Iowa Administrative Code › Agency 441 - Human Services Department › Title VIII - Medical Assistance › Chapter 90 - Case Management Services › Rule 441-90.4 - Case Management Services

Current through Register Vol. 47, No. 3, July 24, 2024
Rule 441-90.4 (249A) applies to all categories of case
				  management and all populations covered by case management.
(1)
Covered services.
The
				following shall be included in case management services provided to members,
				whether FFS members or MCO-enrolled members:
a.
Assessment.
Initial
				assessments and regular reassessments must be done for each applicant and
				member to determine the need for any medical, social, educational, housing,
				transportation, vocational, or other services. The assessments and
				reassessments shall address all of the applicant's and member's areas of need,
				strengths, preferences, and risk factors, considering the person's physical and
				social environment. Applicants and members will receive individualized prior
				notification of the assessment tool to be used and of who will conduct the
				assessment. The assessment and reassessment will be done using the core
				standardized assessment or another tool as designated in 441-Chapter 83 for
				each waiver population and 441-Chapter 78 for the habilitation population.
				Initial assessments must be face to face. Reassessments using the interRAI must
				be done face to face. Only the Supports Intensity Scale® assessment can be
				done telephonically, and then only when the situation meets the criteria
				outlined by the American Association on Intellectual and Developmental
				Disabilities (AAIDD). The off-year assessment (OYA) for the intellectual
				disability waiver can be done telephonically. A reassessment must be conducted
				at a minimum every 365 days and more frequently if material changes occur in
				the member's condition or circumstances. Case managers may participate during
				the assessment or reassessment process at the request of the applicant or
				member; the case manager does not assume the role of the assessor.
b.
Person-centered service
				plan.
At least every 365 days, the case manager shall develop and
				revise a comprehensive, person-centered service plan in collaboration with the
				member, the member's service providers, and other people identified as
				necessary by the member, as practicable. The person-centered service plan will
				be developed based on the assessment and shall include a crisis intervention
				plan based on the risk factors identified in a risk assessment. The case
				manager shall document the member's history, including current and past
				information and social history, and shall update the history annually. The case
				manager shall gather information from other sources such as family members,
				medical providers, social workers, guardians, representatives, and others as
				necessary to form a thorough social history and comprehensive person-centered
				service plan with the member. The person-centered service plan may also be
				referred to as a person-centered treatment plan.
(1) The person-centered service plan shall
				address all service plan components outlined in this chapter and in 441-Chapter
				83 for the waiver in which the member is enrolled or 441-Chapter 78 for members
				enrolled in habilitation.
(2)
				Person-centered planning shall be implemented in a manner that supports the
				member, makes the member central to the process, and recognizes the member as
				the expert on goals and needs. In order for this to occur, there are certain
				process elements that must be included in the process. These include:
1. The member, guardian or representative
				must have control over who is included in the planning process, as well as have
				the authority to request meetings and revise the person-centered service plan
				(and any related budget) whenever reasonably necessary.
2. The process is timely and occurs at times
				and locations of convenience to the member, the member's guardian or
				representative and family members, and others, as practicable.
3. Necessary information and support are
				provided to ensure that the member or the member's guardian or representative
				is central to the process and understands the information. This includes the
				provision of auxiliary aids and services when needed for effective
				communication.
4. A strengths-based
				approach to identifying the positive attributes of the member shall be used,
				including an assessment of the member's strengths and needs. The member should
				be able to choose the specific planning format or tool used for the planning
				process.
5. The member's personal
				preferences shall be considered to develop goals and to meet the member's HCBS
				needs.
6. The member's cultural
				preferences must be acknowledged in the planning process, and
				policies/practices should be consistent with the National Standards for
				Culturally and Linguistically Appropriate Services in Health and Health Care
				(the National CLAS Standards) of the Office of Minority Health, U.S. Department
				of Health and Human Services.
7.
				The planning process must provide meaningful access to members and their
				guardians or representatives with limited English proficiency (LEP), including
				low literacy materials and interpreters.
8. Members who are under guardianship or
				other legal assignment of individual rights, or who are being considered as
				candidates for these arrangements, must have the opportunity in the planning
				process to address any concerns.
9.
				There shall be mechanisms for solving conflict or disagreement within the
				process, including clear conflict of interest guidelines.
10. Members shall be offered information on
				the full range of HCBS available to support achievement of personally
				identified goals.
11. The member or
				the member's guardian or representative shall be central in determining what
				available HCBS are appropriate and will be used.
12. The member shall be able to choose
				between providers or provider entities, including the option of self-directed
				services when available.
13. The
				person-centered service plan shall be reviewed at least every 365 days or
				sooner if the member's functional needs change, circumstances change, or
				quality of life goals change, or at the member's request. There shall be a
				clear process for members to request reviews. The case management entity must
				respond to such requests in a timely manner that does not jeopardize the
				member's health or safety.
