Contract Type: Employment Supports for Brain Injury
The contractor and contractor's staff that provides the services described in this chapter also must comply with Chapters 1–3 of the VR Standards for Providers manual.
On this page:
The Employment Supports for Brain Injury (ESBI) contract must identify the licensed and certified professionals that the provider plans to use in the delivery of ESBI services.
To obtain an ESBI contract, the provider also must either:
When an ESBI provider chooses to partner with another approved TWC-VR Employment Service provider, the ESBI contract must provide documentation signed by all parties that outlines the relationship and roles of the agreement to the ESBI-assigned contract manager and to the state office program specialist assigned to ESBI. When an ESBI provider subcontracts TWC-VR employment services, the ESBI provider must maintain an Employment Services Contract and must comply with Chapter 3: Basic Standards, 3.1.7.1 Subcontractors.
For more information about the VR standards for providers, the provider can contact a state office program specialist at the VR Standards Mailbox.
Definitions of the terms that apply to this contract are listed in the VR Glossary.
Employment Supports for Brain Injury (ESBI) is designed to integrate the therapeutic and employment needs of VR customers who have persistent functional limitations resulting from an acquired brain injury (traumatic and non-traumatic injuries). ESBI services are individualized and multidisciplinary with a focus on employment. ESBI may involve the coordinated services of multiple providers for the achievement and retention of competitive integrated employment consistent with the customer's unique strengths, resources, priorities, concerns, abilities, capabilities, interests, and informed choice.
Customers may:
ESBI services focus on the customer's ability to obtain, maintain, and advance in employment and to participate in community reintegration activities to prepare for employment by:
ESBI services can be performed in either a nonresidential or residential setting. The VR counselor and customer will determine which services are necessary to meet the customer's individual employment needs and circumstances.
Both the ESBI therapist and ESBI employment service provider(s) can provide evaluations and services to address the following:
ESBI services will include one or more employment services, as described in this manual, such as:
An ESBI employment service provider will assist the customer, when necessary, in obtaining competitive integrated employment for a successful employment outcome.
The customer's individualized plan for employment (IPE), Initial Assessment and Evaluation Plan (IAEP), Individualized Program Plan (IPP), and service authorization(s) will identify which assessments, evaluations, and services a customer will receive and who will provide the assessments, evaluations, and services.
The customer's participation in ESBI should lead to the customer obtaining competitive integrated employment, as defined in CFR §361.5(c)(9). The customer must also have unexpired employment authorization documents to participate in the ESBI services.
The VR counselor monitors the customer's progress throughout participation in ESBI services by meeting regularly with the customer and the customer's interested support system, as authorized; the ESBI provider; and other interdisciplinary team members, and by reviewing the documentation submitted.
When rehabilitation treatment is not leading to progress toward employment goals, the VR counselor works with members of the interdisciplinary team (IDT) to develop appropriate modifications to the plan. When this is not possible, the VR counselor may discontinue sponsorship of the treatment and address alternatives for independent living or other services as indicated.
All staff qualifications and training required by the provider's license, registration, and/or credential must be maintained per applicable regulations and requirements.
Each ESBI provider who has an employment services contract must have a designated director who maintains the University of North Texas Workplace Inclusion and Sustainable Employment (UNTWISE) director credential and serves as the primary contact between TWC-VR and the provider. See Chapter 3: Basic Standards, 3.4.2 Director for more information.
TWC-VR purchases services only from providers that comply with the appropriate standards in this manual and applicable federal and state licensing standard and/or certification.
The ESBI provider must keep proof of a license or certification on file for any licensed or certified professional and must produce the license or certification at the request of TWC staff.
Below are the qualifications for the licensed professionals who provide ESBI services:
Must be a psychologist or neuropsychologist, a licensed clinical social worker (LCSW), licensed professional counselor (LPC), or licensed by the Texas Department of Licensing and Regulation as a behavior analyst (BA).
Must be licensed as one of the following:
Must be licensed by the Texas Board of Occupational Therapy Examiners to practice in the state where services are rendered.
Must be licensed by the Texas Board of Physical Therapy Examiners to practice in the state where services are rendered.
Must be licensed by the Texas State Board of Examiners of Psychologists or licensed to practice in the state where services are rendered (unless exempt). Community-based behavioral health and developmental disability services centers and some state agencies are exempt from the licensing act.
Must be licensed as a speech and language pathologist by the Texas Department of Licensing and Regulation.
Below are the qualifications for the certified professionals who provide ESBI services.
Must be certified by the Brain Injury Association of America as a Certified Brain Injury Specialist (CBIS). For information go to the Brain Injury Association of America.
Must be certified by the Commission for Case Manager Certification or be a master-level social worker or licensed or certified professional, as listed in this section of the chapter, with a minimum of five years of experience in case management for individuals with brain injury. For information go to the Commission for Case Manager Certification website.
Must be certified by the National Council for Therapeutic Recreation Certification as a Certified Therapeutic Recreation Specialist (CTRS). For information go to the National Council for Therapeutic Recreation Certification website.
