N.Y. Comp. Codes R. & Regs. tit. 18 § 505.16

Current through Register Vol. 46, No. 50, December 11, 2024

Section 505.16 - Case management

Medical assistance includes case management services furnished in accordance with the provisions of this section.

(a) Definitions.

(1) Case management is a process which assists persons eligible for medical assistance to access necessary services in accordance with goals contained in a written case management plan.

(2) Case management services:

(i) are those services which will assist persons eligible for medical assistance to obtain needed medical, social, psychosocial, educational, financial and other services; and

(ii) are meant to assist persons identified as high users of services, or as having problems accessing medical care or services, or as belonging to certain age, diagnostic or specialized program groups, on a statewide basis or limited to persons residing in definable geographic areas.

(b) Case management services:

(1) must not be utilized to restrict the choice of a case management services recipient to obtain medical care or services from any provider participating in the medical assistance program who is qualified to provide such care or services and who undertakes to provide such care or services, including an organization which provides such care or services or which arranges for the delivery of such care or services on a prepayment basis;

(2) must not duplicate case management services currently provided under the medical assistance program or under any other program;

(3) must not be utilized by providers of case management services to create a demand for unnecessary services or programs, particularly those services or programs within their scope of authority; and

(4) must not be provided to persons receiving institutional care reimbursed under the medical assistance program or to persons in receipt of case management services under a Federal home and community based waiver.

(c) Case management functions. Case management functions are determined by the recipient's circumstances and therefore must be determined specifically in each case and with the recipient's involvement. A separate case record must be established for each recipient of case management services and must document each case management function provided, including but not limited to:

(1) Intake and screening. This function consists of the following activities:

(i) the initial contact with the recipient;

(ii) providing information concerning case management;

(iii) exploring the recipient's interest in the case management process;

(iv) determining that the recipient is a member of the provider's targeted population; and

(v) identifying potential payors for services.

(2) Assessment and reassessment. The case manager must secure directly, or indirectly through collateral sources, with the recipient's permission:

(i) an evaluation of any functional impairment on the part of the recipient, if necessary through referral for a medical assessment;

(ii) a determination of the recipient's functional eligibility for services;

(iii) information from other agencies/individuals required to identify the barriers to care and existing gaps in service to the recipient;

(iv) an assessment of the recipient's service needs including medical, social, psychosocial, educational, financial and other services; and

(v) a description of the recipient's strengths, informal support system and environmental factors relative to his/her care.

(3) Case management plan and coordination. The case management activities required to establish a comprehensive written case management plan and to effect the coordination of services include:

(i) identification of the nature, amount, frequency, duration and cost of the case management services required by a particular recipient;

(ii) selection of the nature, amount, type, frequency and duration of services to be provided to the recipient, with the participation of the recipient, the recipient's informal support network, and providers of services;

(iii) specification of the long-term and short-term goals to be achieved through the case management process;

(iv) collaboration with health care and other formal and informal service providers, including discharge planners and other case managers as appropriate, through case conferences to encourage exchange of clinical information and to assure:

(a) the integration of clinical care plans throughout the case management process;

(b) the continuity of service;

(c) the avoidance of duplication of service (including case management services); and

(d) the establishment of a comprehensive case management plan that addresses the medical, social, psychosocial, educational, and financial needs of the recipient.

(4) Implementation of the case management plan includes:

(i) securing the services determined in the case management plan to be appropriate for a particular recipient through referral to those agencies or persons who are qualified to provide the identified services;

(ii) assisting the recipient with referral and/or application forms required for the acquisition of services;

(iii) advocating for the recipient with all providers of service; and

(iv) developing alternative services to assure continuity in the event of service disruption.

(5) Crisis intervention by a case manager or practitioner, when necessary, includes:

(i) assessment of the nature of the recipient's circumstances;

(ii) determination of the recipient's emergency service needs; and

(iii) revision of the case management plan, including any changes in activities or objectives required to achieve the established goal.

(6) Monitoring and follow-up of case management services includes:

(i) verifying that quality services, as identified in the case management plan, are being received by the recipient, and are being delivered by providers in a cost-conscious manner;

(ii) assuring that the recipient is adhering to the case management plan;

(iii) ascertaining the recipient's satisfaction with the services provided and advising the preparer of the case management plan of the findings if the plan has been formulated by a practitioner;

(iv) collecting data and documenting in the case record the progress of the recipient;

(v) ascertaining whether the services to which the recipient has been referred are and continue to be appropriate to the recipient's needs, and making necessary revisions to the case management plan;

(vi) making alternate arrangements when services have been denied or are unavailable to the recipient; and

(vii) assisting the recipient and/or provider of services to resolve disagreements, questions or problems with implementation of the case management plan.

