(A) The Ohio resilience through
integrated systems and excellence (OhioRISE) plan will assign a care
coordination tier for all youth eligible for enrollment in the OhioRISE plan.
Tier assignment of limited, moderate, or intensive is based on assessed or
indicated needs and may be modified to be based on individual circumstances or
to best fit the youth or family capacity and choice.
(1) Moderate care
coordination (MCC) is recommended for youth six years of age and older when
paragraph (A)(1)(a) and either paragraph (A)(1)(b) or (A)(1)(c) of this rule
are met:
(a) An Ohio children's initiative child and adolescent
needs and strengths (CANS) assessment, the tool available on
https://www.medicaid.ohio.gov (September 20, 2021), indicates for
behavioral/emotional needs domain items, at least one of the following items is
dangerous or disabling and needs immediate action or two or more of the
following items are at least interfering with functioning and need action to
ensure that the identified need is addressed:
(i) Psychosis;
(ii) Impulsivity/hyperactivity;
(iii) Depression;
(iv) Anxiety;
(v) Oppositional
behavior;
(vi) Conduct;
(vii) Adjustment to
trauma;
(viii) Anger
control;
(ix) Substance
use;
(x) Eating
disturbance;
(xi) Interpersonal
problems (for youth age fourteen and older);
(b) For risk behavior domain items, at least one of the
following items is dangerous or disabling and needs immediate action or two or
more of the following items are interfering with functioning and need action to
ensure that the identified behavior is addressed:
(i) Suicide
risk;
(ii) Non-suicidal
self-injury behavior;
(iii) Other
self-harm;
(iv) Danger to
others;
(v) Delinquent
behavior;
(vi) Runaway;
(vii) Intentional
misbehavior;
(viii) Fire
setting;
(ix) Victimization/exploitation;
(x) Sexually problematic
behavior;
(c) For life functioning domain items, at least two of the
following items are dangerous or disabling and needs immediate action or three
or more of the following items are at least interfering with functioning and
need action to ensure that the identified need is addressed:
(i) For the Ohio children's initiative brief CANS
assessment:
(a) Family functioning;
(b) Living situation;
(c) Social functioning;
(d) Developmental/intellectual;
(e) Legal;
(f) Medical/physical;
(g) Sleep;
(h) Decision making;
(i) School.
(ii) For the Ohio children's initiative comprehensive
CANS assessment:
(a) Family functioning;
(b) Living situation;
(c) Social functioning;
(d) Developmental/intellectual;
(e) Legal;
(f) Medical/physical;
(g) Sleep;
(h) Decision making;
(i) School attendance or school behavior.
(2) Intensive care
coordination (ICC) is recommended for youth six years of age and older
when:
(a) Criteria for MCC are met as described in paragraph
(A)(1) of this rule; and
(b) An Ohio children's initiative CANS assessment, the
tool available on https://www.medicaid.ohio.gov (September 20, 2021), indicates
for caregiver resources and needs domain items, at least one of the following
items prevents the provision of care and needs immediate action or two or more
of the following items are interfering with the provision of care and need
action to ensure that the identified need is addressed:
(i) Supervision;
(ii) Knowledge;
(iii) Residential
stability;
(iv) Medical/
physical;
(v) Mental
health;
(vi) Substance
use;
(vii) Family
stress;
(3) MCC is recommended
for youth under six years of age when paragraphs (A)(3)(a), (A)(3)(b), and
either paragraph (A)(3)(c) or (A)(3)(d) of this rule are met.
