Current through Register Vol. 43, No. 02, November 27, 2024
(1) Governmental providers will be paid on a
negotiated rate basis which will not exceed actual costs and which will meet
all requirements of OMB Circular A-87. Nongovernmental providers will be
reimbursed on a negotiated rate basis which will not exceed the upper
limitations of
42
C.F.R. Section 447.325. The following
documentation must be maintained in the recipient's record when billing for
services:
(a) There must be a current
comprehensive service plan which identifies the medical, nutritional, social,
educational, transportation, housing and other service needs which have not
been adequately accessed and a time frame to reassess service needs.
(b) Services must consist of at least one of
the following activities:
1. Establishment of
the comprehensive case file for development and implementation of an
individualized service plan to meet the assessed service needs of the
recipient;
2. Assisting the
recipient in locating needed service providers and making the necessary
linkages to assure the receipt of services identified in the service
plan;
3. Monitoring the recipient
and service providers to determine that the services received are adequate in
meeting the identified needs; or
4.
Reassessment of the recipient to determine services needed to resolve any
crisis situation resulting from changes in the family structure, living
conditions, or other events.
(2) For target group 4 (Foster Children) and
target group 7 (Adult Protective Service Individuals), reimbursement will be as
follows:
(a) Reimbursement rates will be
established based on cost as determined by the quarterly Social Services Work
Sampling Study. Rates will be adjusted annually based on the results of the
previous four quarters. Random Moment Sampling may not be used as a method of
documenting services provided to recipients. The Work Sampling Study must
provide an audit train that identifies each client whose case is included in
the data used for rate formulation and identifies that at least one of the
services listed above in (b) 1, 2, 3, or 4 has been provided.
(b) A maximum of one unit of case management
services will be reimbursed per month for each eligible recipient receiving
case management services. A unit of case management service is defined as at
least one telephone or face to face contact for the purpose of providing at
least one of the services listed above in (b)1, 2, 3, or 4 with the recipient,
a family member, significant other, or agency from which the client receives or
may receive services. All contacts must be documented in the client's record
and must be for the coordination or linkage of services for a specific
identified recipient.
(3) Reimbursement for services provided by
other governmental agencies will be based on actual costs as follows:
(a) Agencies will submit an annual cost
report not later than sixty (60) days following the close of their fiscal year.
This report will indicate not only the costs associated with providing the
service but also statistical data indicating the units of service provided
during the fiscal year.
(b) Cost
reports will be reviewed for reasonableness and an average cost per unit of
service will be computed.
(c) The
average cost, trended for any expected inflation, will be used as the
reimbursement rate for the succeeding year.
(d) If the cost report indicates any
underpayment or overpayments for services during the reporting year, a lump sum
adjustment will be made.
(e) New
rates will be effective as of January 1 of each year.
(4) The Medicaid reimbursement for each
service provided by a case management service provider shall not exceed the
maximum allowable amount established by Medicaid as found in
42 C.F.R. Section
447.304.
(5) Actual reimbursement will be based on the
rates in effect on the date of service.
Author: Dittra Skipper, Administrator, Project
Development/Policy Unit, Long Term Division
Statutory Authority:
42
C.F.R., Section 447.325; OMB Circular A-87;
Section 1915 (g); Social Security Act; State Plan for Medical Assistance
Attachment 3.1-A, Supplement 1; OMB NO. 0939-0193.
