Case Manager Medically Dependent Children Program Handbook

1000
Overview and Eligibility
1100
Program Goal and Handbook Purpose
1200
Program Definitions
1300
Eligibility
1310
Residency
1320
Citizenship
1330
Age
1340
Financial Eligibility
1350
Disability
1360
Medical Necessity
1370
Individual Plan of Care (IPC)
1380
Living Arrangement
1390
Monthly Service Utilization
1400
Safeguarding Personally Identifiable Information
1410
Requests for Information About a Deceased Individual
2000
Intake and Interest List Procedures
2100
Initial Requests
2100.1
Caregiver Support Assessment Initiative
2110
Interest List Release and Notification
2110.1
Rural Addresses
2110.2
Referrals from Midland Document Processing Center
2120
Transfer of Individuals Between Waiver Interest Lists
2130
Conflict of Interest
2140
Creating the Case File
2200
Initial Contact
2210
Scheduling a Home Visit
2210.1
Scheduling a Home Visit after the Release Closure Date
2210.2
Outbreak of Transmittable Disease in the General Population
2220
Declining MDCP Services
2230
Failure to Contact the Individual
2300
Initial Home Visit
2310
Reviewing the Enrollment Materials
2310.1
Individual is Still Unsure about Applying for MDCP Services
2310.2
Opportunity to Register to Vote
2310.3
Explaining Long Term Services and Supports
2320
Initiating the Individual Plan of Care
2330
Assessment for Medical Necessity
2330.1
Authorization to Release Medical Records
2340
Freedom of Choice
2350
Choosing a Provider
2360
Applicant Without Medicaid
2370
Explaining Electronic Visit Verification Requirements
2400
Initial Presentation of the Consumer Directed Services Option
2500
Contacting the CSIL Unit for Interest List Release Activities
2510
Contacting the CSIL Unit to Report the Status of Interest List Releases
2520
Closing the Interest List Release for an Applicant Choosing CLASS
2530
Contacting the CSIL Unit to Reopen an Interest List Closure
2540
Adding Names Back to CSIL
2540.1
Earliest Date for Adding an Individual Back to CSIL After Denial
3000
Eligibility Determination and Individual Plan of Care Development
3100
Eligibility Determination
3110
Medicaid Eligibility for the Initial Application
3110.1
Medicaid Buy-In and Medicaid Buy-In for Children
3110.2
Coordination of Disability Determinations
3111
Qualified Income Trust (QIT)
3111.1
Determination of Copayment
3111.2
Refusal to Participate
3111.3
Refund of Copayment
3111.4
Refusal to Pay the Copayment
3120
Medical Necessity
3121
Medical Necessity Determination for Applicants Residing in Nursing Facilities
3122
Medical Necessity Determination for Applicants Recently Discharged from Nursing Facilities
3123
Medical Necessity Inquiry through the Online Portal
3130
Individual Plan of Care Development
3130.1
Setting Funds Aside in the IPC
3130.2
Coordinating IPC Development with the Provider
3131
Determining Cost Effectiveness
3132
The Individual Plan of Care Service Initiation Date and Effective Period
3132.1
Determining the Number of Weeks in the Initial IPC Period
3133
Notifying MEPD of Approved IPC and MN
3134
Other Resources and Services
3135
Coordinating with IDD Services During the Development of the Initial IPC
3135.1
Access to the CARE System
3200
Personal Care Services (PCS)
3200.1
PCS Data Reports
3200.2
Using the PCS Data Reports
3210
Procedures for the MDCP Applicant Who Receives PCS
3220
Procedures for the MDCP Applicant Who Does Not Receive PCS
3230
FMS for the MDCP Applicant Accessing CDS
3240
Coordination of Services in the MDCP IPC and Personal Care Assessment Form
3300
Targeted Case Management (TCM)
3300.1
Coordination of TCM and MDCP Services
3400
Reserved for Future Use
3500
Money Follows the Person Option
3500.1
Individuals Without Medicaid
3500.2
Individuals With Medicaid
3510
