Case management services covered by MA are services described in this section and provided by an agency certified under s. DHS 105.51
or by a qualified person under contract to an agency certified under s. DHS 105.51
to help a recipient, and, when appropriate, the recipient's family gain access to, coordinate or monitor necessary medical, social, educational, vocational and other services.
Case management services under pars. (b)
are provided under s. 49.45 (25)
, Stats., as benefits to those recipients in a county in which case management services are provided who are over age 64, are diagnosed as having Alzheimer's disease or other dementia, or are members of one or more of the following target populations: developmentally disabled, chronically mentally ill who are age 21 or older, alcoholic or drug dependent, physically or sensory disabled, or under the age of 21 and severely emotionally disturbed. In this subdivision, “severely emotionally disturbed"means having emotional and behavioral problems which:
Have significantly impaired the person's functioning for 6 months or more and, without treatment, are likely to continue for a year or more. Areas of functioning include: developmentally appropriate self-care; ability to build or maintain satisfactory relationships with peers and adults; self-direction, including behavioral controls, decisionmaking, judgment and value systems; capacity to live in a family or family equivalent; and learning ability, or meeting the definition of “child with exceptional educational needs" under ch. PI 1
and s. 115.76 (3)
Require the person to receive services from 2 or more of the following service systems: mental health, social services, child protective services, juvenile justice and special education; and
Include mental or emotional disturbances diagnosable under DSM-III-R. Adult diagnostic categories appropriate for children and adolescents are organic mental disorders, psychoactive substance use disorders, schizophrenia, mood disorders, schizophreniform disorders, somatoform disorders, sexual disorders, adjustment disorder, personality disorders and psychological factors affecting physical condition. Disorders usually first evident in infancy, childhood and adolescence include pervasive developmental disorders (Axis II), conduct disorder, anxiety disorders of childhood or adolescence and tic disorders.
DHS 107.32 Note
Note: DSM-111-R is the 1987 revision of the 3rd edition (1980) of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.
Case management services under par. (d)
are available as benefits to a recipient identified in subd. 2.
The recipient is eligible for and receiving services in addition to case management from an agency or through medical assistance which enable the recipient to live in a community setting; and
The standards specified in s. 46.27
, Stats., for assessments, case planning and ongoing monitoring and service coordination shall apply to all covered case management services.
(b) Case assessment.
A comprehensive assessment of a recipient's abilities, deficits and needs is a covered case management service. The assessment shall be made by a qualified employee of the certified case management agency or by a qualified employee of an agency under contract to the case management agency. The assessment shall be completed in writing and shall include face-to-face contact with the recipient. Persons performing assessments shall possess skills and knowledge of the needs and dysfunctions of the specific target population in which the recipient is included. Persons from other relevant disciplines shall be included when results of the assessment are interpreted. The assessment shall document gaps in service and the recipient's unmet needs, to enable the case management provider to act as an advocate for the recipient and assist other human service providers in planning and program development on the recipient's behalf. All services which are appropriate to the recipient's needs shall be identified in the assessment, regardless of availability or accessibility of providers or their ability to provide the needed service. The written assessment of a recipient shall include:
A record of any physical or dental health assessments and consideration of any potential for rehabilitation;
A record of the multi-disciplinary team evaluation required for a recipient who is a severely emotionally disturbed child under s. 49.45 (25)
A review of the recipient's performance in carrying out activities of daily living, including moving about, caring for self, doing household chores and conducting personal business, and the amount of assistance required;
Significant issues in the recipient's relationships and social environment;
A description of the recipient's physical environment, especially in regard to safety and mobility in the home and accessibility;
The recipient's need for housing, residential support, adaptive equipment and assistance with decision-making;
An in-depth financial resource analysis, including identification of insurance, veterans' benefits and other sources of financial and similar assistance;
If appropriate, vocational and educational status, including prognosis for employment, rehabilitation, educational and vocational needs, and the availability and appropriateness of educational, rehabilitation and vocational programs;
If appropriate, legal status, including whether there is a guardian and any other involvement with the legal system;
Accessibility to community resources which the recipient needs or wants; and
Assessment of drug and alcohol use and misuse, for AODA target population recipients.
(c) Case planning.
Following the assessment with its determination of need for case management services, a written plan of care shall be developed to address the needs of the recipient. Development of the written plan of care is a covered case management service. To the maximum extent possible, the development of a care plan shall be a collaborative process involving the recipient, the family or other supportive persons and the case management provider. The plan of care shall be a negotiated agreement on the short and long term goals of care and shall include:
Identification of all formal services to be arranged for the recipient and their costs and the names of the service providers;
Development of a support system, including a description of the recipient's informal support system;
Identification of individuals who participated in development of the plan of care;
Schedules of initiation and frequency of the various services to be made available to the recipient; and
(d) Ongoing monitoring and service coordination.