(a) An Ohio children's initiative CANS assessment, the
tool available on https://www.medicaid.ohio.gov (September 20, 2021), indicates
for early childhood domain items, at least one of the following items is
dangerous or disabling and needs immediate action or two or more of the
following items are at least interfering with functioning and need action to
ensure that the identified behavior is addressed:
(i) Impulsivity/hyperactivity;
(ii) Depression;
(iii) Anxiety;
(iv) Oppositional
behavior;
(v) Adjustment to
trauma;
(vi) Regulatory;
(b) For caregiver resources and needs domain items, at
least one of the following items prevents the provision of care and needs
immediate or intensive action or at least one of the following items is
interfering with the provision of care and action is needed to ensure that the
identified need is addressed:
(i) Supervision;
(ii) Residential
stability;
(iii) Medical/physical;
(iv) Mental
health;
(v) Substance
use;
(vi) Developmental;
(vii) Family
stress;
(viii) Caregiver
post-traumatic stress reaction;
(ix) Marital/partner
violence;
(x) Family relationship
with the system;
(xi) Legal
involvement;
(xii) Early childhood
domain item developmental/intellectual;
(c) For early childhood domain items, at least one of the
following items is dangerous or disabling and needs immediate action or at two
or more of the following items are at least interfering with functioning and
need action to ensure that the identified need is addressed:
(i) Sleep;
(ii) Family
functioning;
(iii) Early
education;
(iv) Social and emotional
functioning;
(v) Medical/physical;
(vi) Failure to
thrive;
(d) For early childhood domain items, at least one of the
following items is dangerous or disabling and needs immediate action or at
least one of the following items is interfering with functioning and needs
action to ensure that the identified need is addressed:
(i) Aggressive
behaviors;
(ii) Atypical
behaviors;
(iii) Self-harm;
(iv) Exploited;
(v) Problematic sexual
behavior.
(4) ICC is recommended
for youth under six years of age when paragraphs (A)(4)(a), (A)(4)(b) and
either paragraph (A)(4)(c) or (A)(4)(d) of this rule are met.
(a) An Ohio children's initiative CANS assessment, the
tool available on https://www.medicaid.ohio.gov (September 20, 2021) indicates
for early childhood domain items, at least one of the following items is
dangerous or disabling and needs immediate action or two or more of the
following items are at least interfering with functioning and need action to
ensure that the identified behavior is addressed:
(i) Impulsivity/hyperactivity;
(ii) Depression;
(iii)
Anxiety;
(iv) Oppositional
behavior;
(v) Adjustment to
trauma;
(vi) Regulatory;
(b) For caregiver resources and needs domain items, two or
more of the following items prevents the provision of care and needs immediate
or intensive action or three or more of the following items are at least
interfering with the provision of care and action is needed to ensure that the
identified need is addressed:
(i) Supervision;
(ii) Residential
stability;
(iii) Medical/physical;
(iv) Mental
health;
(v) Substance
use;
(vi) Developmental;
(vii) Family
stress;
(viii) Caregiver
post-traumatic stress reaction;
(ix) Marital/partner
violence;
(x) Family relationship
with the system;
(xi) Legal
involvement;
(xii) Early childhood
domain item developmental/intellectual;
(c) For early childhood domain items, at least one of the
following items is dangerous or disabling and needs immediate action or two or
more of the following items are at least interfering with functioning and need
action to ensure that the identified behavior is addressed:
(i) Sleep;
(ii) Family
functioning;
(iii) Early
education;
(iv) Social and emotional
functioning;
(v) Medical/physical;
(vi) Failure to
thrive;
(d) For early childhood domain items, at least one of the
following items is dangerous or disabling and needs immediate action or at
least one of the following items is interfering with functioning and needs
action to ensure that the identified need is addressed:
(i) Aggressive
behaviors;
(ii) Atypical
behaviors;
(iii) Self-harm;
(iv) Exploited;
(v) Problematic sexual
behavior.
(5) MCC or ICC may also
be recommended when the CANS assessment alone does not indicate MCC or ICC as
described in paragraphs (A)(1) through (A)(4) of this rule, but other
documentation supports the need for the frequency and intensity of MCC or ICC
activities. Other supporting documentation that provides clinical justification
may include a comprehensive assessment, psychological evaluation,
biopsychosocial assessment, or documentation illustrating a history of
unsuccessful past services.
(6) Limited care
coordination delivered by the OhioRISE plan is recommended when:
(a) The youth's
needs do not meet the ICC or MCC recommendations; or
(b) The youth meets
criteria for ICC or MCC but declines or does not consent to participate in ICC
or MCC.
(7) Denials of assignment
to ICC or MCC are subject to the appeal process described in rule 5160-26-08.4
of the Administrative Code.
(B) Care management entities
(CMEs).
(1) ICC and MCC are
delivered by care management entities (CMEs) designated by the OhioRISE plan.
