TN No. 11-013 Approval Date: Pm 28 2012 Effectiveprovider.indianamedicaid.com/ihcp/StatePlan/Attachments...State Plan \lnder Title XIX of the 5Oci.1 seGur/tV Act Stat,,/Territorv:

$Page 1: TN No. 11-013 Approval Date: Pm 28 2012 Effectiveprovider.indianamedicaid.com/ihcp/StatePlan/Attachments...State Plan \lnder Title XIX of the 5Oci.1 seGur/tV Act Stat,,/Territorv:$
State of Indiana Supplement 1 to Attachment 3.1-A Page 1

STATE PLAN UNDER TITLE XIX OFTHE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES

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TN No. 11-013 Supersedes TN No. 98-020

Approval Date: Pm 28 2012 Effective Date: July 1. 2011

I I !


STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES

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TN No. 11-013 Supersedes TN'No. 98-020

Approval Dat., FEB' 8 2012 Effective Date: July 1. 2011


STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURI1Y ACT CASE MANAGEMENT SERVICES

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TN No. 11-013 Supersedes TN No. 98"()20

Approval Date: FEB' S ZIIIZ Effective Date: July 1. 2011





FEB 28 ZUlZ Approval Date:' _____ _ Effective Date: July 1. 2011


STATE PlAN UNDER TITLE XIX OFTHE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES



Approval Date: FEB 28 ZOIZ Effective Date: July 1 2011


STATE PLAN UNDER TITLE XIX OFTHE SOCIAL SECURliY ACT CASE MANAGEMENT SERVICES



Approval Dale: FEB J ~ 2Il12 Effective Date: July 1. 2011


STATE PLAN UNDER TITLE XIX Of THE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES


TN No. IHJ13 Supersedes TN No. 98-020

Approval Date: fEB' 8 ZOI2 Effective Date: July 1. 2011

State of Indiana Supplement 1 to Attachment 3.1~A Page g

STATE PLAN UNDER llTLEXIX OFTHESOCIALSECURITY ACT CASE MANAGEMENT SERVICES

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Approval Date: FEB J 8 2D1Z Effective Date: July 1. 2011


STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT CASE MANAGEM ENT SERVICES



Approval Date: FEB 2 B 2012 Effective Date: July 1. 2011


STATE PLAN UNDER TITLE XIX Of THE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES



Approval Date: FEB 282D1Z

Effective Date: July 1. 2011


STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT CASE MANAGEM ENT SERVICES



Approval Date: FEB' 8 2D1Z Effective Date: July 1. 2011


STATE PLAN UNDER mLE XIX OFTHE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES



Approval Date: FEB'SZD1Z Effective Date: July 1. 2011

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FEB!8 ZOll Approval Date:. _____ _ Effe"ctive Date: July i. 2011

State of Indiana Supplement 1 to Attachment 3.1~A Page 14

STATE PLAN UNDER nTLE XIX OF THE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES



Approval Date: FEB' 8 ZD12 Effective Date: July 1. 2011


STATE PLAN UNDER mLE XIX OF THE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES



I'fB 28 2DIZ Approval Date: _____ _ Effective Date: July 1. 2011


STATE PlAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES


TN No. 11-013 Supersedes TN No, 03-023

Approval Date:. _____ _ FEB 282012

Effective Date; July 1. 2011

State of Indiana Supplement 1 to Attachment 3.1-A Page 16a

STATE PLAN UNDER nTLE XIX OF THESOOAlSECURITY ACT CASE MANAGEMENT SERVICES

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TN No. 11-013 Supersedes TN No. OHI23

FEB282D12 Approval Date: . Effective Date: July 1, 2011





Approval Date: FEB J 8 2DIZ Effective Date: July 1 2011


STATE PlAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES



Approval Date: FEB, 8 2D1Z Effective Date: July 1. 2011

State of indiana Supplement 1 to Attachment 3.1-A Page 19

STA IT PLAN UNDER TITLE XIX Df THE SOCIAL SECURITY ACT CASE MANAGEMENT SERVICES



Approval Date: m J 8Z01Z Effective Date: July 1. 2011

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State Plan \lnder Title XIX of the 5Oci.1 seGur/tV Act Stat,,/Territorv: ~

