Mont. Admin. r. 37.86.3906 - TARGETED CASE MANAGEMENT SERVICES FOR CHILDREN AND YOUTH WITH SPECIAL HEALTH CARE NEEDS, PROVIDER REQUIREMENTS
(1)
These requirements are in addition to those contained in rule and statutory
provisions generally applicable to medicaid providers.
(2) To be qualified as a provider of targeted
case management services for children and youth with special health care needs,
an enrolled Montana Medicaid provider must:
(a) be approved by the department;
(b) meet the requirements in (3) through (8);
(c) have knowledge and experience
in the delivery of home and community services to children and youth with
special health care needs;
(d)
demonstrate an understanding of service coordination for children up to 18
years of age; and
(e) have
developed collaborative working relationships with health care and other
providers in the area to be served.
(3) A targeted case management provider must
use an interdisciplinary team that includes members from the professions of
nursing and social work,
(a) The professional
requirements are the following:
(i) nursing
must be provided by a registered nurse, who has a current Montana license and
is either:
(A) a registered nurse whose
education includes course work in public health; or
(B) a certified nurse practitioner;
and
(ii) social work
must be provided by one of the following:
(A)
clinical social worker with a master's in social work (MSW), who has a current
Montana license;
(B) master's
level counselor (LCPC), who has a current Montana license; or
(C) bachelor's in social work (BSW) with two
years' experience in community social services or public health.
(b) The department must
be notified within 30 days regarding any staff changes or updates.
(c) To accommodate special agency and
geographic needs and circumstances, exceptions to the staffing requirements,
including the use of paraprofessionals, may be allowed if approved by the
department. If the targeted case management team includes a paraprofessional,
that individual must have a minimum of an associate's degree in behavioral
sciences or a related field with two years of closely related work experience,
and complete a state-sponsored training for paraprofessional targeted case
managers. Qualifying experience may be substituted, year for year, for
education.
(4) The
targeted case management provider must be able to directly provide services of
at least one of the professional disciplines listed in (3) of this rule. The
other disciplines may be provided through subcontracts. Where services are
provided through a subcontractor, the subcontract must be submitted to the
department or designee for review and approval.
(5) A targeted case management provider must:
(a) conduct activities to inform the target
population and health care and social service providers in the geographic area
to be served of its services for youth and children with special health care
needs;
(b) deliver targeted case
management services appropriate to the child and caregiver's level of need;
(c) respond promptly to requests
and referrals of children for targeted case management;
(d) perform assessments and develop care
plans for the appropriate level of care and document the services
provided;
(e) schedule services to
accommodate the child's situation;
(f) inform a child and the child's caregivers
regarding whom and when to call for health care emergencies;
(g) establish working relationships with
medical providers, community agencies, and other appropriate organizations;
(h) assure ongoing communication
and coordination of the child's care occur within the targeted case management
team and the child's primary care provider at least quarterly or at the time of
any medical referral;
(i) provide
services in a home, office, or clinic setting with telephone contacts as
appropriate;
(j) have a system for
handling grievances; and
(k)
maintain an adequate and confidential record system. All services provided must
be documented in this system.
(6) A case targeted manager must have
knowledge of:
(a) federal, state and local
programs for children and youth such as WIC, immunizations, children's special
health services, genetic services, hepatitis B screening, EPSDT, Montana
Milestones (Part C Early Interventions), and other health care related programs
in Montana;
(b) individual health
care systems, plan development, and evaluation;
(c) community health care systems and
resources; and
(d) nationally
recognized early childhood health care and well child health
standards.
(7) A targeted
case manager must have the ability to:
(a)
develop or participate in the development of an individual care plan based on
assessment of a child's health, nutritional and psychosocial status, and
personal and community resources;
(b) inform a child and the child's caregivers
regarding health conditions and implications of risk factors;
(c) foster the ability of a child's
caregivers to assume responsibility for the child's health care;
(d) assist the child and the child's
caregivers to establish linkages among service providers;
(e) coordinate access to multiple provider
services to benefit the child and the child's caregivers; and
(f) evaluate a child's and the child's
caregiver's progress in obtaining appropriate medical care and other needed
services.
(8) Providers
must maintain case records that meet the maintenance of records and auditing
guidelines set forth in ARM
37.85.414
and that document, for all members receiving targeted case management, the
following:
(a) the name of the member;
(b) the dates of the targeted case
management services;
(c) the name
of the provider agency and the person providing the services;
(d) the nature, content, and units of the
targeted case management services received, and whether goals specified in the
care plan have been achieved;
(e)
whether the member has declined services in the care plan;
(f) the need for, and occurrences of,
coordination with other targeted case managers;
(g) a timeline for obtaining needed services;
and
(h) a timeline for
reevaluation of the plan.
Notes
AUTH: 53-6-113, MCA; IMP: 53-6-101, MCA
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