(1) The disease management program provides coordinated health care interventions and education for Medicaid clients meeting the eligibility criteria listed in ARM 37.86.5205. The purpose of the program is to provide and/or coordinate services that decrease utilization and cost while optimizing treatment and improving health outcomes for clients.

(2) A disease management program must include the following procedures:

(a) evaluate each enrolled client;

(b) prioritize disease management program services provided to an enrolled client based on the client's need or other criteria, as appropriate; and

(c) contact and coordinate with a department or department authorized case manager as appropriate for planned service delivery to an enrolled client.

(3) Disease management program services must provide one or more of the following to each enrolled client:

(a) assistance in establishing a medical home;

(b) educational materials;

(c) instruction regarding self-managing the targeted conditions;

(d) assessment of available services, equipment, and supplies that might enhance the client's ability to manage the client's disease processes; or

(e) coordination with a department or department authorized case managers.

(4) Disease management program services do not:

(a) change the scope of services available to a client eligible under a Title XIX Medicaid program;

(b) interfere with the relationship between an enrolled client and the client's chosen provider(s);

(c) duplicate case management activities available to a client in the client's community; or

(d) substitute for established activities that are available to a client and provided by programs administered through other department divisions or state agencies.