Section 491. Case management services for individuals who have an Axis 1 substance-related disorder

A. Target group: The Medicaid eligible recipient shall meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) diagnostic criteria for an Axis I substance-related disorder. Nicotine or caffeine abuse or dependence shall not be covered. An active client for case management shall mean a recipient for whom there is a plan of care in effect which requires regular direct or recipient-related contacts or communication or activity with the recipient, family or service providers, including at least one face-to-face contact with the recipient every 90 days.

B. Services will be provided to the entire state.

C. Comparability of services: Services are not comparable in amount, duration, and scope. Authority of § 1915(g)(1) of the Act is invoked to provide services without regard to the requirements of § 1902(a)(10)(B) of the Act.

D. Definition of services: Substance abuse case management services assist recipients in accessing needed medical, psychiatric, psychological, social, educational, vocational, and other supports essential to meeting basic needs. The maximum service limit for case management services is 52 hours per year. Case management services are not reimbursable for recipients residing in institutions, including institutions for mental disease.

Services to be provided shall include:

1. Assessment and planning services, to include developing an Individual Service Plan (does not include performing assessments for severity of substance abuse or dependence, medical, psychological and psychiatric assessment, but does include referral for such assessment);

2. Linking the recipient to services and supports specified in the Individual Service Plan. When available, assessment and evaluation information should be integrated into the Individual Service Plan within two weeks of completion. The Individual Service Plan shall utilize accepted patient placement criteria and shall be fully completed within 30 days of initiation of service;

3. Assisting the recipient directly for the purpose of locating, developing, or obtaining needed services and resources;

4. Coordinating services and service planning with other agencies and providers involved with the recipient;

5. Enhancing community integration by contacting other entities to arrange community access and involvement, including opportunities to learn community living skills, and use vocational, civic, and recreational services;

6. Making collateral contacts with the recipients' significant others to promote implementation of the service plan and community adjustment;

7. Follow-up and monitoring to assess ongoing progress and to ensure services are delivered; and

8. Education regarding the need for services identified in the Individualized Service Plan (ISP).

Nicotine or caffeine abuse or dependence shall not be covered.

E. Qualifications of providers:

1. The provider of substance abuse case management services must meet the following criteria:

a. The enrolled provider must have the administrative and financial management capacity to meet state and federal requirements;

b. The enrolled provider must have the ability to document and maintain individual case records in accordance with state and federal requirements;

c. The enrolled provider must be licensed by the Department of Behavioral Health and Developmental Services (DBHDS) as a provider of substance abuse case management services.

2. Providers may bill Medicaid for substance abuse case management only when the services are provided by a professional or professionals who meet at least one of the following criteria:

a. At least a bachelor's degree in one of the following fields (social work, psychology, psychiatric rehabilitation, sociology, counseling, vocational rehabilitation, human services counseling) and has at least one year of substance abuse related clinical experience providing direct services to persons with a diagnosis of mental illness or substance abuse;

b. Licensure by the Commonwealth as a registered nurse or as a practical nurse with at least one year of clinical experience; or

c. At least a bachelor's degree in any field and certification as a substance abuse counselor (CSAC) or has at least a bachelor's degree in any field and is a certified addictions counselor (CAC).

F. The state assures that the provision of case management services will not restrict a recipient's free choice of providers in violation of § 1902(a)(23) of the Act.

1. Eligible recipients shall have free choice of the providers of case management services.

2. Eligible recipients shall have free choice of the providers of other services under the plan.

G. Payment for substance abuse treatment case management services under the Plan does not duplicate payments for other case management made to public agencies or private entities under other Title XIX program authorities for this same purpose.

H. The state assures that the individual will not be compelled to receive case management services, condition receipt of case management services on the receipt of other Medicaid services, or condition receipt of other Medicaid services on receipt of case management services.

I. The state assures that providers of case management service do not exercise the agency's authority to authorize or deny the provision of other services under the plan.

J. The state assures that case management is only provided by and reimbursed to community case management providers.

K. The state assures that case management does not include the following:

1. The direct delivery of an underlying medical, educational, social, or other service to which an eligible individual has been referred.

2. Activities for which an individual may be eligible, that are integral to the administration of another nonmedical program, except for case management that is included in an individualized education program or individualized family service plan consistent with § 1903(c)of the Social Security Act.

Historical Notes

Derived from Volume 26, Issue 08, eff. January 21, 2010.

Statutory Authority

§§ 32.1-324 and 32.1-325 of the Code of Virginia.