The Centers for Medicare & Medicaid Services has issued a new bulletin
regarding employment and employment services for states. The bulletin
provides states with further guidance which also emphasizes the importance
of competitive work and person centered planning.

This guidance is particularly important as we move int implementation of
Employment First Policies here in Illinois.

On page five of this bulletin, the issue about billing for sheltered workshops/
work centers and pre-vocational settings is addressed, it states,

“Waiver funding is not available for the provision of vocational services
delivered in facility based or sheltered work settings, where individuals are
supervised for the primary purpose of producing goods or performing
services. The distinction between vocational and pre-vocational services is
that pre-vocational services, regardless of setting, are delivered for the
purpose of furthering habilitation goals such as attendance, task completion,
problem solving, interpersonal relations and safety, as outlined in the
individual’s person-centered services and supports plan. Prevocational
services should be designed to create a path to integrated community based
employment for which an individual is compensated at or above the minimum
wage, but not less than the customary wage and level of benefits paid by the
employer for the same or similar work performed by individuals without



Centers for Medicare & Medicaid Services

Updates to the §1915 (c) Waiver Instructions and Technical Guide
regarding employment and employment related services

This Informational Bulletin is intended to provide clarification of existing CMS
guidance on development and implementation of §1915 (c) Waivers
regarding employment and employment related services. Specifically, this
letter provides updates to several sections of the current Waiver Technical
Guide Version 3.5, which was released in January of 2008, in advance of a
future release of Technical Guide Version 3.6.

This guidance does not constitute new policy, but rather highlights the
opportunities available to use waiver supports to increase employment
opportunities for individuals with disabilities within current policy. Further, it
underscores CMS’s commitment to the importance of work for waiver
participants and provides further clarification of CMS guidance regarding
several core service definitions.

While States have the flexibility to craft their own service definitions and
modify CMS core service definitions, many States rely on CMS language for
their waiver core service definitions. We hope that by emphasizing the
importance of employment in the lives of people with disabilities, updating
some of our core service definitions, and adding several new core service
definitions to better reflect best and promising practices that it will support
States’ efforts to increase employment opportunities and meaningful
community integration for waiver participants.

The major changes in the Instructions and Technical Guide are summarized

• Highlights the importance of competitive work for people with and without
disabilities and CMS’s goal to promote integrated employment options
through the waiver program

• Acknowledges best and promising practices in employment support,
including self direction and peer support options for employment support

• Clarifies that Ticket to Work Outcome and Milestone payments are not in
conflict with payment for Medicaid services rendered because both Ticket
to Work and Milestone payments are made for an outcome, not service

• Adds a new core service definition- by splitting what had previously been
supported employment into two definitions- individual and small group
supported employment

• Includes a new service definition for career planning, that may be
separate or rolled into the other employment related service definitions

• Emphasizes the critical role of person centered planning in achieving
employment outcomes

• Modifies both the prevocational services and supported employment
definitions to clarify that volunteer work and other activities that are not paid,
integrated community employment are appropriately described in pre-
vocational, not supported employment services

• Explains that pre-vocational services are not an end point, but a time limited
(although no specific limit is given) service for the purpose of helping
someone obtain competitive employment

Link to entire CMS Bulletin

Tony Paulauski
Executive Director
The Arc of Illinois
20901 S. LaGrange Rd. Suite 209
Frankfort, IL 60423
815-464-1832 (OFFICE)
815-464-1832 (CELL)