Health, Health Care Financing, Coverage and Reimbursement Policy

Rule R414-33

Targeted Case Management Services

Notice of Proposed Rule

(Repeal)

DAR File No.: 33514
Filed: 03/29/2010 04:13:17 PM

RULE ANALYSIS

Purpose of the rule or reason for the change:

This repeal is necessary because targeted case management services as outlined in this rule are no longer available to Medicaid clients.

Summary of the rule or change:

This rule is repealed in its entirety.

State statutory or constitutional authorization for this rule:

• Section 26-18-3
• Section 26-1-5

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget because no agencies or individuals have been enrolled to provide these services since 2006.

local governments:

There is no impact to local governments because they do not fund or provide case management services.

small businesses:

There is no impact to small businesses because no agencies or individuals have been enrolled to provide these services since 2006.

persons other than small businesses, businesses, or local governmental entities:

There is no impact to Medicaid providers or to Medicaid clients because no agencies or individuals have been enrolled to provide these services since 2006.

Compliance costs for affected persons:

There is no impact to a single Medicaid provider or to a Medicaid client because no agencies or individuals have been enrolled to provide these services since 2006.

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

This rule repeal is necessary due to changes in the Medicaid program that no longer make these services available. No fiscal impact since this program has been unavailable since 2006.

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:

Health
Health Care Financing, Coverage and Reimbursement Policy
288 N 1460 W
SALT LAKE CITY, UT 84116-3231

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 [email protected]

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:

05/17/2010

This rule may become effective on:

05/24/2010

Authorized by:

David Sundwall, Executive Director

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

[R414-33. Targeted Case Management Services.

R414-33-0. Policy Statement.

Targeted Case Management is a service that assists recipients in the target group to gain access to medical, social, educational, and other services.

 

R414-33-1. Authority and Purpose.

A. 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. The Health Care Financing Administration (HCFA) approved Utah's request for provision of Targeted Case Management services, effective July 1, 1987.

 

R414-33-2. Definitions.

A. "Independent living arrangement financially supported by the Utah Department of Social Services" means a setting other than the individual's natural family home, including supervised apartment and independent living for individuals between the ages of 17 and 21. Room and board in these facilities and in foster and group homes are supported by the Utah Department of Social Services through a combination of state and federal funds (excluding AFDC grants).

B. "Under the statutory responsibility of the Utah Department of Social Services" means children in protective custody who are dependent, neglected, abused, or conduct disordered.

C. "Qualified Targeted Case Manager" means a psychologist, clinical social worker, certified social worker, or social service worker, licensed under the authority of Title 58 (Occupational and Professional Licensing) of the Utah Code Annotated, 1953 as amended, practicing within the scope of his license.

 

R414-33-3. Eligibility Requirements/Coverage.

Targeted Case Management services are provided to recipients under the age of 21 who are under the statutory responsibility of the Utah Department of Human Services, with the exception of youth under the authority of the Utah Division of Youth Corrections.

 

R414-33-4. Program Access Requirements.

A. Recipients must meet one of the following criteria:

1. be discharged from an inpatient facility in the previous 12 months; or

2. be currently residing in a foster home, group home, supervised apartment or independent living arrangement financially supported by the Utah Department of Social Services; or

3. be at risk for placement in a more costly or restrictive living arrangement were case management services not available.

B. In addition, recipients of Targeted Case Management services must exhibit at least one of the following:

1. failure or inability to comply with a treatment regimen or failure or inability to access needed services independently; or

2. frequent crisis episodes; or

3. requirement for multiple services and their coordination; or

4. lack of adequate support networks.

C. Recipients will have the free choice of any enrolled qualified Targeted Case Manager.

D. It is the recipient's option whether he receives Targeted Case Management services. A recipient cannot be forced to receive Targeted Case Management services for which he might be eligible.

E. Targeted Case Management services may not be used to restrict the access of the recipient to other services available under the Medicaid State Plan.

 

R414-33-5. Service Coverage.

Targeted Case Management is a service that assists recipients in the target group to gain access to medical, social, educational, and other services. Targeted Case Management includes:

A. assessing the recipient's need for service and developing a service plan to assure adequate access to medical, social, educational, and other related services.

B. linking the recipient with basic community resources.

C. coordinating the delivery of services and monitoring to assure appropriateness and quality of services.

D. monitoring recipient's progress and continued need for service.

 

R414-33-6. Standards of Care.

A. The Targeted Case Management manager must develop and maintain sufficient written documentation for each unit of targeted case management services billed indicating at least the following:

1. date of service;

2. name of recipient;

3. name of provider agency and person providing the service;

4. units of service; and

5. place of service.

B. Targeted Case Management services must be documented in 15-minute intervals.

C. The following documents must be contained in each recipient's case file:

1. social history that documents need for service;

2. treatment plan that identifies the services the recipient is to receive; and

3. progress notes that track the recipient's progress toward treatment objectives. The progress notes must be updated periodically at intervals of no more than 95 days, or more frequently as required by the client's condition.

D. The Targeted Case Manager must sign a provider agreement with the Division of Health Care Financing, Utah Department of Health, in order to become a qualified provider. The individual must satisfy one of the following:

1. provide documentation of:

a. at least 5 years experience providing case management services to the target group,

b. be licensed to practice independently as a psychologist or clinical social worker under the authority of the Utah Code Annotated, Title 58,

c. current professional malpractice insurance of at least $1,000,000; or

2. provide documentation of:

a. contract or employment with a public or private licensed child placement agency that specializes in providing case management to the target group and has adequate malpractice insurance for its employees or contractors,

b. license as a psychologist, clinical social worker, certified social worker, social service worker, licensed under the authority of Title 58 of the Utah Code Annotated, 1953, as amended.

 

R414-33-7. Limitations.

A. Individuals receiving nursing home or hospital services are not eligible for Targeted Case Management services.

B. Recipients receiving case management services under Home and Community-Based Waiver Services are not eligible for Targeted Case Management services.

C. Discharge planning cannot be billed as a Targeted Case Management service.

D. Outreach activities in which the agency or provider attempts to contact potential recipients of a service do not constitute Targeted Case Management services.

E. A physical or psychological examination/evaluation conducted as a component of a recipient's need for service assessment cannot be considered a Targeted Case Management service.

F. Individual therapy, group therapy, and teaching activities cannot be billed as a Targeted Case Management service.

G. Making referral arrangements for medical treatment may be considered a Targeted Case Management activity; however, the actual provision of the service does not constitute Targeted Case Management services.

H. The following are associated with the necessary activities for the proper and efficient administration of the Medicaid State Plan and cannot be included as components of the Targeted Case Management service:

1. Medicaid eligibility determinations;

2. Medicaid intake processing;

3. Medicaid preadmission screening;

4. prior authorization for Medicaid services;

5. required Medicaid utilization review;

6. CHEC (EPSDT) administration; and

7. activities associated with the "lock-in" provisions of 1915(a) of the Social Security Act.

 

R414-33-8. Prior Authorization.

Not required.

 

R414-33-9. Reimbursement for Services.

A. Payment for Targeted Case Management services is made on a fee-for-service basis.

B. Rates are prospective and established on the basis of the historical cost for the service. Historical cost is inflated by the Consumer Price Index, Urban-All Items, published by the U.S. Department of Labor.

C. Rates are based on a 15-minute unit of service.

D. Payment cannot be made for Targeted Case Management services for which another payer is liable, nor for services for which no payment liability is incurred.

 

KEY: medicaid

Date of Enactment or Last Substantive Amendment: 1990

Notice of Continuation: June 3, 2005

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