New Choices Waiver
Attachment B – Special Provisions
Case Management Services
Version July 1, 2016 Page 1 of 9
INTRODUCTION
The Home and Community-Based Services (HCBS) New Choices Waiver Program (NCW) is a Medicaid
sponsored program administered through the Utah Department of Health, Division of Medicaid and
Health Financing, Bureau of Authorization and Community-Based Services. The Waiver Program is
designed to offer the option to receive supportive services in a home and community-based setting for
qualifying people wishing to move out of nursing facilities, hospitals, and other Utah licensed medical
institutions that are not institutions for mental disease. NCW also offers a limited entry pathway for
qualifying people who have been residing in licensed assisted living facilities or licensed small health
care (Type N) facilities who wish to remain in that setting and enroll in the NCW program. (Special
application and selection of entrants processes apply to ALF and Type N residents.)
The NCW program offers an array of supportive services that are intended to be utilized in conjunction
with other paid and unpaid support systems and contributes to the health, safety and welfare of the
targeted population. Home and community-based services are an element of the Medicaid State Plan
and must operate in accordance with all established federal and state requirements for both HCBS
waivers and the overall Medicaid program.
New Choices Waiver services are one component of the complete Medicaid long term care service
delivery system. The roles of providers of HCBS waiver services must be clearly defined in order to
ensure waiver clients’ needs are identified and services are provided to support successful, integrated
community living.
SERVICE SPECIFICATIONS
NCW Service Name: Case Management Services
HCPCS Billing Code: T2024 (Pre-enrollment and during post-enrollment inpatient admissions)
T1016 (Post-enrollment)
Billing Modifier: U8
Provider qualifications:
All providers must initially and continuously employ at least 2 qualified case managers, one with
registered nurse (RN) licensure and one with social service worker (SSW) licensure or other
licensure that is at least equivalent to or higher than RN and SSW licensure. Providers shall hire
additional qualified case managers as their agency’s client caseload increases in order to meet
workload demands and to maintain quality standards. The State may consider exceptions to the
minimum RN and SSW standards in remote geographical areas of the state where access to care
issues would exist if not for the exception. These situations will be considered on a case by case
basis;
Must be accredited as a case management agency by the Bureau of Authorization and
Community-Based Services;
Must be a Medicaid provider enrolled to provide NCW Case Management Services; and
Non-governmental agencies must have a current business license; or
New Choices Waiver
Attachment B – Special Provisions
Case Management Services
Version July 1, 2016 Page 2 of 9
Must be recognized as a Division of Services for People with Disabilities Entity; or
Must be recognized as an Area Agency on Aging entity within the State of Utah; or
Must be recognized as a Center for Independent Living through the State Office of
Rehabilitation.
Service Description:
(This service description is subject to change. Refer to the New Choices Waiver Provider Manual for
updates. If this agreement is ever found to be in conflict with the New Choices Waiver Provider Manual,
the definition in the Provider Manual takes precedence.)
Case Management Services are services that assist waiver clients to gain access to needed waiver
services and other Medicaid State Plan services, as well as needed medical, social, educational, and
other services, regardless of the funding source. Case Management Services consists of the following
activities:
1. Complete initial comprehensive assessments and periodic reassessments to determine the
services and supports required by clients to prevent unnecessary institutionalization;
2. Perform reevaluations of clients’ level of care;
3. Complete initial comprehensive person-centered care plans and periodic updates to maximize
clients’ strengths while supporting and addressing the identified preferences, goals and needs;
4. Research the availability of non-Medicaid resources needed by clients to address needs
identified through the comprehensive assessment process to assist clients in gaining access to
these resources;
5. Assist clients to gain access to available Medicaid State Plan services necessary to address
identified needs;
6. Assist clients to select from available choices, an array of waiver services to address identified
needs and assist clients to select from the available choice of providers to deliver each of the
waiver services including assisting with locating an appropriate home and community-based
setting and assisting with negotiation of rental agreements when needed;
7. Assist clients to request a fair hearing if choice of waiver services or providers is denied, if
services are reduced, terminated or suspended, or if the client is involuntarily disenrolled;
8. Monitor to assure provision and quality of services identified in the client’s person-centered
care plan;
9. Support clients/legal representatives/family members to independently obtain access to
services when other funding sources are available;
10. Monitor on an ongoing basis the client’s health and safety status and investigate critical
incidents when they occur. The frequency of client contact is based on the case management
agency’s assessment of client need, but at a minimum at least 1 telephone or face-to-face
contact directly with the waiver client is required each month and a minimum of 1 face-to-face
contact with the client is required every 90 days. When meaningful telephone contact cannot
be achieved due to a client’s diminished mental capacity or inability to communicate by phone,
in-person contact must be made with the client monthly;
11. Coordinate across Medicaid programs to achieve a holistic approach to care;
New Choices Waiver
Attachment B – Special Provisions
Case Management Services
Version July 1, 2016 Page 3 of 9
12. Provide case management and transition planning services up to 180 days immediately prior to
the date an individual transitions to the waiver program;
