[NYAPRS Enews] Urgent Alert: CMS Regulatory Changes on Rehabilitation Require Your ACTION!

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E  News Readers: Sorry if you’ve been getting no or too many postings lately. 
We’ve  been trying to work out some difficulties with a list this size not 
being  blocked as spam. Thanks for your patience and understanding!  Harvey
 
NYAPRS Note:  Please forgive the lateness in distributing this very important 
Action Alert due  to last week’s NYAPRS Silver Anniversary Conference. We 
urge you to send in  similar comments by no later than Friday, in order to make 
clear to CMS the  great statewide and national support that exists for a 
regulatory environment  that supports recovery, rehabilitation and person-centered 
planning. Please act  today!
 
A C T I O  N     A L E R T
 
To:             NYAPRS Members and  Friends                                
October 9, 2007
 
From:         Harvey Rosenthal        Executive  Director
 
Re:            Urgent: Please E-Mail Your Comments to CMS on Proposed Federal 
Medicaid Rules  TODAY!
 
Please forgive our lateness in distributing this  very important Action Alert 
due to last week’s NYAPRS Silver Anniversary  Conference. In conjunction with 
our national organization, the United States  Psychiatric Rehabilitation 
Association (USPRA), we urge you to take a version of  the following comments and, 
substituting your agency’s name and letterhead,  e-mail it to CMS before this 
Friday’s 5 pm deadline (see below for  details).
 
Background
Last August, the  Centers for Medicaid and Medicare Services (CMS) published 
the much awaited  notice of proposed rulemaking in the Federal Register, and 
outlined the proposed  regulatory changes to the Medicaid Rehabilitation 
Services Option. 
USPRA  played an active role in the shaping of these regulations and hence we 
owe a  debt of gratitude to a number of USPRA member DC area psychiatric 
rehabilitation  agencies for opening their doors to CMS staff and helping to 
educate them on  quality psychiatric rehabilitation services.  It is clear that 
evidence of  those visits are sprinkled throughout the examples and language used 
in the  draft regulations.
 
Importance of Your  Response
After several years of warnings that CMS would be issuing  regulations that 
would greatly reduce Medicaid rehabilitation practice down to  mere symptom 
maintenance and illness stabilization-based approaches, NYAPRS is  very pleased 
to see all of the emphasis on rehabilitation, recovery,  person-centered 
planning and self-determination. 
Thanks in large part to the  dedicated efforts of our national cross 
disability colleagues, CMS has recently  come to demonstrate a much more familiar and 
supportive stance towards these  values and we believe that the mental health 
community should be heard in large  numbers affirming the application of those 
values and practices to Americans  with psychiatric disabilities. 
We believe that the new regulations and CMS’  recent letter encouraging the 
use of Medicaid peer specialists will strengthen  the role of psychiatric 
rehabilitation, peer support, and psychosocial  services.  Recovery has been 
recognized as possible, and a Medicaid funding  source will be dedicated to 
rehabilitation and recovery.  We agree with  USPRA that “this recognition is a huge 
accomplishment for our  field.”
 
How to Send Your  Comments
Comments must be submitted before 5pm on October 12, 2007.  They must 
reference File Code CMS-2261-P and, at this late date, can be sent  electronically 
via the CMS website. You can do the following:

Cut and paste the  following comments on your letterhead. 
Go to 
_http://www.accessdata.fda.gov/scripts/oc/dockets/comments/COMMENTSMain.CFM?EC
_DOCUMENT_ID=151&SUBTYP=CONTINUE&CID=&AGENCY=CMS_ 
(http://www.accessdata.fda.gov/scripts/oc/dockets/comments/COMMENTSMain.CFM?EC_DOCUMENT_ID=151&SUBTYP=CONT
INUE&CID=&AGENCY=CMS)     It should say “Docket Management Comment  Form   
Docket: CMS-2261-P - Rehabilitation Services: State Plan  Option”; Enter your 
zip code, name, agency name and type and country.   Click to next page. 
Go to General Comments and type in: see  attachment.  Click to next page. 
Attach and send your comments  
------------ 

October 9, 2007
 
Centers for Medicare and Medicaid Services  Department of Health and Human 
Services 
P.O. Box 8018 Baltimore, MD   21244-8018 
Re: CMS-2261-P 
 
To Whom It May Concern: 
 
As the NYS Chapter of the United States  Psychiatric Rehabilitation 
Association (USPRA), the New York Association of  Psychiatric Rehabilitation Services 
(NYAPRS) is pleased to comment on behalf of  its 145 psychiatric rehabilitation 
agencies, practitioners, and interested  organizations and individuals who 
are dedicated to promoting and strengthening  community-oriented rehabilitation 
services that support recovery from  psychiatric disabilities. Based upon the 
collective experience of our members  and state and national colleagues in the 
field of psychiatric rehabilitation  over the past 26 years, we offer the 
following comments on the provisions of the  proposed regulations related to 
Medicaid’s Rehabilitation Services Option. 
 
