No. 27958 (New Rule): R414-33D. Targeted Case Management by Community Mental Health Centers for Individuals with Serious Mental Illness

DAR File No.: 27958
Filed: 06/01/2005, 03:56
Received by: NL

 

RULE ANALYSIS

Purpose of the rule or reason for the change:

This rulemaking is necessary to comply with Subsection 26-18-3(2)(a), which requires program policies to be implemented by rule. Rule R414-33A, Targeted Case Management for the Chronically Mentally Ill, will be repealed as a result of this rulemaking because the rule is outdated and does not reflect current policy. (DAR NOTE: The proposed repeal of Rule R414-33A is under DAR No. 27956 in this issue.)

 

Summary of the rule or change:

This is a proposed new rule for targeted case management for the seriously mentally ill that is provided by community mental health centers. This new rule replaces Rule R414-33A that will be repealed. The rule further delineates reimbursement methodology for nine of the mental health centers where reimbursement for services is included in the capitation rate. For the remaining two fee-for-service mental health centers, providers are paid on a fee-for-service basis for services provided.

 

State statutory or constitutional authorization for this rule:

Section 26-18-3 and 42 USC 1396n(g)

 

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because the policy for targeted case management for the seriously mentally ill is simply being implemented in rule pursuant to Subsection 26-18-3(2)(a).

 

local governments:

There is no impact to local governments as a result of this rulemaking because the policy for targeted case management for the seriously mentally ill is simply being implemented in rule pursuant to Subsection 26-18-3(2)(a).

 

other persons:

There is no impact to other persons as a result of this rulemaking because the policy for targeted case management for the seriously mentally ill is simply being implemented in rule pursuant to Subsection 26-18-3(2)(a).

 

Compliance costs for affected persons:

There are no compliance costs because the policy for targeted case management for the seriously mentally ill is simply being implemented in rule pursuant to Subsection 26-18-3(2)(a).

 

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

This new rule adopts existing Medicaid policies for targeted case management for the seriously mentally ill and therefore should have no new fiscal impact on business. 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
CANNON HEALTH BLDG
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 [e-mail]

 

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:

07/15/2005

 

This rule may become effective on:

07/16/2005

 

Authorized by:

David N. Sundwall, 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 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) Covered services include:

(a) assessing and documenting the client's potential strengths, resources and needs;

(b) developing a written, individualized, and coordinated case management service plan to assure the client's adequate access to needed medical, social, educational, and other related services with input from the client, the client's family, and other agencies knowledgeable about the client's 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;

(d) monitoring the client's symptomatology, functioning, medications, and medication regimen;

(e) coordinating the client's medications and medication regimen with other providers, (f) coordinating the delivery of needed services, including CHEC screenings and follow-up and coordinating with hospital or nursing facility discharge planners in the 30-day period prior to the patient's discharge into the community;

(g) monitoring to assure the appropriateness and quality of services delivered and that they are being obtained in a timely manner;

(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 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.

(3) Case management services provided to a hospital or nursing facility patient are limited to a maximum of five hours per admission.

 

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

2005

26-18-3