Or. Admin. Code § 410-138-0007 - Targeted Case Management - Covered Services
(1) Targeted case management (TCM) services
shall be furnished only to assist individuals eligible under the Medicaid State
Plan 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.
(2) TCM services billed to Medicaid shall be
for allowable activities and include one or more of the following components:
(a) Assessment of an eligible client in the
target group to determine the need for medical, educational, social, or other
services as follows:
(A) Taking client
history;
(B) Identifying the needs
of the client, and completing related documentation;
(C) Gathering information from other sources,
such as family members, medical providers, social workers, and educators, if
necessary, to form a complete assessment of the eligible client;
(D) Periodically reassessing a client to
determine if the client's needs or preferences have changed. A reassessment
shall be conducted at least annually or more frequently if changes occur in the
client's condition;
(b)
Development of a care plan based on the information collected through the
assessment or periodic reassessment, specifying the goals and actions to
address the medical, social, educational, and other services needed by the
eligible client. This may include:
(A) Active
participation of the eligible client in the target group; or
(B) Working with the eligible client or the
eligible client's authorized health care decision maker and others to develop
goals and identify a course of action to respond to the assessed needs of the
eligible client;
(c)
Referral, linking, and coordination of services and related activities
including but not limited to:
(A) Scheduling
appointments for the eligible client in the target group to obtain needed
services; and
(B) Activities that
help link the eligible client with medical, social, or educational providers,
or other programs and services (e.g., food vouchers, transportation, child
care, or housing assistance) that address identified needs and achieve goals
specified in the care plan. The case management referral activity is completed
once the referral and linkage have been made;
(C) Reminding and motivating the client to
adhere to the treatment and services schedules established by providers.
(d) Monitoring or
ongoing face-to-face or other contact:
(A)
Monitoring and follow-up activities include activities and contacts:
(i) To ensure the care plan is effectively
implemented;
(ii) To help
determine if the services are being furnished in accordance with the eligible
client's care plan;
(iii) To
determine whether the care plan adequately addresses the needs of the eligible
client in the target group;
(iv)
To adjust the care plan to meet changes in the needs or status of the eligible
client.
(B) Monitoring
activities may include contacts with:
(i) The
participating eligible client in the target group;
(ii) The eligible client's healthcare
decision makers, family members, providers, or other entities or individuals
when the purpose of the contact is directly related to the management of the
eligible client's care.
(3) TCM services billed to Medicaid shall be
documented in the client's case records for all client's receiving case
management. The documentation shall include:
(a) The client's name;
(b) The dates of the case management
services;
(c) The name of the
provider agency (if relevant) and the person providing the case management
service;
(d) The nature, content,
units of the case management services received and whether goals specified in
the care plan have been achieved;
(e) Whether the client has declined services
in the care plan;
(f) The need
for, and occurrences of, coordination with other case managers;
(g) A timeline for obtaining needed services;
(h) A timeline for reevaluation of
the plan.
Notes
Stat. Auth.: ORS 413.042 & 414.065
Stats. Implemented: ORS 414.065
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