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42 CFR Ch. IV (10–1–08 Edition)§441.18
(2) A hospital-based laboratory thatmeets the requirements for participa-tion in the Medicare program found in§482.27 of this chapter;(3) A rural health clinic, as defined in§491.9 of this chapter; or(4) A skilled nursing facility—basedclinical laboratory, as defined in§405.1128(a) of this chapter.(b) Except as provided under para-graph (c), if a laboratory or other enti-ty is requesting payment under Med-icaid for testing for the presence of thehuman immunodeficiency virus (HIV)antibody or for the isolation and iden-tification of the HIV causative agent asdescribed in §405.1316(f) (2) and (3) of this chapter, the laboratory recordsmust contain the name and other iden-tification of the person from whom thespecimen was taken.(c) An agency may choose to approvethe use of alternative identifiers, inplace of the requirement for patient’sname, in paragraph (b) of this sectionfor HIV antibody or causative agenttesting of Medicaid recipients.
[54 FR 48647, Dec. 2, 1988. Redesignated at 63FR 310, Jan. 5, 1998.]
§441.18Case management services.
(a) If a State plan provides for casemanagement services (including tar-geted case management services), asdefined in §440.169 of this chapter, theState must meet the following require-ments:(1) Allow individuals the free choiceof any qualified Medicaid providerwithin the specified geographic areaidentified in the plan when obtainingcase management services, in accord-ance with §431.51 of this chapter, ex-cept as specified in paragraph (b) of this section.(2) Not use case management (includ-ing targeted case management) serv-ices to restrict an individual’s accessto other services under the plan.(3) Not compel an individual to re-ceive case management services, condi-tion receipt of case management (ortargeted case management) services onthe receipt of other Medicaid services,or condition receipt of other Medicaidservices on receipt of case management(or targeted case management) serv-ices.(4) Indicate in the plan that casemanagement services provided in ac-cordance with section 1915(g) of the Actwill not duplicate payments made topublic agencies or private entitiesunder the State plan and other pro-gram authorities;(5) Provide comprehensive case man-agement services, on a one-to-onebasis, to an individual through onecase manager.(6) Prohibit providers of case man-agement services from exercising theagency’s authority to authorize ordeny the provision of other servicesunder the plan.(7) Require providers to maintaincase records that document for all indi-viduals receiving case management asfollows:(i) The name of the individual.(ii) The dates of the case manage-ment services.(iii) The name of the provider agency(if relevant) and the person providingthe case management service.(iv) The nature, content, units of thecase management services received andwhether goals specified in the care planhave been achieved.(v) Whether the individual has de-clined services in the care plan.(vi) The need for, and occurrences of,coordination with other case managers.(vii) A timeline for obtaining neededservices.(viii) A timeline for reevaluation of the plan.(8) Include a separate plan amend-ment for each group receiving casemanagement services that includes thefollowing:(i) Defines the group (and any sub-groups within the group) eligible to re-ceive the case management services.(ii) Identifies the geographic area tobe served.(iii) Describes the case managementservices furnished, including the typesof monitoring.(iv) Specifies the frequency of assess-ments and monitoring and provides a justification for those frequencies.(v) Specifies provider qualificationsthat are reasonably related to the pop-ulation being served and the case man-agement services furnished.(vi) Specifies the methodology underwhich case management providers will
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Centers for Medicare & Medicaid Services, HHS §441.18
be paid and rates are calculated thatemploys a unit of service that does notexceed 15 minutes.(vii) Specifies if case managementservices are being provided to Med-icaid-eligible individuals who are in in-stitutions (except individuals betweenages 22 and 64 who are served in IMDsor individuals who are inmates of pub-lic institutions).(viii) Specifies if case managementservices are being provided to individ-uals with long-term stays of 180 con-secutive days or longer or to individ-uals with short-term stays of less than180 consecutive days. When Stateschoose to provide case managementservices to individuals in institutionsto facilitate transition to the commu-nity, the State plan must include thefollowing requirements:(A) Specify the time period or otherconditions under which case manage-ment may be provided in this manner.The time period that case managementis provided in an institution must notexceed an individual’s length of stay;(B) Specify the case management ac-tivities and include an assurance thatthese activities are coordinated withand do not duplicate institutional dis-charge planning;(C) Include an assurance that theamount, duration, and scope of thecase management activities would bedocumented in an individual’s plan of care which includes case managementactivities prior to and post-discharge,to facilitate a successful transition tocommunity living; and(D) Specify that case management isonly provided by and reimbursed tocommunity case management pro-viders;(E) Specify that Federal FinancialParticipation is only available to com-munity providers and will not beclaimed on behalf of an individual untildischarge from the medical institutionand enrollment in community services;and(F) Describe the system and processthe State will use to monitor pro-viders’ compliance with these provi-sions.(9) Include a separate plan amend-ment for each subgroup within a groupif any of the following differs amongthe subgroups:(i) The case management services tobe furnished;(ii) The qualifications of case man-agement providers; or(iii) The methodology under whichcase management providers will bepaid.(b) If the State limits qualified pro-viders of case management services fortarget groups of individuals with devel-opmental disability or chronic mentalillness, in accordance with §431.51(a)(4)of this chapter, the plan must identifyany limitations to be imposed on theproviders and specify how these limita-tions enable providers to ensure thatindividuals within the target groups re-ceive needed services.(c) Case management does not in-clude, and FFP is not available in ex-penditures for, services defined in§440.169 of this chapter when any of thefollowing conditions exist:(1) Case management activities arean integral component of another cov-ered Medicaid service.(2) The case management activitiesconstitute the direct delivery of under-lying medical, educational, social, orother services to which an eligible indi-vidual has been referred, including, butnot limited to, services under paroleand probation programs, public guard-ianship programs, special educationprograms, child welfare/child protec-tive services, and foster care programs.(3) The activities are integral to theadministration of foster care programs,including but not limited to the fol-lowing:(i) Research gathering and comple-tion of documentation required by thefoster care program.(ii) Assessing adoption placements.(iii) Recruiting or interviewing po-tential foster care parents.(iv) Serving legal papers.(v) Home investigations.(vi) Providing transportation.(vii) Administering foster care sub-sidies.(viii) Making placement arrange-ments.(4) The activities, for which an indi-vidual may be eligible, are integral tothe administration of another non-medical program, such as a guardian-ship, child welfare/child protectiveservices, parole, probation, or special
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