(7) Counseling and exit planning include:

(i) assuring that the recipient obtains, on an ongoing basis, the maximum benefit from the services received;

(ii) developing support groups for the recipient, the recipient's family and informal providers of services;

(iii) mediating among the recipient, the family network and/or other informal providers of services when problems with service provision occur;

(iv) facilitating the recipient's access to other appropriate care if and when eligibility for the targeted services ceases; and

(v) assisting the recipient to anticipate the difficulties which may be encountered subsequent to admission to or discharge from facilities or other programs, including other case management programs.

(d) Procedural requirements for provision of service.

(1) Assessments.

(i) The case management process must be initiated by the recipient and case manager (or practitioner, as appropriate) through a written assessment of the recipient's need for case management as well as medical, social, psychosocial, educational, financial and other services.

(ii) An assessment provides verification of the recipient's current functioning and continuing need for services, the service priorities and evaluation of the recipient's ability to benefit from such services. The assessment process includes, but is not limited to, those activities listed under paragraph (c)(2) of this section.

(iii) An assessment must be completed by a case manager within 15 days of the date of the referral or as specified in the referral agreement. The referral for service may include a plan of care containing significant information developed by the referral source which should be included as an integral part of the case management plan.

(iv) An updated assessment of the recipient's need for case management and other services must be completed by the case manager every six months, or sooner if required by changes in the recipient's condition or circumstances.

(2) Case management plan.

(i) A written case management plan must be completed by the case manager for each recipient of case management services within 30 days of the date of referral or as specified in the referral agreement, and must include, but is not limited to, those activities outlined under paragraph (c)(3) of this section.

(ii) The recipient's case management goals, with anticipated dates of completion, must be established in the initial case management plan consistent with the recipient's service needs and assessment.

(iii) The case management plan must be reviewed and updated by the case manager as required by changes in the recipient's condition or circumstances, but not less frequently than every six months subsequent to the initial plan. Each time the case management plan is reviewed, the goals established in the initial case management plan must be maintained or revised, and new goals and new time frames may be established, with the participation of the recipient.

(iv) The case management plan must specify:

(a) those activities which the recipient is expected to undertake within a given period of time toward the accomplishment of each case management goal;

(b) the name of the person or agency, including the individual and/or family members, who will perform needed tasks;

(c) the type of treatment program or service providers to which the recipient will be referred;

(d) the method of provision and those activities to be performed by a service provider or other person to achieve the recipient's related goal and objective; and

(e) the type, amount, frequency, duration and cost of case management and other services to be delivered or tasks to be performed.

(3) Continuity of service.

(i) Case management services must be ongoing from the time the recipient is accepted by the case management agent for services to the time when:

(a) the coordination of services provided through case management is not required or is no longer required by the recipient;

(b) the recipient moves from the social services district;

(c) the long-term goal has been reached;

(d) the recipient refuses to accept case management services;

(e) the recipient requests that his/her case be closed;

(f) the recipient is no longer eligible for services; or

(g) the recipient's case is appropriately transferred to another case manager.

(ii) Contact with the recipient or with a collateral source on the recipient's behalf must be maintained by the case manager at least monthly, or more frequently as specified in the provider agreement.

(e) Qualifications of providers of case management services.

(1) Providers. Case management services may be provided by social services agencies, facilities, persons, and groups possessing the capability to provide such services who are approved by the commissioner pursuant to a proposal approved in accordance with subdivision (f) of this section including:

(i) facilities licensed or certified under New York State law or regulation;

(ii) health care or social work professionals licensed or certified in accordance with New York State law;

(iii) State and local governmental agencies; and

(iv) home health agencies certified under New York State law.

(2) Case managers. The case manager must have two years experience in a substantial number of activities outlined in subdivision (c) of this section, including the performance of assessments and development of case management plans. Voluntary or part-time experience which can be verified will be accepted on a pro rata basis. The following may be substituted for this requirement:

(i) one year of case management experience and a degree in a health or human services field; or

(ii) one year of case management experience and an additional year of experience in other activities with the target population; or

(iii) a bachelor's or master's degree which includes a practicum encompassing a substantial number of activities outlined in subdivision (c) of this section, including the performance of assessments and development of case management plans; or

(iv) meeting the regulatory requirements of a State department for a case manager.

(f) Requirements for the provision of services.

(1) Proposals.

