907 KAR 1:440. Case management services.


      RELATES TO: KRS 205.520

      STATUTORY AUTHORITY: KRS 194A.030(2), 194.050(1), 205.520(3), EO 2004-726

      NECESSITY, FUNCTION, AND CONFORMITY: EO 2004-726, effective July 9, 2004, reorganized the Cabinet for Health Services and placed the Department for Medicaid Services and the Medicaid Program under the Cabinet for Health and Family Services. The Cabinet for Health and Family Services has responsibility to administer the program of Medical Assistance in accordance with Title XIX of the Social Security Act. KRS 205.520(3) empowers the cabinet, by administrative regulation, to comply with any requirement that may be imposed, or opportunity presented, by federal law for the provision of medical assistance to Kentucky's indigent citizenry. This administrative regulation sets forth the scope of services for case management and the method for determining amounts payable by the cabinet for case management services.


      Section 1. Definition of Services. Case management is a service instrument by which service agencies assist an individual in accessing needed medical, social, educational, and other support services. Case management providers are required to monitor to assure that recipients of case management services receive the services for which they are referred. Case management activities include:

      (1) Assessment of client's medical, social, and functional status, and identification of client service needs;

      (2) Arranging for service delivery from the client's chosen provider to insure access to required services;

      (3) Insure access to needed services by explaining the need and importance of services in relation to the client's condition;

      (4) Insure access, quality and delivery of necessary services; and

      (5) Preparation and maintenance of case record documentation to include service plans, forms, reports, and narratives, as appropriate.


      Section 2. Target Group. The case management services are limited, as provided for in the Social Security Act at Section 1915(g)(1), to the following targeted groups of Medicaid eligible individuals, with the further provision that these individuals cannot be receiving case management services under a Medicaid waiver program:

      (1) Individuals under age twenty-one (21) who meet the medical eligibility criteria of the Commission for Children with Special Health Care Needs; and

      (2) Individuals of all ages who meet the medical eligibility criteria of the Commission for Children with Special Health Care Needs and who have a diagnosis of hemophilia.


      Section 3. Qualification of Providers. Providers are required to be certified as a Medicaid provider meeting the following criteria:

      (1) Demonstrated capacity to provide all core elements of case management including the following:

      (a) Assessment;

      (b) Care/services plan development;

      (c) Linking/coordination of services; and

      (d) Reassessment/follow-up;

      (2) Demonstrated case management experience in coordinating and linking community resources as required by the target population;

      (3) Demonstrated experience with the target population;

      (4) An administrative capacity to insure quality of services in accordance with state and federal requirements;

      (5) A financial management system that provides documentation of services and costs;

      (6) Capacity to document and maintain individual case records in accordance with state and federal requirements;

      (7) Demonstrated ability to assure a referral process consistent with section 1902(a)(23), freedom of choice of provider;

      (8) Demonstrated capacity to meet the case management service needs of the target population on a statewide basis.


      Section 4. Qualification of Case Managers. Case managers shall meet the following criteria:

      (1) Be licensed as a registered nurse or possess a valid work permit as a registered nurse issued by the Kentucky Board of Nursing; or

      (2) Have a master's degree in social work supplemented by one (1) year of professional social work experience; or

      (3) Have a bachelor's degree as a graduate of a college or university supplemented by two (2) years of professional social work experience.


      Section 5. Other Limitations. The following limitations on service coverage and payments are applicable:

      (1) Recipients shall be allowed to have free choice of case management services; and

      (2) Recipients shall be allowed to have free choice of the providers of other Medicaid services; and

      (3) Payment will not be made for case management services to the extent that payments have been made by the Medicaid program as a part of other program elements for the same purposes. The purpose of this provision is to assure that there is nonduplication of program payments.


      Section 6. Payments. Case management providers will be paid at an interim rate, approximating actual cost, which will be settled back to cost at the end of the state's fiscal year. Providers shall be required to provide acceptable documentation of costs.


      Section 7. Implementation. The provisions of this administrative regulation shall be effective with regard to services provided on or after October 1, 1988. (15 Ky.R. 1380; eff. 12-13-88.)