23 Miss. Code. R. 208-6.3 - Covered Services
The following services are available to B2I persons as documented in the Plan of Services and Supports (PSS):
A. Transition Care Management, defined as
transition care planning occurring for up to one-hundred eighty (180) days
pre-discharge from the institution and post-transition care planning for three
hundred sixty-five (365) days following transition into the community.
1. Transition Care Management includes:
a) Crisis Support, defined as a response to
the transitioning person and/or person's caregiver who is experiencing a crisis
event during the transition process.
1) The
service must be available twenty-four (24) hours a day, seven (7) days a week.
2) Initial contact may take place
over the telephone, but if the situation is determined to be an emergency, the
provider must provide in-person support.
3) Staff must be available to meet with the
person in transition, as well as any other member of the person-centered
planning team, to resolve the crisis and thereby enable the person to remain in
the community.
b)
Person-Centered Planning (PCP), defined as a process directed by the person or
family with long-term care needs which:
1)
Identifies the strengths, capacities, preferences, needs and desired outcomes
of the person.
2) Includes
participants freely chosen by the person or family who are able to serve as
important contributors.
3) Assists
the person to identify and access personalized paid and non-paid services and
supports.
4) The person identifies
planning goals to achieve those personal outcomes in collaboration with those
that the person has identified, including medical and professional staff.
5) The identified
personally-defined outcomes and the training supports, therapies, treatments
and/or other services the person is to receive to achieve those outcomes as
part of the Plan of Services and Supports (PSS).
6) Meets all the following minimum PCP
service contact requirements:
(a) Initial PCP
meeting held within thirty (30) days of the person choosing a B2I provider,
(b) Pre-transition PCP meeting
held a minimum of every thirty (30) days,
(c) Post-transition PCP meeting held a
minimum of every sixty (60) days, and
(d) Interim PCP meetings held as
circumstances change, the person and/or guardian or legal representative
requests a meeting, and/or the needs of the person require that the team meet
on a more frequent basis to best coordinate care.
7) Includes the following documentation in
the enrolled person's record:
(a) Discovery
interviews including, but not limited to, Community Navigator Notes, dates, and
individuals interviewed, such as the person and caregivers,
(b) Activities and observations including,
but not limited to, activity, location, Community Navigator Notes, and dates,
(c) Profile,
(d) Dated Action Plans from each PCP meeting,
(e) Sign-in sheets of all meetings
and dates, and
(f) Minutes from
all PCP meetings.
8)
Includes the development of the PSS which is retained in the person's record
and contains:
(a) B2I services, including,
but not limited to, service amounts, provider name, and beginning and end dates
of services provided,
(b) Other
services received, regardless of payer source, including, but not limited to,
service amounts, provider name, and beginning and end dates of services
provided, and
(c) Narrative of
services, supports, needs and outcomes.
9) Includes a Risk Mitigation Plan, defined
as a comprehensive and pro-active safety/risk mitigation plan developed to
address any safety issue/risk that has been identified through discovery and
planning. The Risk Mitigation Plan must be retained in the person's record and
address any safety issue/risk in the following categories and include a
detailed mitigation plan for any safety issue/risk including, but not limited
to:
(a) Medical and physiological,
(b) Behavioral and psychiatric,
(c) Environmental including, but not limited
to, living conditions or loss of a home,
(d) Financial,
(e) Activities of daily living including, but
not limited to, loss of natural supports,
(f) Service disruption,
(g) Legal including, but not limited to,
prior convictions and recidivism risk,
(h) Natural disaster plan including, but not
limited to, fire, flooding, hurricane and earthquake evacuation plan including
emergency contact information,
(i)
B2I provider staff contact number available twenty-four hours a day, seven days
a week (24/7),
(j) Emergency
contact numbers including, but not limited to, 911, local law enforcement
office, local hospital, and regional CMHC, and
(k) A written and oral explanation of
appropriate responses to emergencies, including health or mental health
emergencies versus situations in need of immediate attention, including broken
medical equipment or failure of a service provider to make an appointment.