Ongoing monitoring of services and service coordination are covered case management services when performed by a single and identifiable employee of the agency or person under contract to the agency who meets the requirements under s. DHS 105.51 (2) (b)
. This person, the case manager, shall monitor services to ensure that quality service is being provided and shall evaluate whether a particular service is effectively meeting the client's needs. Where possible, the case manager shall periodically observe the actual delivery of services and periodically have the recipient evaluate the quality, relevancy and desirability of the services he or she is receiving. The case manager shall record all monitoring and quality assurance activities and place the original copies of these records in the recipient's file. Ongoing monitoring of services and service coordination include:
Face to face and phone contacts with recipients for the purpose of assessing or reassessing their needs or planning or monitoring services. Included in this activity are travel time to see a recipient and other allowable overhead costs that must be incurred to provide the service;
Face to face and phone contact with collaterals for the purposes of mobilizing services and support, advocating on behalf of a specific eligible recipient, educating collaterals on client needs and the goals and services specified in the plan, and coordinating services specified in the plan. In this paragraph, “collateral" means anyone involved with the recipient, including a paid provider, a family member, a guardian, a housemate, a school representative, a friend or a volunteer. Collateral contacts also include case management staff time spent on case-specific staffings and formal case consultation with a unit supervisor and other professionals regarding the needs of a specific recipient. All contacts with collaterals shall be documented and may include travel time and other allowable overhead costs that must be incurred to provide the service; and
Recordkeeping necessary for case planning, service implementation, coordination and monitoring. This includes preparing court reports, updating case plans, making notes about case activity in the client file, preparing and responding to correspondence with clients and collaterals, gathering data and preparing application forms for community programs, and reports. All time spent on recordkeeping activities shall be documented in the case record. A provider, however, may not bill for recordkeeping activities if there was no client or collateral contact during the billable month.
Reimbursement for assessment and case plan development shall be limited to no more than one each for a recipient in a calendar year unless the recipient's county of residence has changed, in which case a second assessment or case plan may be reimbursed.
Reimbursement for ongoing monitoring and service coordination shall be limited to one claim for each recipient by county per month and shall be only for the services of the recipient's designated case manager.
Ongoing monitoring or service coordination is not available to recipients residing in hospitals, intermediate care or skilled nursing facilities. In these facilities, case management is expected to be provided as part of that facility's reimbursement.
Case management services are not reimbursable when rendered to a recipient who, on the date of service, is enrolled in a health maintenance organization under s. DHS 107.28
Persons who require institutional care and who receive services beyond those available under the MA state plan but which are funded by MA under a federal waiver are ineligible for case management services under this section. Case management services for these persons shall be reimbursed as part of the regular per diem available under federal waivers and included as part of the waiver fiscal report.
A recipient receiving case management services, or the recipient's parents, if the recipient is a minor child, or guardian, if the recipient has been judged incompetent by a court, may choose a case manager to perform ongoing monitoring and service coordination, and may change case managers, subject to the case manager's or agency's capacity to provide services under this section.
(3) Non-covered services.
Services not covered as case management services or included in the calculation of overhead charges are any services which:
Involve provision of diagnosis, treatment or other direct services, including:
Any other professional service which is a covered service under this chapter and which is provided by an MA certified or certifiable provider, including time spent in a staffing or case conference for the purpose of case management; or
Involve information and referral services which are not based on a plan of care.
DHS 107.32 History
Cr. Register, February, 1988, No. 386
, eff. 3-1-88; corrections in (1) (a) 1. and (d) (intro.) made under s. 13.92 (4) (b) 7.
, Stats., Register December 2008 No. 636
DHS 107.33 Ambulatory prenatal services for recipients with presumptive eligibility. DHS 107.33(1)(1)
Ambulatory prenatal care services are covered services. These services include treatment of conditions or complications that are caused by, exist or are exacerbated by a pregnant woman's pregnant condition.
(2) Prior authorization.
An ambulatory prenatal service may be subject to a prior authorization requirement, when appropriate, as described in this chapter.
Ambulatory prenatal services shall be reimbursed only if the recipient has been determined to have presumptive MA eligibility under s. 49.465
, Stats., by a qualified provider under s. DHS 103.11
DHS 107.33 History
Cr. Register, February, 1988, No. 386
, eff. 3-1-88; correction in (3) made under s. 13.92 (4) (b) 7.
, Stats., Register December 2008 No. 636
DHS 107.34 Prenatal care coordination services. DHS 107.34(1)(a)1.1.
Prenatal care coordination services covered by MA are services described in this section that are provided by an agency certified under s. DHS 105.52
or by a qualified person under contract with an agency certified under s. DHS 105.52
to help a recipient and, when appropriate, the recipient's family gain access to medical, social, educational and other services needed for a successful pregnancy outcome. Nutrition counseling and health education are covered services when medically necessary to ameliorate identified high-risk factors for the pregnancy. In this subdivision,“successful pregnancy outcome" means the birth of a healthy infant to a healthy mother.
