Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Administrative procedures such as prior authorization, pre-certification, referrals, and claims/encounter data filing may differ from traditional Medicaid (fee-for-service) and from MCO to MCO. Providers should contact the client's specific MCO for details.
Effective for dates of service on or after January 1, 2019, peer specialist services will become a benefit for Texas Medicaid.
Overview of Benefits
This new medical benefit policy includes the following:
- Covered benefits and limitations
- Peer specialist requirements
- Prior authorization requirements
- Documentation requirements
- Claim submission guidelines
Peer specialist services are recovery-oriented, person-centered, relationship-focused, voluntary, and trauma-informed. Peer specialist services may include the following:
- Recovery and wellness support, which includes providing information on and support with planning for recovery
- Mentoring, which includes serving as a role model and providing assistance in finding needed community resources and services
- Advocacy, which includes providing support in stressful or urgent situations and helping to ensure that the client’s rights are respected. Advocacy may also include encouraging the client to advocate for him or herself to obtain services
Peer specialist services are based on a mutual relationship between the peer specialist and the Medicaid-eligible client. A peer specialist uses his or her lived experience to support a client in achieving goals and objectives in the client’s person-centered recovery plan, as well as skill development, problem solving strategies, and coping mechanisms for stressors and barriers encountered when recovering from a mental health condition or a substance use disorder.
Services may be provided individually or in a group.
Peer specialist services (procedure code H0038) may be a benefit of Texas Medicaid for clients who are 21 years of age and older with a mental health condition and/or substance use disorder, and who have peer specialist services included as a component of their person-centered recovery plan.
Reimbursement for procedure code H0038 will be limited to substance use disorders and mental health conditions, including, but not limited to, schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, depressive disorders, anxiety disorders, obsessive-compulsive and related disorders, trauma and stressor related disorders, and feeding and eating disorders.
Procedure code H0038 will be limited to 104 units in a rolling six-month period. This limit may be exceeded with demonstrated medical necessity for the additional services.
Peer specialist services will also be limited as follows:
- May not be delivered simultaneous to other behavioral health services being delivered to an individual or group of individuals
- Must be delivered in person and not via advanced telecommunications technology
- When delivered in a group setting, limited to 12 total individuals per group session
The following services will not be benefits of Texas Medicaid:
- Record keeping or documentation activities
- Services provided without the client present
Peer Specialist Requirements
Peer specialists who are employed by the following Medicaid-enrolled providers may deliver peer specialist services as part of a coordinated, comprehensive, and individualized approach to treating a client’s mental health condition and/or substance use disorder:
- Clinic or group practices treating behavioral health conditions
- Physicians (M.D.s), osteopaths (D.O.s), nurse practitioners (NPs), clinical nurse specialists (CNSs), and physician assistants (PAs) treating behavioral health conditions
- Psychologists, licensed clinical social workers, licensed marriage and family therapists, and licensed professional counselors
- Comprehensive provider agencies of targeted case management and mental health rehabilitative services
- Local mental health authorities and local behavioral health authorities
- Chemical dependency treatment facilities
- Federally qualified health clinics (FQHCs)
- Rural health clinics (RHCs)
Only clinic/group practices or individual health care providers (M.D., D.O, NP, CNS, and PA) with a behavioral health focus may be reimbursed for peer specialist services.
Non-Medicaid-enrolled providers who employ peer specialists may choose to enter into contract with one of the above Medicaid-enrolled providers to furnish peer specialist services as part of a continuum of comprehensive treatment services.
Providers of peer specialist services shall coordinate with all behavioral health service providers involved in the client’s care and utilize a person-centered, recovery-oriented approach to treatment planning and service delivery. Subcontracted peer specialist services must also be part of the coordinated, comprehensive, and individualized person-centered recovery plan.
A peer specialist must meet all of the following criteria:
- Be at least 18 years of age
- Have lived experience with a mental health condition, substance use disorder, or both
- Have a high school diploma or General Equivalency Diploma (GED)
- Be willing to appropriately share his or her own recovery story with clients
- Be able to demonstrate current self-directed recovery
- Pass criminal history and registry checks as described in 1 TAC §354.3201
A peer specialist may not practice psychotherapy, make clinical or diagnostic assessments, or dispense expert opinions; engage in any service that requires a license; or falsify any documentation related to application, training, testing, certification, or services provided.
A peer specialist must complete all required training and certification before providing services.
To deliver peer specialist services, an individual must first complete required orientation and self-assessment activities as outlined in 1 TAC §354.3155, and then complete a core training delivered by a certified training entity.
