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REGS : 10.09.48 Targeted Case Management for People with Intellectual and Developmental Disabilities (MEDICAL CARE PROGRAMS)

PROPOSAL
Maryland Register
Issue Date:  February 6, 2015
Volume 42 • Issue 3 • Pages 354—359
 
Title 10
DEPARTMENT OF HEALTH AND MENTAL HYGIENE
Subtitle 09 MEDICAL CARE PROGRAMS
10.09.48 Targeted Case Management for People with Intellectual and Developmental Disabilities
Authority: Health-General Article, §§2-104(b), 15-103, and 15-105, Annotated Code of Maryland
Notice of Proposed Action
[15-081-P]
The Secretary of Health and Mental Hygiene proposes to amend Regulations .01, .04—.08, and .10 under COMAR 10.09.48 Targeted Case Management for People with Intellectual and Developmental Disabilities.
Statement of Purpose
The purpose of this action is to define certain terms relating to targeted case management, replace the term resource coordination with coordination of community services, and accurately reflect processes and approved reimbursement rates for providers.
Comparison to Federal Standards
There is no corresponding federal standard to this proposed action.
Estimate of Economic Impact
I. Summary of Economic Impact. The proposed regulations have an economic impact on providers of Targeted Case Management services for people with Intellectual and Developmental Disabilities because reimbursement rates are being changed.
 
 
Revenue (R+/R-)
 
II. Types of Economic Impact.
Expenditure (E+/E-)
Magnitude
 

 
 
 
 
 
A. On issuing agency:
(E+)
FY 15 $4,460,000
B. On other State agencies:
NONE
 
C. On local governments:
NONE
 
 
 
Benefit (+)
Cost (-)
Magnitude
 

 
 
 
 