TAIlGETEO CASE MANAGEMENl SERVICES CHILDREN W1Tii ELeVATED Blooo LEAD LEVELS

Target-Group 142 Code of "emal Ri!gulations 441.1!l/a)[Bljii and 441.19!;dIS)):

SUpplement 1 to Attachment:l.l-A Page 20

Me'di<:8id enroPed im,lIridual$ who, through a blood lead sc:reenlll8 conducted in acoordance with tm. EPSDT periodicity $Gh<!dule, af'(o found wilh a <o"flrmed elevated blood lead level iCEBLLl as defined by the Center. for DI5Qse Control and Prevention (CDC).

Target group indudE!$ individuals troos;lIoning to • C(lmmuoity s~g. C_ management selVlce. wlti be made available lor up to __ consecutive days of a cowredstav In a medital Institution, 'rhe tarset group does oot In dude individual. between ages 22 and 64 who are served In lmtitutlons for Mental 0150. sa or InOMduals wno are inmates of public institution,. (Stota Medicaid DIrector> u.n., ISMOL), JUly 25, 2000\

Areas of .!iNt. in Which "'Me ... will be provided !§191Slgl!11 afthe Actl: .JL Enllre State

Onlv in the loNowing geographic area.;

~mparabil!ty ofservke> .~;l.(J)!B) om! 1915iglll)J: Services are provided in accorda""e with §1902{alll(»)(B) otthe Act .

.JL Services are not COmparable In amount duration and $Gop. 1§1915(g\(1».

Definlt!l;!n of se",lees [42. Cf!l.MO.16111: CQf\Slstent wll:h the Oeficlt Reduction Act IORAI of 2005. the t\!l'M ''T~rgeted (:ase Management" "",,,n, services which will ~.$Ist indMdusl~ eligible under the plan In gaining acce .. to needed medlcal. educationaL SOCia! and other seN!ce. rel""""t to elevated blood lea\l levels [ElIlLi and other identified I • ..., ••. Targeted Case mana(!l!ment services a,e go.~"rlented acti\Iltles that ptOliIde. oversee, and coordin.te services to jead poisoned individuals. This Induda> but is not IlI'Ilted to identifying resOUrtes, planning services, Implementing am! coordinating I.ad treatment and $ENices, "nti /I".onltoling the delivery 01 soch ,elVices. Components of the ,.,mee Include: a$ll$sm."t of the impairment, treatm.~t planntng, ano monitoring of the overall service delivery; provision of seMce.ln • ,.ttlns IlCCessiblf.' and apprope'lIt" to the recipient. Tali_ted Case Management for children with ESLt includes the follawll\& a16lst>ru;e :

• A""".ntMt: Initiatl,,! a rls~ .5'."111""' of tn .. indlvlduol', primary addr ... to determine po"lble _roo> of lead e<posure as weU as identification ot Other risk fllctOrt (includill& but not limited to, medical, educational, SOCial, developmental, and behavloral); gathering information 00 the IndMdual's history by intervlewlne. the individual, his/her family, medical provlders, soclalworkefS am! other professional.; compteting ne(;l$.Silry docuMentatton.

.. "'re Planning: De«elopment 01 a care plttn specific to th" ;m!ividual based on information girthered during the Assessment; through specifiC goals lind objectives, the <;<>re pian will add r .... the medical, sodal, education .. and other ffiVice needs telated to the Indillidual'.lead exposure and other identified i>sues; the care pI"n wHI aIsG include objectives related to ar:tlve participation from tna Individual and h's/her familV·

-0- lleierral and Li~age: l\eferral5 for nece,'",,! servltes, including but nOt: fimlted to services to address medical, edu<:atloMl, soda! and nutrition.1 needs, '" appropriate; this Includes aetMtle. that Unk the Individual with needed ;ervlre ..