The ESBI provider must provide sufficient direct-care staff, per state licensure requirements, to manage and supervise customers in accordance with their IPP. The provider must have enough direct-care staff to provide care and services so that customers do not injure themselves or others or destroy property. Special staffing needs identified by the IPP (for example, one-to-one ratios) must be provided. Adequate numbers of direct-care staff must be available to supervise customers during periods of time when other direct-care staff members are unavailable (for example, during breaks, meals, meetings, and training).
Any individual who provides employment-related services, via a TWC-VR Employment Services contract, must meet the staff qualifications prescribed for employment services in this manual. When an ESBI contractor subcontracts any service from another approved Employment Services provider, the contractor must ensure that the staff providing the service(s) meets the prescribed qualifications in this manual. To obtain an Employment Services contract for any service, the applicant must have an employee that meets the qualifications of the service.
The provider's director must approve the VR3455, Provider Staff Information Form, completed by each staff member, and submit the approved form to the provider's assigned TWC contract manager and assigned VR regional program specialist.
The links below will take you to the qualifications:
A supported employment specialist must have a:
All direct care staff and Employment Services provider staff members who provide direct services must receive, before assuming any job responsibilities and at least annually thereafter, training in the following areas:
To provide services in the ESBI model the provider must maintain active TWC-VR contracts for ESBI. For Employment Services, the provider must also maintain a TWC-VR Employment Services contract that includes Supported Employment Services unless the provider has a formal partnership or subcontract with a TWC-VR Employment Services provider that has Supported Employment Services in its contract. The ESBI contractor must provide documentation, signed by all parties, that outlines the relationship and roles of the agreement to the ESBI-assigned contract manager and to the state office program specialist assigned to ESBI.
All residential and nonresidential contractors providing ESBI services must be current in their registration or licensure, with one or more of the following, as applicable and as required by Texas law:
Facilities providing only psychological or neuropsychological services, evaluations and cognitive therapy are waved from the above requirements (registration or licensure) as long as all staff are appropriately licensed or certified, and all other standards and contracting requirements are met. Occupational therapy (OT) and physical therapy (PT) services must be provided from a facility with registration.
A residential ESBI provider also must maintain accreditation from:
TWC-VR may grant a two-year grace period for a residential facility to obtain an accreditation listed above, when the residential facility is a new contractor with TWC-VR.
All contractors must maintain current proof of all required licenses, registrations, and accreditation with the contractor's assigned TWC-VR contract manager and state office program specialist assigned to the ESBI.
When the facility is inspected, the contractor is required to provide any monitoring and/or inspection report summaries by other agencies to the assigned TWC-VR contract manager and the state office program specialist assigned to the ESBI program within five business days of receiving the report.
TWC-VR will not refer new customers to an ESBI contractor whose licensure, registration, or accreditation is under an action to deny or suspend, is revoked, or is not renewed, until such action has been resolved. A facility currently providing services to VR customers is required to notify TWC-VR when the facility's licensure, registration, or accreditation is suspended or revoked within one business day of receiving notification. A facility that fails to timely notify TWC-VR of any such action is considered out of compliance with contract terms and conditions.
TWC-VR mandates that the facility must comply with the Americans with Disabilities Act (ADA) and must complete the "ADA Checklist for Existing Facilities," based on the 2010 ADA Standards for Accessible Design, found at ADA Checklist for Existing Facilities. This document must be kept on file and made available to TWC-VR staff upon request.
In addition to this chapter, the provider is responsible for meeting the requirements published in the following:
Below are additional requirements that apply when a contractor has a contract for the ESBI program.
The provider must notify (within one business day) the VR counselor when any of the following occur:
When an ESBI program owns and operates a vehicle to transport TWC-VR customers, it must ensure that transportation is available in accordance with the ADA and with all applicable state laws. The ESBI program must also comply with SFP 3.4.9 Transportation.
ESBI contractors must use physical and chemical restraints only when necessary to maintain a customer's safety or the safety of others.
Residential providers must have identified staff trained to administer physical and chemical restraints in an emergency to maintain safety, as allowed by the licensees and certifications held as an ESBI provider.
Nonresidential providers must have identified staff members trained to administer basic physical restraint techniques and use community emergency providers, when necessary to physically and chemically restrain a customer.
All providers must develop policies and procedures and train staff on how to respond to emergency situations. TWC-VR requires that all emergency situations, including use of physical and chemical restraints, be reported as explained in Chapter 3: Basic Standards, 3.2.9 Safe and Secure Environments. The provider must document the details of the incident in a written report and provide the report to the VR counselor.
When the customer's escalated behaviors can be managed with a behavior plan, a plan must be developed and included as part of the customer's IPP. See 21.8 Behavior Intervention Plan (BIP) Service Definition for requirements.
Customers who are assessed to have aggressive or dangerous behaviors to themselves or others that cannot be regulated with medication will be considered not ready to benefit from ESBI services until the behavior issues are resolved. The VR counselor will work with the provider to discharge the customer to a safe environment.
If the provider observes or has other evidence of the customer's use of alcohol or drugs, the provider must report the observations and evidence within one business day to the VR counselor. The provider must document that the VR counselor was informed of all observations and other evidence of the customer's use of alcohol or drugs.
