1915(i) Care Coordination Services
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Governance of care coordination services for 1915(i) Medicaid Expansion members, defining responsibilities of care coordinators and care coordination agencies and who is covered by the policy.
No material clinical or coverage changes in this revision.
Coverage criteria and service rules
Coverage criteria and service requirements
Covered care coordination services and operational service requirements. Services are provided when documented in the person-centered Plan of Care (POC) in Therap and delivered according to the standards below.
See Comprehensive Assessment and Reassessment Activities.
Alternate templates are not permitted; use Therap POC template and obtain meeting signatures and Members Rights and Responsibilities form.
Onboarding process and meeting attendee signatures required.
Initial stabilization timeline: submit crisis plan within 30 days; update POC at 60 days.
Quarterly service delivery and monthly monitoring required for continued eligibility.
Link action items from the Individual Plan Agenda into the updated POC.
POC must be submitted in Therap and approved by 1915(i) staff prior to services being rendered.
Use Therap for documentation; follow Documentation Guidelines.
See billing guidance for multidisciplinary meetings and documentation rules.
Goals link to assessed needs and POC progress documentation.
1915(i) Care Coordination Coverage Criteria
Operational coverage and service-delivery criteria for 1915(i) care coordination services.
If referrals are not yet accepted, list TBD in provider name field when submitting.
See Limits.
Coverage criteria and duplication rules
Coverage stance, non-covered items, and rules for duplication between 1915(i) services and other programs/waivers.
Case managers coordinate among themselves to determine billing.
Services to check for duplication under IDEA include Supported Education, Supported Employment and Prevocational Services.
Duplication and documentation criteria
Requirements when other federal programs provide similar supports and the documentation/coordination actions care coordinators must take.
Billing codes, service limits, and frequency
| No codes listed |
| Eight hours (32 units) per day | Service daily maximum |
| H2015 | Care Coordination (per 15 minutes) |
| Supported Employment Age 21+ | Supported Employment under 1915(i) available for members age 21 and over |
| DD Waiver - Age 21+ | Individuals with Intellectual Disabilities and Developmental Disabilities (DD) Waiver employment services for Age 21+ |
| HCBS Waiver - Age 21+ | Home and Community-Based Services (HCBS) Waiver employment services for Age 21+ |
Provider responsibilities, workflows, and documentation
Only 1915(i) care coordinator may bill meeting time
If other service providers or case managers attend a care coordination meeting, only the 1915(i) care coordinator may bill Medicaid Expansion for the meeting time.
Assignment when only one willing/qualified agency exists
Members may be assigned to a care coordination agency when there is only one care coordination agency in the member's county that is willing and qualified to provide care coordination.
Submit POC in Therap and follow Therap referral workflow
Plans of Care (POCs) must be submitted in Therap and approved by 1915(i) staff prior to services being rendered; referrals to supportive service providers are sent via Therap (Therap referral or SComm) and lack of provider response after two full business days may be treated as a denial if documented (save SComm).
- Submit POC in Therap after accepting referrals; use 'TBD' in provider field if referral not yet accepted (POC approval by 1915(i) staff is required before services).
- Send referrals through Therap or SComm with release of information and a copy of the POC; if no response after two full business days, save SComm and document as proof of denial.
- Accepting provider must initiate services within five business days of the Anticipated Admissions Date or it will be considered a denial; provider case note is proof of service.
Initiate exceed-limit requests via care coordinator for Medicaid review
Requests to exceed authorized service limits to prevent imminent institutionalization, hospitalization, or out-of-home/out-of-community placement must be initiated with the care coordinator and will be reviewed by Medicaid Expansion.
- Care coordinator initiates the authorization request to exceed maximum limits.
- Medicaid Expansion staff will review requests deemed necessary to prevent imminent institutionalization, hospitalization, or out-of-home placement.
Create POCs in Therap and document meetings via Care Coordination Case Note
Plans of Care must be created in the Therap system; beginning Jan. 6, 2025, care coordinator meetings not documented in POCs or individual plan agendas must be entered using the Care Coordination Case Note in Therap.
- Use the required Therap POC template to document Plans of Care.
- Enter meetings not captured in the POC/individual plan agenda via Care Coordination Case Note in Therap starting 1/6/2025.
- Refer to the Provider Requirements 'Documentation Guidelines' for Medicaid documentation standards and DHHS documentation resources.
Coordinate with IEP team and document IDEA duplication justification
Before adding any services to a 1915(i) POC for a student, the care coordinator must coordinate with the student's IEP team and document justification that the services are not otherwise available through the student's IEP (per 42 CFR 441.720(a)(7)).
- Document justification in the member's record and retain on file prior to entering services on the 1915(i) POC.
- Check for duplication for Supported Education, Supported Employment, and Prevocational Services.
Coordinate with Vocational Rehabilitation and document Rehabilitation Act justification
The 1915(i) care coordinator must coordinate with the Vocational Rehabilitation Agency and document justification that services are not available under Section 110 of the Rehabilitation Act before providing potentially duplicative 1915(i) services.
- Document justification in the member's record and keep on file prior to providing duplicative services.
- Check duplication for Benefits Planning, Supported Employment, and Prevocational services.
Supported Employment available for members age 21+
Supported Employment is available under the 1915(i) State Plan Amendment for members age 21 and over; related North Dakota 1915(c) waivers also offer employment services for age 21+.
- Supported Employment under 1915(i): Age 21+.
- Related 1915(c) waivers offering employment services include DD Waiver and HCBS Waiver (Age 21+).
Definitions, eligibility, and provider qualifications
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