| (R) Home health nursing services. Home health nursing
services must be medically necessary, be prescribed by a physician,
and be provided only by a licensed and certified home and community
support services agency participating in the program. Home health
nursing services are limited to 200 hours per client per calendar
year. Up to 200 additional hours of service per client per calendar
year may be approved with documented justification of need and cost
effectiveness.
(S) Hospice care. Hospice care includes palliative
care for clients with a presumed life expectancy of six months or
less during the last weeks and months before death. Services apply
to care for the hospice terminal diagnosis condition or illnesses.
Treatment for conditions unrelated to the terminal condition or illnesses
is unaffected. Hospice care must be prescribed by a practitioner licensed
to do so who also is enrolled as a program provider.
(4) Care management.
(A) Medical home. Each program client should receive
care in the context of a medical home.
(i) Comprehensive, coordinated health care of infants,
children, and adolescents should encompass the following services:
(I) provision of preventive care, including but not
limited to, immunizations, growth and development assessments, appropriate
screening health care supervision, client and parental counseling
about health care supervision, and client and parental counseling
about health and psychological issues;
(II) assurance of ambulatory and inpatient care for
acute illness, 24 hours a day, seven days a week (including after
hours and weekends);
(III) provision of care over an extended period of
time to enhance continuity;
(IV) identification of the need for sub-specialty consultation
and referrals, provision of medical information about the client to
the consultant, evaluation of the consultant's recommendations, implementation
of recommendations that are indicated and appropriate, and interpretation
of the consultant's recommendations for the family;
(V) interaction with school and community agencies
to assure that the special health needs of the client are addressed;
(VI) guidance and assistance needed to make the transition
to all aspects of adult life, including adult health care, work, and
independence; and
(VII) maintenance of a central record and database
containing all pertinent medical information about the client including
information about hospitalizations.
(ii) The CSHCN Services Program may require periodic
reports from the medical home.
(B) Case management. Case management services may be
made available to program clients through public health regional offices
or other resources to assist clients and their families in obtaining
adequate and appropriate services to meet the client's health and
related services needs. The program will make available case management
as needed or desired to all clients who are eligible for health care
benefits (includes clients who are on the waiting list for health
care benefits). The program also may make available case management
services to clients who are not eligible for the program's health
care benefits.
(5) Family support services. Family support services
include disability-related support, resources, or other assistance
and may be provided to the family of a client with special health
care needs.
(A) Eligibility. A client is eligible to receive family
support services if:
(i) the client is not receiving services from a Medicaid
waiver program, and the family support needs cannot be met by services
from other family support programs, such as the Department of Aging
and Disability Services or the In-Home and Family Support Program;
and
(ii) the client's family collaborates with the assigned
case manager to identify and pursue other sources of support and to
develop a family assessment and service plan.
(B) Processing and evaluation of requests.
(i) Families of clients indicate their need for family
support services by completing and signing an approved request form.
(ii) Requests for family support services are processed
in chronological order by the date of the request.
(iii) All requests for family support services must
be prior authorized (approved by the program prior to delivery).
(iv) While there is a waiting list for health care
benefits, limitations in reimbursement or prior authorization may
be instituted as provided in §38.16 of this title.
(v) Some services or items may require a written statement
from a physician, physical therapist, occupational therapist, or other
healthcare professional to establish the disability-related nature
of the request.
(vi) Some services or items may require written bids.
(vii) Persons requesting assistance are responsible
for collaborating with their case managers to obtain information as
necessary so that an accurate determination can be made in a timely
manner.
(viii) Families shall be notified in writing of the
outcome of their requests for family support services.
(ix) Families have the right to appeal a denial or
partial approval as described in §38.13 of this title (relating
to Right of Appeal).
(C) Service plan and cost allowances.
(i) The case manager and the client or family must
develop a family assessment and service plan and complete a Family
Support Services request packet to request a prior authorization for
family support services.
(ii) The program may establish annual cost allowances
based upon the client's or family's level of assessed need for family
support services not to exceed:
(I) lifetime benefit of up to $3,600 per eligible client
for minor home modifications; and
(II) annual benefit of up to $3,600 per calendar year
per eligible client for allowable family support services.
(-a-) The annual benefit may increase to no more than
$7,200 per eligible client for the purchase of vehicle lifts and modifications.
(-b-) The lifetime benefit for minor home modifications
and the annual benefit may be used in the same calendar year.
(iii) Service plan cost allowances may be prorated
for plans that cover less than one calendar year.
(iv) Reimbursement:
(I) may be made to the family or to the vendor enrolled
as a program provider; and
(II) may be reduced by the amount of a cost-sharing
requirement, if applicable.
(v) Reimbursement rates for respite providers are established
by the client or family and the selected provider in collaboration
with the case manager.
(vi) The annual family assessment and service plan
may be amended at any time, but must be reevaluated by the client
or family and case manager at least annually.
(D) Allowable services.
(i) Family support services for program clients and
their families include those allowable services and items that:
(I) are above and beyond the scope of usual needs (i.e.,
basic clothing, food, shelter, medical care, and education);
(II) are necessitated by the client's medical condition
or disability; and
(III) directly support the client's living in his or
her natural home and participating in family life and community activities.
(ii) Family support services may not be used to supplant
services available through other public or private programs, but
may be used to supplement services provided by other programs.
(iii) Allowable services include:
(I) respite care;
(II) specialized child care costs for a client that
are expenses directly related to the client's disability and special
needs that are beyond the scope of community-based child care centers,
including specialized training for the child care provider;
(III) counseling, training programs, or conferences
to obtain specific skills or knowledge related to the client's care
that assists family members or caregiver(s) in maintaining the client
in their home and to increase their knowledge and ability to care
for the client;
(IV) minor home modifications such as installation
of a ramp, widening of doorways, bathroom modifications, and other
home modifications to increase accessibility and safety;
(V) vehicle lifts and modifications, such as wheelchair
lifts or ramps, wheelchair tie-downs, occupant restraints, accessories,
modifications such as raising roofs or doors if necessary for lift
installation or usage, hand controls, and repairs of covered modifications
not related to inappropriate handling or misuse of equipment and not
covered by other resources;
Cont'd... |
