Current through Vol. 42, No. 1, September 16, 2024
(a)
Definition. In accordance
with Section (§) 440.169(b) of Title 42 of the Code of Federal Regulations
(C.F.R.), TCM services are defined as services furnished to assist individuals,
eligible under the Oklahoma Medicaid State Plan, in gaining access to needed
medical, social, educational, and other services. TCM includes providing
services that are directly related to identifying the individual's needs and
care, for the purposes of helping the individual access services; identifying
needs and supports to assist the individual in obtaining services; providing
case managers with useful feedback, and alerting case managers to changes in
the individual's needs [
42 C.F.R.
440.169(e)] . TCM includes
the following assistance:
(1) Comprehensive
assessment and periodic reassessment of an individual's needs, to determine the
need for any medical, educational, social, or other services.
(A) All members are assessed using
comprehensive, evidence-based, risk/needs assessment tools at the beginning of
case assignment.
(B)
Comprehensive, evidence-based, risk/needs assessment tools are used to measure
multiple areas or domains in the lives of the members and then linking that
information to case planning.
(C)
Any area showing a moderate to high-risk/need/strength score could result in
additional goals and action steps documented within the individualized
treatment plan.
(D) In addition to
the initial assessment, each member is assessed, at least once every six (6)
months. Assessment activities include:
(i)
Taking member history;
(ii)
Identifying and documenting the member's needs; and
(iii) Gathering information from family
members, medical providers, social workers, educators (if necessary), and other
applicable sources to form a complete assessment of the member.
(E) Should behavior shifts or
life-changing events occur prior to six (6) months, the member is reassessed
and the individualized treatment service plan is adjusted to reflect identified
needs. Any needed changes in services, service providers, treatment type,
frequency, or duration may be adjusted at this time.
(2) Development (and periodic revision) of a
specific individualized treatment service plan is based on the information
collected through the assessment that:
(A)
Specifies the goals and actions to address the medical, social, educational,
and other services needed by the individual;
(B) Includes activities such as ensuring the
active participation of the individual, and working with his or her authorized
health care decision maker and others to develop those goals; and
(C) Identifies a course of action to respond
to the assessed needs of the individual.
(3) Referral and related activities (such as
scheduling appointments for the member) to help the individual obtain needed
services, including activities that help link the member with medical, social,
educational providers, or other programs and services that are capable of
providing needed services to address identified needs and achieve goals
specified in the treatment service plan.
(4) Monitoring and follow-up activities
necessary to ensure the individualized treatment service plan is implemented
and adequately addresses the individual's needs.
(A) The targeted case manager visits with the
child at least once each month, face to face, and/or weekly (via telephone) to
review progress as outlined within the individualized treatment service plan.
The targeted case manager must visit with the parent or legal guardians
monthly. The targeted case manager maintains consistent contact with the
service providers to remain up to date on the child's treatment and progress.
(B) The frequency and type of
visits may be adjusted or revised to better meet the needs of the child.
(C) Monitoring and follow-up
activities may be conducted as frequently as necessary, including at least one
(1) annual monitoring, to determine whether the following conditions are met:
(i) Services are being furnished in
accordance with the member's treatment service plan;
(ii) Services in the treatment service plan
are adequate; and
(iii) Changes in
the needs or status of the member are reflected in the treatment service plan.
Monitoring and follow-up activities include making necessary adjustments in the
treatment service plan and service arrangements with providers.
(b)
Non-covered services. TCM does not include:
(1) Physically escorting or transporting a
member to scheduled appointments or staying with the member during an
appointment;
(2) Monitoring
financial goals;
(3) Providing
specific services such as shopping or paying bills; and/or
(4) Delivering bus tickets, nutritional
services, money, etc.
(c)
Non-duplication of services.
Consistent with
42 C.F.R. §
441.18(a)(4), payment for
case management or TCM services shall not duplicate payments made to public
agencies or private entities under the Oklahoma Medicaid State Plan or other
program authorities.
(d)
Individuals eligible for Part B of Medicare. Case management
services provided to Medicare eligible recipients are filed directly with the
fiscal agent.
