOB Tier 3 outcome/payment code |
| Y4000 | SEOB Tier 4 outcome/payment code |
| Y1098 | SEOB Tier 1 job development code (variant referenced) |
| Y2098 | SEOB Tier 2 job development code (variant referenced) |
| Y3098 | SEOB Tier 3 job development code (variant referenced) |
| Y4098 | SEOB Tier 4 job development code (variant referenced) |
Telehealth modifierModifier
| 95 | Modifier indicating services delivered remotely or through telehealth |
Assessment community percentage — minimum percentage of assessment to occur in the community (80%)
Minimum community assessmentNot less than 80% of the assessment must occur in the community.
Assessment requirementProviders must conduct assessments and create a job development plan and submit both to IDT and enrollee/guardian prior to job placement.
PurposeCommunity-based assessment supports effective matching of member skills/interests to prospective employers and informs job development planning.
Provider Responsibilities, Billing, and Notifications
Prior Authorization
Prior authorization and billing requirements
Submit the completed assessment and the plan for job development to IDT staff and the Enrollee/guardian prior to any job placement; bill using the specified procedure codes and SEOB tier/payment framework.
- Assessment and job development plan must be sent to IDT Staff and the Enrollee/guardian before job placement (job placement cannot occur prior to review).
- Billing uses the SEOB tiered outcome and monthly/hourly payment model; referenced procedure codes include T2018 and T2019 and SEOB tier codes (e.g., Y1000–Y4000).
- Providers must maintain documentation validating hours worked for SEOB billing and authorizations.
Prior Authorization
Referral response and prior authorization
Respond to the IDT within two (2) business days to accept or decline a referral; retain copies of authorization notifications and ensure IDT prior authorizes all services before they are rendered.
- Provider must respond to IDT within two (2) business days to accept or decline a referral and work with IDT to ensure services begin as planned.
- IDT must prior authorize all services and provide authorization details (start date, duration, units, expected outcomes) to Provider.
- Provider must retain copies of the authorization notification; IDT will issue a new authorization when tasks/amount/frequency/duration change.
Billing Rule
Telehealth claim modifier (modifier 95 required)
Include modifier 95 on claims for services delivered remotely or through telehealth.
- Provider must include modifier 95 when submitting claims for services delivered remotely or through telehealth.
Documentation Required
Provider notification requirements
Notify the IDT promptly of changes in service provider, changes in the enrollee’s needs or availability, and when contracted services cannot be rendered; submit formal complaint notifications and periodic written reports as required.
- Report any change in service provider to the IDT.
- Report changes in the Enrollee's needs or abilities and unavailability for scheduled services (within 24 hours unless an alternate date is scheduled).
- Notify IDT of formal complaints or grievances within 48 hours and submit written complaint investigation results to the IDT.
- Send a written report to the IDT at least once every six months; notify Enrollee and IDT when contracted service cannot be rendered.
Documentation Required
Incident reporting (24-hour requirement)
Report all incidents involving an i Care Enrollee to the IDT (Care Coach or Field Care Manager Nurse) within 24 hours via phone, fax, or email; escalate unresolved or serious incidents by phone and follow specified backup contacts if IDT is unreachable.
- Report incidents to the IDT within 24 hours; if resolved and not serious, leaving a message is acceptable if staff cannot be reached.
- If the incident is unresolved or resulted in serious harm, attempt phone contact with the IDT.
- If IDT cannot be contacted: Family Care — call 1-877-622-6700; Family Care Partnership — call 1-800-777-4376 and ask for a Care Management Support Manager.
- All reported incidents will be entered into the MCO Incident Management System and reported to DHS per contract; providers may be asked for additional information.
Policy Summary
Payerintegrated_home_care_services
PolicySupported Employment - Individual (Scope of Service)
Policy CodePolicy N/A
Change TypeNo material changes
Effective DateNov 21, 2025
Next Review DateN/A
Key ActionProviders must submit assessment and job development plan to the IDT before job placement and obtain authorization prior to billing.
SourceLink
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