Transitional Case Management shall mean case management services provided for the purpose of community transition of a Medicaid eligible person residing in an Intermediate Care Facility for Individuals with Intellectual Disabilities (ICF/IID) or other institutional setting who has been determined to qualify for HCBS waiver services upon discharge during the last 180 consecutive days of the person’s institutional stay prior to being discharged and enrolled in the waiver. Transitional Case Management shall assist the waiver participant in identifying, selecting, and obtaining both paid services and natural supports to enhance the waiver participant’s independence, integration in the community, and productivity as specified in the waiver participant’s transitional plan of care. Transitional Case Management shall be person-centered and shall include, but not be limited to, ongoing assessment of the waiver participant’s strengths and needs; development, evaluation, and revision of the transitional plan of care; assistance with the selection of service providers; provision of general education about the waiver program, including waiver participant rights and responsibilities; and monitoring implementation of the transitional plan of care. Transitional case management shall include at least one face-to-face contact with the waiver participant per calendar month. The date the person leaves the ICF/IID or other institutional setting and is enrolled in the waiver shall be the date of service for billing purposes.
Applicable limits, if any, on the amount, frequency, or duration of this service: The last 180 consecutive days of the person’s institutional stay prior to being discharged and enrolled in the waiver.