(1) Case management services include:

(a) comprehensive assessment and periodic reassessment of an eligible individual to determine service needs, including activities that focus on needs identification; and

(b) determination of the need for any medical, educational, social, or other services;

(c) these assessment activities include the following:

(i) taking youth history;

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

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

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

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

(ii) 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; and

(iii) a course of action designed to respond to the assessed needs of the eligible individual.

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

(f) monitoring and follow-up activities, including activities and contacts necessary to ensure that the care plan is effectively implemented and adequately addresses the needs of the eligible individual. This may be with the individual, family members, service providers, or other entities or individuals and may be conducted as frequently as necessary, including at least one annual monitoring review 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) changes in the needs or status of the eligible individual have been accommodated. Monitoring and follow-up activities include making necessary adjustments in the care plan and service arrangements with providers.

(2) 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 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.