4224 PROGRAM SERVICES: CASE MANAGEMENT SERVICES

4224.1 The goal of case management services shall be to ensure EPD Waiver beneficiaries have access to the services and supports needed to live in the most integrated setting including:

1. (a) EPD Waiver Services;
2. (b) Non-waiver Medicaid funded services under the Medicaid State Plan; and
3. (c) Other public and private services including medical, social, and educational services and supports.

4224.2 Case management shall consist of the following:

1. (a) Initial evaluation of the beneficiary's current and historical medical, social, and functional status to determine levels of service needs;
2. (b) Person-centered process for service planning ("person-centered planning"), including development and maintenance of the Person-Centered Service Plan (PCSP) in accordance with Section 4204;
3. (c) Monthly or ongoing care coordination activities, in accordance with Subsection 4224.8 and transitional case management services set forth in Subsection 4224.9; and
4. (d) Annual reassessment activities, in accordance with Subsection 4224.14.

4224.3 Consistent with Subsection 4224.2, each Case Manager shall conduct an in-person initial evaluation of the beneficiary within forty-eight (48) hours of receiving notice of his or her enrollment in the EPD Waiver.

4224.4 The Case Manager shall develop, complete, and submit the PCSP to DHCF, or its designee, within ten (10) business days of initiating the initial evaluation.

4224.5 The Case Manager shall use a person-centered planning process to develop the PCSP, described in Section 4204, with consideration of the following:

1. (a) The beneficiary's personal preferences in developing goals to meet the beneficiary's needs;
2. (b) Convenience of the time and location for the beneficiary and any other individuals included in the planning and potential in-person discussions with all parties and representatives of the beneficiary's interdisciplinary

team;

(c) Incorporating feedback from the beneficiary's interdisciplinary team and other key individuals who cannot attend in-person discussions where the beneficiary is present;

(d) Ensuring information aligns with the beneficiary's acknowledged cultural preferences and communicated in a manner that ensures the beneficiary and any representative(s) understand the information;

(e) Ensuring access to effective, understandable, and respectful services in accordance with the U.S. Department of Health and Human Services' National Standards for Culturally and Linguistically Appropriate Services (CLAS) in Health and Health Care, http://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=2&lvlid=53, and providing auxiliary aids and services, if necessary;

(f) Providing interpreters and translated written documents for those with low literacy or Limited English Proficiency (LEP) to ensure meaningful access for beneficiaries and/or their representatives;

(g) Incorporating a strengths-based approach which identifies the beneficiary's positive attributes, and assesses strengths, preferences, and needs;

(h) Exploration of housing and employment in integrated settings, where planning is consistent with the goals and preferences of the beneficiary; and

(i) Ensuring that a beneficiary under guardianship, other legal assignment, or who is being considered as a candidate for such an arrangement, has the opportunity to address concerns related to the PCSP development process.

4224.6 Except for services approved to be delivered sooner, DHCF, or its designee, shall prior authorize the services recommended in the PCSP within seven (7) business days of its receipt of the request.

4224.7 Following approval of services by DHCF, or its designee, the Case Manager shall follow-up with the selected service providers within five (5) business days to ensure services are in place at the quantity and quality that is sufficient to meet the beneficiary's needs, unless services are needed earlier and not receiving them would place the beneficiary's health in jeopardy.

4224.8 In order for case management services to be reimbursable, a Case Manager shall

perform the following ongoing or monthly care coordination activities:

1. (a) Direct observation of the beneficiary, including the evaluation described in Subsection 4224.3;
2. (b) Follow-up to ensure DHCF, or its designee, timely uploads the beneficiary's level of care determinations into DHCF's electronic management system;
3. (c) Develop and monitor the PCSP in accordance with Section 4204 and Subsection 4224.5;
4. (d) Assist the beneficiary with the selection of eligible EPD Waiver providers;
5. (e) Coordinate the beneficiary's waiver services to ensure safe, timely, and cost effective delivery;
6. (f) Provide information, assistance, and referrals to the beneficiary, where appropriate, related to public benefits and community resources, including other Medicaid services, Medicare, Supplemental Security Income (SSI), transit, housing, legal assistance, and energy assistance;
7. (g) Provide support for the beneficiary and family as needed through additional visits, telephone calls;
8. (h) Monitor the performance of medical equipment and refer malfunction(s) to appropriate providers;
9. (i) Maintain records related to EPD Waiver services that a beneficiary receives and upload all information into DHCF's electronic case management system;
10. (j) Ensure all information uploaded into DHCF's electronic management system is legible, including monthly assessment and status updates and telephone contacts;
11. (k) Assess appropriateness of beneficiary's continued participation in the waiver;
12. (l) Provide information to the beneficiary, authorized representative(s), family members, or legal guardian(s) about the beneficiary's rights, Waiver provider agency procedures for protecting confidentiality, and other matters relevant to the beneficiary's decision to accept services;

