441—90.5 (249A) Service provision.
	   90.5(1) Covered services. The following shall be included in the assistance that case managers provide to members in obtaining services:
	      a.    	  Assessment. The case manager shall perform a comprehensive assessment and periodic reassessment of the member’s individual needs using Form 470-4694, Targeted Case Management Comprehensive Assessment, to determine the need for any medical, social, educational, housing, transportation, vocational or other services. The comprehensive assessment shall address all of the member’s areas of need, strengths, preferences, and risk factors, considering the member’s physical and social environment. A face-to-face reassessment must be conducted at a minimum annually and more frequently if changes occur in the member’s condition. The assessment and reassessment activities include the following:
	       (1)  	 Taking the member’s history, including current and past information and social history in accordance with 441—subrule 24.4(2), and updating the history annually.
	       (2)  	 Identifying the needs of the member and completing related documentation.
	       (3)  	 Gathering information from other sources, such as family members, medical providers, social workers, legally authorized representatives, and others as necessary to form a complete assessment of the member.
	      b.    	  Service plan. The case manager shall develop and periodically revise a comprehensive service plan based on the comprehensive assessment, which shall include a crisis intervention plan based on the risk factors identified in the risk assessment portion of the comprehensive assessment. The case manager shall ensure the active participation of the member and work with the member or the member’s legally authorized representative and other sources to choose providers and develop the goals. This plan shall:
	       (1)  	 Document the parties participating in the development of the plan.
	       (2)  	 Specify the goals and actions to address the medical, social, educational, housing, transportation, vocational or other services needed by the member.
	       (3)  	 Identify a course of action to respond to the member’s assessed needs, including identification of all providers, services to be provided, and time frames for services.
	       (4)  	 Document services identified to meet the needs of the member which the member declined to receive.
	       (5)  	 Include an individualized crisis intervention plan that identifies the supports available to the member in an emergency. A crisis intervention plan shall identify:
	      1. 	  Any health and safety issues applicable to the individual member based on the risk factors identified in the member’s comprehensive assessment.
	      2. 	  An emergency backup support and crisis response system, including emergency backup staff designated by providers, to address problems or issues arising when support services are interrupted or delayed or the member’s needs change. The interdisciplinary team shall determine which of the following options will be included in the crisis intervention plan:
	      ● 	  After-hours contact information for all persons or resources identified for the member and an alternate contact to be used in the event that an individual provider not employed by an agency is not present to provide services as scheduled; or
	      ● 	  After-hours contact information for an on-call system for the provider of case management to ensure that in the event of an emergency, members have access to a case manager 24 hours per day, including weekends and holidays.
	       (6)  	 Include a discharge plan.
	       (7)  	 Be revised at least annually, and more frequently if significant changes occur in the member’s medical, social, educational, housing, transportation, vocational or other service needs or risk factors.
	      c.    	  Referral and related activities. The case manager shall perform activities to help the member obtain needed services, such as scheduling appointments for the member, and activities that help link the member with medical, social, educational, housing, transportation, vocational or other service providers or programs that are capable of providing needed services to address identified needs and risk factors and to achieve goals specified in the service plan.
	      d.    	  Monitoring and follow-up. The case manager shall perform activities and make contacts that are necessary to ensure the health, safety, and welfare of the member and to ensure that the service plan is effectively implemented and adequately addresses the needs of the member. At a minimum, monitoring shall include assessing the member, the places of service (including the member’s home when applicable), and all services. Monitoring may also include review of service provider documentation. Monitoring shall be conducted to determine whether:
	       (1)  	 Services are being furnished in accordance with the member’s service plan, including the amount of service provided and the member’s attendance and participation in the service.
	       (2)  	 The member has declined services in the service plan.
	       (3)  	 Communication is occurring among all providers to ensure coordination of services.
	       (4)  	 Services in the service plan are adequate, including the member’s progress toward achieving the goals and actions determined in the service plan.
	       (5)  	 There are changes in the needs or status of the member. Follow-up activities shall include making necessary adjustments in the service plan and service arrangements with providers.
	      e.    	  Contacts. Case management contacts shall occur as frequently as necessary and shall be conducted and documented as follows:
	       (1)  	 The case manager shall have at least one face-to-face contact with the member every three months.