Individuals Currently Residing in a Nursing Facility
3520
Limited Nursing Facility Stay for Medically Fragile Individuals
3520.1
MFP Procedures for Requesting a Limited Nursing Facility Stay
3520.2
Case Manager Receipt of Form 2406
3520.3
Regional Nurse Approval
3520.4
Submission of Form 2406 to the DADS Physician
3520.5
Determination of Medical Fragility by the DADS Physician
3520.6
Initial Home Visit for Individuals Approved for a Limited Nursing Facility Stay
3520.7
Coordination of the Limited Nursing Facility Stay
3520.8
Delay in Limited Nursing Facility Stay
3530
Money Follows the Person Demonstration (MFPD)
3530.1
MFPD 365-Day Entitlement Period
3540
Closing NF Authorizations for Individuals Transitioning to Community Services
3550
Accessing Relocation Services
4000
Services
4100
Medically Dependent Children Program (MDCP) Services
4110
Respite
4111
Out-of-Home Respite
4112
Respite Service Limits
4113
Respite Service Authorizations
4114
Respite Service Schedule Changes
4120
Flexible Family Support Services
4121
Flexible Family Support Services in Child Care
4122
Flexible Family Support Services for Independent Living
4123
Flexible Family Support Services in Post-Secondary Education
4124
Flexible Family Support Services Limits
4125
Flexible Family Support Services Authorizations
4126
Service Schedule Changes to Flexible Family Support Services
4130
Adaptive Aids
4131
Individual Role in Adaptive Aids
4131.1
Third-Party Resources for Adaptive Aids
4131.2
Adaptive Aid Bidders
4131.3
Specifications for Adaptive Aids
4131.3.1
Specifications for Adaptive Aids with Individual Personal Costs
4131.4
Special Requirements for Van Lifts/Vehicle Modifications
4131.5
Bids for Adaptive Aids
4131.5.1
Bids for Adaptive Aids with Individual Personal Costs
4132
Service Limits on Adaptive Aids
4133
Bid Verification for Adaptive Aids
4134
Individual Personal Costs for Adaptive Aids
4135
Adaptive Aids Service Authorization
4135.1
Approval of Adaptive Aids Not Listed in Section 4132, Service Limits on Adaptive Aids
4136
Adaptive Aid Delivery Time Frames and Confirmation
4140
Minor Home Modifications
4141
Individual Role in Minor Home Modifications
4141.1
Minor Home Modification Bidders
4141.2
Specifications for Minor Home Modifications
4141.2.1
Justifications for Minor Home Modifications Less Than $1,000
4141.2.2
Specifications for Minor Home Modifications with Individual Personal Costs
4141.3
Bids for Minor Home Modifications
4141.3.1
Bids for Minor Home Modifications Less Than $1,000
4141.3.2
Bids for Minor Home Modifications with Individual Personal Costs
4141.4
Home Owner Approval of Minor Home Modifications
4142
Service Limits on Minor Home Modifications
4143
Bid Verification for Minor Home Modifications
4144
Individual Personal Costs for Minor Home Modifications
4145
Minor Home Modification Repairs and Maintenance
4146
Minor Home Modification Service Authorization
4147
Minor Home Modification Time Frames and Completion Confirmation
4150
Transition Assistance Services (TAS)
4151
Transition Assistance Services (TAS) Description
4151.1
Deposits
4151.2
Essential Furnishings
4151.3
Moving Expenses
4151.4
Site Preparation
4152
Limits on Transition Assistance Services (TAS)
4153
Authorizing Transition Assistance Services (TAS)
4153.1
Changes to Transition Assistance Services (TAS) Authorization
4154
Transition Assistance Services (TAS) Delivery Time Frames and Confirmation
4155
Failure to Leave the Nursing Facility
4160
Financial Management Services
4200
Notification and Service Authorization System
4210
Applicant/Individual Eligibility Notification
4220
Provider Notification
4230
Service Authorization System (SAS)
4231
Service Authorization System (SAS) Data Entry
4232
Service Authorization System (SAS) Data Entry for Service Reductions, Suspensions, Denials and Case Closures
4233
SAS Data Entry Procedures for CDSA Provider Transfers
5000
Ongoing Case Management
5100
Changes to the Individual Plan of Care (IPC)
5110
Interim Plan of Care
5120
Budget Revision
5130
Prorating the Cost Limit for an Applicant/Individual Who Will Turn 21 Years of Age
5140
Provider Transfers During the IPC Period
5141
CDSA Transfers During the IPC Period
5142
Assessing an Individual's Satisfaction When a Change in Provider is Requested
5143
Sharing Information with New Providers Regarding Health and Safety Issues
5200
Service Delivery Issues Reported to DADS Staff
5300
Service Delivery Issues Reported by the Provider
5310
Primary Caregiver Refuses to Comply with the IPC
5320
Provider is Unable to Verify Individual’s Medicaid Status
5330
Provider is Unable to Begin Services on the Service Initiation Date
5340
Provider Initiated Changes to the Delivery of Services
5400
Convening a Meeting to Resolve Issues
5500
Loss of Medicaid
5510
Coordination of Fair Hearings with the CRU
5520
Case Manager Responsibilities and Effective Dates of Appeal Decisions
5600
Change in Address
5700
Change in Primary Caregiver
5800
Use of Services Outside the Provider's Contracted Service Delivery Area
6000
Monitoring Services
6100
Monitoring Services and Follow-up Contacts
6110
Monitoring Transition Assistance Services (TAS)
6120
30-Day Contact
6130
IPC Service Monitoring
7000
Annual Reassessment
7100
Annual Reassessment Overview
7100.1
Opportunity to Register to Vote
7110
Annual Eligibility Requirements
7111
Financial Reassessments
7120
Medical Necessity Determination
7130
Individual Plan of Care Development
7131
Setting Funds Aside in the IPC
7132
Completing the Annual Reassessment IPC
7133
Personal Care Services
7133.1
PCS Data Reports
7133.2
Using the PCS Data Reports
7133.3
Procedures for Individuals Not Receiving PCS
7134
Coordinating with IDD Services During the Development of the Annual IPC
7135
FMS for the MDCP Individual Accessing CDS
7136
Coordination of Services in the MDCP IPC and the Personal Care Assessment Form
7140
Notifications for Program Eligibility and Service Authorizations
7141
Respite Service Authorizations
7142
Flexible Family Support Services Authorizations
7143
Practitioner's Orders or Form 2428 for Respite or Flexible Family Support Services
7144
Program Ineligibility at Annual Reassessment
7150
Service Authorization System Data Entry
7160
In-Home Record Review
7161
MDCP Nurse Procedures
7162
Case Manager Procedures
7163
Case Manager Procedures Regarding HCSSAs When Additional Action is Required
7164
Case Manager Procedures Regarding the Consumer Directed Services Option when Additional Action is Required
8000
Consumer Directed Services
8100
Overview
8110
Definitions
8200
Individual Choice in the CDS Option
8210
Initial Presentation of the CDS Option
8220
CDS Option for Ongoing Individuals
8300
Developing the Individual Service Plan
8400
Initiation and Transition to the CDS Option
8410
Initial Orientation of the Employer
8420
Service Back-Up Plans
8430
Corrective Action Plans
8500
Employer Difficulty Managing the CDS Option
8600
Transfer Procedures
8610
Termination of Participation in the CDS Option
8620
Re-enrollment in the CDS Option
8700
CDS Contact Chart
9000
Service Reductions, Suspensions, Denials, Case Closures, Appeals and Fair Hearings
9100
Notification Forms for Service Reductions, Suspensions, Denials and Case Closures
9110
Exceptions to the 30-day Notification Time Frame
9200
Service Reductions
9300
Denying Requests for Specific Services
9400
Service Suspensions
9410
Notification of Service Suspensions
9420
Extension of Suspension
9430
Resuming Services
9440
Procedures for Temporary Nursing Facility Admissions
9500
Service Denials and Case Closure
9510