Prenatal care coordination services are available as an MA benefit to recipients who are pregnant, from the beginning of the pregnancy up to the sixty-first day after delivery, and who are at high risk for adverse pregnancy outcomes. In this subdivision, “high risk for adverse pregnancy outcome" means that a pregnant woman requires additional prenatal care services and follow-up because of medical or nonmedical factors, such as psychosocial, behavioral, environmental, educational or nutritional factors that significantly increase her probability of having a low birth weight baby, a preterm birth or other negative birth outcome. “Low birth weight" means a birth weight less than 2500 grams or 5.5 pounds and “preterm birth" means a birth before the gestational age of 37 weeks. The determination of high risk for adverse pregnancy outcome shall be made by use of the risk assessment tool under par. (c)
Outreach is a covered prenatal care coordination service. Outreach is activity which involves implementing strategies for identifying and informing low-income pregnant women who otherwise might not be aware of or have access to prenatal care and other pregnancy-related services.
(c) Risk assessment.
A risk assessment of a recipient's pregnancy-related needs is a covered prenatal care coordination service. The assessment shall be performed by an employee of the certified prenatal care coordination agency or by an employee of an agency under contract with the prenatal care coordination agency. The assessment shall be completed in writing and shall be reviewed and finalized in a face-to-face contact with the recipient. All assessments performed shall be reviewed by a qualified professional under s. DHS 105.52 (2) (a)
. The risk assessment shall be performed with the risk assessment tool developed and approved by the department.
(d) Care planning.
Development of an individualized plan of care for a recipient is a covered prenatal care coordination service when performed by a qualified professional as defined in s. DHS 105.52 (2) (a)
, whether that person is an employee of the agency or under contract with the agency under s. DHS 105.52 (2)
. The recipient's individualized written plan of care shall be developed with the recipient. The plan shall identify the recipient's needs and problems and possible services which will reduce the probability of the recipient having a preterm birth, low birth weight baby or other negative birth outcome. The plan of care shall include all possible needed services regardless of funding source. Services in the plan shall be related to the risk factors identified in the assessment. To the maximum extent possible, the development of a plan of care shall be done in collaboration with the family or other supportive persons. The plan shall be signed by the recipient and the employee responsible for the development of the plan and shall be reviewed and, if necessary, updated by the employee in consultation with the recipient at least every 60 days. Any updating of the plan of care shall be in writing and shall be signed by the recipient. The plan of care shall include:
Identification and prioritization of all risks found during the assessment, with an attached copy of the risk assessment under par. (c)
Identification and prioritization of all services to be arranged for the recipient by the care coordinator under par. (e) 2.
and the names of the service providers including medical providers;
Description of the recipient's informal support system, including collaterals as defined in par. (e) 1.
, and any activities to strengthen it;
Identification of individuals who participated in the development of the plan of care;
Arrangements made for and frequency of the various services to be made available to the recipient and the expected outcome for each service;
In this paragraph, “
collaterals" means anyone who is in direct supportive contact with the recipient during the pregnancy such as a service provider, a family member, the prospective father or any person acting as a parent, a guardian, a medical professional, a housemate, a school representative or a friend.
Ongoing coordination is a covered prenatal care coordination service when performed by an employee of the agency or person under contract to the agency who serves as care coordinator and who is supervised by the qualified professional required under s. DHS 105.52 (2) (b) 2.
The care coordinator shall follow-up the provision of services to ensure that quality service is being provided and shall evaluate whether a particular service is effectively meeting the recipient's needs as well as the goals and objectives of the care plan. The amount of service provided shall be commensurate with the specific risk factors addressed in the plan of care and the overall level of risk. Ongoing care coordination services include:
Face-to-face and phone contacts with recipients for the purpose of determining if arranged services have been received and are effective. This shall include reassessing needs and revising the written plan of care. Face-to-face and phone contact with collaterals are included for the purposes of mobilizing services and support, advocating on behalf of a specific eligible recipient, informing collateral of client needs and the goals and services specified in the care plan and coordinating services specified in the care plan. Covered contacts also include prenatal care coordination staff time spent on case-specific staffings regarding the needs of a specific recipient. All billed contacts with a recipient or a collateral and staffings related to the recipient shall be documented in the recipient prenatal care coordination file; and
Recordkeeping documentation necessary and sufficient to maintain adequate records of services provided to the recipient. This may include verification of the pregnancy, updating care plans, making notes about the recipient's compliance with program activities in relation to the care plan, maintaining copies of written correspondence to and for the recipient, noting of all contacts with the recipient and collateral, ascertaining and recording pregnancy outcome including the infant's birth weight and health status and preparation of required reports. All plan of care management activities shall be documented in the recipient's record including the date of service, the person contacted, the purpose and result of the contact and the amount of time spent. A care coordination provider shall not bill for recordkeeping activities if there was no client contact during the billable month.
(f) Health education.
Health education, either individually or in a group setting, is a covered prenatal care coordination service when provided by an individual who is a qualified professional under s. DHS 105.52 (2) (a)
and who by education or at least one year of work experience has the expertise to provide health education. Health education is a covered service if the medical need for it is identified in the risk assessment and the strategies and goals for it are part of the care plan to ameliorate a pregnant woman's identified risk factors in areas including, but not limited to, the following: