23 Miss. Code. R. 222-2.2

Current through December 10, 2024

Rule 23-222-2.2 - Covered Services

A. A medical risk screen must be conducted to determine the need to refer an individual for Targeted Case Management (TCM) services. Referrals for TCM services must be initiated during the pregnancy for the woman, or birth through one (1) year of age for the infant. The medical risk screen must:

1. Be completed by a physician, physician assistant, a nurse practitioner, or certified nurse-midwife,

2. Only be conducted once per pregnancy unless the beneficiary changes providers and the new provider is unable to obtain the beneficiary's medical records, and

3. Be completed up to two (2) times for infants, if risk factors are present.

B. Targeted Case Management is a collaborative process of assessment, care planning, care coordination, and evaluation of services to meet the identified needs of eligible women who are pregnant and up to sixty (60) days postpartum or infants from birth through (1) year of age. TCM activities include:

1. An initial comprehensive assessment that is beyond risk screening must be conducted to determine the specific needs of the participant and identify which, if any, referrals for extended or other services are needed. The initial comprehensive assessment must, at a minimum:

a) Be performed by the RN case manager,

b) Be completed within fifteen (15) calendar days after the referral is received for TCM, and

c) Be maintained in the participant's case record.

2. A Plan of Care (POC) must be developed and periodically updated which, at a minimum:

a) Reflects the specific needs identified through applicable assessments,

b) Establishes specific goals (long and short-term),

c) Includes interventions to address the participant's goals and meet the identified needs,

d) Must be action oriented with identifiable outcomes that are measurable and achievable within a manageable time frame,

e) Must be updated timely to reflect changes in the participant's needs or status,

f) Identifies each interdisciplinary team member's responsibilities in addressing identified needs, and

g) Provides a personalized discharge plan that, at a minimum, identifies all goals or needs that extend beyond case closure. Processes must be in place to coordinate appropriate linkages and services prior to case closure. Discharge planning must be documented in the case file.

3. Care Coordination includes regular communication, information-sharing, and collaboration between case management and others serving the participant, within a single agency or among several community-based agencies. All care coordination activities must be recorded in the case file and must, at a minimum include:

a) Regular communication with the participant, participant's family or authorized representative, provider(s), and the interdisciplinary team,

b) Coordinating access to services and benefits, reducing barriers, and establishing linkages with other services providers,

c) Referrals and related activities including, but not limited to, scheduling appointments to help the participant obtain needed services and linking the participant with medical, social, educational, or other program(s) or resource(s) that are capable of providing needed services to address identified needs and achieve goals specified in the POC,

d) Revising the POC to reflect the changes in the needs or status of the participant,

e) Processes for participant transfer to a new TCM provider, if chosen, and

f) Making appropriate referrals as needed and upon case closure to ensure continuation of care.

4. Monitoring and follow-up activities include activities and contacts that are necessary to ensure the POC is implemented and adequately addresses the participant's needs. Activities may be with the participant, the participant's personal or authorized representative, or the participant's service provider and must be conducted at least monthly and more often as necessary. Monitoring and follow-up activities include, but are not limited to:

a) Monthly face-to-face contact with the participant,

b) Monthly case conference with the interdisciplinary team,

c) Initial contact with the participant's primary care provider(s) upon enrollment into the program and continued communication with the primary care provider(s) if the participant's condition or status changes,

d) Routine review and follow-up of case notes from all service providers, and

e) Review and revision of the POC routinely and as needed.

C. Extended services for eligible participants who are pregnant and up to sixty (60) days postpartum or infants from birth through one (1) year of age are based upon the specific needs identified on the initial comprehensive assessment.

1. Appropriate referral(s) for extended services must be initiated by the case manager.

2. Any extended service(s) being provided must be included in the POC and evaluated by the case manager at least monthly. Extended services include:

a) Initial nursing assessment and evaluation performed by a registered nurse (RN) within ten (10) business days from referral,

b) Nursing services performed by an RN which must include health education,

c) Home visit for postpartum assessment and follow-up performed by an RN,

d) Nutritional assessment and counseling performed by a registered dietician or licensed nutritionist within ten (10) business days from referral,

e) Nutritional counseling and dietician visit performed by a registered dietician or licensed nutritionist,

f) Mental health assessment performed by a non-physician practitioner within ten (10) business days from referral, and

g) Behavioral health prevention education services performed by a mental health professional.

23 Miss. Code. R. 222-2.2

Miss. Code Ann. §§ 43-13-121, 43-13-117(19)(a); 42 CFR § 440.169.

Amended 7/1/2024