Ineligibility
9520
Failure to Maintain Enrollment
9530
Death of Individual
9540
Institutional Placement
9541
Additional Procedures for Permanent Nursing Facility Admissions
9550
Aging Out
9551
Aging Out to the Community Based Alternatives (CBA) Program
9552
Aging Out to the STAR+PLUS Waiver Program
9560
Interest List Releases to Other Waiver Programs
9570
Transfer of An Individual to Another Service Area
9571
Procedures for the Original Case Manager
9572
Procedures for the New Case Manager
9600
Appeals and Fair Hearing Procedures
9610
Appeals Process
9611
Case Manager and Designated Data Entry Representative Procedures
9611.1
Procedures for Loss of Medicaid
9611.2
Procedures for Medical Necessity (MN) Denials
9611.3
Procedures for Utilization Review Findings
9612
Sending Additional Information
9613
Request to Withdraw an Appeal
9614
Appeals and Continuation of Services
9620
Fair Hearing
9621
Fair Hearing Decision
9621.1
Action Taken on Fair Hearing Decision
9621.2
Procedures for Sustained Decisions
9621.3
Procedures for Reversed Decisions
9621.4
Procedures When Denied Medical Necessity (MN) is Overturned
9621.5
Procedures When a New Assessment is Required by a Fair Hearing Decision
9622
Fair Hearing Exception
9622.1
Fair Hearing Exception Process
9622.2
Community Services Policy Staff Actions
10000
Case Management Procedures for Utilization Review
10100
Medically Dependent Children Program Utilization Review
10110
New Service Limit Exception Procedures and Utilization Review
10200
Concurrent Reviews
10210
When a Fair Hearing is Pending
10220
When a Fair Hearing Has Been Rendered
10300
Utilization Review Observations and Findings
10310
Reporting Observations by the Utilization Review Nurse
10320
Utilization Review Finding Reports to the Regional Director
10330
Regional Director Response to Utilization Review Findings
10340
Final Utilization Review Findings
10350
Exception Process for Utilization Review Findings
10400
Implementation of Utilization Review Observations, Recommendations and Findings
10410
Implementation of Utilization Review Findings
10420
Case Manager Procedures for Completing Changes
10430
Individual’s Agreement/Disagreement with the IPC Change
10440
Exception to Implementing Termination/Decrease of Services from the Utilization Review Finding
10450
Notifications
11000
Service Authorization System Help File
11100
Medically Dependent Children Program (MDCP)
11200
Create an Initial Service Authorization for MDCP
11205
Client – Initial Service Authorization
11210
Address Area – Initial Service Authorization
11215
Location – Initial Service Authorization
11220
Other Information
11225
Phone – Initial Service Authorization
11230
Authorizing Agent – Initial Service Authorization
11235
Enrollment – Initial Service Authorization
11240
Service Plan – Initial Service Authorization
11245
Level of Service – Initial Service Authorization
11250
Diagnosis – Initial Service Authorization
11255
Medical Necessity – Initial Service Authorization
11260
Service Authorization – Initial Service Authorization
11265
Consumer Directed Services (CDS) Calculation of the Individual Plan of Care (IPC)
11270
Service Authorization for CDS Option – Initial Service Authorization
11300
Reauthorize MDCP Services for Another IPC Period
11310
Address, Location, Phone and Authorizing Agent – Reassessment
11320
Enrollment – Reassessment
11330
Service Plan – Reassessment
11340
Service Authorization – Reassessment
11350
Level of Service – Reassessment
11360
Diagnosis – Reassessment
11370
Medical Necessity – Reassessment
11400
Terminations
11410
Terminating All Services
11420
Terminating a Specific Service Code
11500
Individual Plan of Care (IPC) Changes
11510
Provider Transfers
11520
Service Plan – IPC Changes
10530
All Other IPC Changes