File No. 32860
This filing was published in the 08/15/2009 issue (Vol. 2009, No. 16), of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Section R414-33B-5
Service Coverage
Notice of Proposed Rule
DAR File No.: 32860
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.
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:
HealthHealth 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 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
RULE TEXT
R414. Health, Health Care Financing,Coverage and Reimbursement Policy.
R414-33B. Substance Abuse Targeted Case Management.
R414-33B-5. Service Coverage.
(1)
Medicaid [C]
cover[ed]
s[services are]:
(a) [assessing and documenting the client's need for community
resources and services]
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, coordinated case
management service plan
based on information collected through an assessment that
specifies the goals and actions to address [to assure the client's adequate access to needed]
the client's medical, social, educational and other
[related]service[s]
needs.[with]
This includes input [as appropriate]from the client,
the client's authorized health care decision maker,
family
, and other agencies knowledgeable about the client['s needs;]
, to develop goals and identify a course of action to respond
to the client's assessed 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 and follow-up[, including consultation with other agencies to ensure the
most appropriate interventions and services are provided by all
agencies and providers involved in the client's
care];
(e) [monitoring and coordinating as needed prescribed medications
with prescribing professionals to ensure that all medications
prescribed are appropriate, providing information on the
client's medication regimen to other prescribers and other
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, or the client's clinical treatment 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) [periodic monitoring of the client to ensure needed services
have been identified and that they are being obtained 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, in independently accessing needed services; and
(i) [monitoring the quality and appropriateness of the client's
services; and
(j)]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, telephone or written communication with the
client, family, caretaker, service provider, or other individual
with a direct involvement in providing or assuring 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)
Covered [C]
case management service provided to a hospital or
nursing facility patient 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: [October 15, 2004]
2009
Authorizing, and Implemented or Interpreted Law: 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.