13. Provide safe and orderly discharge planning services to a client disenrolling from the waiver;
14. Perform internal quality assurance activities, addressing all performance measures listed in the
approved state implementation plan; and
15. Monitor participant medication regimens.
Activities not included in the service description above and activities where meaningful case
management contact is not made are not reimbursable under case management services. Examples of
non-reimbursable activities include but are not limited to:
Transporting clients;
Directly assisting with packing and/or moving;
Performing personal budget assistance for clients;
Shopping or running errands for or with clients;
Taking clients on facility tours;
Taking clients to the Social Security office;
Providing emotional support;
Visits with clients, families or providers involving pleasantries/social interactions only;
Leaving or receiving voice mail messages; and
Any other activity that is not in line with the approved service description.
In order to facilitate transition, case management services may be furnished up to 180 days (6 months)
prior to a waiver client’s enrollment and case management providers may bill for these services once
the participant enters the waiver program. 15 units per month or less per client is the expected typical
case management utilization pattern. Care plans that include utilization patterns of 16 units or greater
will require submission of additional documentation to justify the need for additional case management
services.
Provider entities having the capacity to perform case management functions and other waiver or non-
waiver services must assure that the functions of the entity are clearly separated and their respective
responsibilities well defined. If the case management agency is listed on a comprehensive care plan as
the provider for other paid waiver or non-waiver services, the case management agency must document
that there are no other willing, qualified providers available to provide the other paid waiver or non-
waiver service(s). The State Medicaid Agency, New Choices Waiver Program Office will review these
situations on a case by case basis to determine whether or not to override the conflict of interest.
Case management agencies may not assign individual case managers to serve a waiver participant when
any one or more of the following scenarios exist:
1. The case manager is related to the waiver client by blood or by marriage;
2. The case manager is related to any of the waiver client’s paid caregivers by blood or by
marriage;
3. The case manager is financially responsible for the waiver client;
New Choices Waiver
Attachment B – Special Provisions
Case Management Services
Version July 1, 2016 Page 4 of 9
4. The case manager is empowered to make financial or health-related decisions on behalf of the
client; and/or
5. The case manager would benefit financially from the provision of direct care services included in
the client’s comprehensive care plan.
General Requirements:
By signing this attachment, provider agrees to additional terms and conditions as outlined below:
A. Provider will report any negative or critical incident or incidents likely to receive media or
legislative scrutiny involving a NCW client to the New Choices Waiver program office
immediately. This includes but is not limited to medication errors, falls, injuries, missing
persons, abuse, neglect, exploitation, unexpected hospitalizations, unexpected deaths, Adult
Protective Services (APS) or law enforcement involvement, and other similar incidents that raise
concern for client safety. As required by law, provider will also report any suspected or actual
incidences of abuse, neglect or exploitation to APS or to local law enforcement.
B. Provider will investigate Level 2 critical incidents and report findings timely to the State
Medicaid Agency, New Choices Waiver Program Office in accordance with the Critical Incident
Protocol.
C. Provider will accept the NCW Medicaid rate as payment in full, and the provider shall not bill the
client nor their families an additional fee for services rendered.
D. Provider will interact with each NCW client’s chosen waiver and non-waiver providers and will
invite them to participate in the person-centered care planning process when requested by the
client or their representative.
E. Provider will prepare and distribute Service Authorizations to all waiver services providers listed
on client care plans initially, annually and when care plans are updated.
F. Provider will notify a client’s previously authorized waiver providers when case managers
become aware that Service Authorizations have become nullified including for any of the
following events:
The NCW client elects to change to a different NCW provider;
The NCW client elects to altogether discontinue receiving the service(s) that the
provider offers;
The NCW client loses Medicaid eligibility; and/or
The NCW client is disenrolled from the NCW program for any other reason.
