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The Pennsylvania Code website reflects the Pennsylvania Code changes effective through 54 Pa.B. 488 (January 27, 2024).

55 Pa. Code § 5221.42. Payment.

§ 5221.42. Payment.

 (a)  When conditions of this chapter are met and a county plan is approved by the Department, intensive case management paid from county mental health allocations is eligible for 100% State financial participation.

 (b)  If intensive case management is provided to an adult or child eligible for Medical Assistance coverage and the service qualifies for Federal financial participation, the provider shall bill the Medical Assistance Program in accordance with procedures established by the Department under Chapter 1101 (relating to general provisions).

 (c)  The non-Federal portion of the fee shall be met using the State portion of program funds as provided for under this chapter.

 (d)  No eligible adult or child may be denied needed intensive case management merely because the adult or child is ineligible for Federally-reimbursed services. In these circumstances, 100% State funds may be used to provide payment for the necessary service.

 (e)  Provider staff meetings, recordkeeping activities and other nondirect services are not billable as intensive case management.

 (f)  The unit of service for billing purposes shall be 1/4 hour of service or portion thereof in which the intensive case manager or intensive case manager supervisor is in face-to-face or telephone contact with the consumer, the consumer’s family or friends, service providers or other essential persons for the purpose of assisting the consumer in meeting his needs.

   (1)  Staff time spent in necessary travel may be billed as units of services.

   (2)  When one or more intensive case management staff persons, acting together, make service contact with or for one or more consumers or family members, if the consumer is a child, during a 1/4-hour period, the maximum number of units that may be billed shall equal the number of staff persons involved or the number of cases being served, whichever is smaller.

 (g)  A fee-for service payment methodology as established in §  1150.62 (relating to payment levels) shall be used to reimburse intensive case management.

 (h)  The Department will participate in 100% of the approved expenditures for the following components of intensive case management provided under this chapter:

   (1)  Assessment and understanding of the consumer’s history and present life situation; service planning, based on the consumer’s strengths and desires, to include activities necessary to enable the consumer to function as an integral part of the community.

   (2)  Informal support network building.

   (3)  Use of community resources, to include assistance to consumers or the consumers’ parents, if the consumer is a child, in identifying, accessing and learning to use community resources.

   (4)  Linking with resources.

   (5)  Monitoring of service delivery.

   (6)  Aggressive and creative attempts to help the consumer gain access to resources and required services identified in the treatment plan.

   (7)  Life support and problem resolution, to include direct, active efforts to assist the consumer in gaining access to needed services and entitlements.

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