2. Transition Care Management must be
provided by a qualified community navigator who cannot be the person's HCB
waiver/CMHC case manager and who meets the criteria in one (1) of the
following:
a) Licensed social worker (LSW)
with valid state license and a minimum of one (1) year of relevant work
experience,
b) Case manager with
at least one (1) year of relevant work experience and certified by the
Department of Mental Health (DMH),
c) Registered nurse (RN) with valid state
license and a minimum of one (1) year of relevant work experience, or
d) Others with relevant experience
and training with a minimum of a bachelor's degree and one (1) year of work
experience in a social or health service setting or a comparable technical and
human service training will be considered and approved by the Division of
Medicaid, B2I.
3. The
community navigator must document in a narrative form in a Community Navigator
Notes section in the record all contacts made with, about and/or on behalf of
the person and include:
a) Date of the
service,
b) Beginning and end time
of the service,
c) Type of contact
including, but not limited to, face-to-face, phone, e-mail, PCP meeting notes
and activities, meetings and third party calls,
d) Who the contact was with including, but
not limited to, the person, family member, community/natural resource, service
providers, and housing partners,
e) Reason for the contact as well as the
content and issues discussed,
f)
All follow-up activities,
g) When,
why, and what type of information is received about or by the person,
h) When, why, and what type of
information is sent to another party about the person,
i) Any change in services,
j) Other situations based on individual
circumstances, and
k) Community
navigator's signature.
4. A Community navigator must provide the
following minimum service contacts:
a)
Face-to-face meeting with the person and interested parties scheduled within
ten (10) days of a B2I provider receiving referral,
b) One (1) contact per week with the person
and/or family which includes during the Pre-Transition period up to one hundred
eighty (180) days and the Post-Transition period during the first ninety (90)
days,
c) One (1) face-to-face
visit per month with the person Pre-Transition and Post-Transition, not
including PCP meeting,
d) One (1)
PCP team meeting every thirty (30) days Pre-Transition and every sixty (60)
days Post-Transition with the initial PCP meeting held within the first thirty
(30) days after the Consent to Participate Phase II is signed, and
e) One (1) contact per month with an assigned
HCB waiver/CMHC case manager to ensure service coordination during the
Post-Transition period.
5. A community navigator's case load cannot
exceed:
a) A total of thirty (30) persons, or
b) Fifteen (15) persons in each of
the following categories:
1) Pre-Transition
refers to persons for whom a community navigator is providing Transition Care
Management services on an ongoing basis prior to transition up to one hundred
eighty (180) days and in the first ninety (90) days after transition.
2) Ninety (90) days
Post-Transition refers to persons for whom a community navigator is continuing
to provide ongoing Transition Care Management services but whose primary health
care oversight and management responsibilities have been turned over to
appropriate HCB waiver/CMHC case managers.
B. Life Skills Training, defined
as assisting persons with transitioning to the community through independent
living skills that include, but are not limited to, money management, the use
of technology, accessing community resources, employment skills development,
grooming and personal hygiene, and interpersonal relationships with others in
the community.
1. A life skills service plan
must be developed with the person's input to address life skills needed which
must be contained in the person's record and include:
a) Date of life skills service plan,
b) Life skills to be addressed,
c) Activities used to meet the
life skill need, and
d) Date of
goals met and improvement of life skills.
2. Documentation of services provided must be
retained in the person's record and contain:
a) Date of the service,
b) Beginning and end time of the service
delivery,
c) Description of the
service, and
d) Signature of staff
person providing service.
C. Peer Supports, defined as counseling from
peers with similar circumstances who may be able to share their own experiences
with the person to reduce feelings of isolation and to promote inclusion.
1. Peer supporters must meet the following
criteria:
a) Be a resident of Mississippi,
b) Self-identify as a current or
former recipient of disability services for persons with physical,
intellectual, developmental, and/or mental disabilities,
c) Complete all training required by the
provider agency,
d) Demonstrate a
minimum of six (6) consecutive months in self-directed recovery and/or of
successful community living, and
e) Demonstrate emotional readiness to provide
supports to a peer.
2.
