Or. Admin. Code § 410-138-0005 - [Effective 4/19/2025] Payment for Targeted Case Management Services Eligible for Federal Financial Participation
(1) This rule is to
be used in conjunction with Targeted Case Management (TCM) rules OAR
410-138-0000 through
410-138-0009 and
410-138-0390 and the Division 's
General Rules chapter 410, division 120.
(2) The TCM services rules are designed to
assist the TCM provider organizations in matching state and federal funds for
TCM services defined by Section 1915(g) of the Social Security Act,
42 USC §
1396n(g). Providers of
Tribal TCM and the Newborn Nurse Home Visiting Program are exempt from
cost-sharing requirements to pay non-federal matching funds.
(3) Payment shall be made to the TCM provider
enrolled with the Authority as a unit of government provider meeting the
requirements set forth in the provider enrollment agreement.
(4) Signing the provider enrollment agreement
sets forth the relationship between the State of Oregon, the Authority, and the
TCM provider and constitutes agreement by the TCM provider to comply with all
applicable Authority rules and federal and state laws and
regulations.
(5) The TCM provider
shall bill according to administrative rules in chapter 410, division 138 and
the TCM supplemental information. Payments shall be made using the Medicaid
Management Information System (MMIS), and the TCM provider shall retain the
full payment for covered services provided. The TCM provider shall have a
Trading Partner Agreement with the Authority prior to submission of electronic
transactions.
(6) TCM authorized
under these rules is a cost-sharing (Federal Financial Participation (FFP)
matching) program in which the TCM provider as a public entity, unit of
government , shall pay the non-federal matching share of the amount of the TCM
claims, calculated using the Federal Medical Assistance Percentage (FMAP) rates
in effect during the quarter when the TCM claims will be paid:
(a) The TCM provider's non-federal matching
share means the public funds share of the Medicaid payment amount. Pursuant to
the Social Security Act,
42 CFR
433.51, public funds may be considered as the
state's share in claiming federal financial participation, if the public funds
meet the following conditions:
(A) The public
funds are transferred to the Authority from public entities that are units of
government;
(B) The public funds
are not federal funds, or they are federal funds authorized by federal law to
be used to match other federal funds; and
(C) All sources of funds shall be allowable
under the Social Security Act 42 CFR 433 Subpart B;
(b) The unit of government TCM provider shall
pay the non-federal matching share to the Authority in accordance with OAR
410-120-0035.
(7) Before the Authority pays for TCM claims,
the Authority shall receive the corresponding local match payment as described
in this rule. Failure to timely pay the non-federal matching funds to the
Authority will delay payment.
(8)
The Authority shall not be financially responsible for payment of any claim
that CMS disallows under the Medicaid program. If the Authority has previously
paid the TCM provider for any claim, which CMS disallows, the TCM provider
shall reimburse the Authority the amount of the claim that the Authority has
paid to the TCM provider, less any amount previously paid by the unit of
government TCM provider to the Authority for the non-federal match portion for
that claim.
(9) Providers shall
only bill Medicaid for allowable activities in the TCM program that assist
individuals eligible under the Medicaid State Plan to gain access to needed
medical, social, educational, and other services. One or more of the following
allowable activities shall occur before billing:
(a) Assessment ;
(b) Development of a care plan ;
(c) Referral and follow up; and
(d) Monitoring and follow up.
(10) TCM claims may not duplicate
payments made to:
(a) Public agencies or
private entities for any other case management activities or direct services
provided under the State Plan or OHP, through fee for service, managed care, or
other contractual arrangement, that meet the same need for the same client at
the same point in time;
(b) A TCM
provider by program authorities under different funding authority than OHP,
including but not limited to other public health funding;
(c) A TCM provider for administrative
expenditures reimbursed under agreement with the Authority or any other program
or funding source.
(11)
Medicaid is only liable for the cost of otherwise allowable case management
services if there are no other third parties liable to pay. However, while
schools are legally liable to provide IDEA-related health services at no cost
to eligible children, Medicaid reimbursement is available for these services
because section 1903(c) of the Act requires Medicaid to be primary to the U.S.
Department of Education for payment for covered Medicaid services furnished to
a child with a disability. These services may include health services included
in a child's Individualized Education Program (IEP) or Individual Family
Service Plan (IFSP) under the IDEA. Payment for those services that are
included in the IEP or IFSP may not be available when those services are not
covered Medicaid services.
(12) The
Authority's acceptance of cost data provided by provider organizations for the
purpose of establishing rates paid for TCM services does not imply or validate
the accuracy of the cost data provided.
(13) Reimbursement is subject to all rules
and laws pertaining to federal financial participation.
Notes
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
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