 
D. On regulated industries or trade groups:
(+)
FY 15 $4,460,000
E. On other industries or trade groups:
NONE
 
F. Direct and indirect effects on public:
NONE
 
III. Assumptions. (Identified by Impact Letter and Number from Section II.)
A. A. The proposed rate increases represent a $4,460,000 increase over the current published rate of $14.62 per unit in FY15. The State will pay this increase to providers of Targeted Case Management.
D. D. As a result of increasing the per unit rate for Targeted Case Management Services, providers will receive increased payments, totaling $4,460,000 in FY15.
Economic Impact on Small Businesses
The proposed action has a meaningful economic impact on small business. An analysis of this economic impact follows.
The proposed action has a meaningful economic impact on small businesses because the higher reimbursement rates infuse dollars into targeted case management entities that provide these services in the community.
Impact on Individuals with Disabilities
The proposed action has no impact on individuals with disabilities.
Opportunity for Public Comment
Comments may be sent to Michele Phinney, Director, Office of Regulations and Policy Coordination, 201 W. Preston Street, Room 512, Baltimore, MD 21201, or call 410-767-6499, or email to dhmh.regs@maryland.gov, or fax to 410-767-6483. Comments will be accepted through March 9, 2015. A public hearing has not been scheduled.
.01 Definitions.
A. (text unchanged)
B. Terms Defined.
(1)—(4) (text unchanged)
(5) “Comprehensive assessment” means an assessment of the applicant’s needs and supports to determine eligibility.
[(5)] (6) Comprehensive Community Services.
(a) (text unchanged)
(b) “Comprehensive community services” does not mean funding for low intensity support services or [resource] coordination of community services.
[(6)] (7) “Contact” means a face-to-face meeting, phone conversation, or written correspondence related to the covered services in this [regulations] chapter.
(8) “Coordination of community services” means targeted case management services that assist participants in gaining access to the full range of medical assistance services, as well as access to any additional needed generic, medical, social, habilitative, vocational, recreational, housing, financial, counseling, legal, educational, and other support services.
(9) “Coordinator of community services” means an individual employed by the coordination of community services agency to assist participants in selecting, obtaining, and monitoring the most responsive and appropriate services and supports.
(10) “Coordination of community services supervisor” means an individual who is employed to oversee coordination of community services and performance of coordinators of community services.
(11) “Core services” means the following community services:
(a) Comprehensive assessment;
(b) Development of the individual plan;
(c) Referrals and related activities; and
(d) Monitoring and follow-up.
[(7)] (12) “Critical incident” means [an incident] a reportable event that presents an immediate and serious threat of injury, harm, impairment, or death of an individual.
[(8)] (13)[(13)] (18) (text unchanged)
[(14)] (19) “Individual plan” means a comprehensive, outcome-directed service plan that is developed and revised by the [resource] coordinator of community services in collaboration with the individual and his or her identified representatives.
[(15) “Maryland Community Services Reimbursement Rate Commission” means the independent commission within the Department responsible for assessing and determining rates paid to providers and direct care providers for individuals with developmental disabilities as set forth in Health-General Article, §13-801 et. seq., Annotated Code of Maryland.]
[(16)] (20) “Medicaid waiver programs” means any program under §1915(c) of the Social Security Act[, Title XIX, §1915].
[(17)] (21)[(19)] (23) (text unchanged)
[(20)] (24) “Participant” means an individual who meets the qualifications for participation in [resource] coordination of community services as specified in Regulation .03 of this chapter.
[(21)] (25) “Person-directed supports” means service and supports that empower the individual, and the legally authorized representative on the individual’s behalf, to direct the development and implementation of a plan of supports and services that meet the individual’s personal [outcomes] goals.
[(22)] (26)[(23)] (27) (text unchanged)
[(24)] (28) “Provider” means an entity [which] that meets the conditions for participation specified in [Regulations] Regulation .04 of this chapter, and is authorized by DDA to provide [resource] coordination of community services for individuals with an intellectual and developmental disability.
[(25)] (29) (text unchanged)
[(26)] (30) “Reportable events” means specified incidents and complaints noted in the DDA Policy [for] on Reportable Incidents and Investigations (PORII) established to ensure the health, safety, and welfare of individuals receiving services from DDA-licensed and DDA-funded providers.
[(27)] (31) (text unchanged)
