Targeted Case Management Programs
(1)This rule includes services in the State Plan for TCM and includes: Public Health Nurse Home Visiting, Babies First!, CaCoon, and Nurse-Family Partnership services approved by CMS effective January 1, 2017, and Family Connects Nurse Home Visiting approved by CMS effective July 1, 2019.
(2)TCM programs include the following:
(b)Early Intervention/Early Childhood Special Education (EI/ECSE);
(c)Human Immunodeficiency Virus (HIV);
(d)Public Health Nurse Home Visiting programs including, Babies First!, CaCoon, Family Connects and Nurse-Family Partnership;
(e)Substance Abusing Pregnant Women and Substance Abusing Parents with Children Under Age 18; and
(f)Federally Recognized Tribal Governments.
(3)The TCM Programs are medical assistance programs operated by public health authorities, unit of government providers, or Federally Recognized Tribal Governments in Oregon who are enrolled as TCM providers with the Authority. Participation by providers is voluntary and subject to approval by the Authority and CMS. With the exception of the Federally Recognized Tribal Governments TCM programs, the TCM programs authorized under these rules are cost-sharing (Federal Financial Participation (FFP) matching) programs in which the public fund agency, public entity, unit of government, shall pay the non-federal matching share of the amount of the TCM claims.
(4)The Public Fund Agency may contract TCM services provided by a Local Public Health Authority or other public or private agency if the public fund agency’s obligations for providing payment for the non-federal share for services provided and billed to Medicaid are met in compliance with 42CFR433.51 and the TCM services are provided by an enrolled Medicaid TCM provider who will receive and retain 100 percent of the TCM payments. See OAR 410-138-0005 (Payment for Targeted Case Management Services Eligible for Federal Financial Participation) (Payment for Targeted Case Management Services Eligible for Federal Financial Participation).
(5)Federally Recognized Tribal Governments TCM services authorized under these rules provided to tribal members (American Indian/Alaska Native) at an Indian Health Service (IHS/638) facility operated by the Indian Health Service, by an Indian tribe or tribal organization are reimbursed at 100 percent by Title XIX (Medicaid) and Title XXI Children’s Health Insurance Program (CHIP). TCM services provided by IHS/638 facilities to non-tribal American Indian/Alaska Native members shall be reimbursed at the applicable FMAP rate.
(6)The Authority may not authorize services or reimbursement for direct care as part of any TCM activity. The following are TCM programs and services:
(a)The TCM Asthma/Healthy Homes program improves access to needed services for eligible clients with poorly controlled asthma or a history of environmentally induced respiratory distress. The TCM Asthma/Health Homes program services include management of medical and non-medical services, which address medical, social, nutritional, educational, housing, environmental, and other needs. Home visits constitute an integral part of the delivery of TCM services, provided by a TCM Asthma/Healthy Homes case manager consistent with these rules;
(b)The TCM Early Intervention/Early Childhood Special Education (EI/ECSE) program is a medical assistance program provided by enrolled EI/ECSE providers that meet the criteria approved by the State Superintendent of Public Instruction to administer the provision of EI and ECSE. The TCM EI/ECSE program provides services to categorically eligible children with disabilities, receiving EI/ECSE services from birth until they are eligible for public school. These TCM services are available on a fee-for-service basis, within the limitations established by the Division and chapter 410, division 138 rules, consistent with the requirements of the Individuals with Disabilities Education Act (IDEA). This qualifies such programs for state reimbursement under EI/ECSE programs OAR 581-015-2700 (Definitions — EI/ECSE Program) through 581-015-2910 (Authorization of Early Childhood Supervisor). An enrolled TCM EI/ECSE provider shall be a contractor/agency designated by the Oregon Department of Education (ODE) to administer the provision of EI and ECSE within selected service areas or be a sub-contractor with such a contractor. TCM EI/ECSE program services include management of medical and non-medical services to assist children with disabilities in gaining access to needed medical, social, educational, developmental, and other appropriate services in coordination with a child’s Individualized Family Service Plan (IFSP) developed and implemented pursuant to IDEA and based on information collected through the TCM assessment or periodic reassessment process;
(c)The TCM HIV program improves access to needed medical and non-medical services, which address physical, psychosocial, nutritional, educational, and other services for Medicaid categorically eligible clients with symptomatic or asymptomatic HIV disease. Home visits constitute an integral part of the delivery of TCM services, provided by a TCM HIV case manager consistent with these rules. Without TCM case management services, an eligible client’s ability to remain safely in their home may be at risk;
(e)The TCM Substance Abusing Pregnant Women and Substance Abusing Parents with Children under age 18 program improves access to needed medical and non-medical services, which address physical, psychosocial, educational, nutritional, and other services to Medicaid categorically eligible pregnant women or custodial parents with children under the age of 18 who have alcohol or drug addiction issues. Targeted clients are those who are not yet ready to actively engage in addiction treatment services. TCM services are provided by an enrolled TCM Substance Abusing Pregnant Women and Substance Abusing Parents with Children under age 18 provider consistent with these rules. Participation by all TCM providers is voluntary and subject to approval by the Division and CMS;
(f)The TCM Federally Recognized Tribal Government program improves access to needed medical and non-medical services, which address health, psychosocial, economic, educational, nutritional, and other services for Medicaid categorically eligible tribal members served by tribal programs, provided by an enrolled tribal TCM provider consistent with these rules. The target group includes those members receiving elder care; individuals with diabetes; children and adults with health and social service care needs, and pregnant women.
(7)Refer to the State Plan Amendments for participating counties for each TCM program. The State Plan Amendments are located at http://www.oregon.gov/OHA/HPA/HP/Pages/Medicaid-CHIP-State-Plans.aspx.
(8)Provision of any TCM Program services may not restrict an eligible client’s choice of providers, in accordance with 42 CFR 441.18(a):
(a)Eligible clients shall have free choice of available TCM Program service providers or other TCM service providers available to the eligible client, subject to the Social Security Act, 42 USC 1396n and 42 CFR 441.18(b);
(b)Eligible clients shall have free choice of the providers of other medical care within their benefit package of covered services.
Rule 410-138-0020 — Targeted Case Management Programs,