OAR 410-138-0000
Targeted Case Management Definitions
(1)
“Assessment” means the act of gathering information and reviewing historical and existing records of an eligible client in a target group to determine the need for medical, educational, social, or other services. To perform a complete assessment, the case manager shall gather information from family members, medical providers, social workers, and educators, if necessary.(2)
“Care Plan” means a Targeted Case Management (TCM) Care Plan that is a multidisciplinary plan that contains a set of goals and actions required to address the medical, social, educational, and other service needs of the eligible client based on the information collected through an assessment or periodic reassessment.(3)
“Case Management” means services furnished by a case manager to assist individuals eligible under the Medicaid State Plan Amendment (SPA) in gaining access to and effectively using needed medical, social, educational, and other services (such as housing or transportation) in accordance with 42 CFR 441.18. See also the definition for Targeted Case Management.(4)
“Centers for Medicare and Medicaid Services (CMS)” means the federal agency under the U.S. Department of Health and Human Services that provides the federal funding for Medicaid and the Children’s Health Insurance Program (CHIP).(5)
“Children and Youth with Special Health Care Needs (CYSHCN)” means those children and youth who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.(6)
“Department” means the Department of Human Services (Department).(7)
“Division” means the Oregon Health Authority’s Health Systems Division.(8)
“Duplicate Payment” means more than one payment made for the same services to meet the same need for the same client at the same point in time.(9)
“Early Childhood Special Education (ECSE)” means free, specially designed instruction to meet the unique needs of a preschool child with a disability, three years of age until the age of eligibility for public school, including instruction in physical education, speech-language services, travel training, and orientation and mobility services. Instruction is provided in any of the following settings: home, hospitals, institutions, special schools, classrooms, and community childcare or preschool settings.(10)
“Early Intervention (EI)” means services for preschool children with disabilities from birth until three years of age, including Indian children and children who are homeless and their families.(11)
“Early Intervention/Early Childhood Special Education (EI/ECSE) Services” means services provided to a preschool child with disabilities, eligible under the Individuals with Disabilities Education Act (IDEA) from birth until they are eligible to attend public school, pursuant to the eligible child’s Individualized Family Service Plan (IFSP).(12)
“EI/ECSE Case Manager (i.e., service coordinator)” means an employee of the EI/ECSE contracting or subcontracting agency meeting the personnel standards requirements in OAR 581-015-2900 (Personnel Standards). The EI/ECSE case manager serves as a single point-of-contact and is responsible for coordinating all services across agency lines for the purpose of assisting an eligible client to obtain needed medical, social, educational, developmental, and other appropriate services (such as housing or transportation) identified in the eligible client’s care plan in coordination with the client’s IFSP.(13)
“EI/ECSE TCM Program” means a service under the State Plan and includes case management services furnished to eligible EI/ECSE preschool children age 0-5 with disabilities, assisting them to gain access to needed medical, social, educational, developmental, and other appropriate services (such as housing or transportation) in coordination with their IFSP. EI/ECSE TCM providers shall meet the criteria for the provision of special education programs approved by the State Superintendent of Public Instruction qualifying such programs for state reimbursement under OAR 581-015-2710 (Selection of Contractor) EI/ECSE and shall be contractors with the Oregon Department of Education in the provision of EI/ECSE services or be sub-contractors with such a contractor. Medicaid reimbursement for EI/ECSE TCM services is available only to eligible clients in the target group and does not restrict an eligible client’s free choice of providers.(14)
“Eligible Client” means an individual who is found eligible for Medicaid or the Children’s Health Insurance Program (CHIP) by the Oregon Health Authority (Authority) and eligible for case management services (including TCM services) as defined in the Medicaid State Plan at the time the services are furnished.(15)
“Federal Financial Participation (FFP)” means the portion paid by the federal government to states for their share of expenditures for providing Medicaid services. FFP was created as part of the Title XIX, Social Security Act of 1965. There are two objectives that permit claims under FFP. They are:(a)
To assist individuals eligible for Medicaid to enroll in the Medicaid program; and(b)
To assist individuals on Medicaid to access Medicaid providers and services. The second objective involves TCM.(16)
“Federal Medical Assistance Percentage (FMAP)” means the percentage of federal matching dollars available to a state to provide Medicaid services. The FMAP is calculated annually based on a three-year average of state per capita personal income compared to the national average. The formula is designed to provide a higher federal matching rate to states with lower per capital income. No state receives less than 50 percent or more than 83 percent.(17)
“Individualized Family Service Plan (IFSP)” means a written plan of early childhood special education, related services, early intervention services, and other services developed in accordance with criteria established by the State Board of Education for each child eligible for services. (See OAR 581-015-2700 (Definitions — EI/ECSE Program) to 581-015-2910 (Authorization of Early Childhood Supervisor), Early Intervention and Early Childhood Special Education Programs.)(18)
“Medical Assistance Program” means a program administered by the Division that provides and pays for health services for eligible Oregonians. The Medical Assistance Program includes TCM services provided to clients eligible under the Oregon Health Plan (OHP) Title XIX and the Children’s Health Insurance Program (CHIP) Title XXI.(19)
“Monitoring” means ongoing face-to-face or other contact to conduct follow-up activities with the participating eligible client or the client’s health care decision makers, family members, providers, or other entities or individuals when the purpose of the contact is directly related to managing the eligible client’s care to ensure the care plan is effectively implemented.(20)
“Oregon Health Plan (OHP)” means the Medicaid program in Oregon that is known as the OHP and governed by a series of laws passed by the Oregon Legislature with the intention of providing universal access to healthcare to Oregonians. OHP is also governed by many federal laws.(21)
“Perinatal (for the purpose of the State Plan amendment for Public Health Nurse Home Visiting, Expanded Babies First!, CaCoon, and Nurse-Family Partnership TCM)” means the period inclusive of pregnancy through two years postpartum to the child’s second birthday. Services to a parent or primary caregiver may be available during this same two-year period following the birth of the child.(22)
“Reassessment” means periodically re-evaluating the eligible client to determine whether or not medical, social, educational, or other services continue to be adequate to meet the goals and objectives identified in the care plan. Reassessment decisions include those to continue, change, or terminate TCM services. A reassessment shall be conducted at least annually or more frequently if changes occur in an eligible client’s condition, or when resources are inadequate, or the service delivery system is non-responsive to meet the client’s identified service needs.(23)
“Referral” means performing activities such as scheduling appointments that link the eligible client with medical, social, or educational providers, or other programs and services, and follow-up and documentation of services obtained.(24)
“Targeted Case Management (TCM) Services” means case management services furnished to a specific target group of eligible clients under the Medicaid State Plan to gain access to needed medical, social, educational, and other services (such as housing or transportation).(25)
“Unit of Government” means a city, a county, a special purpose district, or other governmental unit in the state.
Source:
Rule 410-138-0000 — Targeted Case Management Definitions, https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-138-0000.