14. The
				planning process should not be constrained by any case manager's or guardian's
				or representative's preconceived limits on the member's ability to make
				choices.
15. Employment and housing
				in integrated settings shall be explored, and planning should be consistent
				with the member's goals and preferences, including where the member resides and
				with whom the member lives.
(3) Elements of the person-centered service
				plan. The person-centered service plan shall identify the services and supports
				that are necessary to meet the member's identified needs, preferences, and
				quality of life goals. The person-centered service plan shall:
1. Reflect that the setting where the member
				resides is chosen by the member. The chosen setting must be integrated in, and
				support full access to, the greater community, including opportunities to seek
				employment and work in competitive integrated settings, engage in community
				life, control personal resources, and receive services in the community to the
				same degree of access as individuals not receiving HCBS.
2. Be prepared in person-first singular
				language and be understandable by the member or the member's guardian or
				representative.
3. Note the
				strengths-based positive attributes of the member at the beginning of the
				plan.
4. Identify risks, while
				considering the member's right to assume some degree of personal risk, and
				include measures available to reduce risks or identify alternate ways to
				achieve personal goals.
5. Document
				goals in the words of the member or the member's guardian or representative,
				with clarity regarding the amount, duration, and scope of HCBS services that
				will be provided to assist the member. Goals shall consider the quality of life
				concepts important to the member.
6. Describe the services and supports that
				will be necessary and specify what HCBS services are to be provided through
				various resources, including natural supports, to meet the goals in the
				person-centered service plan.
7.
				Document the specific person or persons, provider agency and other entities
				providing services and supports.
8.
				Ensure the health and safety of the member by addressing the member's assessed
				needs and identified risks.
9.
				Document non-paid supports and items needed to achieve the goals.
10. Include the signatures of everyone with
				responsibility for the plan's implementation, including the member or the
				member's guardians or representatives, the case manager, the support
				broker/agent (when applicable), and providers, and include a timeline for
				review of the plan. The plan must be discussed with family, friends, and
				caregivers designated by the member so that they fully understand it and their
				roles.
11. Identify each person and
				entity responsible for monitoring the plan's implementation.
12. Identify needed services based upon the
				assessed needs of the member and prevent unnecessary or inappropriate services
				and supports not identified in the assessed needs of the member.
13. Document an emergency back-up plan that
				encompasses a range of circumstances (e.g., weather, housing, and
				staff).
14. Address elements of
				self-direction through the consumer choices option (e.g., financial management
				service, support broker/agent, alternative services) whenever the consumer
				choices option is chosen.
15. Be
				distributed directly to all parties involved in the planning process.
c.
Referral and
				related activities.
The case manager shall assist, as needed, the
				member in obtaining needed services, such as by scheduling appointments for the
				member and by connecting the member with medical, social, educational, housing,
				transportation, vocational or other service providers or programs that are
				capable of providing needed services to address identified needs and risk
				factors and to achieve goals specified in the person-centered service
				plan.
d.
Monitoring and
				follow-up.
The case manager shall perform monitoring activities and
				make contacts that are necessary to ensure the health, safety, and welfare of
				the member and to ensure that the person-centered service plan is effectively
				implemented and adequately addresses the needs of the member. At a minimum,
				monitoring shall include assessing the member, the places of service (including
				the member's home, when applicable), and all services regardless of the service
				funding stream. Monitoring shall also include review of service provider
				documentation. Monitoring of the following aspects of the person-centered
				service plan shall lead to revisions of the plan if deficiencies are noted:
(1) Services are being furnished in
				accordance with the member's person-centered service plan, including the amount
				of service provided and the member's attendance and participation in the
				service;
(2) The member has
				declined services in the service plan;
(3) Communication among providers is
				occurring, as practicable, to ensure coordination of services;
(4) Services in the person-centered service
				plan are adequate, including the member's progress toward achieving the goals
				and actions determined in the person-centered service plan; and
(5) There are changes in the needs or
				circumstances of the member. Follow-up activities shall include making
				necessary adjustments in the person-centered service plan and service
				arrangements with providers.
e.
Contacts.
Case managers
				shall make contacts with the member, the member's guardians or representatives,
				or service providers as frequently as necessary and no less frequently than
				necessary to meet the following requirements:
(1) The case manager shall have at least one
				face-to-face contact with the member in the member's residence at least
				quarterly;
(2) The case manager
				shall have at least one contact per month with the member or the member's
				guardians or representatives. This contact may be face to face or by
				telephone;
(3) Community-based case
				management contacts will be made in accordance with the Medicaid contract
				MED-16-019, or subsequent Medicaid managed care contracts with the department,
				in those instances where the contract specifies contacts different from this
				rule.