Regulation .16 Limitations.
Regulation .16 Limitations.LinkCopy Citation
A.
Care coordination services are facilitative in nature.
B.
A restriction may not be placed on a qualified recipient’s option to receive mental health case management services.
C.
Care coordination services do not restrict or otherwise affect:
(1)
Eligibility for Title XIX benefits or other available benefits or programs, except as limited by §E of this regulation;
(2)
The freedom of a participant or, if the participant is a minor, the minor’s parent or guardian to select from all available services for which the participant is found to be eligible; or
(3)
A participant’s free choice among qualified providers or, if the participant is a minor, the minor’s parent or guardian’s free choice among qualified providers.
D.
The CCO may not bill the Program for:
(1)
The direct delivery of an underlying medical, educational, social, or other service to which a participant has been referred;
(2)
Activities integral to the administration of foster care programs;
(3)
Activities not consistent with the definition of case management services under Section 6052 of the federal Deficit Reduction Act of 2005 (P.L. 109—171);
(4)
Activities for which third parties are liable to pay;
(5)
Activities delivered as part of institutional discharge planning; or
(6)
A 15-minute unit of service for telephonic contact, unless the provider has delivered at least 8 minutes of service.
E.
Reimbursement may not be made for care coordination services if the participant is receiving a comparable care coordination service under another Program authority.
F.
A participant’s care coordinator may not be the participant’s family member or a direct service provider for the participant.
G.
Units of services for all levels of care coordination shall be 15 minutes of contact, which may include face-to-face and, with the exception of §G(4) of this regulation, non-face-to-face contacts with the participant, or, if the participant is a minor, with the minor’s parent or guardian, and indirect collateral contacts on behalf of the participant with other community providers, as per the following:
(1)
For participants in Level I — General Coordination, allows a maximum of 12 units of service per month, with a minimum of two units of face-to-face contact;
(2)
For participants in Level II — Moderate Care Coordination, allows a maximum of 30 units of service per month, with a minimum of four units of face-to-face contact;
(3)
For participants in Level III — Intensive Care Coordination, allows a maximum of 60 units of service per month, with a minimum of six units of face-to-face contact; and
(4)
For Level I and Level II, four additional units of service above and beyond the monthly maximum may be billed during the first month of service to the participant and every 6 months thereafter to allow for comprehensive assessment and reassessment of the participant, which shall be performed as a face-to-face service.