(2) CMEs
will:
(a) Maintain an active, valid medicaid provider agreement
as defined and set forth in rule 5160-1-17.2 of the Administrative
Code;
(b) Comply with all applicable provider requirements set
forth in this rule;
(c) Participate in initial and ongoing training, coaching,
and supports from an independent validation entity recognized by the Ohio
department of medicaid (ODM) to ensure consistency in delivering care
coordination;
(d) Have documentation of completion of an initial
readiness review by an independent validation entity recognized by ODM prior to
providing ICC or MCC;
(e) Ensure that all child and family-centered care plans
(including initial plans, changes to plans, and transition plans) are submitted
to the OhioRISE plan for review and approval;
(f) Exchange electronic, bidirectional data and other
information regarding the youth and family receiving ICC and MCC with the
OhioRISE plan and the independent validation entity recognized by
ODM;
(g) Report incidents in accordance with rule 5160-44-05 of
the Administrative Code;
(h) Implement quality improvement activities related to the
CME's performance consistent with ODM's population health management
strategy;
(i) Provide all staff with training regarding cultural and
trauma-informed care competency within three months of the date of hire and
annually thereafter;
(j) Conduct virtual, in-person, or telephonic engagement to
the youth's family within two business days of receipt of referral to ICC
or MCC to explain the service and obtain consent;
(k) Have administrative and program staff, in sufficient
quantity to meet all the CME requirements to achieve the quality, performance,
and outcome measures set by ODM;
(l) Ensure care coordination staff and supervisors have the
experience necessary to manage complex cases and the ability to navigate state
and local child serving systems:
(m) Have sufficient care coordination staff to meet care
coordinator-to-youth ratio requirements described in this rule;
(n) Have supervisory personnel to provide coaching and
support for ICC and MCC care coordinators, not to exceed the supervisor ratio
described in this rule;
(o) Provide real-time or on demand clinical and psychiatric
consultation for youth engaged in ICC or MCC;
(p) Respond to the youth and family twenty-four hours a
day;
(q) Ensure youth and family choice is incorporated
regarding the services and supports they receive and from whom;
(r) Ensure that all care coordination services are provided
in a conflict-free manner, with particular attention to ensuring care
coordination services, functions, and staff are separated from the
organization's function and staff related to other services. If the CME
has multiple lines of business, the CME will establish firewalls between its
care coordination services and staff and the functions and staff of its other
services;
(s) Identify and inform the OhioRISE plan of unmet needs
and barriers to effective care and assist in developing community resources to
meet youth and families' needs; and
(t) Assist with required activities related to the OhioRISE
1915(b)/(c) waivers, including:
(i) Gather and submit
information to assist ODM in determining OhioRISE 1915(c) waiver
eligibility;
(ii) Assess the initial
and ongoing settings where youth will receive 1915(c) home and community-based
services for settings requirements using the review tool designated by ODM;
and
(iii) Help youth and
caregivers in determining the need for OhioRISE 1915(b)/(c) waiver
services.
(C) Care coordination
activities.
(1) CMEs delivering ICC
will:
(a) Provide structured service planning and care
coordination through high-fidelity wraparound as established by the national
wraparound initiative, found at https://nwi.pdx.edu (October 1, 2021),
including:
(i) Offering initial
face-to-face contact within two calendar days of conducting initial engagement
contact for ICC; and
(ii) Completing an
initial supplemental assessment with the youth that includes:
(a) Information from a new Ohio children's initiative
CANS assessment or existing Ohio children's initiative CANS assessment
that was completed within the ninety calendar days prior to the supplemental
assessment; and
(b) Other tools as determined necessary that inform and
result in the development of the child and family-centered care plan;
(iii) Completing an Ohio
children's initiative comprehensive CANS assessment with the youth if not
already completed;
(iv) Updating the Ohio
children's initiative CANS assessment at a minimum of every ninety
calendar days or whenever there is a significant change in the youth's
needs or circumstances;
(v) Convening and
facilitating the child and family team that will:
(a) Develop and implement the initial child and
family-centered care plan; and
(b) Review, and when appropriate, update, the child and
family-centered care plan every thirty calendar days, and whenever there is a
significant change in the youth's needs or circumstances. When a youth and
their caregiver is unable to participate in the review of the child and
family-centered care plan within thirty calendar days, the child and
family-centered care plan will be reviewed, and when appropriate, updated,
within sixty calendar days.
(c) For individuals enrolled in the OhioRISE 1915(c)
waiver;
(i) Develop and implement the initial child and
family-centered care plan within thirty calendar days of enrollment on the
OhioRISE 1915(c) waiver;
(ii) Review, and when appropriate, update, the child and
family-centered care plan at least every thirty calendar days. If there is a
significant change in the youth's needs or circumstances, the child and
family-centered care plan will be reviewed and updated within fourteen calendar
days of identifying a change in the youth's needs and
circumstances;
(iii) Develop the back-up waiver service plan, as described
in rule 5160-59-01 of the Administrative Code, to be included in the child and
family-centered care plan. The back-up waiver service plan should be updated
when the child and family-centered care plan is updated; and
(iv) Submit the child and family-centered care plan to the
OhioRISE plan within one business day of completion and signature from the
youth, caregiver, and OhioRISE waiver providers.
(vi) Developing an
individual crisis and safety plan as soon as possible. For youth with behaviors
that pose safety concerns for the youth or others, a licensed clinician working
within or for the CME will consult on the individual crisis and safety plan,
recommend de-escalation strategies that can be learned and used by the youth,
parents, other caregivers to support the youth and prevent the use of
restrictive interventions, and approve of the crisis and safety plan prior to
its submission to the OhioRISE plan;
(a) For youth following an established individual crisis
and safety plan previously created through another mechanism, the crisis and
safety plan created by another mechanism will be reviewed to ensure it contains
the required plan elements. If the plan includes required elements, it can be
used as a preliminary OhioRISE crisis and safety plan and be updated during a
child and family team meeting. If it does not meet the required plan elements,
a new individual crisis and safety plan will be developed as soon as
possible.
(b) For youth who are enrolled in the OhioRISE 1915(c)
waiver, the individual crisis and safety plan will need to be completed within
fourteen calendar days following enrollment in the OhioRISE 1915(c) waiver. The
individual crisis and safety plan will be reviewed, and when appropriate,
updated, at least every ninety calendar days.
(vii) Monitoring the
child and family-centered care plan to ensure that services are delivered in
accordance with the plan;
(viii) Performing
referrals and linkages to appropriate services and supports, including natural
supports, along the continuum of care;
(ix) Facilitating
discharge planning activities for youth admitted to a facility for behavioral
health treatment or inpatient behavioral health treatment; and
(x) Facilitating
transition planning and activities for youth exiting the OhioRISE program or
the OhioRISE 1915(c) waiver. For youth receiving ICC who are enrolled in the
OhioRISE 1915(c) waiver, transition planning will identify supports the youth
will need for the ninety calendar days following disenrollment from the
OhioRISE 1915(c) waiver.
(b) Have documentation of annual fidelity review,
monitoring, and adherence to high-fidelity wraparound by an independent
validation entity recognized by ODM. The fidelity review will assess for
consistent use of high-fidelity wraparound standards established by the
national wraparound initiative.
(c) Submit the child and family-centered care plan to the
OhioRISE plan upon completion.
(2) CMEs delivering MCC
will:
(a) Provide structured service planning and care
coordination based on wraparound principles, as established by the national
wraparound initiative, found at https://nwi.pdx.edu (October 1, 2021),
including;
(i) Offering an initial
face-to-face contact within seven calendar days of conducting initial
engagement contact for MCC; and
(ii) Completing an
initial supplemental assessment with the youth that includes:
(a) Information from a new Ohio children's initiative
CANS assessment or existing Ohio children's initiative CANS assessment
completed within the ninety calendar days prior to the supplemental assessment;
and
(b) Other tools as determined necessary that inform and
result in the development of the child and family-centered care
plan.
(iii) Completing an Ohio
children's initiative comprehensive CANS assessment with the youth if not
already completed;
(iv) Updating the Ohio
children's initiative CANS assessment at a minimum of every ninety
calendar days or whenever there is a significant change in the youth's
behavioral health needs or circumstances;
(v) Convening and
facilitating the child and family team that will:
(a) Develop and implement the initial child and
family-centered care plan; and
(b) Review, and when appropriate, update, the child and
family-centered care plan every sixty calendar days, and whenever there is a
significant change in the youth's needs or circumstances.
