section .0200 – general case management

Link to law: http://reports.oah.state.nc.us/ncac/title 10a - health and human services/chapter 25 - medical assistance provided/subchapter f/10a ncac 25f .0201.html
Published: 2015

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section .0200 – general case management

 

10a NCAC 25F .0201        CASE MGMT SVCS/ADULTS/CHILDREN AT‑RISK/ABUSE/

NEGLECT/ EXPLOITATION

(a)  Case management is a set of interrelated activities

under which responsibility for locating, coordinating and monitoring appropriate

services for an individual rests with a specific person or organization.  The

purpose of case management services for adults and children at‑risk of

abuse, neglect, or exploitation is to assist them in gaining access to needed

medical, social, educational, and other services; to encourage the use of cost‑effective

medical care by referrals to appropriate providers; and to discourage over‑utilization

of costly services.  Case management services will provide necessary

coordination with providers of non‑medical services such as nutrition

programs like WIC or educational agencies, when services provided by these

entities are needed to enable the individual to benefit from programs for which

he or she is eligible.  The set of interrelated activities are as follows:

(1)           Evaluation of the client's individual

situation to determine the extent of or need for initial or continuing case

management services.

(2)           Needs assessment and reassessment to

identify the service needs of the client.

(3)           Development and implementation of an

individualized plan of care to meet the service needs of the client.

(4)           Providing assistance to the client in

locating and referring him or her to providers or programs that can meet the

service needs.

(5)           Coordinating delivery of services when

multiple providers or programs are involved in care provision.

(6)           Monitoring and following‑up to ensure

services are received, adequate to meet the client's needs, and consistent with

good quality of care.

(b)  The target group includes:

(1)           Adults who are at‑risk or show

evidence of abuse, neglect, or exploitation as defined in G.S. 108A‑101. 

Children who are at‑risk or show evidence of abuse or neglect as defined

in G.S. 7A‑517; and

(2)           Who are Medicaid recipients; and

(3)           Who are not institutionalized; and

(4)           Who are not recipients of other Medicaid‑reimbursed

case management services provided through the State's home and community‑based

services waivers or the State Plan; and

(5)           Who reside in counties providing the non‑Federal

matching funds to offer this service.

(c)  The case manager shall determine whether an adult or

child is at‑risk of abuse, neglect, or exploitation as follows:

(1)           At‑Risk Adult:  An at‑risk

adult is an individual who is at least 18 years old, or an emancipated minor,

and meets one or more of the following criteria:

(A)          An individual with only one consistent identified

caregiver, who needs personal assistance 24 hours per day with two or more of

the activities of daily living (bathing, dressing, grooming, toileting, transferring,

ambulating, eating, communicating); or

(B)          An individual with no consistent identified

caregiver, who is unable to perform at least one of the activities of daily

living (bathing, dressing, grooming, toileting, transferring, ambulating, eating,

communicating); or

(C)          An individual with no consistent identified

caregiver, who is unable to carry out instrumental activities of daily living

(managing financial affairs shopping, housekeeping, laundry, meal preparation,

using transportation, using a telephone, reading, writing); or

(D)          An individual who was previously abused, neglected

or exploited, and the conditions leading to the previous incident continue to

exist; or

(E)           An individual who is being abused, neglected, or

exploited and is in need of protection.

(2)           At‑Risk Child:  An at‑risk

child is an individual under 18 years of age who meets one or more of the

following criteria:

(A)          A child with a chronic or severe physical or mental

condition whose parent(s) or caretaker(s) are unable or unwilling to meet the

child's care needs;

(B)          A child whose parents are mentally or physically

impaired to the extent that there is a need for assistance with maintaining

family stability and preventing or remedying problems which may result in abuse

or neglect of the child; or

(C)          A child of adolescent (under age 18) parents or

parents who had their first child when either parent was an adolescent and

there is a need for assistance with maintaining family stability, strengthening

individual support systems, and preventing or remedying problems which may

result in abuse or neglect of the child; or

(D)          A child who was previously abused or neglected, and

the conditions leading to the previous incident continue to exist; or

(E)           A child who is being abused or neglected and is in

need of protection.

(d)  Enrollment of providers shall be accomplished in

accordance with section 1902(a) (23) of the Social Security Act.

(1)           Case Manager Qualifications.  Case managers

must meet the following qualifications:

(A)          A case manager for at‑risk adults must:

(i)            Have a Master of Social Work degree or a

Bachelor of Social Work degree, or be a social worker who meets State

requirements for Social Worker II classification; and

(ii)           Have training in recognizing risk factors

related to abuse, neglect, or exploitation of elderly or disabled adults and in

assessment of functional capacity and needs related to activities of daily

living; and

(iii)          Have experience in case management services for

elderly and disabled adults.

(B)          A case manager for at‑risk children must:

(i)            Have a Master of Social Work degree or a

Bachelor of Social Work degree, or be a social worker who meets State

requirements for Social Worker II classification; and

(ii)           Have training in recognizing risk factors

related to abuse or neglect of children and in assessing family functioning;

and

(iii)          Have experience in case management services for

children and their families.

(2)           Provider Qualifications.  Providers must

meet the following qualifications:

(A)          Meet applicable State and Federal laws governing the

participation of providers in the Medicaid program.

(B)          Be certified by the Division of Social Services as a

qualified case management provider.  To be certified, a provider must:

(i)            Have qualified case managers with supervision

provided by a supervisor who meets State requirements for Social Work

Supervisor I or Social Work Supervisor II classification.

(ii)           Have the capability to access multi‑disciplinary

staff, when needed.  For adults this includes, at a minimum, medical

professionals as needed and an adult protective services social worker meeting

the qualifications in Subparagraphs (d)(1)(A)(i) and (d)(1)(A)(ii) of this

Rule.  For children, this must include medical professionals as needed and a

child protective services social worker meeting the qualifications in

Subparagraphs (d)(1)(B)(i) and (d)(1)(B)(ii) of this Rule.

(iii)          Have experience as a legal guardian of persons

and property.

 

History Note:        Authority G.S. 108A‑25(b); 108A‑54;

Social Security Act, 1915(g);

Eff. October 1, 1992;

Recodified from 10 NCAC 26B .0122 Eff. October 1, 1993;

Temporary Amendment Eff. January 9, 1997;

Recodified from 10 NCAC 26B .0123 Eff. January 1, 1998;

Amended Eff. August 1, 1998;

Transferred from 10A NCAC 22O .0123 Eff. May 1, 2012.