RELATES TO:
KRS
205.520
NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective
July 9, 2004, reorganized the Cabinet for Health Services and placed the
Department for Medicaid Services and the Medicaid Program under the Cabinet for
Health and Family Services. The Cabinet for Health and Family Services has
responsibility to administer the program of Medical Assistance in accordance
with Title XIX of the Social Security Act.
KRS
205.520(3) empowers the
cabinet, by administrative regulation, to comply with any requirement that may
be imposed, or opportunity presented, by federal law for the provision of
medical assistance to Kentucky's indigent citizenry. This administrative
regulation sets forth the scope of services for case management and the method
for determining amounts payable by the cabinet for case management
services.
Section 1. Definition of
Services. Case management is a service instrument by which service agencies
assist an individual in accessing needed medical, social, educational, and
other support services. Case management providers are required to monitor to
assure that recipients of case management services receive the services for
which they are referred. Case management activities include:
(1) Assessment of client's medical, social,
and functional status, and identification of client service needs;
(2) Arranging for service delivery from the
client's chosen provider to insure access to required services;
(3) Insure access to needed services by
explaining the need and importance of services in relation to the client's
condition;
(4) Insure access,
quality and delivery of necessary services; and
(5) Preparation and maintenance of case
record documentation to include service plans, forms, reports, and narratives,
as appropriate.
Section
2. Target Group. The case management services are limited, as
provided for in the Social Security Act at Section 1915(g)(1), to the following
targeted groups of Medicaid eligible individuals, with the further provision
that these individuals cannot be receiving case management services under a
Medicaid waiver program:
(1) Individuals under
age twenty-one (21) who meet the medical eligibility criteria of the Commission
for Children with Special Health Care Needs; and
(2) Individuals of all ages who meet the
medical eligibility criteria of the Commission for Children with Special Health
Care Needs and who have a diagnosis of hemophilia.
Section 3. Qualification of Providers.
Providers are required to be certified as a Medicaid provider meeting the
following criteria:
(1) Demonstrated capacity
to provide all core elements of case management including the following:
(a) Assessment;
(b) Care/services plan development;
(c) Linking/coordination of services;
and
(d)
Reassessment/follow-up;
(2) Demonstrated case management experience
in coordinating and linking community resources as required by the target
population;
(3) Demonstrated
experience with the target population;
(4) An administrative capacity to insure
quality of services in accordance with state and federal
requirements;
(5) A financial
management system that provides documentation of services and costs;
(6) Capacity to document and maintain
individual case records in accordance with state and federal
requirements;
(7) Demonstrated
ability to assure a referral process consistent with section 1902(a)(23),
freedom of choice of provider;
(8)
Demonstrated capacity to meet the case management service needs of the target
population on a statewide basis.
Section 4. Qualification of Case Managers.
Case managers shall meet the following criteria:
(1) Be licensed as a registered nurse or
possess a valid work permit as a registered nurse issued by the Kentucky Board
of Nursing; or
(2) Have a master's
degree in social work supplemented by one (1) year of professional social work
experience; or
(3) Have a
bachelor's degree as a graduate of a college or university supplemented by two
(2) years of professional social work experience.
Section 5. Other Limitations. The following
limitations on service coverage and payments are applicable:
(1) Recipients shall be allowed to have free
choice of case management services; and
(2) Recipients shall be allowed to have free
choice of the providers of other Medicaid services; and
(3) Payment will not be made for case
management services to the extent that payments have been made by the Medicaid
program as a part of other program elements for the same purposes. The purpose
of this provision is to assure that there is nonduplication of program
payments.
Section 6.
Payments. Case management providers will be paid at an interim rate,
approximating actual cost, which will be settled back to cost at the end of the
state's fiscal year. Providers shall be required to provide acceptable
documentation of costs.
Section 7.
Implementation. The provisions of this administrative regulation shall be
effective with regard to services provided on or after October 1,
1988.
