Sec. 10.09.90.16. Limitations

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.