Or. Admin. Code § 410-138-0020 - [Effective 9/5/2025] 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 Newborn Nurse Home Visiting
approved by CMS effective July 1, 2019.
(2) TCM programs include the following:
(a) Asthma/Healthy Homes;
(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, Newborn Nurse Home Visiting 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 and the Newborn Nurse Home
Visiting Program, 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
42 CFR
433.51 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).
(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 through
581-015-2910. 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;
(d) The TCM Public Health
Nurse Home Visiting Programs, Babies First!, CaCoon, Newborn Nurse Home
Visiting and Nurse-Family Partnership improve access to needed medical and
non-medical services that address medical, social, educational, and other
services:
(A) The Babies First!, and
Nurse-Family Partnership programs include Medicaid eligible perinatal women,
eligible infants and children through four years of age who have one or more
risk factors for poor perinatal, birth, and other poor health outcomes. TCM
services may also be provided to a parent or other caretaker relative of the
eligible child. See Table 1 and 2 Risk Criteria as outlined in OAR
410-138-0040 risk
criteria;
(B) The CaCoon program
shall be provided to Medicaid eligible Children and Youth with Special Health
Care Needs (CYSHCN), up to age 21, who have one or more diagnosis. TCM services
may also be provided to a parent or other caretaker relative of the eligible
child. See Table 1 and 2 as outlined in OAR
410-138-0040 risk
criteria;
(C) NNHV may be provided
to Medicaid eligible infants 0 through 6 months of age. As part of a phased
implementation services may be provided in the following counties: Lincoln,
effective July 1, 2019; Benton, Crook, Deschutes, Gilliam, Hood River,
Jefferson, Linn, Malheur, Wasco, Washington, Wheeler and Sherman, effective
January 1, 2021,Baker, Clatsop, Marion, effective February 1, 2021. (D) Home
visits constitute a significant part of the delivery of targeted case
management services, provided by a Public Health Nurse Home Visiting(Babies
First!, CaCoon, NNHV and Nurse-Family Partnership) targeted case manager
consistent with these rules. All providers for Babies First!, CaCoon, Family
Connects, NNHV and Nurse-Family Partnership TCM programs shall follow a case
management plan developed by the nurse;
(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.
Notes
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
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