Conn. Agencies Regs. § 17-134d-82

Current through October 16, 2024

Section 17-134d-82 - Requirements for payment of case management services

(a)Scope

These regulations set forth the requirements for payment of Case Management Services provided by the State of Connecticut Department of Mental Retardation to persons determined eligible to receive services under Connecticut's Medical Assistance Program pursuant to Section 17-134d of the General Statutes of Connecticut.

(b)Definitions

For the purposes of Regulation Section 17-134d-82, the following definitions shall apply:

(1) "Case manager" means the person responsible for assisting an eligible person to gain access to needed services, managing the development of a plan of services, securing and coordinating needed services, monitoring an eligible person's progress, maintaining family contact, collecting or disseminating data and information.

(2) "Case management services" means a continuum of supportive activities systematically carried out by an individual case manager that are available to assist and enable an eligible person to gain access to needed medical, social, educational, or other services.

(3) "Calendar quarter" means the periods of time in any state fiscal year inclusive of July 1 through September 30; October 1 through December 31; January 1 through March 30; and April 1 through June 30.

(4) "Department" means the State of Connecticut Department of Income Maintenance.

(5) "Eligible person" means a person who qualifies to receive services under the Connecticut Medical Assistance Program pursuant to Section 17-134b of the General Statutes of Connecticut, as amended from time to time, and regulations promulgated pursuant to Section 17-134d of the General Statutes of Connecticut.

(6) "Needed services" means any medical, social, educational, or other services identified as required by an eligible person in a plan of services.

(7) "Plan of services" means a written document which is developed by a team on an annual basis that identifies an eligible person's unique characteristics, needs, needed services, and public agencies or private entities that will provide or may provide the needed services.

(8) "Representative" means any person, organization, or entity authorized to act on the behalf of an eligible person through an agreement, or a family member, or a court appointed delegate of the eligible person pursuant to provisions in the General Statutes of Connecticut, as amended from time to time.

(9) "Target group" means those eligible persons specified by the Department to receive case management services by age, type or degree of disability, illness or condition, or any other identifiable characteristics, or geographic areas or political subdivisions, or combination thereof.

(10) "Team" means a group of persons which consists of the case manager and shall include one or more of the following: the eligible person or his representative; actual or potential providers of needed services; pertinent professionals from various disciplines; and any other persons whose participation is relevant who convene to develop or review a plan of services.

(c)Provider Participation

In order to participate in the Connecticut Medical Assistance Program and receive payment from the Department for the case management services rendered, the Department of Mental Retardation shall:

(1) Provide case management services pursuant to all applicable provisions under federal and state statutes and regulations promulgated thereunder;

(2) Meet and maintain all Department provider enrollment requirements;

(3) Have a valid Connecticut Medical Assistance Program provider agreement on file with the Department which is signed by the Department of Mental Retardation Commissioner or the Commissioner's designee. The provider agreement will be effective upon the Department approved date of enrollment. The provider agreement specifies conditions and terms (Federal and State regulations, standards and statutes) which govern the Connecticut Medical Assistance program and to which the Department of Mental Retardation is mandated to adhere to in order to participate in the program; and

(4) Assign an individual case manager to serve as the primary person responsible for case management services.

(5) Pursuant to subsection (f) (2) below a case manager is limited to qualified case managers designated by the Department of Mental Retardation.

(d)Eligibility

Payment for case management services is available only on behalf of all persons specified as members of a target group pursuant to subsection (f) (1) below who are eligible to receive services pursuant to the Connecticut Medical Assistance Program subject to conditions and limitations which apply to such case management services.

(e)Services Covered

Covered case management services may include a continuum of supportive activities performed by an individual case manager which enable an eligible person to gain access to needed services. At a minimum, such case management services shall include one or more of the following types of case management activities in a calendar quarter:

(1) Case advocacy to enable an eligible person to make his preferences known, to ensure the smooth flow of information and minimize conflict between service delivery systems and to mobilize resources to obtain or access needed services;

(2) Collaboration through direct or collateral contacts with an eligible person or his representative to support a person-or family-centered planning process for development and maintenance of a plan of services;

(3) Coordinating or attending team meetings to develop or revise a plan of services;

(4) Liaison activities to arrange for assessments that may be necessary to determine an eligible person's needed services;

(5) Coordination of a plan of services through direct or collateral contacts with the eligible person or his representative, members of their informal support networks, and public or private entities that provide or may provide needed services;

(6) Monitoring the quality and quantity of needed services that are being provided as they relate to an eligible person's needs, plan of services, and safety;

(7) Providing information and referral; and

(8) Review and maintenance of an eligible person's plan of services.

