Clinical Criteria
2.80 COMMUNITY SUPPORT SERVICES
2.80 Community Support Services
Description of Services: Services within the community support system (CSS) represent an array of services,
supports, and opportunities needed by persons with long-term mental illnesses in order to live, work, and
participate in their communities. This spectrum of services (also known as “wraparound” services) allows for
creative and flexible planning, as guided by a consumer’s strengths, unique needs, and desires. In developing
treatment plans and coordinating discharge and transition processes, Care Managers and providers will
recommend locally-based services and supports such as the following:
2.801 Housing Programs: A variety of housing services is available through community-based resources.
Among them:
 Supported housing services: assist consumers with finding their own homes and then provide the
rehabilitation services necessary to help them function as effectively as possible.
 Supervised apartments: a housing arrangement that is shared by several people who receive various levels of
supervision and services from rehabilitation agency staff.
2.802 Supported Education: This program assists people with severe mental illnesses in developing and
achieving academic goals in educational settings. Program models include freestanding career development and
assessment services on college campuses, mental health and academic service coordination, and mental health
supports to individuals with mental disabilities who are attending school.
2.803 Vocational Rehabilitation: Vocational rehabilitation services, which are often provided by rehabilitation
agencies, include the following:
 Supported Employment services entail the assistance of a job coach who provides consumers with on-thejob training and support. Supported Employment services provide individualized assistance in choosing and
obtaining employment at integrated work sites in jobs in the community of their choice. Supports are
provided by identified staff that will assist the individual in keeping employment and/or finding another job
as necessary. This included “Psychosocial Rehabilitative Services” related to addressing the symptoms of
mental illness affecting an individual’s ability to obtain and retain employment as well as non- billable
vocational specific training., and long term supports provided by identified staff who will assist individuals in
keeping employment and/or finding another job as necessary.
 Transitional Employment services enable consumers to move from a series of part time placements to full
time, permanent employment, with assistance from a rehabilitation agency staff person.
 Enclave Employment supports the development of individuals with severe mental illness by providing a
flexible environment in which they can work less than full time but not lose their job if absent on a given day
or for a period of time. Under this arrangement, a group of individuals work in various businesses (e.g.,
landscape maintenance, manufacturing, restaurant operations) and are overseen by an agency supervisor.
 Agency-Run Businesses are operated by rehabilitation agencies and provide employment opportunities for
individuals with mental illnesses.
 Group placements involve small groups of individuals with psychiatric disabilities working in a business with
an agency staff supervisor.
2.804 Clubhouse Program: Clubhouse programs provide assistance in developing or reestablishing social
Reviewed 12/14/06, 12/13/07, 11/18/09, 11/30/10, 11/21/11, 11/19/12, 11/18/13, 11/17/14, 2/5/15, 11/17/15
Revised 12/08/05, 11/18/09, 11/30/10, 11/17/14, 2/5/15
Page 1 of 3
This criterion is consistent with NCD and/or LCD.
Beacon Health Options Policies and Procedure and Medical Necessity Criteria cover the operations of all entities within the BVO Holdings,
LLC corporate structure, including but not limited to Beacon Health Strategies LLC, Beacon CBHM LLC and ValueOptions, Inc.
Clinical Criteria
relationships, a sense of self-esteem, group affiliation, natural community resources and reintegration into a
meaningful community life. They promote recovery through membership in the club and offer such supports as
vocational and leisure activities, skills training, self-help, recovery groups, and outreach.
2.805 Prevention Services: Prevention services are primarily educational-based programs which assist
individuals with mental illness and those at risk of becoming ill in learning skills to increase preventive self-care
and promote wellness. Services may include classes on stress reduction, parenting, relapse prevention, activities
and development of other coping skills.
2.806 Representative Payee Program: Representative payee programs entail the designation of an individual to
manage a consumer’s social security benefit. Representative payees may be a family member, friend, caretaker,
volunteer attorney, or human services agency staff, such as the consumer’s case manager. A social security worker
who is concerned about a consumer’s ability to manage his/her benefit usually makes referral to the program.
Medical documentation that the consumer is incapable of benefit management is required.
2.807 Guardianship Program: Guardianship programs involve court designation of an individual (the
“guardian”) to be responsible for making personal and/or property decisions for another individual (the “ward”).
The appointment of a guardian is prompted by a judge’s decision that the ward lacks the capacity to make
decisions. Statutes regarding guardianship vary from state to state.
2.808 Family/Parenting Support / Treatment Program: These programs are designed to support parents
diagnosed with mental illness in developing and working toward parenting goals. Services may include parenting
education and training programs, support groups and rehabilitation services. For individuals at risk of having their
child removed from the home and placed in foster care, services must also be coordinated with the local Social
Services agency.