If a customer requires medical treatment for an injury sustained while receiving ESBI services or requires treatment for an illness derived from participating in services (such as food poisoning, known food allergic reaction from an known allergy) that is not related to the customer's acquired brain injury, the customer's medical services and expenses would be the liability of the contractor and are not covered by the VR program as ESBI services. If for any reason the customer should become unable to participate and/or is not progressing toward goal attainment in the IPP, the IDT will need to prepare the customer for discharge to another appropriate resource.
If the provider plans termination of services for reasons other than successful employment, the provider must inform the VR counselor that a customer's services are being terminated before the termination takes place. The provider must document that the provider informed the VR counselor about the termination of services to a customer.
The provider must follow the state and federal requirements applicable to the license or certification relating to discharge procedures. The provider must ensure the customer is safe, determine a discharge site, and facilitate placement.
Some reasons for termination before achieving goals include:
Also refer to VR-SFP 3.4.12 Termination of Service Delivery.
See Chapter 3: Basic Standards, 3.2.6 Referrals to VR by Providers for information.
The ESBI provider must comply with Chapter 3: Basic Standards, 3.4.11 Contracted Services Modification Request.
ESBI programs are monitored for the success rate of customers obtaining and maintaining competitive integrated employment while receiving ESBI services and after VR closure.
When applicable, Chapter 3: Basic Standards, 3.1.3 Contract Noncompliance and Performance Deficiencies will be enforced.
The weekly activity schedule for residential and non-residential services must:
Additionally, for residential services, the weekly activity schedule must include activities of daily living, meals, and non-therapy activities focused on further skill development.
Weekly time logs must include all therapy sessions and applicable employment services provided to the customer. Time is recorded in 15-minute increments:
A week is defined as Sunday through Saturday.
Weekly time logs are submitted to the VR counselor weekly and included with the monthly invoice submitted to the VR unit's purchasing specialist. Services recorded in the weekly time log must match the entries in daily and weekly progress notes for any service provided by licensed and certified professionals. Refer to 21.2.1 Licensed and Certified Professionals for information and requirements for licensed and certified professionals.
Any services provided by licensed and certified professionals must be documented with a daily progress note. All services provided must related to a goal on the customer's IPP. Goals addressed in the daily service must be noted in the documentation. The amount of services provided must be noted in 15-minute increments. Time recorded in the progress report for documentation, communication (for example, email messages and phone calls), and travel time is noted with 0 (zero). Reimbursement for administrative cost related to documentation, email messages and phone calls are included in the rates. Progress reports are submitted weekly to the VR counselor and included with the monthly invoice submitted to the VR unit's purchasing specialist.
A detailed summary report for each discipline providing service must be completed after each IAEP and IPP meeting. The summary must describe the progress status toward any goals identified on the plans, discharge disposition information, and/or newly identified issues.
ESBI services are designed to integrate clinical therapies and employment services to result in the customer achieving competitive integrated employment. Clinical therapies are partnered with employment service providers to achieve the goals outlined in an IPP.
Evaluations and assessments are authorized by the VR counselor with a TWC-VR service authorization to determine if ESBI services are necessary. Assessments and evaluations cannot be performed without a service authorization.
When a customer has transferred from another therapy-based service to ESBI services, the evaluation(s) previously completed may be sufficient to determine whether ESBI services are necessary and to develop the customer's ESBI IPP. The IDT recommends when evaluations are necessary. The VR counselor determines the evaluations that will be provided via the service authorization.
The results of the initial assessments identify the goals for cognitive rehabilitation, goals for other therapies and employment services, and the need for any additional supports to be included in the customer's case-managed IPP. The IDT provides services and supports for the customer when authorized by the VR counselor with a service authorization.
Initial and continued funding for ESBI services is contingent on the availability of VR funds and the decision of the VR counselor on the customer's progress toward the established goals of preparing for, securing, retaining, or advancing in employment.
Below are descriptions of services available through ESBI services.
Case management services are client-centered, safe, timely, effective, efficient, and equitable, and are in alignment with customer's IAEP or IPP. Case management services are only available for customers in a nonresidential setting.
Case managers serving customers in a residential setting must provide the same tasks as those described below; the fee to perform the services is included in the residential service base rate.
The case manager may provide the following:
Service |
Includes Tasks Such As: |
Allowed Up To |
---|---|---|
Facilitation of the IAEP Meeting and Associated Reports |
Includes tasks such as the following:
Note: When residential services are recommended, the VR counselor coordinates a referral with a ESBI provider, and case management services begin with the coordination of initial evaluation and associated reports.
|
Allowed 1 time per admission |
Coordination of Initial Evaluation and Associated Reports |
Includes tasks such as the following:
|
Allowed 1 time per admission |
Coordination of Initial IPP and Associated Reports |
Includes tasks such as the following:
|
Allowed 1 time per admission |
Coordination of Monthly IPP Reviews and Associated Reports |
Includes tasks such as the following:
|
Allowed 1 time per month |
Coordination of Discharge Summary and Associated Reports |
Includes tasks such as the following:
|
Allowed 1 time per admission |
The ESBI provider receives a referral and a service authorization for case management and assigns a case manager.
When residential services are recommended, the VR counselor coordinates a referral with an ESBI provider and case management services begin with the coordination of initial evaluation and associated reports.