[(28) “Resource coordination” means targeted case management services which will assist participants in gaining access to the full range of Medical Assistance services, as well as to any additional needed generic, medical, social, habilitative, vocational, recreational, housing, financial, counseling, legal, education, and other support services.
(29) “Resource coordination agency” means DDA-licensed agents responsible for providing resource coordination services to individuals with developmental disabilities who are authorized for services by the Developmental Disabilities Administration.
(30) “Resource supervisor” means an individual who is employed to provide oversight of resource coordination services rendered and performance of resource coordinators.
(31) “Resource coordinator” means an individual employed by the resource coordination agency to assist authorized individuals in selecting, obtaining, the most responsive and appropriate services and supports.]
(32)—(33) (text unchanged)
(34) Transition Coordination Services.
(a) “Transition coordination services” means [resource] coordination of community services provided to individuals transitioning to the community from an institution.
(b) (text unchanged)
(35)(36) (text unchanged)
(37) Waiting List Coordination Services.
(a) “Waiting list coordination services” means [resource] coordination of community services provided to individuals on the DDA waiting list.
(b) (text unchanged)
.04 Conditions for Participation — General.
A. In this chapter, targeted case management services are referred to as [resource] coordination of community services.
B. (text unchanged)
C. Administrative and Professional Requirements. To participate in the Program as a provider of services covered under this chapter, the provider shall:
(1) Be incorporated in the State in good [standings] standing with the Maryland Department of Assessments and Taxation unless operating as a local health department;
(2) (text unchanged)
(3) Be selected by DDA as an approved provider of [resource] coordination of community services, as evidenced by an executed DDA-approved contract;
(4)—(6) (text unchanged)
(7) Serve all individuals in the DDA-defined [region] jurisdiction referred by the DDA [or, if a local health department, serve all individuals in their designated jurisdiction referred by the DDA];
(8)—(11) (text unchanged)
(12) Have a means for individuals, their families, community providers, and DDA staff to contact the [resource] coordination of community services designated staff directly in the event of an emergency and at times other than standard operating hours;
(13) Annually advise participants of their right to choose among qualified providers of services [to include resources] including coordination of community services;
(14)—(15) (text unchanged)
(16) Notify the DDA immediately in writing of any critical incidents that affect the health, safety, and welfare of an individual, as well as administrative and quality of care complaints as required by [State and federal law] the DDA Policy on Reportable Incidents and Investigations; and
(17) (text unchanged)
D. Operational Requirements. To participate in the Program as a provider of services covered under this chapter, the provider shall:
(1) (text unchanged)
(2) Complete and submit an initial and annual written quality assurance plan to the DDA which meets the requirements in COMAR 10.22.02.14 and [include] includes the following:
(a) (text unchanged)
(b) Self-assessment, remediating, monitoring, reporting, and system improvements strategies, or other quality and compliance actions related to [resource] coordination of community services;
(3) Submit monthly service delivery statistical reports as defined by the Department by the 15th of each month unless otherwise directed by the Department;
[(3)] (4) Submit quarterly updates, as defined by the Department, on progress on quality assurance plans by October 15, January 15, and April 15 of each year unless otherwise directed by the Department;
[(4)] (5) (text unchanged)
[(5) Submit monthly service delivery statistical reports as defined by the Department by the 15th of every month;]
(6) Maintain a thorough understanding and knowledge of:
(a) Eligibility requirements, application procedures, and scope of services of local, State, and federal resources and programs which are applicable to individuals eligible for DDA services; [and]
(b) Medicaid, Medicaid waiver programs, and DDA eligibility requirements, application procedures, and service delivery systems; and
(c) Person-centered planning methodology and individualized plan development and monitoring;
(7)—(8) (text unchanged)
(9) Obtain [preauthorization] authorization from the DDA [for resource] before providing any coordination of community services [which meet the following conditions:] to any individual;
(10) In providing coordination of community services, meet the following requirements:
(a) All individuals referred for [resource] coordination of community services by the DDA shall be contacted within 3 business days of receipt of referral unless otherwise authorized by the DDA;
(b) A face-to-face meeting[,] with the referred individual shall be arranged at a time and location convenient for the referred individual during the first contact;
(c) (text unchanged)
