The Department of Health and Mental Hygiene (DHMH) administers a Rare and Expensive Case Management (REM) program to address the special needs of waiver-eligible individuals diagnosed with rare and expensive medical conditions. The REM program, a part of the HealthChoice program, was developed to ensure individuals who meet specific criteria receive high-quality, medically necessary health services in a timely manner.
Qualifying diagnoses for inclusion in the REM program must meet the following criteria:
Occurrence is generally fewer than 300 individuals per year
Cost is generally more than $10,000 per year, on average
Need is for highly specialized and/or multiple providers/delivery systems
Chronic condition
Increased need for continuity of care
Complex medical, habilitative and rehabilitative needs Medicaid Services and Benefits
To qualify for the REM program, a member must have one or more of the diagnoses specified in the Rare and Expensive Disease List at the end of this section. The members may elect to enroll in the REM Program or to remain with Amerigroup if DHMH agrees it is medically appropriate. REM participants are eligible for fee-for-service benefits currently offered to Medicaid-eligible recipients not enrolled in MCOs, as well as additional, optional services described in COMAR 10.09.69. All certified Medicaid providers other than HMOs, MCOs, ICF-MRs and IMDs are available to REM participants in accordance with the individual’s plan of care.
Case Management Services
In addition to the standard and optional Medicaid services, REM participants have a case manager assigned to them. The case manager’s responsibilities include:
Gathering all relevant information needed to complete a comprehensive needs assessment
Assisting the member with selecting an appropriate PCP, if needed
Consulting with a multidisciplinary team that includes providers, participants, and family or caregivers to develop the member’s plan of care
Implementing the plan of care, monitoring service delivery and making modifications to the plan as warranted by changes in the participant’s condition
Documenting findings and maintaining clear and concise records
Care Coordination
REM case managers are also expected to coordinate care and services from other programs and/or agencies to ensure a comprehensive approach to REM case management services. Examples of these agencies and programs are:
DHMH — Healthy Start program newborn follow-up assessments
Developmental Disability Administration — coordinates services for those also in the Home and Community-Based Services Waiver Program
DHMH — Maternal Child Health Division on EPSDT — guidelines, benchmarks and other special needs children’s issues
AIDS Administration — consults on pediatric AIDS
DHR — coordinates medical assistance eligibility issues, coordinates/consults with Child Protective Services and Adult Protective Services, and coordinates with foster care programs
Department of Education — coordinates with service coordinators of the Infants and Toddlers Program and other special education programs
Mental Hygiene Administration — referral for mental health services to the Specialty Mental Health System as appropriate and coordination of these services with somatic care Referral and Enrollment Process
Candidates for REM are generally referred from HealthChoice MCOs, providers or other community sources. Self-referral or family-referral is also acceptable. Referral must include a provider’s signature and the required supporting documentation for the qualifying diagnosis. A registered nurse reviews the medical information to determine the member’s eligibility for REM. If the intake nurse determines there is no qualifying REM diagnosis, the application is sent to the REM physician advisor for a second-level review before a denial notice is sent to the member and referral source.
If the intake nurse determines the member has a REM-qualifying diagnosis, the nurse approves the member for enrollment. However, before actual enrollment is completed, the Intake Unit contacts the PCP to see if he or she will continue providing services in the fee-for-service environment. If not, the case is referred to a case manager to arrange for a PCP consultation with the member. If the PCP will continue providing services, the Intake Unit then calls the member to notify of the enrollment approval, briefly explains the program and gives the member an opportunity to refuse REM enrollment. If enrollment is refused, the member remains in the MCO. At the time of member notification, the Intake Unit also ascertains if the member is receiving services in the home (e.g., home nursing, therapies, supplies, equipment, etc.). If so, the case is referred to a case manager for service coordination. We are responsible for providing the member’s care until the member is actually enrolled in the REM program. If the member does not meet the REM criteria, the member will remain enrolled in Amerigroup.
For questions or to request a REM Intake and Referral Form, please call 1-800-565-8190. Instructions for completing and accessing the REM Intake and Referral Form are located at http://mmcp.dhmh.maryland.gov/longtermcare/docs/REM-packet-Jan-2011.pdf. Referrals may be faxed to the REM Intake Unit at 410-333-5426 or mailed to the following address:
REM Program Intake Unit
Maryland Department of Health and Mental Hygiene Office of Health Services
201 W. Preston St., Room 210 Baltimore, MD 21201-2399