2.809 Family Education and Training Program: Family education programs provide families of individuals
with severe mental illness support services and educational sessions which address the following:
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Coping with a family member’s mental illness;
Consumer and family independence;
Medications;
Advocacy for consumers and family members;
Stigma of mental illness;
The mental health system (e.g., structure, benefits);
How to manage stress, and
Resiliency and recovery.
2.810 Peer Support Services: Peer support services are provided by a trained Peer or Family-peer Specialist in a
variety of settings including practicing in home and community based settings. Peer services are offered to enable
clients who have a diagnosis of mental illness or disability to live in their community, in a setting appropriate to
their individual support requirements and preferences. The Peer Support service is an individualized, recoveryfocused service that allows individuals the opportunity to learn to manage their own recovery and advocacy
process. Interventions of peer specialist staff serve to enhance the development of natural supports, coping skills,
and other skills necessary to function as independently as possible in the community. Peer Specialist interventions
may also provide services to help a person’s re-entry into the community after a hospitalization or residential
treatment. Peer support services focus on personal safety, confidence, growth, goal achievement, connection to
the community, boundary setting, planning, self advocacy, personal fulfillment, development of natural supports
Reviewed 12/14/06, 12/13/07, 11/18/09, 11/30/10, 11/21/11, 11/19/12, 11/18/13, 11/17/14, 2/5/15, 11/17/15
Revised 12/08/05, 11/18/09, 11/30/10, 11/17/14, 2/5/15
Page 2 of 3
This criterion is consistent with NCD and/or LCD.
Beacon Health Options Policies and Procedure and Medical Necessity Criteria cover the operations of all entities within the BVO Holdings,
LLC corporate structure, including but not limited to Beacon Health Strategies LLC, Beacon CBHM LLC and ValueOptions, Inc.
Clinical Criteria
and effective communication skills. Services emphasize acquiring, developing and expanding rehabilitation skills
necessary for a person to move forward in their recovery. Examples of peer support interventions include:
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Self Help: developing a person’s ability to make informed, independent choices; helping the person develop a
network of contacts for information and support with the help of the experienced peer specialist.
Community Education: Peer specialists work with community providers and other natural support entities
to teach them about recovery, mental illness, and help create an environment of acceptance and support.
Through education, peer specialists work to decrease the stigma and discrimination that surrounds mental
illness.
Individual Advocacy: Peer specialists discuss concerns the consumer may have about medication or
diagnosis with prescribers and other professional staff if the consumer requests this service. Peer specialists
also help the consumer make appointments for medical, mental health and other human services. The most
important role of the peer specialist, however, is to teach the consumer skills to enable them to effectively
advocate for themselves.
Pre-crisis support: Peer specialists work with the consumer to help them create and implement a WRAP
plan or personal crisis plan. They make appropriate referrals if a consumer may be escalating to a crisis.
Education, Volunteering, Employment: Peer specialist help the consumer get information about returning
to school, applying for volunteer positions, and job training. They also work with the consumer to teach them
how to ask for reasonable accommodations.
Managing distressing symptoms: Peer specialists work with the consumer and treatment team to help the
consumer identify effective strategies for managing distressing symptoms. This is done from an experiential
basis, and is done in collaboration with other treatment interventions such as formal counseling, groups and
medication.
2.811 Advocacy Services: Advocacy services support clients in achieving recovery in the context of where they
live their day to day lives. Children and adults with mental health disorders experience numerous environmental
challenges, in addition to symptoms of their mental illness. Often, the negative aspects of a person’s environment
affect his or her well-being, intensifying personal problems and creating obstacles to recovery. Problems such as
poverty, discrimination and lack of awareness of rights affect individuals as significantly as symptoms of a mental
disorder. Advocacy services involve speaking for the client to help them manage their environment and create a
setting that fosters recovery. Advocacy also involves working with the client or family, to empower them,
increasing their sense of personal power. Advocacy services include:
1. Individual advocacy
a. Educating individuals and families about their rights and assuring individuals are afforded their
rights.
b. providing access to the grievance process,
c. helping individuals gain access to needed services outside of the mental health system (housing,
transportation, education):
d. providing information about services and systems
e. providing tools to help individuals advocate for themselves.
2. Program advocacy and outreach – reaching out to agencies and organizations to educate them about the needs of
Medicaid members; Collaboration with organizations to assure individuals get the services they need.
3. System advocacy - taking action to eliminate or reduce social problems and stigma, which adversely affect
clients.
Reviewed 12/14/06, 12/13/07, 11/18/09, 11/30/10, 11/21/11, 11/19/12, 11/18/13, 11/17/14, 2/5/15, 11/17/15
Revised 12/08/05, 11/18/09, 11/30/10, 11/17/14, 2/5/15
Page 3 of 3
This criterion is consistent with NCD and/or LCD.
Beacon Health Options Policies and Procedure and Medical Necessity Criteria cover the operations of all entities within the BVO Holdings,
LLC corporate structure, including but not limited to Beacon Health Strategies LLC, Beacon CBHM LLC and ValueOptions, Inc.