(d) [The] If applicable, the provider shall document in the case record reasons why face-to-face meetings did not occur within the required timeframe and [shared upon request of] share the document as requested by the DDA or its designee;
(e) Authorization for specific [resource] coordination of community services shall be based on referrals from the DDA regional office; and
(f) In the event of emergencies, the individual referred for [resource] coordination of community services by the DDA shall be contacted by the [resource] coordinator of community services as circumstances require or as requested by the DDA.
E. [Client] Participant Record. The provider shall maintain a record on each participant which meets the Program’s requirements and which includes:
(1) (text unchanged)
(2) The dates of the [resource] coordination of community services;
(3) The name of the provider agency and the name of agency employee providing the [resource] coordination of community service;
(4)—(6) (text unchanged)
(7) Documentation that the [resource] coordinator of community services provided the participant with a choice among qualified providers of services, including [resource] coordination of community services;
(8) Documentation that indicates whether the individual has declined services in the individual plan and the reason for [the decline] declining;
(9)—(11) (text unchanged)
(12) Documentation for each contact made by the [resource] coordinator of community services including:
(a)—(d) (text unchanged)
(e) Nature and extent of [resource] coordination of community services provided;
(f)—(h) (text unchanged)
F. Technology Requirements. To participate in the Program as a provider of services covered under this chapter, the provider shall:
(1) [Manage] Utilize an electronic information system which, at a minimum:
(a) (text unchanged)
(b) Provides documentation of [resource] coordination of community services and number of units provided for individuals receiving services;
(c)—(d) (text unchanged)
(2) Adhere to the following information technology requirements:
(a) Use the DDA’s designated data system [to include the provider client information system] unless [otherwise] another data system is approved annually by the DDA;
(b) (text unchanged)
(c) Report security violations and actual or attempted security breaches affecting the managed systems with participant information [within] immediately but not later than 48 hours [of] after the violation or breach;
(d)—(e) (text unchanged)
G. Billing. To participate in the Program as a provider of services covered under this chapter, the provider shall:
(1)—(2) (text unchanged)
(3) Permit the DDA or [DHMH] the Department or its agent, or any State or federal entity operating within its statutory authority to conduct audits and provide immediate access to all records upon request; and
(4) (text unchanged)
H. Freedom of Choice. The provider shall place no restrictions on the qualified participant’s freedom of choice among:
(1) Providers of [resource] coordination of community services;
(2)—(3) (text unchanged)
I. Transfer of Personal Health Records. For participants changing from one DDA-authorized coordination of community services provider to a different DDA-authorized coordination of community services provider, the outgoing provider shall:
(1) Transfer the complete participant record to the new provider; and
(2) Share with the new provider the participant’s demographic information and the most recent individual plan within 5 business days of notification of transfer for the continued coordination of services.
[I.] J. (text unchanged)
.05 Conditions for Participation — Staff Requirements.
A. Staff Capability Requirements. The provider shall:
(1)—(2) (text unchanged)
(3) Have administrative and supervisory staff to ensure the quality of [resource] coordination of community services;
(4) Have a management capability team, each member of which has at least 3 years of experience providing [resource] coordination of community services or management experience in human services[,]; and
(5) (text unchanged)
B. Staff Training Requirements.
(1) All DDA-licensed [resource] coordination of community services providers shall ensure through appropriate documentation that [resource] coordination of community services staff receive training in person-directed supports focusing on outcomes, as required by DDA.
(2) All DDA-licensed [resource] coordination of community services supervisors shall receive training in the following:
(a)—(c) (text unchanged)
(3) All [resource] coordination of community services staff shall receive [retraining] training on procedures, protocols, processes, and regulations as required by the DDA.
C. [Resource coordination] Coordination of community services staff shall:
(1) Receive required training as specified in COMAR 10.22 [and §C of this regulation that], which shall be documented and [shall be] made available upon request;
(2) (text unchanged)
(3) Demonstrate [skills] a high level of skill and working knowledge in the following areas:
(a)—(i) (text unchanged)
(j) Regulations governing services for individuals with intellectual and developmental disabilities.
D. [Resource] Coordination of Community Services Supervisor. The [resource] coordination of community services supervisor shall:
(1)—(3) (text unchanged)
