Section 210-RICR-50-00-5.5 - Development of Plan of Care, Service Planning and Authorization, and Case ManagementA. The development of a plan of care is a multifaceted and multilayered process that may start prior to making a request for Medicaid LTSS if a prospective applicant and his or her family are seeking LTSS information and referral or counseling on the available LTSS options. In instances in which an applicant by-passes these options, care planning typically starts at the point of application and continues after a determination of level of care has been completed and services have been authorized. The core elements of the care planning process include, but are not limited to: 1. Person-centered -- Irrespective of the type of Medicaid LTSS a person is seeking (health institution v. HCBS), the care planning process is driven by an applicant's health care goals, expectations and choices.2. Health institutions and service planning -- Federal regulations require that health institutions providing Medicaid funded LTSS conduct in-depth evaluations that consider a prospective resident's needs, values, and preferences when establishing a plan of care. Agency representatives consider the results of these evaluations when determining level of care, assisting in the development of the plan of care, and authorizing services. In addition: a. NF and PASRR. In accordance with federal law, the State Preadmission Screening and Resident Review (PASRR) evaluation for all prospective NF residents focuses on cognitive, developmental and intellectual disabilities and behavioral health conditions that may require specialized services in a health institution. The results of this evaluation are used to incorporate specific services into the plan of care for applicants determined to have special needs as set forth in subsection § 5.7 of this Part below. The State must authorize payment for any such services included in the plan of care for Medicaid beneficiaries.b. HCBS transitions. Health institutions must inform prospective residents and patients, as well anyone about to be discharged, who needs continuous LTSS about HCBS options. This information must be considered and recorded in any continuity of care service plans. NF and ICF/I-DD health institutions must also report to EOHHS any Medicaid applicant or beneficiary expressing a preference for HCBS options, as indicated subsection § 5.5 of this Part.2. HCBS care planning -- HCBS person-centered planning supports an individual's right and ability to share his or her desires and goals, to consider different options for support, and to learn about the benefits and risks of each option. The essential elements of this process are set forth in in Subchapter 10 Part 1 of this Chapter.B. For Medicaid LTSS coverage to begin, services must be authorized. Both the needs assessment and care planning process provide the critical information Agency representatives require to develop and authorize a service plan that meets the individual needs of a beneficiary. The scope of service planning from this point may be broadened or targeted more narrowly depending on whether a beneficiary is currently receiving or has chosen the type of LTSS and/or a service option. 1. Type of LTSS and service setting and delivery options - The Medicaid LTSS authorization of services is a function of the level of care determination and the applicant/beneficiary choice of the available LTSS type (health institution and/or HCBS) and service options therein. LTSS type and options are: health institution (NF, ICF/I-DD, LTH) or HCBS (assisted living residence, PACE, home care, shared living, IDD group home, habilitation at home or in a congregate setting, personal choice self-directed care). Availability of service options is based on the extent of a person's need for a particular institutional level of care -- that is, whether that need meets the applicable criteria to qualify as high or highest or some level within these categories for persons with intellectual/developmental disabilities.2. Service plan [DOT] An agency representative or community representative includes a service plan that incorporates the results of the care planning process into the plan authorizing LTSS type and service option. Accordingly, the service plan identifies the scope of authorized services in a health institution (such as skilled v. custodial in a NF) or in an HCBS setting (such as degree of supervision, number of homemaker v. skilled hours, and/or the availability of direct supports.)C. Case management is a set of inter-related activities that ensure access to coordinated Medicaid LTSS and the monitoring of service needs and outcomes. Case management is an LTSS covered service under the Medicaid State Plan and Section 1115 waiver and may be provided by agency representatives, Medicaid managed care plans, community-based providers and organizations, and/or other contractual case management entities authorized by the State. Depending on the agency and the population served, this may be performed by multiple entities working in collaboration or a single entity. In addition: 1. Conflict-free -- Case management must be conflict free to the full extent feasible. Accordingly, persons or entities providing LTSS case management services should not have a fiduciary interest in or influence over the scope, amount, or duration of Medicaid LTSS that beneficiaries receive. In instances in which such conflicts appear or may exist, the State is bound by federal law to establish firewalls that ensure that care management activities are performed independently, in accordance with State standards, and under the direction of agency representatives. The State reserves the discretion to limit or terminate any arrangement for case management services that does not operate in compliance with these firewalls or that otherwise fails to serve the best interests of beneficiaries.2. Scope of Services -- Case management services include, but are not limited to, assisting in or conducting screening and/or more in-depth assessments prior to and during the eligibility determination process, facilitating the person-centered planning process, aiding in the development of service plans, conducting periodic reviews and reassessments of functional/clinical needs, and coordinating services with the beneficiary's primary care and community service providers, LTSS program representatives, agency LTSS specialists, and family members when appropriate. 210 R.I. Code R. 210-RICR-50-00-5.5