12 Va. Admin. Code § 30-50-415 - Case management for individuals receiving early intervention (Part C) services
A.
Target group for early intervention case management . Medicaid eligible children
from birth up to three years of age who have (i) a 25% developmental delay in
one or more areas of development, (ii) atypical development, or (iii) a
diagnosed physical or mental condition that has a high probability of resulting
in a developmental delay who participate in the early intervention services
system described in Chapter 53 (§ 2.2-5300 et seq.) of Title 2.2 of the
Code of Virginia are the target group.
B. Services are provided throughout the
Commonwealth.
C. Services are not
comparable in amount, duration, and scope. The authority of § 1915(g)(1)
of the Social Security Act (the Act ) is invoked to provide services without
regard to the requirements of § 1902(a)(10)(B) of the Act .
D. Definition of services. Early intervention
case management services are services furnished to assist individuals eligible
under the State Plan who reside in a community setting in gaining access to
medical, social, educational, and other services. Early intervention case
management includes the following assistance:
1. Comprehensive assessment and at least
annual reassessment of individual needs to determine the need for any medical,
educational, social, or other services, including EPSDT services.
2. Development and at least annual revision
of an individualized family service plan (IFSP) as defined in coverage of early
intervention services under Part C of Individuals with Disabilities Education
Act (IDEA) (12VAC30-50-131 ) based on the
information collected through the assessment. A face-to-face contact with the
child's family is required for the initial development and revision of the
IFSP. The case manager shall be responsible for determining if the family's
particular situation warrants additional face-to-face visits.
3. Referral and related activities to help
the eligible individual obtain needed services, including activities that help
link the individual with medical, social, and educational providers or other
programs and services that are capable of providing needed services to address
identified needs and achieve goals specified in the IFSP.
4. Monitoring and follow-up activities,
including activities and contacts that are necessary to ensure that the IFSP is
effectively implemented and adequately addresses the needs of the eligible
individual. At a minimum one telephone, email, or face-to-face contact shall be
made with the child's family every three calendar months, or attempts of such
contacts. This contact or attempted contact shall be documented. The case
manager shall be responsible for determining if the family's particular
situation warrants additional family contacts.
5. Early intervention case management
includes contacts with family members, service providers, and other noneligible
individuals and entities who have direct knowledge of the eligible individual's
needs and care.
E.
Qualifications of providers. Individual providers of early intervention case
management must be certified as early intervention case managers by the
Department of Behavioral Health and Developmental Services.
F. Freedom of choice. The Commonwealth
assures that the provision of case management services will not restrict an
eligible individual's freedom of choice of providers.
1. Eligible recipients shall have free choice
of the providers of early intervention case management services within the
specified geographic area identified in this plan.
2. Eligible recipients shall have free choice
of the providers of other medical care under the plan .
3. Providers of early intervention case
management shall be limited to entities designated by the local lead agencies
under contract with the Department of Behavioral Health and Developmental
Services pursuant to § 2.2-5304.1 of the Code of Virginia.
G. Access to services. The
Commonwealth assures the following:
1. Case
management services shall be provided in a manner consistent with the best
interest of recipients and shall not be used to restrict an individual's access
to other Medicaid services.
2.
Individuals shall not be compelled to receive case management services. The
receipt of other Medicaid services shall not be a condition for the receipt of
case management services, and the receipt of case management services shall not
be a condition for receipt of other Medicaid services.
3. Providers of case management services do
not exercise DMAS authority to authorize or deny the provision of other
Medicaid services.
H.
Payment for early intervention case management services shall not duplicate
payments made to public agencies or private entities under other program
authorities for this same purpose.
I. Case records. Case management services
shall be documented and maintained in individual case records in accordance
with 42 CFR
441.18(a)(7). Case records
shall include:
1. The name of the
individual;
2. The dates of the
case management services;
3. The
name of the provider agency and the person providing the case management
services;
4. The nature, content,
and units of the case management services received and whether the goals
specified in the care plan have been achieved;
5. Whether the individual has declined
services in the care plan;
6. The
need for, and occurrences of, coordination with other case managers;
7. A timeline for obtaining needed services;
and
8. A timeline for reevaluation
of the plan .
J.
Limitations.
1. Early intervention case
management shall not include the following:
b. The direct delivery of an underlying
medical, educational, social, or other service to which an eligible individual
has been referred.
c. Activities
integral to the administration of foster care programs.
d. Activities for which third parties are
liable to pay, except for case management that is included in an IFSP
consistent with § 1903(c) of the Social Security Act .
2. Providers shall not be reimbursed for case
management services provided for these groups when these children also fall
within the target group for early intervention case management as set out in
this subdivision:
a. Seriously mentally ill
adults and emotionally disturbed children (12VAC30-50-420 );
b. Youth at risk of serious emotional
disturbance (12VAC30-50-430 );
c. Individuals with intellectual disability
(12VAC30-50-440 ); or
d.
Individuals with intellectual disability and related conditions who are
participants in the home and community-based care waivers for persons with
intellectual disability and related conditions (12VAC30-50-450 ).
3. Case management shall be
reimbursed only when all of the following conditions are met:
a. A least one documented case management
service is furnished during the month; and
b. The provider is certified by the
Department of Behavioral Health and Developmental Services and enrolled with
DMAS as an early intervention case management provider.
Notes
Statutory Authority: § 32.1-325 of the Code of Virginia.
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