(4) Supervise the work of [resource] coordinators of community services; and
(5) (text unchanged)
E. [Resource] Coordinator of Community Services. The [resource] coordinator of community services shall:
(1) (text unchanged)
(2) Use all communication methodologies, strategies, devices, and techniques necessary, including sign language, assistive technology, or language interpreter services, to facilitate the involvement of the participant in the assessment, development, and monitoring of services and supports; and
[(3) Ensure that each individual receives an individual plan that is designed to meet the individual’s needs, preferences, goals, and outcomes in the most integrated setting appropriate to meet the individual’s needs and in the most cost effective manner and as directed by the participant for those individuals that select self-direction; and]
[(4)] (3) Annually advise participants of their right to choose among qualified providers of services [to include] resource] including coordination of community services.
F. Education and Experience Waiver.
(1) [Resource] Coordination of Community Services Supervisor. Education and experience requirements may be waived if an individual has been employed as a [resource] coordination of community services supervisor for at least 1 year as of January 1, 2014.
(2) [Resource] Coordinator of Community Services. Education and experience requirements may be waived if an individual has been employed as a [resource] coordinator of community services for at least 1 year as of January 1, 2014.
G. An individual is ineligible for employment by a [resource] coordination of community services provider, agency, or entity in Maryland if the individual:
(1)—(7) (text unchanged)
.06 Covered Services.
A. Only core services shall be authorized for payment by DDA as covered coordination of community services.
B. The coordinator of community services shall provide the core services listed in this regulation to every participant assigned to the coordinator.
[A.] C. Comprehensive Assessment. [Resource coordination] Coordination of community services shall include a comprehensive assessment of the individual’s needs and supports to determine eligibility, [as noted in] in accordance with COMAR 10.22.12. The assessment shall be completed within 45 days [of] after referral by the DDA and include:
(1)—(5) (text unchanged)
[B.] D. Individual Plan.
(1) The coordinator of community services shall ensure that each individual receives an individual plan that is designed to meet the individual’s needs, preferences, goals, and outcomes in the most integrated setting and in the most cost effective manner.
[(1) General requirements for the individual plan are that the individual plan shall:]
(2) The individual plan shall:
(a)—(c) (text unchanged)
(d) Be completed within 30 days after [notification of selection as the resource coordination agency and subsequent] initial contact with the participant, and, if necessary, updated or modified within 30 days [of] after service initiation;
(e)—(i) (text unchanged)
[(2)] (3) (text unchanged)
[C.] E. Referral and Related Activities.
(1) At the time of the initial meeting and any follow-up contacts, [resource] coordinators of community services shall provide information, make referrals, [or] and assist participants with applications [to] for services provided by:
(a)—(c) (text unchanged)
(2) (text unchanged)
[D.] F. Monitoring and Follow-Up.
(1) [Monitoring] The coordinator of community services shall provide monitoring and follow-up activities, which shall include:
(a) Assessment of:
(i)—(iv) (text unchanged)
(v) The individual’s needs and supports to maintain eligibility for Medicaid, [waivers] Medicaid waiver programs, DDA services, and any other relevant benefits or services;
(b)—(c) (text unchanged)
(d) Requests for service change and modifications of the individual plan as necessary to meet health and safety needs, preferences, and goals;
(e)—(h) (text unchanged)
(2) Frequency of Monitoring and Follow-up Contact.
(a) (text unchanged)
(b) [Monitoring services shall be provided to individuals receiving waiting list coordination services at the frequencies set in] Individuals on the DDA waiting list shall be monitored in accordance with [§D(2)(a)] §F(2)(a) of this regulation unless:
(i)—(ii) (text unchanged)
(c) (text unchanged)
(d) For individuals receiving transition coordination services, monitoring and follow-up activities shall be performed face-to-face at least once a month for the first 90 days, after which face-to-face contacts shall be made quarterly.
(3) (text unchanged)
.07 Limitations.
A. [A restriction] Restrictions may not be placed on a qualified recipient’s option to receive [resource] coordination of community services.
B. DDA [resource] coordination of community services does not restrict or otherwise affect eligibility for Title XIX benefits or other available benefits or programs.
C. DDA [resource] coordination of community services may not be:
(1)—(2) (text unchanged)
(3) Rendered in connection with the implementation of another service authorized under §1915(b) or §1915(c) of the Social Security Act[, Title XIX, §1915(b) or 1915(c)]; or
(4) (text unchanged)