Individualized Rehabilitation Plan Signed by the  Person Served
NYAPRS enthusiastically supports the inclusion of a required  rehabilitation 
plan and recovery-oriented goals that is developed with the  individual and 
requires a signature to demonstrate involvement, approval and  receipt of the 
plan [§440.130(d)(3)].  The creation of a rehabilitation  plan is good practice 
and is necessary for shared decision making and  accountability.  It is our 
belief that quality rehabilitation services are  strength-based and 
person-centered, and are built upon the values of choice and  self-determination within 
the cultural context of the individual receiving  services.  
 
Person Centered Planning
We are pleased that  these values have been applied in the proposed 
regulations, and hope CMS will  consider making person-centered planning a formal 
requirement of the written  rehabilitation plan [§440.130(d)(3)(iii)] beyond the 
proposed recommendation. In  fact, we believe these values should apply to all 
Medicaid funded services, not  just rehabilitation. 
 
The Value of Psychiatric Rehabilitation
We  also appreciate the recognition of psychiatric (or psychosocial) 
rehabilitation  services as an integral component of mental health services and its 
role in an  individual’s recovery.  The presence (or absence) of psychiatric  
rehabilitation services directly impacts the achievement of recovery-oriented  
outcomes.  In this context, recovery refers to the process the individual  goes 
through as they rebuild their lives, not just the treatment of  symptoms.  
Certainly, treatment or medical activities should be  incorporated within the 
rehabilitation plan, but are not necessarily the primary  driver under the rehab 
option. 
 
Engagement
Unfortunately, because of prior  negative experiences or stigma, some 
individuals may not be initially ready or  willing to become engaged in an intensive 
and formally documented rehabilitation  plan. Therefore, NYAPRS recommends 
that CMS consider including the following  language to §440.130(d)(3) to 
recognize the need for and use of early engagement  services: “In the event that an 
individual is initially unwilling or refuses to  participate in the development 
of a rehabilitation plan, early engagement  services may be used as a 
short-term reimbursable expense that encourages a  sense of trust, hope and 
empowerment to improve an individual’s participation in  rehabilitation goal setting, 
assessment, planning and/or development  activities.”  
In the absence of a signed rehabilitation plan, early  engagement services 
must document efforts to revise approaches and engage the  person to build a 
mutually satisfying course of action, including documentation  of engagement 
goals and related services.  Examples of early engagement  services include 
opportunities to sit in on group activities and meet other  people in recovery using 
the program; educating the individual about the  recovery process, recovery 
outcomes, and the individual’s rights and  responsibilities; and motivational 
interviewing techniques or other explorations  of personal interests and 
values. 
 
Reimbursement Flexibility
NYAPRS is pleased  that the proposed regulations allow for flexibility in how 
rehabilitation  services are paid. Allowing States to specify the methodology 
under which  rehabilitation providers are paid [§441.45(a)(5)] will ensure 
the continuation  of many highly effective programs, such as Assertive Community 
Treatment,  Clubhouses, and Crisis and Transitional Residential Treatment 
Programs, that  tend to bill through a single daily rate or case rate. If 
executed correctly,  these services would focus on the improvement of the disability 
and achievement  of specific rehabilitative goals, as specified in the 
rehabilitation plan, and  not duplicate services that are intrinsic to programs 
outside of Medicaid. 
 
Intrinsic Services
Because of this, NYAPRS  recommends that the term “intrinsic” be further 
clarified within §441.45(b)(1)  of the regulations, and suggests that CMS 
consider defining it in the following  way: Intrinsic services are those that are the 
major focus of another agency  based on their statutory requirements. This 
definition is NOT meant to preclude  funding of services under the 
rehabilitation option which may mirror those by  another agency (e.g., housing, employment) 
but which are provided pursuant to an  approved rehabilitation plan as 
defined in these regulations [§440.130(d)(1)]  and are consistent with medical 
necessity. 
 
Value of Certification Programs like the  CPRP
NYAPRS supports allowing States the flexibility to set forth the  
qualifications for providers of rehabilitation services  [§440.130(d)(1)(iii)].  However, 
while the proposed regulations imply a set  of core competencies are 
required, USPRA recommends that CMS emphasize within  the regulations the need to 
employ professionals who are competent in mental  health rehabilitation practice 
(e.g., those with national certification as  psychiatric rehabilitation 
practitioners like the Certification Program for  Psychiatric Rehabilitation 
Practitioners originally developed by USPRA), as well  as persons in recovery trained 
as peer providers as indicated in the CMS  guidance letter valuing Medicaid 
Peer Support services. 
 
Thank you for your consideration of our  comments.
 
Harvey Rosenthal
Executive Director
New  York Association of Psychiatric Rehabilitation Services
_harveyr at nyaprs.org_ (mailto:harveyr at nyaprs.org)  
 
 
 





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