Documentation of services provided must be retained in the person's record and
contain:
a) Date of the service,
b) Beginning and end time of the service
delivery,
c) Description and
summary of the service, and
d)
Signature of staff person providing the service.
D. Caregiver Support, defined as a
service to enable the caregiver to transition into a more active role and to
assist identified and qualified caregivers of persons enrolled in B2I to cope
with stress and to develop caregiver skills in order to help them become a
source of support for the transitioning person. Caregivers qualified to receive
caregiver support must perform or assist the person in one (1) or more life
activities, such as finances, health care, or general decision making, and
includes:
1. Peer-to-Peer service designed
for identified caregivers of the person enrolled in B2I to assist with the
management of stress and the development of caregiver skills and must be
provided by an individual who must:
a)
Identify as a former or current caregiver of someone with a physical,
intellectual, developmental or mental disability,
b) Complete all training required by the
provider agency, and
c)
Demonstrate emotional readiness to provide emotional support to another
caregiver and understand when to seek professional help for a caregiver.
2. Individual Therapy
Support, defined as services designed to assist identified caregivers of the
person enrolled in B2I through therapy/counseling sessions and must be:
a) Provided by an individual who holds a
master's degree and professional license as a licensed professional counselor
(LPC), licensed psychologist, licensed certified social worker (LCSW) or
licensed marriage and family therapist (LMFT), and
b) Documented in the person's record and
contain:
1) Date of the service,
2) Beginning and end time of the service
delivery,
3) Description and
summary of the service, and
4)
Signature of staff providing service.
E. Transportation, defined as any
appropriate form of transporting the person from one (1) location to another to
maximize community inclusion for the person.
1. Documentation of services provided must be
retained in person's record and contain:
a)
Date of service,
b) Time of
service,
c) Destination to and
from, and
d) Signature of staff
providing service.
F. Security and Utility Deposits, defined as
specific up-front costs to establish a residence in the community with detailed
receipts retained in the person's record.
G. Household Furnishings and Goods, defined
as, but not limited to, essential items and furnishings, appliances, household
supplies, and pantry items required to set-up a household in the HCB setting
based on the needs of the person with detailed receipts retained in the
person's record.
H. Moving
Expenses, defined as moving costs associated with a transition for items
transported from the facility in which the person is residing to their new
community residence or community-based setting and may also cover commercial
transportation of household furnishings from a store to the person's community
residence or community-based setting with detailed receipts retained in the
person's record.
I. Environmental
Accessibility Adaptations, defined as certain required modifications completed
by a licensed and bonded contractor to the person's residence to enable the
care of the person in a HCB setting with detailed receipts retained in the
person's record. Only persons enrolled in the E&D or ID/DD Waivers are
eligible for Environmental Accessibility Adaptations.
J. Durable Medical Equipment (DME), defined
as medically necessary equipment, based on the person's PSS, which allows for
community living. Only persons enrolled in the E&D, ID/DD or AL Waivers are
eligible for DME.
K. Extended
Pharmacy, defined as up to three (3) additional prescriptions over the Medicaid
five (5) prescription limit allowed in the State Plan for a total not to exceed
eight (8) prescriptions per month with no more than five (5) of which may be
non-generics.
1. The person is only eligible
for the extended pharmacy benefit if their prescriptions are in excess of the
Medicaid monthly prescription limit.
2. Community navigators must assist the
person in managing the extended pharmacy benefit to access needed pharmacy
services under existing options in the Mississippi State Plan.
3. Community navigators must coordinate with
the person's community providers including, but not limited to, physicians and
pharmacists for medication management.
4. The person enrolled in B2I should utilize
preferred medications on the Universal Preferred Drug List (PDL) and the Ninety
(90) Day Maintenance List when possible, to maintain the person on the least
amount of prescriptions required for therapeutic benefit.
L. Adaptive Equipment/Technology, defined as
an assistive equipment/technological device which includes an item, piece of
equipment, or product system, whether acquired commercially, modified, or
customized, used to increase, maintain, or to improve the person's level of
independence, ability to access needed supports and services in the community
or maintain or improve the person's safety with detailed receipts retained in
the person's record.
Notes
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