The case manager performs the tasks listed in the service definition by completing a progress report to document the completed task(s).
The case manager ensures the requirements for the following are completed:
The case manager submits the progress report that describes the tasks completed and submits the invoice.
The case manager documents in descriptive terms the tasks completed for the following:
Payment for the above case management services is made when the VR counselor approves the submitted:
See:
The IAEP is completed to identify any therapy evaluations or employment services to be used to determine the customer's abilities related to obtaining and maintaining competitive integrated employment. During the meeting any existing evaluation(s) are reviewed to determine what evaluations, if any, need to be completed before the IPP is developed.
The IAEP must include measurable goals that identify:
TWC-VR sends a referral packet to the ESBI provider.
The case manager:
The VR counselor outlines the TWC-VR expectations for the customer's participation in ESBI services.
The IDT completes the IPP.
The case manager obtains the required prescriptions.
TWC-VR issues service authorizations for therapies and employment services for the amount of time described in the IAEP.
The case management fee is available only for nonresidential services.
See the requirement for the case management services definitions for:
See:
The assessments and evaluations are performed by licensed and/or certified professionals, as previously defined, and/or by TWC-VR qualified Employment Services providers. Initial assessments are performed for both residential and nonresidential customers, as authorized by the VR counselor and as prescribed by the treating physician. Assessments and evaluations results must identify recommendations for:
Therapy evaluations include the following:
The following employment services can be used to conduct evaluation activities.
Vocational Evaluation is an assessment of an individual's work and training background, general functional capacities, and social and/or behavioral characteristics. The vocational evaluation must contain a detailed description of the customer's behaviors and must describe any implications for the workplace. The evaluation must be designed to determine the customer's present and future vocational potential. For a detailed service description, the process and procedures, and the outcomes required for payment, see Chapter 4: Employment Assessments, 4.3 Vocational Evaluation.
Vocational Evaluation—Situational Assessments and Work Samples are tools to help the customer and VR counselor determine the customer's long-term goals related to obtaining competitive integrated employment. The prerequisite is a completed vocational evaluation. For a detailed service description, the process and procedures, and the outcomes required for payment, see Chapter 4: Employment Assessments, 4.4 Vocational Evaluation - Situational Assessments and Work Samples.
Environmental Work Assessment (EWA) is a diagnostic tool that assesses how the customer responds to variables in a work environment. The EWA is an accurate assessment of the correlations between a customer's performance and environmental variables and is critical to the customer's ability to obtain and maintain employment. Results of the assessment identify the variables in a work environment that affect the customer's ability to function at the customer's full potential. For a detailed service description, the process and procedures, and the outcomes required for payment, see Chapter 4: Employment Assessments, 4.5 Environmental Work Assessment.
Work experience services allow a customer to be placed at a business or an agency within the community to gain short-term experience to obtain skills that are transferable to future long-term competitive integrated employment. Work experience can assist in determining whether a customer is ready for competitive integrated employment; exploring career options; and/or developing skills to include in the individual's résumé for a certain vocation. There are three Work Experience Services. For detailed service descriptions, the process and procedures, and the outcomes required for payment of each service, see the applicable link below:
Supported Employment Assessment (SEA) is for customers with the most significant disabilities. The SEA is a person-centered evaluation that includes a discovery process that takes approximately 20–30 hours to:
For a detailed service description, the process and procedures, and the outcomes required for payment for each, see Chapter 18: Supported Employment Services.
The ESBI service provider and/or employment service provider receives the service authorization(s) for the approved assessment(s) and evaluation(s) identified in the customer's IAEP.
Assessments and evaluations are scheduled.
The assessments and/or evaluations are performed by licensed and/or certified professionals and/or by qualified TWC-VR employment service providers.
Weekly Activity Schedules and Weekly Time Logs are completed.
A licensed and/or certified professional or qualified employment service provider completes the required assessment and/or evaluation reports.
Reports are submitted to the VR counselor.
The VR counselor receives the following accurate and descriptive documents associated with the licensed and/or certified professional evaluation or assessment or qualified employment service evaluations:
The assessment and evaluation results contain:
Assessments and evaluations are paid based on:
Payment for assessment and evaluation services are paid when the VR counselor approves the submitted:
A case manager can bill for attendance, reporting, and documentation related to the IAEP for Nonresidential services. A licensed and/or certified professional may bill one 15-minute increment for attendance of a customer's IAEP or IPP.
See:
The IPP is completed to identify any therapy or employment services interventions to be provided to improve the customer's skills and abilities related to obtaining and maintaining competitive integrated employment. During the initial meeting, goals are established; goal status is reported in monthly meetings; and goals are updated, added, and removed as necessary. The customer's IPP is updated at a minimum of every 30 calendar days or more frequently to respond to a customer's change needs that require immediate attention for safety or continued engagement in the program and at discharge. The completed IPPs must be submitted three business days after the IPP meeting is held. The IPP must be approved and signed by the VR counselor, with a service authorization issued before service delivery.
The IPP must include measurable goals that identify:
TWC-VR sends the case manager and the employment service provider the service authorizations.
The case manager arranges the IPP meeting.
The IDT completes and updates the IPP.
The case manager obtains the required prescriptions.
TWC-VR issues service authorization for therapy, employment service, and any ancillary good/service as defined in the IPP.
Case management fee is only available for nonresidential services.
See requirement for case management service definition for the following:
See:
Therapy services are performed by licensed and/or certified professionals. Services are performed for both residential and nonresidential customers, as authorized by the VR counselor and prescribed by the treating physician. Residential therapy services are limited to 120 cumulative calendar days of therapy, unless a TWC-VR manager approves additional days of therapy. Nonresidential hours must total 20 hours or fewer per week, for no more than 12 weeks. Additional times require VR manager approval.
Therapy services should develop and improve the customer's:
Time spent completing documentation, phone calls, emails, and travel are not counted as therapy services. A licensed and/or certified professional may bill one 15-minute increment for attendance of a customer's IAEP or IPP.
When therapy services are performed in the community setting, the ESBI provider can bill for travel once per day. See 21.12.4 Premium Payments.
Therapy services include, but are not limited to the following:
All services must be prescribed by a treating physician. In the case of cognitive rehabilitation therapy, psychological and neuropsychological services, the neuropsychologist/psychologist is allowed to diagnose and/or provide cognitive therapy without an additional prescription.
The case manager obtains prescriptions from the treating physician.
Therapy services are scheduled.
Therapy services are provided, as defined in the customer's IPP.
Therapy services are performed by licensed health care professionals and as defined in the customer's IPP.
Weekly activity schedules and weekly time logs are completed.
Licensed and/or certified professionals complete the required progress report describing each treatment session in detail.
Reports are submitted to the VR counselor.
The status of goals is updated in the monthly IPP meetings.
VR counselor receives the following complete, accurate, and descriptive documents:
The therapy documentation contains progress notes and recommendations related to:
The time to attend the IPP meeting and update the IPP is not billable.
Therapy services are paid based on:
Payment for therapy services is made when the VR counselor approves the submitted:
Employment services focus on:
Employment services, as defined in this manual by the ESBI program, includes the following:
Vocational Adjustment Training (VAT) prepares participants to successfully obtain and maintain competitive integrated employment. There are six VAT services. Use the links below to obtain information on the service description, the process and procedures, and the outcomes required for payment:
Work Experience Services allow a customer to be placed at a business or an agency within the community to complete short-term experience to gain skills that are transferable to future long-term competitive integrated employment. Work experience can assist in determining whether a customer is ready for competitive, integrated employment; exploring career options for an individual; and/or developing skills to include in an individual's résumé for a certain vocation. There are three Work Experience Services. For a detailed service description, the process and procedures, and the outcomes required for payment of each, see the following:
Bundled Job Placement is a benchmark service that assists customers in preparing for and completing the job search process. Bundled Job Placement helps customers obtain a job that meets their needs, as outlined in the VR1845B, Bundled Job Placement Services Benchmark Service Plan–Part B and the Benchmark Status Report. For a detailed service description, the process and procedures, and the outcomes required for payment, see Chapter 17: Basic Employment Services, 17.4 Bundled Job Placement Services.
Job Skills Training teaches skills, reinforces skills, and develops or sets up accommodations and/or compensatory techniques to increase the customer's independence and ability to meet the employer's expectations when placed in the final placement for VR case closure. The training is purchased when a customer needs more training and support than is provided by the employer. For a detailed service description, the process and procedures, and the outcomes required for payment, see Chapter 17: Basic Employment Services, 17.5 Job Skills Training.
Supported Employment is an outcome-based system service that uses the Place, Then Train model for employment placement. Supported Employment is for customers with the most significant disabilities. The service includes an assessment, assistance in finding an appropriate job match, support services to learn the job and set-up and establish extended services, sometimes called long-term supports, for the customer to maintain a long-term competitive integrated employment outcome. For a detailed service description, the process and procedures, and the outcomes required for payment, see Chapter 18: Supported Employment Services.
The service authorization is received.
The services are scheduled and provided, as defined in the customer's IPP.
The employment services are performed by qualified employment service providers that meet the required staff qualifications.
The employment service provider completes the required documentation, as described in this manual.
Reports are submitted to the VR counselor.
The status of goals is updated in the monthly IPP review.
Refer to the employment service Outcomes Required for Payment at the service links above.
Employment service fees are not included in the ESBI residential or non-residential rates. Employment services are invoiced separately. The time needed to attend Initial Assessment and Evaluation Plan (IAEP) meetings is paid at $37.50 per meeting.
Refer to the employment service fees located at the service links above.
Providers must develop a discharge summary for each employed customer that includes:
When the customer is not employed at discharge, the providers must provide a detailed description documenting the following:
The case manager ensures that the IDT completes the discharge plan, including all required information prescribed in the discharge plan service description.
At discharge, the discharge plan is implemented, and a summary is developed by the case manager, with input from all members of the IDT. Each clinical therapy service must complete and attach a formal discharge summary. For any employment services the provider will attach the required documentation for the applicable service, as defined in this manual's service description, the process and procedures, and the outcomes required for payment.
The case manager's completed discharge summary with all required information submitted simultaneously to the VR counselor and the unit program specialist within 10 business days of the customer's discharge.