New Choices Waiver
Attachment B – Special Provisions
Case Management Services
Version July 1, 2016 Page 5 of 9
G. Provider will verify client Medicaid eligibility each month. Utah Medicaid offers two methods
that providers may use to verify client eligibility:
Medicaid Eligibility Lookup Tool (https://medicaid.utah.gov)
Access Now (1-800-662-9651 option 1, option 1)
H. Provider shall not bill Medicaid for services that were not actually provided or for services that
the provider anticipates providing to a client in the near or distant future.
I. Provider shall not bill a client for a missed or canceled appointment unless the client or the
client’s legal representative has signed a written cancelation policy which expressly allows the
provider to charge the client for missed or canceled appointments.
J. Provider will not engage in unsolicited direct marketing activities to prospective NCW clients.
Marketing strategies shall be limited to mass outreach and advertisements. Provider will not
approach prospective or currently enrolled NCW clients or their representatives unless the client
or representative explicitly requests information from the provider. Provider shall refrain from
offering incentives or other enticements or from otherwise persuading a prospective or
currently enrolled NCW client to choose or to transfer to the provider or to an individual case
worker for case management services. If a case manager leaves employment with one NCW
case management provider and becomes employed with another NCW case management
provider, that case manager shall not advise clients on their existing NCW caseload to switch to
the new case management agency in order to keep that case manager. Provider may not
require NCW clients to select a certain waiver or non-waiver provider for other services listed on
the person-centered care plan.
K. Upon accepting a client into case management services, provider will continue to provide case
management services and advocate for the client’s needs until the client is either disenrolled
from the New Choices Waiver program or until the client freely and without prompting or
coercion voices a preference to switch to a different case management agency. Provider shall
not discharge a client from case management services unless a volatile situation exists making
provision of case management services impossible due to a breakdown in the relationship
between the client and the case management agency. The New Choices Waiver Program Office
will review these situations on a case by case basis and must approve them prior to transfers
taking place.
L. Provider will document each service encounter. At a minimum each service encounter record
should include:
The client’s first and last name
The date of service for each service encounter
New Choices Waiver
Attachment B – Special Provisions
Case Management Services
Version July 1, 2016 Page 6 of 9
The start and end times for each service provided
The number of service units provided in service increments applicable to the service
The services provided by service title
Notes describing the service encounter
The printed name of the individual who performed the service
The credentials of the individual who performed the service
The signature of the individual(s) who performed the service
If the entry is not billable, please note “Not Billable to Medicaid”
M. Provider will abide by the policies and procedures outlined in the NCW Provider Manual and to
stay apprised of policy updates and changes regarding Medicaid and the NCW program. If this
agreement is ever found to be in conflict with the NCW Provider Manual, the NCW Provider
Manual will take precedence over this agreement. The NCW Provider Manual is posted on the
Utah Medicaid website: https://medicaid.utah.gov
N. Provider will review the Medicaid Information Bulletins (MIBs) and stay apprised of policy
updates and changes regarding Medicaid and the NCW program. The MIB is the tool that the
Utah Department of Health, Division of Medicaid and Health Financing uses to disseminate such
information to providers and stakeholders. The MIB is published quarterly or more frequently
as needed. To subscribe to the Newsletter or to view the MIB releases, visit the Medicaid
website: https://medicaid.utah.gov
O. If the provider has Medicare and/or Medicaid certification and loses Medicare and/or Medicaid
certification, the provider’s New Choices Waiver contract shall also be terminated effective the
same day as the termination of the Medicare and/or Medicaid certification. The provider will
notify the New Choices Waiver Program Office within 3 business days of receiving the
notification letter from Medicare and/or Medicaid. The provider will make every effort to
ensure a safe and orderly transition of all NCW clients to other service providers prior to final
termination of their NCW contract.
P. If the provider is aware that it is about to undergo a change of ownership or otherwise elects to
voluntarily terminate their New Choices Waiver contract, the provider shall give at least 30 days
advance written notice of the change of ownership or voluntary termination to the New Choices
Waiver Program Office. Providers shall assist in ensuring a safe and orderly transition of waiver
clients to another service provider prior to termination.
Q. The State Medicaid Agency may terminate the provider’s New Choices Waiver contract after
giving the provider 30 days advance written notice for either of the following reasons:
1. The State Medicaid Agency detects a pattern of non-compliance with general Utah
Medicaid provider standards,
New Choices Waiver
Attachment B – Special Provisions
Case Management Services
Version July 1, 2016 Page 7 of 9
2. The State Medicaid Agency detects a pattern of non-compliance with NCW policies,
procedures and/or provisions listed in this contract.
