(1) These requirements are in addition to those contained in rule and statutory provisions generally applicable to medicaid providers.
(2) To be qualified as a provider of targeted case management services for children and youth with special health care needs, an enrolled Montana Medicaid provider must:
(a) be approved by the department;
(b) meet the requirements in (3) through (8);
(c) have knowledge and experience in the delivery of home and community services to children and youth with special health care needs;
(d) demonstrate an understanding of service coordination for children up to 18 years of age; and
(e) have developed collaborative working relationships with health care and other providers in the area to be served.
(3) A targeted case management provider must use an interdisciplinary team that includes members from the professions of nursing and social work.
(a) The professional requirements are the following:
(i) nursing must be provided by a registered nurse, who has a current Montana license and is either:
(A) a registered nurse whose education includes course work in public health; or
(B) a certified nurse practitioner; and
(ii) social work must be provided by one of the following:
(A) clinical social worker with a master's in social work (MSW), who has a current Montana license;
(B) master's level counselor (LCPC), who has a current Montana license; or
(C) bachelor's in social work (BSW) with two years' experience in community social services or public health.
(b) The department must be notified within 30 days regarding any staff changes or updates.
(c) To accommodate special agency and geographic needs and circumstances, exceptions to the staffing requirements, including the use of paraprofessionals, may be allowed if approved by the department. If the targeted case management team includes a paraprofessional, that individual must have a minimum of an associate's degree in behavioral sciences or a related field with two years of closely related work experience, and complete a state-sponsored training for paraprofessional targeted case managers. Qualifying experience may be substituted, year for year, for education.
(4) The targeted case management provider must be able to directly provide services of at least one of the professional disciplines listed in (3) of this rule. The other disciplines may be provided through subcontracts. Where services are provided through a subcontractor, the subcontract must be submitted to the department or designee for review and approval.
(5) A targeted case management provider must:
(a) conduct activities to inform the target population and health care and social service providers in the geographic area to be served of its services for youth and children with special health care needs;
(b) deliver targeted case management services appropriate to the child and caregiver's level of need;
(c) respond promptly to requests and referrals of children for targeted case management;
(d) perform assessments and develop care plans for the appropriate level of care and document the services provided;
(e) schedule services to accommodate the child's situation;
(f) inform a child and the child's caregivers regarding whom and when to call for health care emergencies;
(g) establish working relationships with medical providers, community agencies, and other appropriate organizations;
(h) assure ongoing communication and coordination of the child's care occur within the targeted case management team and the child's primary care provider at least quarterly or at the time of any medical referral;
(i) provide services in a home, office, or clinic setting with telephone contacts as appropriate;
(j) have a system for handling grievances; and
(k) maintain an adequate and confidential record system. All services provided must be documented in this system.
(6) A case targeted manager must have knowledge of:
(a) federal, state and local programs for children and youth such as WIC, immunizations, children's special health services, genetic services, hepatitis B screening, EPSDT, Montana Milestones (Part C Early Interventions), and other health care related programs in Montana;
(b) individual health care systems, plan development, and evaluation;
(c) community health care systems and resources; and
(d) nationally recognized early childhood health care and well child health standards.
(7) A targeted case manager must have the ability to:
(a) develop or participate in the development of an individual care plan based on assessment of a child's health, nutritional and psychosocial status, and personal and community resources;
(b) inform a child and the child's caregivers regarding health conditions and implications of risk factors;
(c) foster the ability of a child's caregivers to assume responsibility for the child's health care;
(d) assist the child and the child's caregivers to establish linkages among service providers;
(e) coordinate access to multiple provider services to benefit the child and the child's caregivers; and
(f) evaluate a child's and the child's caregiver's progress in obtaining appropriate medical care and other needed services.
(8) Providers must maintain case records that meet the maintenance of records and auditing guidelines set forth in ARM 37.85.414 and that document, for all members receiving targeted case management, the following:
(a) the name of the member;
(b) the dates of the targeted case management services;
(c) the name of the provider agency and the person providing the services;
(d) the nature, content, and units of the targeted case management services received, and whether goals specified in the care plan have been achieved;
(e) whether the member has declined services in the care plan;
(f) the need for, and occurrences of, coordination with other targeted case managers;
(g) a timeline for obtaining needed services; and
(h) a timeline for reevaluation of the plan.