Peer Support Services (Georgia)

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1 Easy Choice Health Plan Harmony Health Plan of Illinois Missouri Care Ohana Health Plan, a plan offered by WellCare Health Insurance of Arizona OneCare (Care1st Health Plan Arizona, Inc.) Staywell of Florida WellCare (Arizona, Arkansas, Connecticut, Florida, Georgia, Illinois, Kentucky, Louisiana, Mississippi, Nebraska, New Jersey, New York, South Carolina, Tennessee, Texas) WellCare Prescription Insurance s APPLICATION STATEMENT Peer Support Services (Georgia) Policy Number: Original Effective Date: 4/6/2017 Revised Date(s): 3/1/2018 The application of the Clinical Coverage Guideline is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations and state-specific Medicaid mandates, if any. DISCLAIMER The Clinical Coverage Guideline (CCG) is intended to supplement certain standard WellCare benefit plans and aid in administering benefits. Federal and state law, contract language, etc. take precedence over the CCG (e.g., Centers for Medicare and Medicaid Services [CMS] National Coverage Determinations [NCDs], Local Coverage Determinations [LCDs] or other published documents). The terms of a member s particular Benefit Plan, Evidence of Coverage, Certificate of Coverage, etc., may differ significantly from this Coverage Position. For example, a member s benefit plan may contain specific exclusions related to the topic addressed in this CCG. Additionally, CCGs relate exclusively to the administration of health benefit plans and are NOT recommendations for treatment, nor should they be used as treatment guidelines. Providers are responsible for the treatment and recommendations provided to the member. The application of the CCG is subject to the benefit determinations set forth by the Centers for Medicare and Medicaid Services (CMS) National and Local Coverage Determinations, and any state-specific Medicaid mandates. Links are current at time of approval by the Medical Policy Committee (MPC) and are subject to change. Lines of business are also subject to change without notice and are noted on Guidelines are also available on the site by selecting the Provider tab, then Tools and Clinical Guidelines. BACKGROUND Peer support is a collegial service and an evidence-based practice delivered in a variety of places such as community settings, individuals homes, provider offices, or ER departments by those qualified by training and certification to perform this service under the supervision of a Master s-level licensed clinician. Services may be delivered face-to-face or telephonically, and may occur one-on-one or in a group. Peer support services are provided directly by adult consumers of mental health services who are presently stable regarding their mental illness. The services are targeted toward the support of an individual with SMI. Such services are supportive in nature and may be rehabilitative in focus and are initiated when there is a reasonable likelihood that such services will benefit the individual s functioning and assist him/her in maintaining community tenure. Services may include: peer specialist activities, peer mentoring, peer education, recovery coach services and mental health services provided by peers. Services do not include: paperwork for consumers, attendance at NAMI or other consumer Clinical Coverage Guideline page 1

2 support meetings, offering meeting space for consumer meetings, travel time or transportation of consumers, peer specialist time that is not spent on education or self-help activities, or other administrative services. The Peer Support Specialist will also provide the following health skill-building and supports: 1 Share basic health information that is pertinent to the individual s personal health; Promote awareness regarding health indicators; Assist the individual in understanding the idea of whole health and the role of health screening; Support behavior changes for health improvement; Make wellness tools available (e.g., relaxation response, positive imaging, education, wellness toolboxes, daily action plans, stress management, etc.) to support the individual s identified health goals; Provide concrete examples of basic health changes and work with the individual in his/her selection of incremental health goals; Teach, model, and demonstrate skills such as nutrition, physical fitness, healthy lifestyle choices; Promote and offer healthy environments and skill development to assist the individual in modifying his/her own living environments for wellness; Support the individual as s/he practices creating healthy habits, personal self-care, self-advocacy, and health communication (including, but not limited to, disclosing history, discussing prescribed medications, asking questions in health settings, etc.); Support the individual to identify and understand how family history, genetics, etc. contribute to his/her overall health picture; Support the individual in understanding medication and related health concerns; Promote health skills, considering fitness, healthy choices, nutrition, healthy meal preparation, teaching early warning signs/symptoms indicating a need for health intervention, etc.; and Support the individual during transition of care periods which includes helping with aspects of care coordination. Specific interventions may include supporting the individual in being able to have conversations with various providers to access health support and treatment and assisting individuals in gaining confidence in asserting personal health concerns and questions, while also assisting the person in building and maintaining selfmanagement skills. Health should be discussed as a process instead of a destination. Assistance will be provided to the individual to facilitate his/her active participation in the development of the Individualized Recovery Plan (IRP) health goals, which may include, but are not limited to, attention to dental health, healthy weight management, cardiac health/hypertension, vision care, addiction, smoking cessation, vascular health, diabetes, pulmonary function, nutrition, sleep disorders, stress management, reproductive health, human sexuality, and other health areas. 1 The following highlights six major Peer Support Specialist skills: Engage in person-centered planning to identify strengths and supports in 10 science-based whole health and resiliency factors; Support the person in writing a whole health goal based on personal motivation and person-centered planning; Support the person in creating and logging a weekly action plan; Facilitate peer support groups that create new healthy behaviors; Build the person s cognitive self-management skills to avoid negative thinking; and Consult with behavioral health nurses and licensed therapists as necessary for technical medical advice and referral support Recovery/Self-Help Groups: A common form of peer support, recovery groups meet regularly on a formal or informal basis to share ideas, information, resources, and experiences and offer mutual support. These groups are run by and for people who have behavioral health issues. They are typically designed to share experiences and support around a common issue including living with a specific illness. They may have a focus on support- where personal stories are shared and the group works together in problem solving or have more of an educational focus on a specific skill or subject. Groups may have components of both activities, and may or may not have a spiritual component as well. Clinical Coverage Guideline page 2

3 Peer support specialists may supplement other services and linking individuals to community supports and resources, including mutual self-help groups and other peer-provided services. This level of involvement is appropriate for individuals who are actively involved in their recovery and choose to have Peer Support Services as an essential element in their individualized Recovery Plan. Peer Support Services must be provided by a Georgia Certified Peer Support Specialist. These individuals must provide a documented support and/or treatment benefit to WellCare of Georgia enrollees. Services must be individualized and demonstrate a recovery and resiliency focus. These services may be ordered for a specified period of time to assess the benefit and effectiveness. The Georgia Provider s Manual addresses 4 types of peer support services: Parent Peer Support, Youth Peer Support, Adult Peer Support, and Mental Health Peer Support. All four types of support services are led by stable certified persons with similar life and illness experience. This allows the service providers and the members to relate closely and assist the member in their own environment. The hope for peer support services is that they will be used for members coming out of the hospital as a key component of their post-acute stabilization plan. The member may have up to 20 units of post-hospital services authorized within their first month post discharge. POSITION STATEMENT Applicable To: Medicaid Georgia Exclusions Member s condition/symptoms are too severe and a higher level of care is needed for member safety. The member is not cognitively able to participate in the services. The member refuses the services. Coverage Parent Peer Support (PPS) is targeted to the parent/guardian of youth/young adult. PPS Service are a covered benefit when the following are met: 1. Individual is 21 or younger; AND, 2. Individual has a substance related issue and/or mental illness; AND TWO or more of the following: a) Individual and his/her family needs peer-based recovery support for the acquisition of skills needed to engage in and maintain youth/family recovery; OR, b) Individual and his/her family need assistance to develop self-advocacy skills to achieve selfmanagement of the youth s behavioral health status; OR, c) Individual and his/her family need assistance and support to prepare for a successful youth work/school experience; OR, d) Individual and his/her family need peer modeling to increase responsibilities for youth/family recovery. NOTE: For the purposes of this service, "family" is defined as the person(s) who live with or provide care to the targeted youth, and may include a parent, guardians, other caregiving relatives, and foster caregivers. 2. Progress notes document parent/guardian progress relative to goals which the youth/family identified in the Individualized Recovery Plan, but treatment/recovery goals have not yet been achieved. 1. An adequate continuing recovery plan has been established; AND ONE or more of the following: b) Individual served/family requests discharge; OR, c) Transfer to another service/level is more clinically appropriate. Clinical Coverage Guideline page 3

4 Youth Peer Support (YPS) is targeted at youth. YPS is a covered benefit when the following are met: 1. Youth (through age 21); AND, 2. Individual has a substance related issue and/or mental illness; AND TWO or more of the following: a) Individual and his/her family needs peer-based recovery support for the acquisition of skills needed to engage in and maintain youth/family recovery; OR, b) Individual and his/her family need assistance to develop self-advocacy skills to achieve selfmanagement of the youth s behavioral health status; OR, c) Individual and his/her family need assistance and support to prepare for a successful youth work/school experience; OR, d) Individual and his/her family need peer modeling to increase responsibilities for youth/family recovery. 2. Progress notes document youth progress relative to goals which the youth/family identified in the Individualized Recovery Plan, but treatment/recovery goals have not yet been achieved. 1. An adequate continuing recovery plan has been established; AND ONE or more of the following: b) Individual served/family requests discharge Adult Peer Support Programs are a covered benefit when the following are met: 1. Individual must have a substance related issue; AND ONE or more of the following: a) Individual needs peer-based recovery support for the acquisition of skills needed to engage in and maintain recovery; OR, b) Individual needs assistance to develop self-advocacy skills to achieve decreased dependency on formalized treatment systems; OR, c) Individual needs assistance and support to prepare for a successful work experience; OR, d) Individual needs peer modeling to increase responsibilities for his/her own recovery. 2. Progress notes document progress relative to goals identified in the Individualized Recovery Plan, but treatment/recovery goals have not yet been achieved. 1. An adequate continuing care plan has been established; AND ONE of the following: a. Goals of the Individualized Recovery Plan have been substantially met; OR, b. Individual served/family requests discharge; or c. Transfer to another service/level is more clinically appropriate. Mental Health Peer Support Programs are a covered benefit when the following are met: 1. Individual must have a mental health issue which is the focus of support; AND ONE or more of the following: a) Individual requires and will benefit from support of peer professionals for the acquisition of skills needed to manage symptoms and utilize community resources; OR, b) Individual may need assistance to develop self-advocacy skills to achieve decreased dependency on the mental health system; OR, c) Individual may need assistance and support to prepare for a successful work experience; OR, d) Individual may need peer modeling to take increased responsibilities for his/her own recovery; OR, e) Individual needs peer supports to develop or maintain daily living skills. Clinical Coverage Guideline page 4

5 2. Progress notes document progress relative to goals identified in the Individualized Recovery/Resiliency Plan, but treatment/recovery goals have not yet been achieved. 1. An adequate continuing care plan has been established; AND ONE or more of the following: b) Individual/family requests discharge; OR, c) Transfer to another service/level is more clinically appropriate. CODING Covered HCPCS Codes H0038 Self-help/peer services, per 15 minutes H0025 Behavioral health prevention education service (delivery of services with target population to affect knowledge, attitude and/or behavior) *Current Procedural Terminology (CPT ) 2016 American Medical Association: Chicago, IL. REFERENCES 1. Supervisor's Guide to Peer Support Whole Health and Wellness. Georgia Department of Behavioral Health and Developmental Disabilities Web site. Published Accessed February 8, Provider Manual for Community Behavioral Health Providers. Georgia Department of Behavioral Health & Developmental Disabilities. Fiscal year MEDICAL POLICY COMMITTEE HISTORY AND REVISIONS Date Action 3/1/2018 Approved by MPC. No changes. 4/6/2017 Approved by MPC. New. Clinical Coverage Guideline page 5