When case management is not a covered expense by comparable benefit, an invoice must be submitted with the discharge report.
Only a case manager can bill for attendance, reporting, and documentation related to the IPP.
All IDT members, including the case manager's fee, are included in the Residential base daily rate.
A behavior intervention plan (BIP) is a plan designed to teach emotional self-regulation skills and reward positive behaviors. A BIP may include use of therapeutic medications. This can help prevent or stop problem behaviors that will affect a customer's success with maintaining competitive integrated employment. The BIP is based on the results of the Functional Behavior Analysis (FBA). When the IAEP and IPP are being developed and updated, the IDT provides observation and feedback combined with the results of the FBA to develop a BIP that compliments the customer's IPP.
Both the FBA and the BIP can be created, monitored, and updated by a:
The BIP describes the problem behavior, the reasons the behavior occurs, and the intervention strategies that will address the problem behavior. A BIP can help a customer learn problem-solving skills, coping skills, and use compensatory techniques to better respond to a situation that maybe present as the customer prepares for, obtains, and maintains competitive integrated employment. The plan can also explain who is responsible for helping the customer with each aspect of the BIP. Refer to 21.4.3 Safe and Secure Environment to ensure compliance with use of physical and chemical restraints.
Customers who are assessed to have aggressive or dangerous behaviors to themselves or others are not ready to benefit from ESBI services until issues have been resolved and the focus can be directed on building appropriate social skills required for work behavior.
The IDT identifies whether a customer may benefit from a BIP.
Required prescriptions and service authorizations are obtained.
A functional behavior analysis is completed with an assessment report.
As needed, a BIP is created by the FBA evaluator with input from the IDT.
The IDT implements the BIP.
The customer's responses to the BIP are evaluated at the customer's monthly IPP meeting but can be updated more frequently when necessary. BIP progress is documented at the IPP and other times as deemed necessary.
A report of the customer's progress must be submitted any time a behavior management service is invoiced.
An FBA is required when a BIP is developed.
Behavior management can be invoiced if the therapy or employment service being provided is solely focused on the BIP implementation.
A progress report describing the professional interventions based on the approved BIP and the customer's response is required.
Time must be documented in the weekly time logs.
Nonresidential Rate Structure (link to 21.12.5 Nonresidential Rate Structure):
Only a case manager can bill for attendance, reporting, and documentation related to the IPP.
All IDT members, including the case manager's fee, are included in the Residential base daily rate.
Goods and services related to an individual's acquired brain injury, which are not therapy services and are not delivered as part of ESBI nonresidential or residential services, are considered to be supports of ESBI services. The provider must submit an IPP that identifies the goods and services needed for the customer to obtain a service authorization from the VR counselor.
The IPP must include:
These services may include, but are not limited to:
TWC-VR will consider purchasing support services when required to enable participation in an ESBI-approved service. These support services are paid according to the Maximal Affordable Payment Schedule (MAPS) or the durable medical equipment (DME) contract as applicable.
ESBI services are provided at a facility that can address post-acute medical issues, can address rehabilitation issues, and provide 24-hour-a-day support and services that are based on a customer's individual needs. Residential services can be provided while the customer is receiving initial assessments and evaluations, as described in the customer's Initial Assessment and Evaluation Plan (IAEP) and/or during the implementation of the customer's Individual Program Plan (IPP). The facility must meet all applicable requirements outlined in 21.3 ESBI Provider Qualifications and 21.4 ESBI Provider Requirements. A service authorization will identify the number of days approved for residential services. The customer must actively participate in the program and make progress toward the goals in either the IAEP or IPP for continued sponsorship of residential services.
The base residential service rate includes administrative costs, room and board, paraprofessional services, medical services (that is, physician and nursing services), dietary and nutritional services, case management, time spent for documentation, communication (such as emails and phone calls), and travel time. When a customer is absent from the facility, the facility is not eligible to invoice for the base service rate. These services may not be billed separately to the VR program. For information about ESBI residential base services, refer to 21.12.6 Residential Rate Structure.
Goods and services related to an individual's acquired brain injury, which are not delivered as part of ESBI residential services, may be considered ancillary if approved by the VR counselor. Refer to 21.9 Other Support Goods and Services.
ESBI services provided as a day program or as outpatient therapy services are nonresidential services. The facility must meet all applicable requirements outlined in 21.3 ESBI Provider Qualifications and 21.4 ESBI Provider Requirements. Nonresidential services can be provided while the customer is receiving an initial assessment or evaluation, as described in the customer's IAEP and/or during the implementation of the customer's IPP. All services provided must be provided by individuals who meet the staff qualifications described in 21.2 Staff Qualifications, Ratios, and Training. A nonresidential service provider must offer cognitive therapy but is not required to provide all of the other core services described in 21.5.2 Initial Assessment and Evaluation Plan Service Definition and 21.12.5.1 Core Services. The IDT will be coordinated to include other service providers, as needed.
Time spent for documentation, for communication (such as emails and phone calls), cannot be billed as a core service or as an ancillary service. When a customer is absent from nonresidential services for any reason, the ESBI provider is not eligible to invoice TWC-VR for any fees, including no-show fees. The nonresidential service provider must notify the VR counselor of an absence greater than one day. For information about the ESBI Nonresidential service fees go to 21.12.5 Nonresidential Rate Structure. A service authorization will identify the type and amount of nonresidential services and must be obtained before service delivery. The customer must actively participate in the program and make progress towards the goals in either the IAEP or IPP for continued sponsorship by TWC-VR for Nonresidential Services.
