§ 52.26. Service coordination services.
(a) To be paid for rendering service coordination services, an SCE shall:
(1) Complete a person-centered assessment.
(2) Complete a level of care re-evaluation at least annually.
(3) Develop a service plan for each participant for whom the SCE renders service coordination services. The provider shall complete the following:
(i) Develop and modify the participant’s service plan at least annually.
(ii) Modify the participant’s service plan, if necessary, when the participant has a significant medical or social change.
(4) Review the participant need, the participant goal and participant outcome with the participant and other persons that the participant requests to be part of the review as required by conducting the following:
(i) At least one telephone call or face-to-face visit per calendar quarter. At least two face-to-face visits are required per calendar year.
(ii) More frequent calls or visits if the service coordinator or the Department determines more frequent calls or visits are necessary to ensure the participant’s health and safety.
(5) Coordinate a service, TPR and informal community supports with the participant to ensure the participant need, the participant goal and the participant outcome are met.
(6) Provide the participant with a list of providers in the participant’s service location area that are enrolled to render the service that meet the participant needs.
(7) Inform the participant of the participant’s right to choose any willing and qualified provider to provide a service on the participant’s service plan.
(8) Confirm with the participant’s selected provider that the provider is able to provide the service in the type, scope, amount, duration and frequency as listed on the participant’s service plan.
(9) Provide information regarding the authorized type, scope, amount, duration and frequency of services as listed in the participant’s service plan to the provider rendering the service.
(10) Ensure and document at least on a quarterly basis that the participant’s services are being delivered in the type, scope, amount, duration and frequency as required by the participant’s service plan.
(11) Evaluate if the participant need, participant goal and participant outcome are being met by the service.
(12) Ensure a participant exercising participant-directed budget authority does not exceed the number of service hours approved in the participant’s service plan.
(b) If additional information is necessary to ensure that services are provided to a participant in the type, scope, amount, duration or frequency as required by the participant’s service plan, the SCE shall convey the additional information to a provider.
(c) The SCE shall ensure a waiver or Act 150 service assigned to a participant is a service offered under the waiver or Act 150 service in which the participant is enrolled.
(d) If a participant is available to receive only a portion of the service coordination services in subsection (a), the Department will pay for those portions of the services rendered to the participant.
(e) If the SCE is an OHCDS, then the SCE shall be a direct service provider of at least one vendor good or service.
(f) If services are not being delivered by a provider to a participant in the type, scope, amount, duration or frequency as required by the participant’s service plan, then the SCE shall work with the provider to do either of the following:
(1) Ensure that services are being delivered to the participant in the type, scope, amount, duration and frequency required by the participant’s service plan.
(2) Transition the participant to a provider who is willing and qualified to provide services to the participant in accordance with the participant’s service plan.
(g) The Department may limit the number of service coordination units available to participants as provided in the approved applicable waiver, including approved waiver amendments.
(h) A provider may not bill for more units of service coordination services for a participant than provided for in the participant’s service plan.
(i) If a participant requires more units of service coordination services than provided for in the participant’s service plan, then the SCE shall submit:
(1) A request to increase the number of service coordination units for the participant to the Department.
(2) Justification for why the participant requires more units of service.
(3) The number of service coordination units the participant is assessed to need.
(j) If the service is also offered as a Medicaid State Plan service, then the Medicaid State Plan service shall be accessed prior to another Departmental program to provide the service.
(k) The SCE or the Department’s designee shall assist a participant to collect and send information to the Department to determine the participant’s continued eligibility for the waiver or Act 150 program, including financial eligibility.
Source The provisions of this § 52.26(g) and (i) effective June 27, 2012, 42 Pa.B. 4545. Immediately preceding text appears at serial pages (361351) to (361353).
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