OAR 410-138-0020: Targeted Case Management Programs

(1) This rule includes services in the State Plan for Targeted Case Management. (2) TCM programs include the following: (a) Human Immunodeficiency Virus (HIV); (b) Public Health Nurse Home Visiting programs including, Babies First!, CaCoon, Newborn Nurse Home Visiting and Nurse-Family Partnership; (c) Reentry Targeted Case Management; (d) Federally Recognized Tribal Governments. (e) Oregon Youth Authority (OYA) Targeted Case Management Program (3) With the exception of the Newborn Nurse Home Visiting program, 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 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; (b) 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 people, 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, Benton, Crook, Deschutes, Gilliam, Hood River, Jefferson, Linn, Malheur, Wasco, Washington, Wheeler, Sherman, Baker, Clatsop, Marion, Lane, Polk, Yamhill, Douglas, Multnomah and Coos. (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, NNHV and Nurse-Family Partnership TCM programs shall follow a case management plan developed by the nurse. (c) Reentry Targeted Case Management services are provided to FCAA-Covered Youth as part of Reentry FCAA Services. The Reentry FCAA Service requirements are described in OAR 410-155-0000, and OAR 410-155-0010. (d) 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. (e) The OYA provides TCM services to Medicaid-eligible youth under age 21 who are residing in independent living situations, in-home settings, foster homes, group homes, or residential care facilities under OYA's responsibility—including those transitioning to the community and those receiving services for up to 180 consecutive days during covered institutional stays—as described in Oregon’s Title XIX State Plan (Transmittal 25-0018), effective July 1, 2025. (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.