Section 686.910  Case Management Provider Responsibilities

a)         Case Management

1)         The case management agency (hereafter referred to as provider) shall receive customer referrals from hospitals, the Illinois Department of Public Health's AIDS Hotline, HSP AIDS Unit, other State and local agencies, and other referral services (e.g., doctors and individuals).  The provider shall assign a case manager to each customer.

2)         The case manager shall have full responsibility for the determination of eligibility, including assessment, development of plans of care, and arrangement and implementation of services to be provided.  There shall be two levels of case managers: provisional case managers and case managers.  Provisional case managers are those who have not achieved a competency score of 98% or greater for the on-site case reviews done by the HSP AIDS unit, per Section 686.930(d).  Assessments, service plans and reassessments completed by case managers may be implemented without consultation with the HSP AIDS Unit.  Provisional case managers shall submit all developed plans to the HSP AIDS Unit for approval.  Approval of the plan will be based on a review to determine that:  the Determination of Need Assessment on which the plan is developed is complete and accurate; the plan meets the needs identified by the assessment; the plan does not place the customer's health and safety at risk; the plan is cost effective compared to comparable institutional care; and the plan has been approved by the customer's physician.

3)         The case manager shall have the option of using a Registered Nurse to review and advise the case manager on the health aspects of the assessment and reassessment and to act as a liaison with hospital discharge planner, physician, home health agencies and other medical provider agencies.

b)         The case manager shall provide the following services:

1)         initial assessment of eligibility and information gathering (89 Ill. Adm. Code 682);

2)         development of a care plan and implementation (89 Ill. Adm. Code 684);

3)         reassessment of level of care at least every six months for those cases in formal eligibility, three months for those cases that have been presumptively determined eligible for interim services (89 Ill. Adm. Code 684.80), or at such time when the customer's financial or physical condition or need for services changes;

4)         networking/coordination/brokering services (i.e., referring and assisting the customer in obtaining other agencies' services);

5)         assisting the customer when personal assistance problems develop. Documentation of these problems and the case management team's responses will be kept in the customer's case file;

6)         counseling and advocacy;

7)         acting as inter-agency liaison (e.g., with other DHS programs, vendors, hospitals);

8)         contacting customer a minimum of three times per month, one contact being a face-to-face visit;

9)         maintaining and updating customer records; and

10)         monitoring the cost effectiveness of the service plan (89 Ill. Adm. Code 679.50).

c)         Eligibility for AIDS Waiver

1)         Within 10 working days (exceptions being 2 working days for prescreening referrals from cooperating hospitals for interim/emergency services, 5 working days for all other prescreening for interim/emergency services) after receipt of a referral, the case manager shall complete an individual's eligibility determination for the AIDS Waiver program.

2)         The case manager shall determine customer eligibility for the AIDS Waiver by completing an assessment from a home visit or while the applicant is hospitalized (89 Ill. Adm. Code 682).  To determine customer eligibility, the case manager will utilize the HSP Determination of Need Assessment (89 Ill. Adm. Code 682).

3)         The case manager shall assess the customer's limitations in activities of daily living (ADLs) (e.g., cooking, bathing, shopping) and what resources are available to assist the customer in performing the ADLs (89 Ill. Adm. Code 682).

4)         Notice of eligibility must be mailed to the HSP AIDS Unit within ten working days after the date on which a completed application is received by the case management contracting agency.

d)         The case manager will provide a case action notice to each customer informing him or her of the eligibility determination, of all rights and responsibilities under the case management program, including the customer's right to request an appeal, the appeals procedures promulgated by the Department, the right to receive assistance in filing the request for appeal and information about the services of the Client Assistance Program (CAP) and how to reach CAP.

e)         Service Plan

1)         If the assessment demonstrates the need for intermediate care facility (ICF), skilled nursing facility (SNF), or hospital care because of the disability of AIDS/HIV, the case manager shall develop a service plan that will allow the customer to live at home (89 Ill. Adm. Code 684.70).

2)         The service plan will be retained during the time the case is opened and for five years after closure, unless an audit exception has occurred.  In the case of an audit exception, the service plan will be retained until the audit exception has been resolved.  Copies of the service plan will be maintained in the case management team's locations and the HSP AIDS Unit.  Closed cases will be retained in the HSP Central Office.

3)         The service plan shall be approved by the customer's physician.  If the plan is not approved by the customer's physician, it cannot be implemented and the customer cannot be served under the AIDS Waiver.

4)         If implementation of services is delayed beyond required time limits in subsection (c) of this Section, the case manager must inform the HSP AIDS Unit and assist the customer to obtain an alternative provider.

f)         Records of contact with the customer will be entered and maintained in the customer's confidential case records.  All contacts, verbal or written, with or on behalf of a customer shall be documented in a confidential case record.  The case manager is responsible for obtaining consents for the release of information as necessary and when required by law or regulation (Confidentiality of Records in 42 USC 290dd-2, the AIDS Confidentiality Act [410 ILCS 305]; 89 Ill. Adm. Code 505, Confidentiality of Information); and the Health Insurance Portability and Accountability Act (42 USC 1320(d) et seq.).

(Source:  Amended at 28 Ill. Reg. 6453, effective April 8, 2004)