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Library: Policy

317:30-5-1010.1. Scope of service

Revised 6-25-09

(a) Description of targeted case management services.

  • (1) Case management services are services furnished to assist members, eligible under the Medicaid State Plan, in gaining access to needed medical, social, educational and other services. Case management includes the following assistance:

    • (A) assessment of a member to determine the need for medical, educational, social, or other services.  Assessment activities include:

      • (i) taking member history;

      • (ii) identifying the member's needs and completing related documentation; and

      • (iii) gathering information from other sources such as family members, medical providers, social workers, and educators to form a complete assessment of the member.

    • (B) development of an individual plan and a specific plan of care that:

      • (i) are based on the information collected through the assessment;

      • (ii) specify the goals and actions to address medical, social, educational, and other services needed by the member;

      • (iii) include activities such as ensuring the active participation of the eligible member; and work with the member or member's authorized health care decision maker, and others to develop the goals; and

      • (iv) identify a course of action to respond to the assessed needs of the eligible member.

  • (C) referral and related activities to help an eligible member obtain needed services including activities that help link a member with:

      • (i) medical, social, educational providers; or

      • (ii) other programs and services capable of providing needed services, such as making referrals to providers for needed services and scheduling appointments for the member.

    • (D) monitoring and follow-up activities include activities and contact necessary to ensure the individual plan and the plan of care are implemented and adequately address the member's needs.  Activities and contact may be with the member, his or her family members, providers, other entities or individuals, and may be conducted as frequently as necessary including at least one annual monitoring to assure the following conditions are met:

      • (i) services are being furnished in accordance with the member's plan of care;

      • (ii) services in the plan of care are adequate; and

      • (iii) if there are changes in the needs or status of the member, necessary adjustments are made to the plan of care, and to service arrangements with providers.

  • (2) Case management may include contact with individuals who are directly related to identifying the needs and supports for helping the eligible member to access services.

(b) Targeted Case Management Service Requirements.  DDSD assures that:

  • (1) case management services are provided in a manner consistent with the best interest of members and are not used to restrict a member's access to other services under the plan;

  • (2) members are not compelled to receive case management services, condition receipt of case management services on the receipt of other SoonerCare services, or condition receipt of other SoonerCare services on receipt of case management services;

  • (3) case management conducts activities to ensure the health and welfare of HCBS waiver members.  For members who refuse case management services, these activities are completed as follows:

    • (A) the member develops an Individual Plan (IP) per OAC 340:100-5-50 through 340:100-5-58.

    • (B) the member develops a plan of care requesting authorization for services and submits it with the IP to the Developmental Disabilities Services Division (DDSD) plan of care reviewer for review and approval per OAC 340:100-3-33 and OAC 340:100-3-33.1.

    • (C) monthly progress reports, incident reports, OKDHS form 06HM005E, OKDHS form 06HM006E, and other documentation required to be submitted to case management are submitted to the DDSD state office program manager for case management for monitoring and follow-up per OAC 340:100-3-27.

    • (D) monitoring visits required by OAC 340:100-3-27 are conducted by DDSD Quality Assurance staff.

    • (E) the DDSD state office program manager assigns staff responsibility for maintaining the record in Client Contact Manager (CCM), obtaining necessary documents from the member and others for continuing service eligibility, providing information regarding available HCBS Waiver providers, making referrals to other programs and identifying training available to assist the member in completing the required tasks.

  • (4) providers of case management services do not exercise the agency's authority to authorize or deny the provision of other services under the plan.

(c) Non-Duplication of services.  To the extent any eligible members in the identified target population are receiving case management services from another provider agency as a result of being members of other covered target groups, the provider assures that case management activities are coordinated to avoid unnecessary duplication of service.

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