(1) Case management services for adults with severe and disabling mental illness include:

(a) comprehensive assessment and reassessment at least once every 90 days of an eligible individual to determine service needs, including activities that focus on needs identification for any medical, educational, social, or other services. These assessment activities include the following:

(i) taking client history;

(ii) identifying the needs of the individual, and completing related documentation; and

(iii) gathering information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the eligible individual and to avert crisis.

(b) development (and periodic revision) of a specific care plan based on the information collected through the assessment that:

(i) specifies goals and actions to address the medical, social, educational, and other services needed by the eligible individual;

(ii) includes activities such as ensuring the active participation of the eligible individual and working with the individual (or the individual's authorized health care decision maker) and others to develop those goals;

(iii) identifies a course of action to respond to the assessed needs of the eligible individual and to avert crisis.

(c) referral and related activities (such as making referrals and scheduling appointments for the individual) to help the eligible individual obtain needed services, including activities that link the individual with medical, social, and educational providers or other programs and services that address identified needs and achieve goals specified in the care plan; and

(d) monitoring and follow-up activities, including activities and contacts to ensure that the care plan is effectively implemented and addresses the needs of the eligible individual. Activity may be with the individual, family members, service providers, or other entities or individuals and conducted as frequently as necessary, and at least once every 90 days, to help determine whether the following conditions are met:

(i) services are being furnished in accordance with the individual's care plan;

(ii) services in the care plan are adequate to meet the needs of the individual; and

(iii) there are changes in the needs or status of the eligible individual. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.

(2) Case management services for adults with severe disabling mental illness are provided by a licensed mental health center in accordance with these rules and the provisions of Title 50, chapter 5, part 2, MCA.

(3) Case management may include contacts with noneligible individuals that are directly related to the identification of the eligible individual's needs and care, for the purpose of helping the eligible individual access services, identifying needs and supports to assist the eligible individual in obtaining services, providing case managers with useful feedback, and alerting case managers to changes in the eligible individual's needs, and averting crisis.

(4) "Case management" does not include the:

(a) direct delivery of a medical, educational, social, or other service to which an eligible individual has been referred; and

(b) transportation.

(5) Delivery of case management may be provided outside of a clinical or mental health program setting.

(6) Case management reimbursement requirements include those described in (1) through (5) and the following:

(a) case managers must inform eligible individuals they have the right to refuse case management at the time of eligibility determination and annually thereafter at the time of reassessment; and

(b) providers must document in the case record that the individual has been informed and if the individual has refused services.