D. Unless otherwise approved by the Department, reimbursement may not be made for [resource] coordination of community services if the participant is receiving comparable case management services under any other State program.
E. A participant’s [resource] coordination of community services provider may not also [be a] provide DDA-funded direct services [provider] for the participant.
F. Service Exclusions.
(1) Unless an individual is transitioning into the community, [resource] coordination of community services may not be provided to:
(a)—(b) (text unchanged)
(2) (text unchanged)
G. (text unchanged)
.08 Payment Procedures.
A. (text unchanged)
B. Payment Rates.
 (1) Providers shall be reimbursed within 45 days of approved invoice for services rendered based on the rates set forth in [§C(2) and (3)] §C(1) and (2) of this regulation.
(2) (text unchanged)
(3) For all other services, providers shall be reimbursed [$14.62 per unit of service.]:
(a) $17.54 per unit of service from July 1, 2013 through June 30, 2014;
(b) $14.63 per unit of service from July 1, 2014 through July 2, 2014;
(c) $16.59 per unit of service from July 3, 2014 through December 31, 2014; and
(d) $16.88 per unit of service thereafter.
C. Changes in Rates.
[(1) The Program’s rates as specified in §B of this regulation shall be effective July 1, 2013 through June 30, 2014.]
[(2)] (1) (text unchanged)
[(3)] (2) The rates may be [increased] changed on July 1 of each year beginning July 1, [2014] 2015, based on [recommendations of the Maryland Community Services Reimbursement Rate Commission] legislative action, and subject to limitations of the State budget.
[(4)] (3) (text unchanged)
D. Payment Limitations.
(1)—(4) (text unchanged)
(5) Ongoing [case management] coordination of community services shall be billed on a monthly basis.
E. Units of Services and Limitations.
(1) All coordination of community services other than the initial comprehensive assessment shall be billed to DDA in units of service.
(2) DDA shall provide payment for only those coordination of community services that were authorized by DDA before the provision of the service.
(3) Each fiscal year, DDA shall authorize a specific number of units of service of coordination of community services for each participant.
(4) Each fiscal year, the coordinator of community services shall complete the core services for each participant, using the units of service authorized for that fiscal year.
(5) Additional units of service may not be authorized beyond those authorized for the fiscal year for any participant, except as specifically provided in §E(6) of this regulation.
(6) Authorization of Payment for Additional Units of Service.
(a) A request by a coordinator of community services for authorization of payment for units of service in addition to those authorized for a participant in a single fiscal year may not be granted except in extraordinary circumstances.
(b) In deciding a request for authorization of payment for additional units of service, DDA shall consider:
(i) The services provided to date using the annual units of service authorized;
(ii) The extent to which the core services have been completed for the fiscal year;
(iii) Whether and, if so, the extent to which, the annual units of service were used to provide services other than core services;
(iv) The extent to which services were provided in an inefficient manner;
(v) Any unusual or unforeseeable needs of the participant that created a need for more than the allotted units of service; and
(vi) Any unusual or unforeseeable circumstances of the participant that caused the delivery of coordination of community services to be more difficult and time-consuming than was anticipated when the annual units of service were allotted.
(c) Requests for authorization of payment for additional units of service for a participant in a single fiscal year shall be accompanied by documentation demonstrating:
(i) All coordination of community services provided to date;
(ii) Any physical, emotional, or mental conditions of the participant that created extraordinary challenges to the provision of coordination of community services within the units of service authorized for the fiscal year; and
(iii) Any unusual or unforeseeable circumstances that required the expenditure of more time to provide the core services than was anticipated when the annual units of service were allotted.
(d) A request for authorization of payment for additional units of service for a participant in a single fiscal year may not be granted in order to provide services other than core services.
(e) A request for authorization of payment for additional units of service for a participant in a single fiscal year may not be considered unless all required data regarding the participant and the coordination of community services provided has been entered or uploaded into the DDA-designated data system.
(f) An authorization of payment for additional units of services shall specify the number of units of service authorized.
.10 Cause for Suspension or Removal and Imposition of Sanctions.
Cause for suspension or removal and imposition of sanctions shall be as set forth in COMAR 10.09.36.08 and [10.22.02] 10.22.03.
JOSHUA M. SHARFSTEIN, M.D.
Secretary of Health and Mental Hygiene
 
 
 

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