Utah Department of Administrative Services Division of Administrative Rules

Health, Health Care Financing, Coverage and Reimbursement Policy

Section R414-33C-5

Service Coverage

Notice of Proposed Rule

DAR File No.: 32861
Filed: 07/30/2009

RULE ANALYSIS

Purpose of the rule or reason for the change:

This change is necessary to implement provisions of the Deficit Reduction Act (DRA) that reform case management and targeted case management (TCM) activities. This change also implements Medicaid policy into rule in accordance with Subsection 26-18-3(2)(a).

Summary of the rule or change:

This change implements covered case management under the DRA and clarifies the limits of direct delivery of foster care services. It also specifies other noncovered services and activities, and clarifies the allowance for targeted case management during an inpatient stay.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5
• Deficit Reduction Act of 2005 Pub. L. No. 109-171 Section 6052

Anticipated cost or savings to:

the state budget:

There is no budget impact because this amendment only implements ongoing Medicaid policy into rule and clarifies service coverage under the DRA.

local governments:

There is no budget impact because local governments do not fund targeted case management services.

small businesses:

There is no impact to other persons and small businesses because this amendment only implements ongoing Medicaid policy into rule and clarifies service coverage under the DRA. This amendment does not affect client eligibility and current TCM services. The change, therefore, does not increase costs to Medicaid recipients and does not impact providers that render TCM services.

persons other than business:

There is no impact to other persons and small businesses because this amendment only implements ongoing Medicaid policy into rule and clarifies service coverage under the DRA. This amendment does not affect client eligibility and current TCM services. The change, therefore, does not increase costs to Medicaid recipients and does not impact providers that render TCM services.

Compliance costs for affected persons:

There are no compliance costs because this amendment only implements ongoing Medicaid policy into rule and clarifies service coverage under the DRA. This amendment does not affect client eligibility or current TCM services. The change, therefore, does not increase costs to a Medicaid recipient and does not impact a provider that renders TCM services.

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

Current Medicaid policy is not changed by this rule adoption of those policies. No fiscal impact expected.

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:

09/14/2009

This rule may become effective on:

09/21/2009

Authorized by:

David Sundwall, Executive Director

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

R414-33C. Targeted Case Management for the Homeless.

R414-33C-5. Service Coverage.

(1) [Targeted case management services include:] Medicaid covers:

(a) [assessing and documenting the client's potential strengths, resources and needs] client assessment to determine service needs, including activities that focus on needs identification to determine the need for any medical, educational, social, or other services. Assessment activities include taking client history, identifying the needs of the client and completing related documentation, gathering information from other sources such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the client;

(b) develop[ing] ment of a written, individualized, [and]coordinated case management service plan[:] based on information collected through an assessment that specifies the goals and actions to address the client's medical, social, educational and other service needs. This includes input from the client, the client's authorized health care decision maker, family, and other agencies knowledgeable about the client, to develop goals and identify a course of action to respond to the client's assessed needs;

[(i) that assures adequate access to medical, social, educational, and other related services; and

(ii) that is developed with input from the client, family, and other agencies knowledgeable about the client's needs;

](c) [linking the client with community resources and needed services, including assisting the client to establish and maintain eligibility for entitlements other than Medicaid] referral and related activities to help the client obtain needed services, including activities that help link the client with medical, social, educational providers or other programs and services that are capable of providing needed services, such as making referrals to providers for needed services and scheduling appointments for the client;

(d) coordinating the delivery of services to the client, including CHEC screening[s,] and follow-up[, and consultation with other agencies to ensure that the most appropriate interventions and services are provided by all agencies and providers involved in the client's care];

(e) [monitoring and coordinating prescribed medications with professionals to ensure that all medications are appropriate, as well as providing information on the client's medication regimen to other prescribers, agencies, and providers involved in the client's care] client assistance to establish and maintain eligibility for entitlements other than Medicaid;

(f) [periodically assessing and monitoring the client's status and functioning and modifying the targeted case management service plan as needed] monitoring and follow-up activities, including activities and contacts that are necessary to ensure the targeted case management service plan is effectively implemented and adequately addressing the needs of the client, which activities may be with the client, family members, providers or other entities, and conducted as frequently as necessary to help determine whether services are furnished in accordance with the client's case management service plan, whether the services in the case management service plan are adequate, whether there are changes in the needs or status of the client, and if so, making necessary adjustments in the case management service plan and service arrangements with providers;

(g) [monitoring to assure that appropriate and quality service is delivered in a timely manner] contacting non-eligible or non-targeted individuals when the purpose of the contact is directly related to the management of the eligible individual's care. For example, family members may be able to help identify needs and supports, assist the client to obtain services, and provide case managers with useful feedback to alert them to changes in the client's status or needs;

(h) instructing the client or caretaker, as appropriate, [to] in independently access ing needed services; and

(i) monitoring the client's progress and continued need for targeted case management and other services.

(2) The agency may bill Medicaid for the above activities only if :

(a) the activities are identified in the case management service plan and the time spent in the activity involves a face-to-face encounter[and] , telephone or written communication with the client, family, caretaker, service provider, or other individual with a direct involvement in providing or assuring [that]the client obtains the necessary services documented in the service plan[.] ; and

(b) there are no other third parties liable to pay for services, including reimbursement under a medical, social, educational, or other program.

(3) [Targeted case management services] Covered case management service provided to a hospital or nursing facility patient [are] is limited to a maximum of five hours per admission.

(4) Medicaid does not cover:

(a) documenting targeted case management services with the exception of time spent developing the written case management needs assessment, service plans, and 180-day service plan reviews;

(b) teaching, tutoring, training, instructing, or educating the client or others, except when the activity is specifically designed to assist the client, parent, or caretaker to independently obtain client services. For example, Medicaid does not cover client assistance in completing a homework assignment or instructing a client or family member on nutrition, budgeting, cooking, parenting skills, or other skills development;

(c) directly assisting with personal care or daily living activities that include bathing, hair or skin care, eating, shopping, laundry, home repairs, apartment hunting, moving residences, or acting as a protective payee;

(d) routine courier services. For example, running errands or picking up and delivering food stamps or entitlement checks;

(e) direct delivery of an underlying medical, educational, social, or other service to which an eligible individual has been referred. For example, providing medical and psychosocial evaluations, treatment, therapy and counseling, otherwise billable to Medicaid under other categories of service;

(f) direct delivery of foster care services that include research gathering and completion of documentation, assessing adoption placements, recruiting or interviewing potential foster care placements, serving legal papers, home investigations, providing transportation, administering foster care subsidies, or making foster care placement arrangements;

(g) traveling to the client's home or other location where a covered case management activity occurs, nor time spent transporting a client or a client's family member;

(h) services for or on behalf of a non-Medicaid eligible or a non-targeted individual if services relate directly to the identification and management of the non-eligible or non-targeted individual's needs and care. For example, Medicaid does not cover counseling the client's sibling or helping the client's parent obtain a mental health service;

(i) activities for the proper and efficient administration of the Medicaid State Plan that include client assistance to establish and maintain Medicaid eligibility. For example, locating, completing and delivering documents to a Medicaid eligibility worker;

(j) recruitment activities in which the mental health center or case manager attempts to contact potential service recipients;

(k) time spent assisting the client to gather evidence for a Medicaid hearing or participating in a hearing as a witness; and

(l) time spent coordinating between case management team members for a client.

KEY: Medicaid

Date of Enactment or Last Substantive Amendment: [April 7, 2005] 2009

Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3