1. (m) Identify and resolve problems as they occur;
2. (n) Acknowledge and respond to beneficiary inquiries within twenty-four (24) hours of receipt, unless a quicker response is needed to address emergencies;
3. (o) Develop and implement a utilization review plan to achieve appropriate service delivery, ensure non-duplication of services, and evaluate the appropriateness, efficiency, adequacy, scope, and coordination of services;
4. (p) Conduct at least monthly, or more frequently as needed, in-person monitoring visits in the beneficiary's home;
5. (q) Supplement in-person monitoring visits described in Paragraph 4224.8(p) with ongoing telephone contact, as required by the individual needs of the beneficiary;
6. (r) Respond to requests received during monitoring activity within forty-eight (48) hours, making necessary updates to the PCSP within seven (7) days of monitoring activity or the beneficiary or representative's request to update the PCSP, and ensure the process and all updates comport with Section 4204 including in-person requirements;
7. (s) Ensure that the updated PCSP is conducted in-person with the beneficiary, the interdisciplinary team, and others chosen by the person and other requirements of the PCSP planning and development process described in this Section;
8. (t) Review the implementation of the PCSP at least quarterly, and as needed, in accordance with Subsection 4224.13;
9. (u) Promptly communicate any major updates, issues, or problems to DHCF, or its designee;
10. (v) Conduct all other activities related to the coordination of EPD Waiver services, including ensuring that services are utilized and are maintaining the beneficiary in the community;
11. (w) Provide transitional case management services for a period not to exceed one hundred twenty (120) days during an institutional stay in order to facilitate the beneficiary's transition back to the community, in accordance Subsection 4224.9; and
12. (x) Perform other service-specific responsibilities and annual reassessment

activities described in Subsections 4224.10 and 4224.14.

4224.9 In order for transitional case management services to be reimbursable by Medicaid, a Case Manager shall document and perform the following activities:- (a) Maintain contact with the beneficiary or representative during the institutional stay;

- (b) Ensure the beneficiary stays connected to community resources (e.g., housing) during the institutional stay and provide assistance to connect to new or reconnect to existing community resources upon discharge;

- (c) Participate in-person in the discharge planning meetings at the institutional care provider's site; and

- (d) Secure prior authorization(s) for service(s) to ensure they are in place on the first day of the beneficiary's discharge.4224.10 In addition to the duties described in Subsections 4224.8 and 4224.9, a Case Manager shall perform the following service-specific care coordination responsibilities, if applicable:- (a) Ensure occupational or physical therapy services provided under Early and Periodic Screening, Diagnostic and Treatment (EPSDT) are fully utilized and waiver services neither replace nor duplicate EPSDT services for a beneficiary ages eighteen (18) through twenty-one (21);

- (b) Examine existing responsibilities of the landlord or homeowner pursuant to the lease agreement (or other applicable residential contracts, laws, and regulations) prior to ordering chore aide services through the PCSP if the beneficiary needs chore aide services and resides in a rental property or a residential facility (e.g., assisted living); and

- (c) Assist the beneficiary with home adaptation assessments, evaluations, or bids in accordance with this chapter if the beneficiary requires EAA services.4224.11 In accordance with Chapter 101 of Title 29 DCMR, for the participant-directed services program, Services My Way, Case Managers shall complete a standard training course on that program conducted by DHCF and participate in all required, ongoing training. Case Managers shall also perform activities related to Services My Way as follows:- (a) Provide waiver applicants/beneficiaries with information about Services

My Way as follows: at the time an EPD Waiver beneficiary is initially evaluated; when a beneficiary is reassessed for continued EPD Waiver eligibility; when the PCSP is updated; and at any other time upon request of the beneficiary or authorized representative;

(b) Assist applicants/beneficiaries who want to enroll in Services My Way by overseeing the beneficiary's completion of enrollment forms and incorporating program goals into the initial PCSP or a revision of an existing PCSP;

(c) Submit all Services My Way forms to the designated DHCF program coordinator;

(d) Communicate with support brokers to address health and safety concerns identified for Services My Way participants; and

(e) Facilitate transition from Services My Way to agency-based personal care aide services when a beneficiary is voluntarily or involuntarily terminated from the program.

4224.12 Case Managers shall also perform any other duties specified under the individual program services sections of this chapter.

4224.13 When conducting PCSP quarterly reviews, the Case Manager shall perform the following activities:

(a) Review and update risk factors;

(b) Review stated goals, identified outcomes, services, and supports to ensure the beneficiary is receiving appropriate services for his or her needs;

(c) Review service utilization;

(d) Communicate with other providers regarding the beneficiary's goals and progress;

(e) Identify and resolve problems;

(f) Provide referrals or linkages to community resources;

(g) Revise the PCSP, if needed, to reflect changes in needs, goals, and services; and

(h) Document results of PCSP quarterly reviews in DHCF's electronic case

management system, including a summary of the status of the beneficiary's receipt of services and supports.

4224.14 The Case Manager shall ensure a beneficiary timely completes Medicaid reassessment(s) as part of the annual recertification requirements. This includes, but is not limited to, the following activities:

1. (a) Collecting and submitting documentation to DHCF, or its designee, such as medical assessments, /clinician authorization forms, and case manager attestation/evaluation forms;
2. (b) Effective April 1, 2018, conducting an evaluation of each beneficiary's health status at least once every twelve (12) months or upon a significant change in the beneficiary's health status and completing the case manager attestation/evaluation form following each evaluation;
3. (c) Assisting the beneficiary to receive a level of care assessment from DHCF, or its designee when there is a change in health status, as determined by the evaluation described in (b);
4. (d) Ensuring information is uploaded to DHCF's electronic case management system at least sixty (60) days prior to the expiration of the beneficiary's current certification period;
5. (e) Collecting financial eligibility (i.e., income) information from the beneficiary and/or the authorized representative and transmitting to DHCF, or its designee;
6. (f) Reevaluating the beneficiary's goals, level of service and support needs, and updating and/or revising the PCSP to reflect any updates;
7. (g) Assessing progress in meeting established goals, as documented in the PCSP and ensuring that the information is forwarded to DHCF;
8. (h) Coordinating any change requests, including adding new services; and
9. (i) After the approval of services by DHCF, or its designee, following-up with selected service providers within five (5) business days of the approval to ensure services are in place.

SOURCE: Final Rulemaking published at 50 DCR 9025 (October 24, 2003); as amended by Final Rulemaking published at 64 DCR 6784 (July 21, 2017).