Okla. Admin. Code § 317:30-5-971.1

Current through Vol. 42, No. 3, October 15, 2024

Section 317:30-5-971.1 - Description of targeted case management (TCM) services

(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.

Okla. Admin. Code § 317:30-5-971.1

Adopted by Oklahoma Register, Volume 37, Issue 24, September 1, 2020, eff. 9/14/2020