Sec. 10.09.90.11. Covered Services

A. The Department shall reimburse for the care coordination services in this regulation when these services have been documented, pursuant to the requirements of this chapter, as necessary.

B. Care coordination services shall be coordinated with, and may not duplicate activities provided as part of, institutional services and discharge planning activities.

C. Care coordination may include contacts that are directly related to identifying the needs and supports for helping the participant to access services.

D. The CCO shall engage in participant advocacy, including:

(1) Empowering the participant and, if the participant is a minor, the minor’s parent or guardian to secure needed services;

(2) Taking any necessary actions to secure services on the participant’s behalf; and

(3) Encouraging and facilitating the participant’s decision making and choices leading to accomplishment of the participant’s goals or, if the participant is a minor, encouraging the parent or guardian to carry out these decisions.

E. Comprehensive Participant Assessment and Periodic Participant Reassessment.

(1) Providers shall use a child and youth assessment tool approved by the Department to perform participant assessments and reassessments.

(2) Initial assessment or reassessment involves the participant’s stated needs and review of information concerning the participant’s mental health, social, familial, educational, cultural, medical, developmental, legal, vocational, and economic status to assist in the formulation of a POC.

(3) The initial assessment or reassessment of the participant’s needs and progress shall be facilitated by the care coordinator and monitored by the CFT, which includes the participant, family members, and friends of the participant, as appropriate, or, if the participant is a minor, the minor’s parent or guardian, and community service providers, such as mental health providers, medical providers, social workers, and educators, as appropriate.

(4) Coordination and Facilitation of the CFT. The care coordinator shall:

(a) Identify a location for the CFT meetings that is suitable to the participant’s needs;

(b) Convene the CFT at least every 6 months, or more frequently, as clinically necessary; and

(c) For 1915(i) participants, convene as per the timeline and functions pursuant to COMAR 10.09.89.

(5) After an initial assessment, each participant shall be reassessed at a minimum of every 6 months.

F. Development and Periodic Revision of the POC.

(1) After the initial assessment is completed, a POC shall be developed based on the information obtained through the comprehensive screening and assessment tools approved by the Department.

(2) The CCO shall finalize the POC within 30 calendar days of notification of enrollment and submit it to the Department or its designee.

(3) Development of and updates to the POC shall be youth- and family-directed and managed through CFT meetings.

(4) The POC shall meet the requirements of Regulation .12 of this chapter.

(5) The POC development process shall include:

(a) The CFT meeting, which includes the participant, and if the participant is a minor, the minor’s parent or guardian, providers, family members, and other interested persons, as appropriate, for the purpose of establishing, revising, and reviewing the POC;

(b) The development of the written, individualized POC based on the participant’s strengths, needs, and progress toward outcome measures;

(c) Transitional care planning that involves contact with the participant or, if the participant is a minor, the minor’s parent or guardian, or the staff of a referring agency, or a service provider who is responsible to plan for continuity of care from inpatient level of care or an out-of-home placement to another type of community service; and

(d) Discharge planning from care coordination, when appropriate and when the family is closer to its identified vision, when family needs have been met, and when outcome measures for care coordination have been achieved.

(6) After the POC is developed, the CCO shall update the POC as often as clinically indicated based on the strengths and needs of the participant but not less than:

(a) For Level I participants, every 6 months;

(b) For Level II participants, every 3 months;

(c) For Level III participants, every 45 calendar days; and

(d) For all participants, within 7 calendar days following a crisis event.