(i) Each entity listed in paragraph (e)(1) of this section, including those units or subdivisions operating under the statutory or regulatory authority of a State department, which seeks to provide case management services to persons or groups of persons residing in definable geographic areas of the State must:

(a) in conjunction with the social services district(s) where services will be provided, submit a written proposal to the department;

(b) establish a written memorandum of understanding or referral agreement describing their current or projected relationship with the social services district(s) where case management services will be provided. A copy of the proposed memorandum of understanding or referral agreement must accompany the proposal submitted to the department.

Such proposals and agreements/memoranda of understanding will become the basis for a provider agreement between the department and the provider of case management services.

(ii) Those entities seeking to provide case management services on a statewide basis, including those units or subdivisions operating under the statutory or regulatory authority of a State department, must submit to the department a written proposal setting forth their plan for provision of case management services. Such proposal will become the basis for a written provider agreement between the provider of services and the department.

(iii) Any State department seeking to serve through case management the population with whose care it has been charged, must submit to the department a written proposal setting forth its plan and rates or fees for provision of case management services. Such proposal will become the basis for a written provider agreement between the State department providing case management services and the department.

(iv) All proposals for provision of case management services become the property of the department and must:

(a) be for a period of not more than three years; and

(b) include a budget on forms prescribed by the department documenting, pursuant to paragraph (h)(3) of of this section, the estimated cost of providing case management services and identifying other funding sources available for providing case management services.

(v) Proposals for the provision of case management services must be completed on forms prescribed by the department.

(vi) At the discretion of the department, any proposal submitted to the department may be referred to other appropriate State departments for consultation prior to final approval by the department.

(vii) All proposals are subject to review and final approval by the department and the Division of the Budget.

(viii) A State department approved by the commissioner to provide case management services may be considered a social services district for the purposes of this subdivision. The agreement between this department and another State department must specify when that State department may act as a social services district and the authority to be given to such State department.

(2) Referral agreements/memoranda of understanding. Referral agreements and memoranda of understanding between providers of services and social services districts must:

(i) include all terms of the agreement in one instrument, and be dated and signed by authorized representatives of the parties to the agreement subsequent to the department's approval;

(ii) contain an effective date and termination date for the agreement;

(iii) specify the characteristics of and maximum number of persons eligible for medical assistance to be targeted for case management referred to in subparagraph (a)(2)(ii) of this section;

(iv) describe the goals and objectives to be achieved through provision of case management services to the target population;

(v) define those specific functions and activities to be performed through the case management processes outlined in subdivision (c) of this section;

(vi) describe the amount, duration, scope and method of providing such case management services under the agreement including the projected frequency and types of contact that will be sustained with the particular target group;

(vii) specify that determination of eligibility for medical assistance will be the sole responsibility of the social services district, regardless of any assistance the case management agency may provide in obtaining documentation necessary to the determination of such eligibility;

(viii) specify the locations of the facilities to be used in providing case management services;

(ix) specify the qualifications required for case managers serving the target population including copies of their job descriptions;

(x) contain assurances that recipients will be informed of services available to address emergencies that occur outside of usual working hours;

(xi) provide for informing recipients of the right to request a fair hearing in accordance with Part 358 of this Title;

(xii) specify the requirements for fiscal and program responsibility, recordkeeping, and reports, and any formats prescribed by the department for such recordkeeping and reports;

(xiii) provide for access by State and Federal officials to financial and other records specified by the department which pertain to the program;

(xiv) contain assurances that no restrictions will be imposed upon a recipient's choice of provider of case management or any other service provided under the medical assistance program and that each recipient will be advised that refusal of such services included in the case management plan does not carry the threat of fiscal or other sanctions, except in such instances where acceptance of services is otherwise a condition of eligibility for public assistance or care;

(xv) outline the provider's contingency plan for assuring smooth transition of recipients to other available sources of case management if the provider is unable to continue providing services, if the agreement between the provider and the department is not renewed, or if the agreement is terminated;

(xvi) include a copy of the forms which will be utilized in completing assessments and preparing case management plans; and

(xvii) contain assurances that an annual evaluation of the program's effectiveness will be completed.

(3) Provider agreement. Upon approval of a proposal submitted by an entity listed in paragraph (e)(1) of this section, a provider agreement will be established between the provider of service and the department. Such provider agreements must include a copy of:

(i) the provider's proposal required by paragraph (1) of this subdivision;

(ii) the referral agreement or memorandum of understanding between the provider of service and the social services district, if required under paragraph (1) of this subdivision;

(iii) a work plan outlining the case management process as it applies to the particular target population; and

(iv) the forms to be utilized in the provision of case management services.