Examples of conduct that constitutes patterns of non-compliance include but are not limited to:
Abuse, neglect or exploitation of waiver clients;
Billing Medicaid in excess of the amount, duration and frequency of services that have
been authorized;
Billing Medicaid for services not provided;
Inadequate or non-existent record keeping;
Repeatedly tardy care plan submission;
Billing Medicaid for case management services provided by individuals that do not meet
the minimum qualifications of RN or SSW licensure (or equivalent or higher licensure);
Not maintaining minimum provider qualifications such as required business license or
certification;
Acts of direct marketing to prospective or currently enrolled NCW clients or their
representatives;
Acts of coercion or manipulation of client freedom of choice rights;
Acts of offering or receiving incentives or kick-backs to or from other providers or
entities in an effort to manipulate client freedom of choice rights;
Lack of adequate provider representation at the annual mandatory provider training;
and/or
Billing NCW clients or their representatives for services covered by Medicaid.
If the State Medicaid Agency discovers conduct that constitutes a pattern of non-compliance but
elects not to terminate the provider’s New Choices Waiver contract, the State Medicaid Agency
may instead suspend making new referrals to the provider, require the provider to repay any
overpayments, complete additional training and/or to submit to additional monitoring activities
in order to avoid contract termination. The provider will be given hearing rights for any adverse
actions taken by the State Medicaid Agency.
R. All new NCW case management agencies must complete the NCW New Case Management
Agency Training before the State Medicaid Agency, New Choices Waiver Program Office will
forward the provider’s enrollment application to the next step in the enrollment process. This
training is scheduled as needed. To arrange a training session please contact the NCW Program
Office and ask to speak with the NCW Training Coordinator. (800)662-9651, option 6.
After the provider is enrolled, additional training is available if the provider requests it by
contacting the NCW Program Office at the same number listed above.
New Choices Waiver
Attachment B – Special Provisions
Case Management Services
Version July 1, 2016 Page 8 of 9
All employed case managers who meet the minimum qualifications to perform nursing facility
level of care assessments for waiver clients using the Minimum Data Set-Home Care (MDS-HC)
evaluation tool must receive formal training from an approved State official prior to
administering the MDS-HC for the first time. For New Choices Waiver, only RNs or physicians
licensed in the state of Utah are permitted to administer the MDS-HC to waiver clients. To
arrange for MDS-HC training, contact the State Medicaid Agency, New Choices Waiver Program
Office and ask to speak with the MDS-HC Training Coordinator: (800)662-9651, option 6.
The New Choices Waiver Program Office provides annual training to all enrolled Case
Management Services providers. This training is mandatory and all employed RN and SSW case
managers and supervisors/team leaders must attend in order to get credit for the annual
training. At a minimum, provider must send an appropriate representation of experienced staff
members who can receive and understand the training and later disseminate the materials to all
employees who could not attend.
______________________________________________________________________________
(The rest of this page is intentionally left blank.)
New Choices Waiver
Attachment B – Special Provisions
Case Management Services
Version July 1, 2016 Page 9 of 9
Signatures and Attestation:
I am the owner, the executive director or another duly authorized representative of this provider entity.
I have been empowered to review and sign this contract on behalf of the provider entity. I have read all
of the requirements contained within the pages of this Attachment B – Special Provisions contract and I
hereby agree that this provider entity will abide by all of the requirements.
I understand that in order to become fully enrolled as a New Choices Waiver provider this application
must be approved by the New Choices Waiver Program Office within the Division of Medicaid and
Health Financing, Bureau of Authorization and Community-Based Services and by the Bureau of
Medicaid Operations.
Type or Print PROVIDER AGENCY Name: ___________________________________________________
_____________________________________________________________________________________
Type or Print Name of Corporation, DBA or Other Affiliation
_____________________________________________________________________________________
PROVIDER Mailing Address
_______________________________________ _______________________________________
PROVIDER Primary Telephone Number PROVIDER Secondary Telephone Number
PROVIDER Email Address
_________________________________________ _________________________________________
Authorized Representative’s Name Authorized Representative’s Signature
_________________________________________
Signature Date
When this contract has been reviewed and signed with a “wet signature,” THIS PAGE ONLY must be
scanned and uploaded to your New Choices Waiver provider enrollment file within PRISM. If you have
any questions, please call (800)662-9651, option 6, and ask to speak with the NCW Provider Specialist.