lNNO.~ Supersedes TNNQ.~

ApptOValOate: MAR -- 9 2012 Effective Date: !I!I1t 1, 22AA

c)u.'M. f8 1 ;).. QO '1 ~¥,--\'l. ~~

~l 11'-

State plan underl1t1e )(IX of the Socia! Security Act Statll/T."ilory; Indiana

TARGETED CASE M.o.NAGEMENTSERVICES CHILDREN WITH ELEVATED BLOOD LEAD LEVELS

Supplement 1 to Attachment 3.1·A Pag.21

* Monitoring; Follow-up 1!ct"lVili .. and contacts Wl!h th~ lndividuol and his/her family to en5ure effect!ve Implementation altha t:lIre PWI and that t!u; care plan i. addressing the individuar, need •. Adjuumentst<> the !:are plan WID be made as netllSSary. follow",,, services mUst be provided as approPriate to trul lndl\lldual's c:a5e and nO! less frequently thar: one: /1) (;Ontatt e<l0lV thrat' ~) months.

.. ca,. CI_r<r. The cue manager will terminate case management ~ervi'es in accordance ",,;tiI t_ Closure iui/le§n.". set out in 410 lAC 29-l-l.

C9ie mamillement includes contacts with non..,liglble individuals that are directly relatt;d \0 leentifvinB the eligible lnaivldual'S need. and tare, for the purposes of helping the ellgihle individual atee ... ervltes; identlf'llng flIle<15 and supports to assist the eliglbl~ Indivldu.11n obtaining services; providing case managers with us.ful feedback, and alerting (lOse managers TO changes In the eligible indM~u.r. needs. ;42 CFR 440.169(e»)

QuaHfi9!lon. of providers (42 CFR ~1,18la\t8l!v) and 42 (FR 44usIbU: Q)oe ma""g"r. have, at a minimum, either a bachelor's degree In ,oda! wort lor a relati!d field) or ~re a Realotered !<IUlSe (RIIII lOnd are authorized b~ a local health dePllrtment (LHO) through a provider agreement case manag(;j's reeeive ,peclalized t.-.inl,,!I. thrc;>ugh the Indiana Slate Department of ll.ealth (ISDH) wIthin ,Ix (6l months of hire, Case managers must provide service. In accordance with 41tHAC 2!J-l and §1915(g) of the Social Security Act Ca,e man<lgers report to the County Health Officer, a Medical Doctor (MDlllcensed by the Slate of Indiana.

Freedom of choice 141 CFB 441.18IaWlll: The State assu,es that the provIs1on of case management servlceswill not restrict an ind\vid~al" free choice of providers In violation of §1902(at(23) of the AI::;\.

1, ,"sible IndlYldual$ WlIl have free choice of any qualified Medicaid provider within the specified geosr;'phlc orea Identified In 1;1\1. plan.

2. Eligible individuals wlll have f,ee choke of any qualified Medicaid providers of other medical care under the plan. 3, Individuals of the target population may choose whether or mat<> receive targeted case management servlc ... 4. Any person or entity meeting the State'. requirements who ""shes [0 become a Medicaid pfO\lider of targeted

case management...-vi<:es may be !lIven the opportunity to do so. S. T ¥/leted (as. m.n~gement wllll'Ot be used to ,.,Strict the acees. to other service. alillilable under the plan,

Freedom 01 Cholte E"",ption [U91Sh!lUI and 42 CFR 44H8fb)1: Target grOUf> consists of eIlilDle Indl,,;dUSIs with d_lopmentai disabilities or with chronic mental illness. ProIIlden are limited to quallfled Medicaid providers of case management "'rvI~~ ~bJe of en$Uri"ll that Individuals with deWllopmemal disabilities- Of with chronic mental i~!12SS receive needed servic ....

AcCl¥ t<> Ser\Ii,es!4? Cf!l441.1B1illlll. 42 CF/! 441,l!!(alf3J. 42 (fR ~1.l8[a)(6lJ: To. State assures the following:

1. Q)5i! m~na&ement fincludlns targeted ClISi> management) senlices .. in not be used to restrict an indlviduar, aci:e .. to miter _. under the plan.

