405 IAC 5-21.5-14 - Case management services

Authority: IC 12-15

Affected: IC 12-13-7-3

Sec. 14.

The services reimbursable as case management services are services that help members gain access to needed medical, social, educational, and other services. Case management services include the assessment of the eligible member to determine service needs, development of an individualized integrated care plan, referral and related activities to help the member obtain needed services, monitoring and follow-up, and evaluation. Case management is a service on behalf of the member, not to the member, and is management of the case, not the member. Requirements for case management services shall be as follows:

(1) Services may be provided for members of all ages.

(2) Providers must meet any of the following qualifications:

(A) A licensed professional.

(B) A QBHP.

(C) An OBHP.

(3) Programming standards shall be as follows:

(A) Medicaid case management services must provide direct assistance in gaining access to needed medical, social, educational, and other services.

(B) Case management services include:

(i) development of an individualized integrated care plan;

(ii) limited referrals to services; and

(iii) activities or contacts necessary to ensure that the individualized integrated care plan is effectively implemented and adequately addresses the mental health or addiction needs of the member.

(C) Services specifically may include the following:

(i) Needs assessment focusing on needs identification of the member in order to determine the need for any medical, educational, social, or other services.

(ii) Development of an individualized integrated care plan to identify the rehabilitative activities and assistance needed to accomplish the objectives of the plan.

(iii) Referral or linkage to activities that help link the member with services that are capable of providing needed rehabilitative services.

(iv) Monitoring or follow-up with the member, family members, nonprofessional caregivers, providers, or other entities, including making necessary adjustments in the individualized integrated care plan and service arrangement with providers.

(v) Evaluation consistent with the needs of the member; time devoted to formal supervision of the case between case manager and licensed supervisor are included activities and should be documented accordingly.

(D) Exclusions shall be as follows:

(i) Activities billed under behavioral health level of need redetermination.

(ii) The actual or direct provision of medical services or medical treatment.

Notes

405 IAC 5-21.5-14

Office ofthe Secretary of Family and Social Services; 405 IAC 5-21.5-14; filed May 27, 2010, 9:15 a.m.: 20100623-IR-405100045FRA; readopted filed Oct 28, 2013, 3:18 p.m.: 20131127-IR-405130241RFA Filed 8/1/2016, 3:44 p.m.: 20160831-IR-405150418FRA Readopted filed 7/28/2022, 2:21 p.m.: 20220824-IR-405220205RFA Readopted filed 5/30/2023, 11:54 a.m.: 20230628-IR-405230292RFA