Goods and services related to an individual's acquired brain injury, which are not delivered as part of ESBI nonresidential services, maybe considered ancillary if approved by the VR counselor. Refer to 21.9 Other Support Goods and Services.
All rates are inclusive of any administrative activities (such as emails, phone calls and documentation) required to produce the service.
Two therapists cannot bill for the same period of time. In co-treatments, therapy units and/or time are divided by the number of therapists delivering the service to determine the amount of time to be attributed to each. For example, if a physical therapist and an occupational therapist deliver one hour of individual therapy to a customer together, then the physical therapist's time is billed as 30 minutes and the occupational therapist's time is also billed as 30 minutes.
A small group is no more than two customers to one licensed or credentialed professional. A group is three and no more than six customers to one licensed or credentialed professional.
Core services must be provided by a contractor's staff member who meets the qualifications prescribed in 21.2.1 Licensed and Certified Professionals.
When a clinical therapist provides and employment services as defined in this manual, such as Work Experience, Job Placement, or Supported Employment, it must be provided through an Employment Services Contract and the service can only be invoiced as an employment service. When a clinical therapist co-treats with an employment service provider, the clinical therapist and the employment service provider must be addressing independent goals. The role of a clinical therapist in the co-treatment is to increase the customer's independence related to the disability such as: evaluating safety/cognitive abilities in the employment environment, identifying compensatory techniques and/or use of adaptive equipment that will increase abilities and/or independence, and/or training the customer, employment service provider and/or employer in disability-related issues that will be managed long-term by parties other than the clinical therapist. The role of the employment service provider is to deliver the services as defined in the Standards for Providers achieving all required outcomes for payment.
Premium payments compensate the contractor:
Premium payment amounts are:
Premium Payments |
Rates |
---|---|
Licensed or Certified Professional who is a CBIS, as described in 21.2.1 Licensed and Certified Professionals |
$2.19 per 15-minute increment |
Community-Based Service |
$3.96 per 15-minute increment |
Transportation costs related to all core services delivered within the community within 24 hours. |
$47.08 per day |
Core services must be provided by a contractor's staff member who meets the qualifications prescribed in 21.2.1 Licensed and Certified Professionals. Nonresidential hours must total 20 hours or fewer per week, for no more than 12 weeks. Additional times require VR manager approval. All rates below are in 15-minute increments.
Core Services (rates set in 15-minute increments) |
Rates |
---|---|
Behavior Management |
|
Behavior Management Individual |
$28.31 |
Cognitive Rehabilitation Therapy (CRT) |
|
Cognitive Rehabilitation Therapy Individual |
$29.03 |
Cognitive Rehabilitation Therapy Group |
$5.81 |
Cognitive Rehabilitation Therapy Small Group |
$14.51 |
Medical Services Team |
|
Attend IDT meeting with customer and family |
$28.43 |
Attend IDT meeting without customer and family |
$18.59 |
Neuropsychological Services |
|
Neuropsychological Services Individual |
$32.61 |
Neuropsychological Services Evaluation |
$48.15 |
Neuropsychological Services Reevaluation |
$21.95 |
Neuropsychological Services Group |
$6.52 |
Neuropsychological Services Small Group |
$16.31 |
Occupational Therapy |
|
Occupational Therapy Individual |
$34.38 |
Occupational Therapy Evaluation |
$33.24 |
Occupational Therapy Reevaluation |
$31.32 |
Occupational Therapy Group |
$6.88 |
Occupational Therapy Small Group |
$17.19 |
Physical Therapy |
|
Physical Therapy Individual |
$29.25 |
Physical Therapy Evaluation |
$45.01 |
Physical Therapy Reevaluation |
$43.25 |
Physical Therapy Group |
$5.85 |
Physical Therapy Small Group |
$14.62 |
Recreational Therapy (Therapeutic Recreation) |
|
Recreational Therapy Individual |
$31.17 |
Recreational Therapy Group |
$6.23 |
Recreational Therapy Small Group |
$15.59 |
Speech/Language Pathology |
|
Speech/Language Pathology Individual |
$27.81 |
Speech/Language Pathology Evaluation |
$40.24 |
Speech/Language Pathology Reevaluation |
$33.81 |
Speech/Language Pathology Group |
$5.56 |
Speech/Language Pathology Small Group |
$13.90 |
Licensed and certified professionals may bill one 15-minute increment for attendance of a customer's IAEP or monthly IPP.
Occupational Therapy Individual for 45 minutes |
3 X $34.38 |
$103.14 |
Occupational Therapist is CBIS-certified |
3 X $2.19 |
$6.57 |
Occupational Therapy was conducted at the library—customer volunteer learning to perform transferable skills |
3 X $3.96 |
$11.88 |
Total for the Occupational Therapy Individual Session |
$121.59 |
Case management services must be provided by a contractor's staff member who meets the qualifications prescribed in 21.2.1 Licensed and Certified Professionals for a case manager.
