Medicaid, IEPs and the right to case management services

What is Case Management Here's how the federal regulators of Medicaid recently (June 30, 2009) described case management services for an individual with disabilities:

we recognize the advantages of a team approach to case management services. For example, a lead case manager could coordinate resources and expertise from providers of medical, education, social, or other services for the benefit of the individual in developing a comprehensive plan of care and facilitating access to services. To facilitate this service model, States may set differential rates to reflect case or task complexity that would ensure sufficient payment to reflect the costs that case managers may incur in consulting with other practitioners.

For the parents and caregivers of people with special health care needs, dealing with all the different local, state and federal bureaucrats can be "the death of a thousand cuts." This definition entitles the people we're caring for to an individual (or maybe two) whose job it is to coordinate with all the different government departments -- Medicaid, EPSDT, Department of Education, Department of Health, Department of Human Services, Vocational Rehab -- plus the individual's doctors, therapists and service providers. Who is entitled to case management under Medicaid? Case management is a federally required minimum service to be offered by every state's Medicaid program for children under the age of 21 (EPSDT) (42 U.S.C. 1397jj). Case management is also required for adults and children with special health care needs who are participants in a Medicaid waiver program authorized under Section 1915(b) or 1915(c) of the Social Security Act (see 1915(c)(4)(B) and 1915(b)(1). In Hawaii, this would cover everyone who is still enrolled in the state's DDMR waiver program. And at least in the state of Hawaii, case management is a requirement for all 37,000 aged, blind and disabled individuals who are participants in the state's new Section 1115 QExA managed care program (see Chaper VI, section 28(c)(ii) of the document authorizing the creation of the QExA program). How to obtain case management services A 2004 government pamphlet aimed at explaining to parents how to use EPSDT includes instructions on how to obtain medically necessary items and services directly from your Medicaid provider. The process of obtaining individualized case management services should be as simple as giving your Medicaid provider a letter of medical necessity written by a physician or other appropriate medical or educational professional, and a doctor's prescription for the services. If you live in a state that adheres to federal Medicaid law, that should be it. If you live in a state that does not adhere to federal Medicaid law, or worse, has for-profit insurance companies interpreting federal laws, the process can be full of stress, frustration and never-ending delays. Case Management and your child's IEP Federal law requires "Medicaid to be primary to the Department of Education for payment of the health-related services provided under IDEA." More recently, the federal office that regulates Medicaid published the following in the Federal Register on June 30 2009:

Medicaid reimbursement remains available for targeted case management services and other covered services, which are included in an eligible child’s Individualized Education Program (IEP) or Individualized Family Service Plan, consistent with section 1903(c) of the [Social Security] Act.

A handbook published by CMS in May 2003, and re-ratified by the June 30 ruling, includes a list of services that are the responsibility of the case manager of a child under the age of 21. Some of these include:

1. Making referrals for and/or coordinating medical or physical examinations and necessary medical/dental/mental health evaluations.
2. Making referrals for and/or scheduling EPSDT screens, interperiodic screens, and appropriate immunization, but NOT to include the state-mandated health services.
3. Referring students for necessary medical health, mental health, or substance abuse services covered by Medicaid.
4. Arranging for any Medicaid covered medical/dental/mental health diagnostic or treatment services that may be required as the result of a specifically identified medical/dental/mental health condition.
5. Gathering any information that may be required in advance of medical/dental/mental health referrals.
6. Participating in a meeting/discussion to coordinate or review a student’s needs for health-related services covered by Medicaid.
7. Providing follow-up contact to ensure that a child has received the prescribed medical/dental/mental health services covered by Medicaid.
8. Coordinating the delivery of community based medical/dental/mental health services for a child with special/severe health care needs.
9. Coordinating the completion of the prescribed services, termination of services, and the referral of the child to other Medicaid service providers as may be required to provide continuity of care.

A parent or caregiver can apply to their Medicaid provider directly for a case manager, and expect all these services to be provided for their child. These services could also be provided by the school, which will then bill Medicaid for the services, and for the administrative time spent arranging for them. In 1979, Jimmy Carter formed the first federal Department of Education. In the 14 months between then and the change of Administration in January 1981, the DOE published a blueprint for how schools and Medicaid should work together for the benefit of the student.

Coordination of all services -- outreach activities, screening programs, treatment, and follow-up services -- should be emphasized between school health and other health care providers, and social agencies in the community, to avoid duplicating efforts, increasing costs of services and adding further stress to the child and family. A means by which one care plan, if at all possible, can be used as a principle vehicle for monitoring the provision of services is a priority area for action... Schools should develop a plan ...[to] determine the extent to which health services are being provided, and the degree to which coordination of services between EPSDT and other programs is taking place.

For any child on Medicaid, the IEP should be a single document that incorporates all the services a child receives, whether from DOE, Medicaid, a Medicaid managed care company, or private organizations. And that IEP needs to include the case manager who will coordinate all the services being received. Who can NOT be the case manager? Federal law [42 CFR section 441.18(a)(6)] prohibits "providers of case management services from exercising the agency’s authority to authorize or deny the provision of other services under the plan." This means that the people at Medicaid who authorize and deny Medicaid services cannot also provide case management services. In Hawaii, for instance, UnitedHealth Group and WellCare Health Plans, which authorize and deny services for their Medicaid participants, cannot also provide the case management services for these participants. It would be a conflict of interest.