(f)Limitations

(1) Target Group Limitations

Payment for case management services is limited to case management services provided to eligible persons with mental retardation as defined in the General Statutes of Connecticut Section 1-1g and to eligible persons with conditions related to mental retardation as defined in subsection (e) (7) (G) (ii) of section 1919 of the Social Security Act and implementing federal regulations, as amended from time to time, who receive case management services from the Department of Mental Retardation pursuant to subsection (f) (2) below.

(2) Provider Limitations

(A) For eligible persons with mental retardation or with conditions related to mental retardation the Department of Mental Retardation shall be the sole entity enrolled with the Department to provide case management services to eligible persons and to enter into a provider agreement with the Department for the provision of such services.

(B) For eligible persons with mental retardation or with conditions related to mental retardation qualified case managers are limited to case managers designated to render services to said persons by the Department of Mental Retardation in accordance with the General Statutes of Connecticut and rules regarding provision of services adopted by said agency, as amended from time to time.

(3) Payment Limitations

(A) Payment for case management services will be made only when the eligible person or his representative has requested or applied to receive services from the Department of Mental Retardation.

(B) Payment for case management services may not duplicate payments made under the Connecticut Medical Assistance Program for other services that are covered under the program. Specifically, separate payment for case management services is not available when the same case management service is provided as an integral and inseparable part of another Connecticut Medical Assistance program covered service, including as part of intermediate care facility services for the mentally retarded (ICF/MR).

(C) Payment for case management services by the Department will not be made unless one or more of the case management activities pursuant to subsection (e) above are rendered in a calendar quarter.

(g)Need for Services

Payment for case management services will be made by the Department only if the eligible person evidences a need for case management services. If the eligible person meets the requirements to receive services from the Department of Mental Retardation in accordance with the General Statutes of Connecticut and rules regarding provision of services adopted by said agency, as amended from time to time, the eligible person evidences a need for case management services.

(h)Documentation Requirements

Case management services will be reimbursed by the Department only when the following requirements are documented and are on file with the Department of Mental Retardation:

(1) Plan of Services Requirement

Case management services are provided in accordance with the eligible person's plan of services. At a minimum, the plan shall:

(A) Be developed by a team based upon the outcome of a team meeting conducted at least annually or more frequently if needed; and

(B) Be based on a uniform assessment, in accordance with the Department of Mental Retardation's regulations or policies as amended from time to time, of an eligible person's needs which may include: assessments of medical, social, educational and other needs;

(C) Be reviewed and followed by the case manager;

(D) Indicate that the eligible person or his representative has participated in, or has been given the opportunity to participate in, the development of the eligible person's plan of services;

(E) Identify issues, needs, and goals relevant for the eligible person for the coming year;

(F) Identify the needed services required by an eligible person and the anticipated frequency, duration, and limitations of needed services;

(G) Indicate the case management services needed, and the anticipated frequency, duration, and limitations of case management services; and

(H) Indicate the various public agencies or private entities that will or may provide the needed services as identified by the team.

(2) Permanent Service Record

An individualized permanent service record for an eligible person must be maintained. At a minimum, the record shall contain the following:

(A) The eligible person's name, address, and other relevant historical and financial information;

(B) Assessments of the eligible person performed as necessary, to determine needed services;

(C) A plan of services pursuant to subsection (h) (1) above;

(D) Signed monthly service entries indicating the date, place of service, and type of case management services rendered; and

(E) A quarterly summary progress note reviewing the eligible person's needs and the plan of services which is dated and signed by the case manager.

(3) Other Documentation Requirements

All documentation shall be incorporated into the eligible person's permanent service record in a complete, prompt, and accurate manner. All documentation shall be made available to authorized Department personnel upon request as permitted by federal statute.

(i)Billing Requirements

All bills submitted to the Department for payment of case management services must be substantiated by documentation in the eligible person's permanent service record pursuant to subsection (h) above.

(j)Payment

Payment by the Department for case management services rendered to eligible persons shall be based on the Department of Mental Retardation's actual direct and indirect costs to provide case management services. Said costs shall be filed at the end of each state fiscal year with the Department by the Department of Mental Retardation.

For each state fiscal year the Department shall establish a payment rate based upon the said costs for the previous state fiscal year which shall be updated for inflation, using the most recent estimates of the price deflator for the gross national product as published in February of said state fiscal year in the "Economic Report of the Governor" of the State of Connecticut.

(k)Audit

All supporting accounting and business records, statistical data, and all other records relating to the provision of case management services paid for by the Department shall be subject to audit. If an audit discloses discrepancies in the accuracy and/or allowableness of actual direct or indirect costs or statistical data as submitted for each state fiscal year by the Department of Mental Retardation, the Department's payment rate for the said rate period shall be subject to adjustment.

Conn. Agencies Regs. § 17-134d-82

Effective August 31, 1990