Case Management |
Frequency |
---|---|
Facilitation of the Evaluation Plan Meeting and Associated Reports |
|
Coordination of Initial Evaluation and Associated Reports |
|
Coordination of Initial IPP and Associated Reports |
|
Coordination of Monthly IPP Reviews and Associated Reports |
|
Coordination of Discharge Summary and Associated Reports |
|
Residential base rate includes administrative costs, room and board, paraprofessional services, medical services (that is, physician and nursing services), dietary and nutritional services, and case management. These services may not be billed separately to the VR program.
Rate Description |
Amount |
---|---|
Residential Base Rate (1 time per day) |
$236.09 |
A week is defined as Sunday through Saturday.
Most customers should receive a minimum of three hours of core services per day.
Core Services Hour Description |
Core Services Tier Rate |
Therapy Evaluation Per Diem |
---|---|---|
Greater than 0, but fewer than 1 hour of core services |
$70.08 |
$3.48 |
Greater than or equal to 1 hour per day, but fewer than 2 hours per day, not exceeding 7 hours per week of core services |
$210.24 |
$3.48 |
Greater than or equal to 2 hours per day, but fewer than 3 hours per day, not exceeding 14 hours per week of core services |
$350.40 |
$3.48 |
Greater than or equal to 3 hours per day, but fewer than 4 hours per day, not exceeding 21 hours per week of core services |
$490.56 |
$3.48 |
Greater than or equal to 4 hours per day, but fewer than 5 hours per day, not exceeding 28 hours per week of core services |
$630.72 |
$3.48 |
Greater than or equal to 5 hours per day, but fewer than 6 hours per day, not exceeding 35 hours per week of core services |
$770.88 |
$3.48 |
Greater than or equal to 6 hours per day, but fewer than 7 hours per day, not exceeding 42 hours per week of core services |
$911.04 |
$3.48 |
Greater than or equal to 7 hours per day, but fewer than 8 hours per day, not exceeding 49 hours per week of core services |
$1,051.20 |
$3.48 |
Greater than or equal to 8 hours per day, but fewer than 9 hours per day, not exceeding 56 hours per week of core services |
$1,191.36 |
$3.48 |
Licensed and certified professionals may bill one 15-minute increment for attendance of a customer's IAEP or monthly IPP. The non-residential quarter hour rate found in 21.12.5.1 Core Services will be used for attendance of IAEP and IPP meetings.
Rate Description |
Rate |
---|---|
Residential base rate (1 time per day) |
$236.09 |
Occupational therapy provided for 1 hour; Physical therapy provided for 1 hour; and Speech therapy evaluation provided for 30 minutes Note: No more than 14 hours of care were provided during the week (Sunday–Saturday) |
$350.40 |
Speech therapy evaluation per diem |
$3.48 |
Total Daily Rate: |
$589.97 |
An employment services provider rate to attend an interdisciplinary meeting (IEAP or IPP) is $37.50 per meeting.
All other employment service rates are found in the SFP chapter associated with the service. See links below.
If a VR customer has comparable benefits, the provider must bill the comparable benefits before billing the VR program.
If comparable services and benefits are available, the VR program may participate in the cost of services if the combined amount of the VR payment and the comparable benefit payment does not exceed the maximum amount allowed by the following, as appropriate:
All other pay sources must be exhausted before the VR program is billed for services.
When a customer has health insurance, Medicare, or Medicaid, the ESBI provider first submits a timely claim to these entities, as applicable, for payment of the provided ESBI services. An Explanation of Benefits (EOB) is sent by the insurer to the ESBI provider to document the payment made per benefit coverage and the patient's payment responsibility (the customer's portion). The ESBI provider submits to the VR counselor a copy of the EOB with the provider's invoice in order for the VR payment responsibility to be determined.
If the comparable benefit denies the service, the EOB is reviewed to determine the reason for the denial. If the service was denied for insufficient documentation, the VR counselor contacts the ESBI provider and requests that the provider resubmit the claim with the proper documentation. The VR program is not responsible for payment of services when an ESBI provider fails to file the claim with the comparable benefit in a timely manner.
If the comparable benefit is paid by:
In some cases, customers will be required to participate in the cost of services. In those cases, the customer and the provider will be notified of the customer's share. The provider may not bill beyond that cost and will not collect from the customer until the VR payments and/or any comparable benefits payments have been received.
The provider is responsible for billing and collecting or writing off cost-share amounts owed by the liable party.
For information on VR invoicing requirements, refer to Chapter 3: Basic Standards.
When applicable, billing must be submitted to third-party payers promptly. Billing to VR must be submitted upon partial payment or denial of payment from third-party payers. If the family is required to share in the cost of services, the customer and the provider will be notified of the customer's share. The provider may not bill beyond that cost and will not collect from the customer until the VR payment and/or any comparable benefits payments have been received. When the provider's facility is closed or a customer is not present for the service within a customer's dates of service, payment is not made for that date.
Invoices must be submitted at least monthly, no later than the 15th day of each month, on one of the following forms:
The provider must submit invoices to the address on the VR service authorization, comply with the terms and conditions of the customer contract, and include, at a minimum, the:
The provider must: