No. 27327 (New Rule): R414-33B. Substance Abuse Targeted Case Management

DAR File No.: 27327
Filed: 08/02/2004, 04:20
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 that programs previously allowed to be implemented by policy now be implemented by rule.

 

Summary of the rule or change:

This is a new rule for Substance Abuse Targeted Case Management that puts into rule the program that Section 26-18-3 previously allowed to be in policy.

 

State statutory or constitutional authorization for this rule:

Section 26-18-3 and 42 U.S.C. 1396n(g)

 

Anticipated cost or savings to:

the state budget:

There is no impact to the state budget associated with this rulemaking because the program was previously implemented by policy and now needs to be implemented in rule pursuant to Subsection 26-18-3(2)(a).

 

local governments:

There is no budget impact to local governments as a result of this rulemaking because the program was previously implemented by policy and now needs to be implemented in rule pursuant to Subsection 26-18-3(2)(a).

 

other persons:

There is no budget impact to other persons as a result of this rulemaking because the program was previously implemented by policy and now needs to be implemented in rule pursuant to Subsection 26-18-3(2)(a).

 

Compliance costs for affected persons:

There are no compliance costs for affected persons because the program was previously implemented by policy and now needs to be 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:

There is no fiscal impact on businesses because of this rulemaking as it only places in rule a program that was previously allowed to be in policy. Scott Williams, 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:

09/14/2004

 

This rule may become effective on:

09/15/2004

 

Authorized by:

Scott D. Williams, Executive Director

 

 

RULE TEXT

R414. Health, Health Care Financing, Coverage and Reimbursement Policy.

R414-33B. Substance Abuse Targeted Case Management.

R414-33B-1. Introduction and Authority.

(1) This rule outlines targeted case management services available to Medicaid clients diagnosed with a substance abuse disorder.

(2) This rule is authorized under UCA 26-18-3 and governs the services allowed under 42 USC section 1396n(g) which authorizes targeted case management services.

 

R414-33B-2. Definitions.

In this rule, "Substance abuse disorder" means diagnoses listed in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revision (DSM-IV-TR), in the range of 291.00-291.99, 292.00-292.99, 303.00-303.99, 304.00-304.99 and 305.00-305.99

 

R414-33B-3. Client Eligibility Requirements.

(1) Targeted case management is available to Medicaid clients with substance abuse disorders who meet the categorically and medically needy eligibility categories and who are enrolled in the Traditional Medicaid Plan.

(2) Targeted case management is available to the children of Medicaid clients who are at risk of developing a substance abuse disorder due to the client's history of substance abuse and current substance abuse.

 

R414-33B-4. Program Access Requirements.

(1) Targeted case management services must be provided by or through a substance abuse program that is under contract with or directly operated by a local county substance abuse authority.

(2) Targeted case management may be provided to a Medicaid client who is diagnosed with a substance abuse disorder for whom a needs assessment completed by a qualified targeted case manager documents that:

(a) the individual requires 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.

(3) Targeted case management may be provided to a child of a Medicaid client for whom a needs assessment completed by a qualified targeted case manager documents that:

(a) the child is at risk of developing a substance abuse disorder due to parental history of substance of substance abuse or current substance abuse.

(b) the child requires treatment or services from a variety of agencies and providers to meet his documented medical, social, educational, and other needs; and

(c) there is reasonable indication that the child 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.

 

R414-33B-5. Service Coverage.

(1) Covered services are:

(a) assessing and documenting the client's need for community resources and services;

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

(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;

(g) periodic monitoring of the client to ensure needed services have been identified and that they are being obtained in a timely manner;

(h) instructing the client or caretaker, as appropriate, in independently accessing needed services;

(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 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 service provided to a hospital or nursing facility patient is limited to a maximum of five hours per admission.

 

R414-33B-6. Qualified Providers.

Targeted case management services must be provided by an individual 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 substance abuse counselor, a licensed marriage and family counselor; or

(2) an individual working toward licensure in one of the professions identified in subsection (a); or

(3) a licensed practical nurse or a non-licensed individual working under the supervision of one of the individuals identified in subsection (1) or (2).

 

R414-33B-7. Reimbursement Methodology.

The Department pays the lower of the amount billed and the rate on the 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.

 

KEY: Medicaid

2004

26-18-3