DAR File No. 27956

Health, Health Care Financing, Coverage and Reimbursement Policy

R414-33A

Targeted Case Management for the Chronically Mentally Ill

NOTICE OF PROPOSED RULE

DAR File No.: 27956
Filed: 06/01/2005, 03:42
Received by: NL

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rule needs to be repealed and will be replaced with the new rule, R414-33D, that specifies community mental health center services for the seriously mentally ill and how these services are provided throughout the state, either under capitation or on a fee-for-service basis. (DAR NOTE: The proposed new Rule R414-33D is under DAR No. 27958 in this issue.)

Summary of the rule or change:

This rule is repealed in its entirety and will be replaced with a new rule, R414-33D. The new rule further delineates reimbursement methodology for nine of the mental health centers where reimbursement for services is included in the capitation rate. For the remaining two fee-for-service mental health centers, providers are paid on a fee-for-service basis for services provided.

State statutory or constitutional authorization for this rule:

Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this repeal because policies that are included in the new rule are currently in place.

local governments:

There is no impact to local governments as a result of this rulemaking because policies that are included in the new rule are currently in place.

other persons:

There is no impact to other persons as a result of this rulemaking because policies that are included in the new rule are currently in place.

Compliance costs for affected persons:

There are no compliance costs for affected persons because policies that are included in the new rule are currently in place.

Comments by the department head on the fiscal impact the rule may have on businesses:

The repeal of this rule has no fiscal impact on business. The replacement rule, R414-33D, filed contemporaneously with this repeal adopts existing policy and should also have no new fiscal impact. David N. Sundwall, MD, Executive Director

The full text of this rule may be inspected, during regular business hours, at the Division of Administrative Rules, or at:

Direct questions regarding this rule to:

Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

Interested persons may present their views on this rule by submitting written comments to the address above no later than 5:00 p.m. on:

07/15/2005

This rule may become effective on:

07/16/2005

Authorized by:

David N. Sundwall, Executive Director

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

[R414-33A. Targeted Case Management for the Chronically Mentally Ill.

R414-33A-0. Policy Statement.

A. Targeted case management may be provided to chronically mentally ill Medicaid eligibles who are not otherwise eligible for targeted case management service as part of another approved target group. The need for targeted case management services will be identified by a physician or other mental health professional in the recipient's treatment plan for mental health clinic, outpatient hospital, or physician service.

B. Targeted case management services may not be provided to individuals between the ages of 22 and 64 who are inpatients in institutions for mental disease.

C. Targeted case management shall be at the option of the individual in the target population.

D. Targeted case management services may not restrict an individual's free choice of providers of case management services or other Medicaid services.

R414-33A-1. Authority and Purpose.

A. Authority

The Consolidated Omnibus Budget Reconciliation Act (P.L. 99-272, COBRA) added Targeted Case Management to the list of optional services which can be provided under the State Medicaid Plan.

B. Purpose

The purpose of targeted case management for the chronically mentally ill is to assist individuals in the target group to access needed medical, social, educational and other services and thereby promote the individual's ability to function independently and successfully in the community.

R414-33A-2. Definitions as Used in this Chapter.

A. "Chronically mentally ill" means those individuals who meet criteria specified in the Utah Mental Health Program Evaluation Committee (UMPEC) Scale on the Persistently and Seriously Mentally Ill.

B. "Targeted case management services" means a set of planning, coordinating, and monitoring activities that assist individuals in the target group to access needed medical, social, educational, and other services and thereby promote the individual's ability to function independently and successfully in the community.

R414-33A-3. Eligibility Requirements/Coverage.

Targeted case management services are available to Medicaid recipients who are categorically or medically needy and meet the criteria for chronic mental illness as specified in the Utah Mental Health Program Evaluation Committee (UMPEC) Scale on the Persistently and Seriously Mentally Ill and are determined by a physician or other mental health professional to need targeted case management services. This scale, as of February 9, 1990, is hereby incorporated by reference.

R414-33A-4. Program Access Requirements.

Targeted case management services are covered benefits only when provided by employees of comprehensive community mental health clinics. Qualified targeted case managers include:

A. licensed mental health professionals, including psychologist, certified or clinical social worker, social service worker, registered nurse with training or experience in psychiatric nursing, or marriage and family therapist, who are employed by comprehensive community mental health clinics; or

B. non-licensed individuals who meet the State Division of Mental Health's training standards for case managers and who are supervised by one of the licensed mental health professionals listed in R414-33A-4.

R414-33A-5. Service Coverage.

A. Targeted case management for the chronically mentally ill must include an assessment of the recipient's potential strengths, resources, and needs, and the development of a comprehensive service plan that identifies the client's need for medical, social, educational/vocational and other services that promote independent functioning.

B. Targeted case management services may also include:

1. advocating for and linking the recipient with services identified in the service plan such as mental health, housing, medical, social, or nutritional services;

2. assisting the recipient to acquire necessary independent living skills such as compliance with the prescribed medication regimen, preparing for job interviews, and managing money, and assisting the recipient during acute crisis episodes to ensure the provision of the most appropriate cost-effective service;

3. monitoring to assess the recipient's progress and continued need for service;

4. coordinating the delivery of needed service and monitoring to assure the appropriateness and quality of services delivered, including coordinating with the hospital and nursing facility discharge planner in the thirty-day period prior to the patient's discharge into the community.

C. Targeted case management services for hospital or nursing facility inpatients are limited to the services listed in R414-33A-5B4 and to a maximum of three hours per patient per year.

R414-33A-6. Standards of Care.

Targeted case management services for the chronically mentally ill may be provided only according to a service plan developed by staff employed by comprehensive community mental health clinics who meet professional qualifications in R414-33A-4.

A. Assessment

The targeted case management record shall include an assessment report. Assessment data may be based on information that is already available from other sources such as the clinical evaluation.

B. Service Plan

The targeted case management record shall include a service plan signed by the client. The service plan must be developed in conjunction with the recipient, family, and other significant individuals. The service plan must be distinct from the treatment plan for mental health clinic services.

C. Documentation

1. The targeted case management provider shall develop and maintain sufficient written documentation for each targeted case management activity billed that indicates at least the following:

a. the date of service;

b. the name of the recipient;

c. the name of the person providing the service;

d. a description of the case management activity;

e. the duration of the activity and units of service; and

f. the place of service.

2. At least every 90 days, the targeted case management provider shall document progress toward goals specified in the service plan.

3. The record shall be kept on file and made available as requested for state or federal assessment purposes.

R414-33A-7. Limitations.

A. Targeted case management services may not include medical or other treatment services.

B. Payment for case management services under the plan may not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

C. Targeted case management services shall be billed only if that service would not ordinarily be considered an integral part of the mental health clinic service. Services described in the mental health clinic manual as (1) a direct clinic service (e.g. evaluation, medication management,) or (2) an indirect service (e.g. supervision of mental health staff, interdisciplinary team conference for the development of a clinical treatment plan) may not be billed as a case management activity. These services shall be billed as clinic services or be included as an administrative cost in establishing the cost of mental health clinic services.

D. Targeted case management services may not be provided to individuals between the ages of 22 and 64 who are inpatients in institutions for mental disease.

E. Targeted case management services may not be billed for patients in a hospital or nursing facility prior to the thirty-day period before the patient's discharge into the community. This service is limited to three hours per patient per year.

F. Outreach activities in which the clinic attempts to contact potential recipients for the service do not constitute targeted case management services.

G. Each targeted case management activity involving more than one member of the case management team may be billed only once by one member of the case management team.

H. Targeted case management activities conducted with a group of clients shall be billed for only one individual member of the group.

R414-33A-8. Prior Authorization.

A. Prior authorization is required only for the targeted case management services provided to patients in a nursing facility or hospital. Prior authorization may be granted for a maximum of three hours of targeted case management per patient per year only for services provided in the thirty-day period prior to the patient's discharge into the community from a nursing facility or hospital.

B. The targeted case manager shall obtain prior authorization from the Community-Based Services Unit before the services are provided. Authorization may be obtained by phone or in writing. The targeted case management provider must specify the following:

1. date of admission to the nursing facility or hospital;

2. name of the facility;

3. expected date of discharge.

R414-33A-9. Reimbursement for Services.

A. Interim payments for targeted case management services to mentally ill medicaid recipients are based on the lower of usual and customary charges or the established fee schedule. Rates are established on an hourly basis.

B. A cost settlement will be made annually for each mental health center. Targeted case management will be included as part of the mental health clinic's annual cost settlement.

KEY: medicaid

1990

Notice of Continuation August 2, 2000

26-1-4.1

26-1-5

26-18-3]

ADDITIONAL INFORMATION

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For questions regarding the content or application of this rule, please contact Craig Devashrayee at the above address, by phone at 801-538-6641, by FAX at 801-538-6099, or by Internet E-mail at cdevashrayee@utah.gov

For questions about the rulemaking process, please contact the Division of Administrative Rules (801-538-3764). Please Note: The Division of Administrative Rules is NOT able to answer questions about the content or application of these administrative rules.