2. IndMduals wiIJ not be compelled to receive co .. management services, condition receipt of case management ,Of

!"'lIMed q)SE managementl ",1/1005 on the receipt of otrulr Medicaid serv1ces, or conditlotl cec~pt of other Medicaid "'",i<:eS On rece'pt of case management ior iargeted <aSe man~£ementl services; and

3, Pr",,'!!." of case management services do not exel'dse the agency"authority to autharile or deny the provision "f other s .... ce' under the plan.

TN No. Oll-009 Supersedes TN No./!ID'i

MAR -9 ZOIZ Approval Date: . Effe<:ti .... Dale: ,ilI1y h i{!Ilt

~w.. \8\~"

Pw ~$. ~~~ ""{)/ $..-

Payment 142 eFlt 441.ll!Ia)(4U;

State Plan under ntle XlX of the So<i~1 Security Ad Slatejierritory: "'diana

TAAGElEO CASE MANAGEMENT SERVICES ' .. ILOilEN WITH EUVAlEO ~LOO[lI.EAO tMLS

Supplement 1 to Attachment 3.1-A Page 22

Pavmentfor case manasemem ortatgellod eMe man.sement services under the pian does not dupUeate payments m.de to public asenties or priVa~ eml!!.s under other program authorities for ttlls same purpose,

Qln.Beconl. 142 CER 441.l!l1!ll1l1. ~tQ\lldan; malmaln Cii5e re<:ords th.t dOCUll'lt!1rt for all individuals recEiving case managem.nt as follows:

1, ihenameofthelndlvidu.l; 2. The dates of the tose man<>aemen! •• !Vices; 3, Th",name afthe pr01rider agency (if rei"",."!) and the perron prOllidins the case management servic,,; .t, The nature, cal'Jtent, units of the case management .e!Vices reCJlived and whether goals spedfied in the care plan

h ave been athieved; S. Whether the Individual has declined services In the car. pI;! n; 6, The need for, an d oct:Urreru:es of, coordination VoI!th other caie managers; 7. A tlm~lif1e fa,obtainin! neodetJ seMces; 8. I\. timan". for reevaluation of the plan.

JJmltatlpn5: Case management doe. not ;nelude. and Fedtf,,1 Rnantial Participation jFFP1 is nat avallable in ."".ndilu, .. for. services , defined In §441.169 when the ca •• management activities are an integralall<l isueparable component of anather CO\II!red Medicaid serviee (S@le Medicaid Manual C5MM14302.fl.

Case manacement does nat include, and Federal financial Partit!p.tkln (FFP) ls not available in ""pendltutes fo,. s.!Vices def\netJ in 1441.169 whO!n the tase management _dlville. consUtute the direct delivery of underlying med leal, educ::nlonal, SOCial, or other services to whkh an eligible rndMdual has been referred, including fot foster Cit'e programs, service. suCh a .. but nat limited to, the followin8; researc~ gathering and completion of documentation r'lqulr!!d by the roster care program; O$ ..... iog adoption plaooroenu; recruiting or interviewing potential foster c.r~ parents; S1!fVing ieglll papers; h()!IlI! investigations: providillll transportation;admini.terillll foster care subsidies; makingplacemenl arrangement>. {42 QR 44US(c))

Fl'P only is available for case management services or targeted case managemellt set.lees If there are no other third partie. liable to pay lor suCh .le/Vi(es, including a< reimbursement un<ler a medical, social, etiu<:.tlonel, or ather p'<'2ram e>cept for case "",n"Bement thaI 1$ Included In an lntiMd"aliled &ducat;"" program or indMduaflzed family seNiee plan cOo1sistent with §1903je) of the Act. {§il902{a)(251 and J.9051'H

EPSDT Assurance: UndO!r the EPSDT benefit, TeM nrvlt. ... WId be ptOVided to any individual determined to meet the medical necessity/or the serYk.-e.

TN No, 0$-009 Supersedes 1NN(), NEW

MAR - 9 Z012 Approval Date: . .....;;. __ _ Effective D.te'~8

.)lI.o\t. rll t ;..oo~

Documents

TN No. 11-013 Approval Date: Pm 28 2012 Effectiveprovider.indianamedicaid.com/ihcp/StatePlan/Attachments...State Plan \lnder Title XIX of the 5Oci.1 seGur/tV Act Stat,,/Territorv: