Care Management/Care Coordination.

(a)

the performance of a comprehensive individualized face-to-face assessment conducted in the client's place of residence;

(b)

the development of a Plan of Care;

(c)

the performance of a comprehensive, individualized reassessment at least every six months;

(d)

when desired by the individual and determined necessary by the Care Management Provider Agency, coordination of appropriate services and ongoing monitoring of the delivery of such services; and

(e)

the development of a discharge plan when the Care Management Provider Agency services, or the Policy benefits, are about to be terminated and if further care is needed. If the insured is immediately eligible for Medi-Cal, the Care Management Provider Agency shall prepare a transition plan.