OAR 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.