(4) Agreement period.

(i) A provider agreement may not remain in effect for a period exceeding 12 months. This provision may be waived at the discretion of the department if the provision of service to the targeted population for a greater or shorter period of time is justified.

(ii) Any provider agreement which is not being properly fulfilled must be terminated in accordance with the terms of the agreement.

(iii) Agreements to be renewed must be renegotiated in a timely manner.

(iv) Any amendment to an agreement must be considered an amendment to the proposal required by paragraph (1) of this subdivision.

(5) Annual evaluation. An annual evaluation of each case management program must be performed by the provider and must be transmitted to the department as required by the provider agreement. The annual evaluation must be received by the department at least 90 days preceding the annual anniversary of the effective date of each provider agreement. The annual evaluation must:

(i) restate the program goals and objectives of the case management services that have been provided, as listed in the approved provider proposal;

(ii) restate the population served and the scope of case management provided;

(iii) using evaluation hypotheses, demonstrate the extent to which the provider has achieved the program goals and objectives listed in the approved provider proposal;

(iv) set forth the types and sources of data collected and used in the evaluation; and

(v) recommend any program changes based upon the conclusions of the evaluation.

(6) Monitoring of program performance and provider agreements.

(i) To assure that the quality of services provided is in accordance with the requirements of this section, the following program performance monitoring is required:

(a) The program performance of any entity which operates under the statutory or regulatory authority of a State department must be monitored by that department.

(b) The program performance of any other entity entering into an agreement with this department on less than a statewide basis must be monitored by the social services district(s) involved.

(c) The program performance of any State department establishing an agreement with this department for the provision of case management services must be monitored by this department.

(d) The program performance of any other entities entering into an agreement with this department must be monitored by this department.

(e) Program performance monitoring includes on-site visits, at six-month intervals, to providers of case management services. The six-month on-site monitoring requirement may be waived by the department to permit annual on-site monitoring of providers when, after two years of operation, no significant deficiencies have been identified in reports prepared pursuant to clause (f) of this subparagraph. In order for the department to grant a waiver, the appropriate social services district or State agency must submit to the department a written request for a waiver and copies of the four most recent monitoring reports prepared pursuant to clause (f) of this subparagraph. Upon receipt of such request and reports, the department will determine whether there are significant operational deficiencies identified in the monitoring reports. If no significant deficiencies are identified, the waiver will be granted.

(f) Reports, based upon monitoring by a social services district or by a State department, and any other evaluations required by a provider agreement must be forwarded to this department commencing with the sixth month following the effective date of each provider agreement and annually thereafter and must be received by this department no later than 90 days prior to the anniversary of the provider agreement.

(ii) The department must monitor the performance of all provider agreements.

(a) Provider agreements must be reviewed by the department at least annually to verify conformity with the terms of such agreements. Such monitoring may include:

(1) the review of periodic reports, including those program performance reports referenced in clause (i)(f) of this paragraph;

(2) any other evaluations or information required by the department or required by the provider agreement; and

(3) on-site visits to providers of service.

(b) Continuation of case management services is subject to review and approval by the department.

(g) Authorization for case management services.

(1) Authorization by the social services district or by another State agency empowered by the commissioner is required prior to the provision of case management services.

(2) No single authorization for a recipient to receive case management services will exceed 12 months.

(h) Reimbursement for case management services.

(1) Reimbursement for case management services is available only when such services are provided in accordance with this section.

(2) Rates, fees or amounts reimbursed for case management services are to be determined utilizing cost estimates included in the provider's proposal and any other data and information deemed appropriate, and are subject to the approval of the Division of the Budget.

(3) Documentation of the basis for case management reimbursement rates, fees or amounts including the qualifications of staff providing case management services must accompany the provider's proposal specified in subdivision (f) of this section.

(4) No payment to the provider of case management services can be made for authorized services unless such claim is supported by documentation of the time spent in providing services to each recipient. Such documentation must be maintained by the provider pursuant to regulations of the department.

(5) Payment for case management services may be made on the basis of units of service provided at a particular skill level (i.e., payment per hour or per visit), on a capitated basis (i.e., payment of a flat fee per month or per day for each person eligible for medical assistance in the program, although varied amounts or levels of service may be required), or on such other payment basis as may be approved by the department.

(i) The provisions of this section apply to case management services provided on or after January 1, 1988.

N.Y. Comp. Codes R. & Regs. Tit. 18 § 505.16