DAR File No. 38707
This rule was published in the August 15, 2014, issue (Vol. 2014, No. 16) of the Utah State Bulletin.
Health, Health Care Financing, Coverage and Reimbursement Policy
Rule R414-33D
Targeted Case Management by Community Mental Health Centers for Individuals with Serious Mental Illness
Notice of Proposed Rule
(Amendment)
DAR File No.: 38707
Filed: 07/22/2014 11:30:40 AM
RULE ANALYSIS
Purpose of the rule or reason for the change:
The purpose of this change is to remove sections of the rule specified in the summary provided below and to reflect the current Medicaid State Plan.
Summary of the rule or change:
This amendment removes sections in the rule text that specify reimbursement, eligibility, and service coverage, and defers to the scope of services found in the Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual and in the Medicaid State Plan. This amendment also removes "by community mental health centers" from the title of the rule text.
State statutory or constitutional authorization for this rule:
- Section 26-1-5
- Section 26-18-3
Anticipated cost or savings to:
the state budget:
There is no impact to the state budget because the services provided to Medicaid recipients are unaffected by this change.
local governments:
There is no impact to local governments because the services provided to Medicaid recipients are unaffected by this change.
small businesses:
There is no impact to small businesses because the services provided to Medicaid recipients are unaffected by this change.
persons other than small businesses, businesses, or local governmental entities:
There is no impact to Medicaid providers and to Medicaid recipients because the services provided to Medicaid recipients are unaffected by this change.
Compliance costs for affected persons:
There are no compliance costs to a single Medicaid provider or to a Medicaid recipient because this change only consolidates the scope of targeted case management services for Medicaid recipients.
Comments by the department head on the fiscal impact the rule may have on businesses:
No impact on business because change will not alter current practice.
David Patton, PhD, 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
CANNON HEALTH BLDG
288 N 1460 W
SALT LAKE CITY, UT 84116-3231
Direct questions regarding this rule to:
- Karen Ford at the above address, by phone at 801-538-6637, by FAX at 801-538-6099, or by Internet E-mail at kford@utah.gov
- 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
- Nina Baker at the above address, by phone at 801-538-9127, by FAX at 801-538-6412, or by Internet E-mail at nabaker@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:
09/15/2014
This rule may become effective on:
09/22/2014
Authorized by:
David Patton, Executive Director
RULE TEXT
R414. Health, Health Care Financing, Coverage and Reimbursement Policy.
R414-33D. Targeted Case Management [by Community Mental Health Centers ]for Individuals with Serious Mental Illness.
R414-33D-1. Introduction.
Targeted Case Management may be provided to Medicaid recipients with serious mental illness in accordance with the Targeted Case Management for Individuals with Serious Mental Illness Utah Medicaid Provider Manual and Attachment 4.19-B of the Medicaid State Plan, as incorporated into Section R414-1-5.
[R414-33D-1. Introduction and Authority.
(1) This rule outlines targeted case management services
provided to individuals with serious mental illness to assist in
gaining access to needed medical, educational, social, and other
services.
(2) This rule implements 42 USC 1396n(g), which
authorizes targeted case management services and is authorized
under UCA 26-18-3.
R414-33D-2. Definitions.
"Serious mental illness" means a serious and
often persistent mental illness in an adult or a serious
emotional disorder in a child that severely limits the
individual's welfare and development or functioning.
R414-33D-3. Client Eligibility Requirements.
Targeted case management is available for individuals
with serious mental illness who are categorically or medically
needy.
R414-33D-4. Program Access Requirements.
(1) Targeted case management is provided to individuals
with serious mental illness for whom a case management needs
assessment completed by a qualified targeted case manager
documents that:
(a) the individual requires a comprehensive coordinated
system of care and treatment or services from a variety of
agencies and providers to meet his documented medical, social,
educational, and other needs; and
(b) there is reasonable indication that the individual
will access needed services only if assisted by a qualified
targeted case manager who in accordance with an individualized
case management service plan, locates, coordinates, and regularly
monitors the service.
(2) Targeted case management services are at the option
of the individual in the target population.
(3) Targeted case management services may not restrict an
individual's free choice of providers of case management
services or other Medicaid services.
R414-33D-5. Service Coverage.
(1) Medicaid covers:
(a) 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) development 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;
(c) 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;
(e) client assistance to establish and maintain
eligibility for entitlements other than Medicaid;
(f) 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) 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 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 case management service provided to a
hospital or nursing facility patient is limited to a maximum of
five hours per admission in the 30-day period before the
patient's discharge into the community. This provision does
not apply to a patient who resides in the Utah State
Hospital.
(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.
R414-33D-6. Qualified Providers.
Targeted case management for individuals with serious
mental illness must be provided by an individual employed by
community mental health centers who is:
(1) a licensed physician, a licensed psychologist, a
licensed clinical social worker, a licensed certified social
worker, a licensed social service worker, a licensed advanced
practice registered nurse, a licensed registered nurse, a
licensed professional counselor, a licensed marriage and family
counselor; or
(2) an individual working toward licensure in one of the
professions identified in subsection (1) to the extent permitted
by Utah Code Title 58; or
(3) a licensed practical nurse or a non-licensed
individual who has met the State Division of Substance Abuse and
Mental Health's training standards for case managers and who
is working under the supervision of one of the individuals
identified in subsection (1) or (2).
R414-33D-7. Reimbursement Methodology.
(1) For fee-for-service community mental health centers,
the Department pays the lower of the amount billed or the rate on
the mental health center's fee schedule. The fee schedule was
initially established after consultation with provider
representatives. A provider shall not charge the Department a fee
that exceeds the provider's usual and customary charges for
the provider's private-pay patients.
(2) For capitated community mental health centers, the
Department pays monthly premiums to the centers for all mental
health services, including targeted case management.]
KEY: Medicaid
Date of Enactment or Last Substantive Amendment: [August 31, 2010]2014
Notice of Continuation: June 7, 2010
Authorizing, and Implemented or Interpreted Law: 26-1-5; 26-18-3
Additional Information
More information about a Notice of Proposed Rule is available online.
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For questions regarding the content or application of this rule, please contact Karen Ford at the above address, by phone at 801-538-6637, by FAX at 801-538-6099, or by Internet E-mail at kford@utah.gov; 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; Nina Baker at the above address, by phone at 801-538-9127, by FAX at 801-538-6412, or by Internet E-mail at nabaker@utah.gov. For questions about the rulemaking process, please contact the Division of Administrative Rules.