Upon completion of the core training, supplemental training in one of the two following specialty areas must be completed:
- Mental health peer specialist
- Recovery support peer specialist
A person may apply for initial certification after successful completion of core and supplemental training and a knowledge assessment.
A peer specialist who is initially certified may begin to deliver Medicaid-covered services while participating in a supervised internship at their place of employment. The internship consists of 250 hours of supervised work experience that should be completed within a 6-month period. An extension may be granted by the certification entity should a peer be unable to complete the required hours within the 6-month timeframe.
Independent study, such as reading or watching instructional videos, does not count toward the required supervised work experience hours. Time spent receiving supervision, other than observation of the peer specialist providing services, does not count toward the required hours.
After completing the required internship hours, initially certified peer specialists may apply for renewed certification through the approved certified body. Certification must be renewed every two years, including any required continuing education hours.
Certified peer specialists should only deliver services within their specialty area.
An organization in which peer specialists deliver services must provide supervision for peer specialists. Peer specialist supervision must be provided by one of the following:
- Qualified Credentialed Counselor (QCC) as defined in 1 TAC §354.3003
- Licensed Practitioner of the Healing Arts (LPHA) as defined in 1 TAC §354.3003
- Qualified Mental Health Professional (QMHP) as defined in 1 TAC §354.3003, with a QCC or LPHA supervising the QMHP
- Qualified Peer Supervisor (QPS) as defined in 1 TAC §354.3003, with a QCC or LPHA supervising the QPS
Peer specialist supervision must focus on a peer specialist’s provision of services, including review of cases and activities, skill building, problem resolution, and professional growth. Supervision may also include aspects specific to the organization, such as following organizational policy or other administrative matters.
Peer specialist supervision may be provided as follows:
- Individually or in a group setting
- Face-to-face or via teleconference
- Include observation of the peer specialist providing services
Peer specialist supervision must occur at least once weekly for a peer specialist with an initial certification, at least once a month for a peer specialist with a two-year certification, or more frequently at the request of the peer specialist.
A QCC or LPHA supervising a QMHP or QPS must provide individual or group supervision at least once a month, and conduct an observation of the QMHP or QPS conducting peer specialist supervision at a frequency determined by the QCC or LPHA, based on the QMHP’s or QPS’s skill level.
A peer specialist supervisor must successfully complete supervisory training on peer specialist services and the recovery model from a certified training entity before supervising a peer specialist. Supervisor training must include all of the following:
- Clarification of the distinction between peer support and therapy
- The unique role of peer support in building and sustaining recovery goals
- Advocating for peer specialists and peer specialist services
- Providing strengths-based, timely, and respectful feedback about the peer specialist’s job performance
- Basic skills in supervising others, such as working with a variety of personality types and communication styles
After completing training, each prospective supervisor must successfully complete a knowledge assessment before a certified training entity approves him or her to supervise certified peer specialists. Peer specialist supervisor certification must be renewed every two years, including any required continuing education hours.
Prior authorization is not required for the first 104 units of peer specialist services in a rolling 6-month period. Prior authorization is required once an individual exceeds 104 units of individual or group peer specialist services in a rolling 6-month period.
Prior authorization requests for procedure code H0038 must be submitted to TMHP using the Special Medical Prior Authorization (SMPA) Request Form. Requests for continued services should demonstrate all of the following:
- The individual continues to meet eligibility criteria as outlined above, including current DSM diagnosis codes
- Current person-centered recovery plan and goals
- Progress made, relative to the goals outlined in the person-centered recovery plan
- The need for continued services
Requests should indicate how many additional units of service are being requested (up to 30 units are allowed per request) and which type (individual and/or group), as well as an expected timeframe when services will be delivered.
Note: The requesting provider may be asked for additional information to clarify or complete a request.
Retrospective review may be performed to ensure documentation supports the medical necessity of the requested service.
The Medicaid-enrolled provider must ensure proper documentation of all peer specialist services delivered. Documentation of peer specialist services must indicate the date, time, and place of service. The documentation must summarize the purpose and content of the services, along with specific strategies and activities utilized as related to the goal(s) in the client’s plan of care.
Peer specialist supervisors must document all supervisory sessions and maintain records in the peer specialist’s employee personnel file.
Claim Submission Guidelines
Procedure code H0038 must be submitted with one of the following modifiers to identify the specialty focus:
- Modifier HE – mental health
- Modifier HF – substance use
If services are provided in a group setting, procedure code H0038 must also be submitted with modifier HQ.
Mental health rehabilitative services are billed separately from peer specialist services.
FQHCs and RHCs should submit claims using H0038 for informational purposes only.
For more information, call the TMHP Contact Center at 800-925-9126.