	       (2)  	 The case manager shall have at least one contact per month with the member, the member’s legally authorized representative, the member’s family, service providers, or other entities or individuals. This contact may be face-to-face or by telephone. The contact may also be by written communication, including letters, E-mail, and fax, when the written communication directly pertains to the needs of the member. E-mail contacts are allowed only when other means of communication are not feasible for the member, representative or family and the necessity for E-mail communication is documented in the member’s comprehensive service plan. A copy of any written communication must be maintained in the case file. When E-mail communication is used, there must be clear two-way communication in the member’s record showing an exchange of information as well as follow-up activity related to the information.
	       (3)  	 The case manager may bill for contacts with non-eligible persons if the contacts are directly related to identifying the member’s needs and care as necessary for the purpose of helping the member access services, identifying needs and supports to assist the member in obtaining services, providing case managers with useful feedback, and alerting case managers to changes in the member’s needs.
	       (4)  	 When applicable, documentation of case management contacts shall include:
	      1. 	  The name of the service provider.
	      2. 	  The need for and occurrences of coordination with other case managers within the same agency or of referral or transition to another case management agency.
	   90.5(2) Exclusions. Payment shall not be made for activities otherwise within the definition of case management when any of the following conditions exist:
	      a.    	 The activities are an integral component of another covered Medicaid service, including but not limited to assertive community treatment (ACT).
	      b.    	 The activities constitute the direct delivery of underlying medical, social, educational, housing, transportation, vocational or other services to which a member has been referred. Such services include, but are not limited to:
	       (1)  	 Services under parole and probation programs.
	       (2)  	 Public guardianship programs.
	       (3)  	 Special education programs.
	       (4)  	 Child welfare and child protective services.
	       (5)  	 Foster care programs.
	      c.    	 The activities are integral to the administration of foster care programs, including but not limited to the following:
	       (1)  	 Research gathering and completion of documentation required by the foster care program.
	       (2)  	 Assessing adoption placements.
	       (3)  	 Recruiting or interviewing potential foster care parents.
	       (4)  	 Serving legal papers.
	       (5)  	 Home investigations.
	       (6)  	 Providing transportation.
	       (7)  	 Administering foster care subsidies.
	       (8)  	 Making placement arrangements.
	      d.    	 The activities for which a member may be eligible are integral to the administration of another nonmedical program, such as a guardianship, child welfare or child protective services, parole, probation, or special education program, except for case management that is included in an individualized education program or individualized family service plan consistent with Section 1903(c) of the Social Security Act.
	      e.    	 The activities duplicate institutional discharge planning.
	   90.5(3) Transition to a community setting. Case management services may be provided to a member transitioning to a community setting during the 60 days before the member’s discharge from a medical institution when the following requirements are met:
	      a.    	 The member is an adult who qualifies for targeted case management under a targeted population. Transitional case management is not an allowable service under the HCBS brain injury waiver, the HCBS elderly waiver, or HCBS habilitation services.
	      b.    	 Case management services shall be coordinated with institutional discharge planning, but shall not duplicate institutional discharge planning.
	      c.    	 The amount, duration, and scope of case management services shall be documented in the member’s plan of care, which must include case management services before and after discharge, to facilitate a successful transition to community living.
	      d.    	 Payment shall be made only for services provided by community case management providers.
	      e.    	 Claims for reimbursement for case management shall not be submitted until the member’s discharge from the medical institution and enrollment in community services.
	   90.5(4) Rights restrictions. Member rights may be restricted only with the consent of the member or the member’s legally authorized representative and only if the service plan includes:
	      a.    	 Documentation of why there is a need for the restriction;
	      b.    	 A plan to restore those rights or a reason why restoration is not necessary or appropriate; and
	      c.    	 Documentation that periodic evaluations of the restriction are conducted to determine continued need.
	   90.5(5) Documentation. Service documentation shall also meet the requirements set forth in rule 441—79.3(249A) and 441—subrule 24.4(4).
[ARC 7957B, IAB 7/15/09, effective 7/1/09; ARC 9588B, IAB 6/29/11, effective 9/1/11]