(c) For individuals enrolled in the OhioRISE 1915(c)
waiver;
(i) Develop and implement the initial child and
family-centered care plan within thirty days of enrollment on the OhioRISE
1915(c) waiver; and
(ii) Review, and when appropriate, update, the child and
family-centered care plan at least every thirty days. If there is a significant
change in the youth's needs or circumstances, the child and
family-centered care plan will be reviewed and updated within fourteen calendar
days of identifying a change in the youth's needs and circumstances;
and
(iii) Develop the back-up waiver service plan, as described
in rule 5160-59-01 of the Administrative Code, to be included in the child and
family-centered care plan. The back-up waiver service plan should be updated
when the child and family-centered care plan is updated; and
(iv) Submit the child and family-centered care plan to the
OhioRISE plan within one business day of completion and signature from the
youth, caregiver, and OhioRISE waiver providers.
(vi) Developing an
individual crisis and safety plan as soon as possible. For youth with behaviors
that pose safety concerns for the youth or others, a licensed clinician working
within or for the CME will consult on the individual crisis and safety plan,
recommend de-escalation strategies that can be learned and used by the youth,
parents, other caregivers to support the youth and prevent the use of
restrictive interventions, and approve of the crisis and safety plan prior to
its submission to the OhioRISE plan;
(a) For youth following an established individual crisis
and safety plan previously created through another mechanism, the crisis and
safety plan created by another mechanism will be reviewed to ensure it contains
the required plan elements. If the plan includes required elements, it will be
used as a preliminary OhioRISE crisis and safety plan and be updated during a
child and family team meeting. If it does not meet the required plan elements,
a new individual crisis and safety plan will be developed as soon as
possible.
(b) For youth who are enrolled in the OhioRISE 1915(c)
waiver, the individual crisis and safety plan needs to be completed within
fourteen calendar days following enrollment in the OhioRISE 1915(c) waiver. The
individual crisis and safety plan will be reviewed, and when appropriate,
updated, at least every ninety calendar days.
(vii) Monitoring the
child and family-centered care plan to ensure that services are delivered in
accordance with the plan;
(viii) Performing
referrals and linkages to appropriate services and supports, including natural
supports, along the continuum of care;
(ix) Facilitating
discharge planning activities for youth admitted to a facility for behavioral
health treatment or inpatient behavioral health treatment; and
(x) Facilitating
transition planning and activities for youth exiting the OhioRISE program or
the OhioRISE 1915(c) waiver. For youth receiving MCC who are enrolled in the
OhioRISE 1915(c) waiver, transition planning will identify supports the youth
will need for the ninety calendar days following disenrollment from the
OhioRISE 1915(c) waiver.
(b) Have documentation of annual fidelity review,
monitoring, and adherence to MCC by an independent validation entity recognized
by ODM. The fidelity review will assess for consistent application of system of
care principles adherence to the MCC planning process and service
components.
(c) Submit the child and family-centered care plan to the
OhioRISE plan upon completion.
(D) CME care coordinator
qualifications.
(1) An ICC or MCC care
coordinator will be a licensed or an unlicensed practitioner in accordance with
rule 5160-27-01 of the Administrative Code, except that an ICC or MCC care
coordinator will be employed by or under contract with a CME as described in
this rule.
(2) ICC and MCC care
coordinators will complete the high-fidelity wraparound training program
provided by an independent validation entity recognized by ODM. Care
coordinators will successfully complete initial skill and competency-based
training to provide ICC and MCC.
(3) ICC and MCC care
coordinators will:
(a) Have experience providing community-based services and
supports to children and youth and their families or caregivers in areas of
children's behavioral health, child welfare, intellectual and
developmental disabilities, juvenile justice, or a related public sector human
services or behavioral health care field for:
(i) Three years with a
high school diploma or equivalent; or
(ii) Two years with an
associate's degree or bachelor's degree; or
(iii) One year with a
master's degree or higher; or
(iv) With ODM or its
designee approval, partially meets years of experience in paragraph
(D)(3)(a)(i), (D)(3)(a)(ii), or (D)(3)(a)(iii) of this rule and meets the
following until experience requirements are met:
(a) Demonstrates specific skills and competencies needed
for the care coordination activities described in paragraph (C) of this rule;
and
(b) Receives additional supervision to monitor skills and
competencies to ensure effective care coordination; and
(c) Receives additional quarterly training to improve
skills and competencies to ensure effective care coordination.
(b) Have a background and experience in one or more of the
following areas of expertise:
(i) Family
systems;
(ii) Community systems
and resources;
(iii) Case
management;
(iv) Child and family
counseling or therapy;
(v) Child protection;
or
(vi) Child
development.
(c) Be culturally competent or responsive with training and
experience necessary to manage complex cases; and
(d) Have the qualifications and experience needed to work
with children and families who are experiencing serious emotional disturbance
(SED), trauma, co-occurring behavioral health disorders and who are engaged
with one or more child-serving systems (e.g., child welfare, intellectual and
developmental disabilities, juvenile justice, education).
(E) CME care coordinator supervisory
qualifications.
(1) A supervisor of ICC
or MCC will meet CME care coordinator qualifications described in paragraph
(D), with exception of (D)(3)(a)(iv), of this rule.
(2) A supervisor that is
an unlicensed practitioner will have regular supervision with a licensed
practitioner and real-time access to a psychiatrist for case
consultation.
(3) Supervisors of ICC or
MCC will complete the high-fidelity wraparound training program provided by an
independent validation entity recognized by ODM. Supervisors will successfully
complete skill and competency-based training to supervise delivery of ICC and
MCC.
(F) ICC and MCC staffing
requirements.
(1) ICC will be
facilitated by a care coordinator with a ratio of one full-time care
coordinator to no more than ten OhioRISE youth receiving ICC.
(2) MCC will be
facilitated by a care coordinator with a ratio of one full-time care
coordinator to no more than twenty OhioRISE youth receiving MCC.
(3) Supervisory staffing
ratios will not exceed one supervisor to eight care coordinators.
(G) Care coordination documentation will
include:
(1) Care coordination
activities set forth in paragraphs (C)(1) and (C)(2) of this rule will be
identified on claims submitted in accordance with rule 5160-26-05.1 of the
Administrative Code;
(2) Progress notes to
document the care coordination activities described in this rule, including
face-to-face and telehealth meetings with the youth and the youth's family
or collateral contacts;
(3) An individual crisis
and safety plan for each youth receiving ICC or MCC;
(4) A back-up plan for
each youth receiving ICC or MCC who is enrolled in the OhioRISE 1915(c)
waiver;
(5) Assessments and child
and family-centered care plans, including specifications for standard
assessment and plan elements in CME's electronic health records;
and
(6) Upon transition of a
youth from ICC or MCC to a different care coordination tier, the CME will
document the circumstances regarding transition.
(H) Transition from ICC or
MCC.
(1) A youth or the
youth's guardian may request to transition out of ICC or MCC at their
discretion. The CME will notify the OhioRISE plan of the transition
request.
(2) The CME or OhioRISE
plan may pursue transition of a youth to other care coordination tiers when a
CANS assessment or the child and family-centered care plan indicates that the
youth's needs are no longer appropriate for the current tier.
(I) Limitations.
(1) The following
activities are not reimbursable as ICC or MCC:
(a) Transportation for the youth or family;
and
(b) Direct services to which the youth has been referred
such as medical, behavioral, educational, or social services.
(2) Reimbursement for
substance use disorder targeted case management is not allowable when a youth
is enrolled in ICC or MCC.
(J) Reimbursement for MCC and ICC
services as described in the rule is listed in Appendix A of this
rule.
(K) Reimbursement for a CANS assessment
is listed in the Appendix to rule 5160-27-03 of the Administrative
Code.
(L) Care coordination activities
described in paragraph (C) of this rule may be provided via telehealth in
accordance with rule 5160-1-18 of the Administrative Code.
(M) When a youth's OhioRISE
eligibility is added for a month that has already passed, the established
timeframes for CME activities in paragraph (B) of this rule and care
coordination activities in paragraph (C) of this rule will be based on the date
the CME receives the referral for care coordination of the youth from the
OhioRISE plan.
