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Targeted Case Management (TCM) Changes

Iowa Medicaid Enterprise

October 14, 2008

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Federal Policy Changes

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Federal Policy Changes

• December 4, 2007• The Centers for Medicare and Medicaid Services (CMS) issued an

interim final rule with comment period (IFC) implementing section 6052 of the Deficit Reduction Act (DRA) of 2005.

• The IFC clarified the Medicaid definition of covered case management and targeted case management services (TCM).

• Provision that State plan TCM services must be paid and rates calculated that employ a unit of service that does not exceed 15 minutes.

• Effective date of March 3, 2008.

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Federal Policy Changes

• Summary of major changes contained in the IFC: Medicaid beneficiaries receiving case management can have only

one plan and case manager. Case management must be billed in increments of 15 minutes, or

less. No bundling of any kind is allowed for case management services

in Fee-for-Service states. Case management cannot be a required service and case managers

cannot function as gate keepers to other services. Services provided by case managers are principally a referral and

linkage activity, and other services provided by case managers cannot be reimbursed as case management. These services may be eligible for reimbursement through other Medicaid options.

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Federal Policy Changes

• June 30, 2008• The Supplemental Appropriations Act, 2008, was signed into law.

• Precludes CMS from taking any action prior to April 1, 2009 that would be more restrictive than applied on December 3, 2007 with respect to the IFC.

• In general, section 6052 of the DRA of 2005 and CMS guidance issued prior to December 4, 2007 is in effect.

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Service Definitions

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Service Definitions

• Medicaid case management services are defined as services that assist individuals eligible under the plan in gaining access to needed medical, social, educational, vocational, transportation, and housing .

• Case management services include the following allowable activities:

1) Comprehensive assessment

2) Development of a comprehensive service plan

3) Referral and follow-up

4) Monitoring and follow-up

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Eligible Individual

• An “eligible individual” is a person who is eligible for Medicaid and eligible for case management services (including targeted case management services) as defined in the Medicaid State plan, at the time the services are furnished.

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Comprehensive Assessment

• Comprehensive assessment of an individual to determine the need for any medical, educational, social, vocational, transportation, and housing.

• Comprehensive assessment activities include: Taking client history; Identifying the individual’s needs and completing related

documentation; Gathering information from other sources such as family

members, medical providers, social workers, and educators, to form a complete comprehensive assessment of the individual.

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Development of a ComprehensiveService Plan

• Development of a specific comprehensive service plan that:

Is based on the information collected through the comprehensive assessment;

Specifies the goals and actions to address the medical, social, educational, vocational, transportation, and housing services needed by the individual;

Includes activities such as ensuring the active participation of the eligible individual, and working with the individual (or the individual’s authorized health care decision maker) and others to develop goals;

Identifies a course of action to respond to the assessed needs of the eligible individual.

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Referral and Follow-Up

• Referral and follow-up related activities: To help an eligible individual obtain needed services

including activities that help link an individual with: Medical, social, educational, vocational, transportation,

housing providers; or Other programs, services, or community resources

capable of providing needed services, such as making referrals to providers for needed services and scheduling appointments for the individual.

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Monitoring and Follow-Up

• Monitoring and follow-up activities: Activities, and contact, necessary to ensure the

comprehensive service plan is implemented and adequately addressing the individual’s needs.

These activities, and contact, may be with the individual, his or her family members, legal guardian, providers, other entities or individuals and may be conducted as frequently as necessary

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Monitoring and Follow-Up

• The State of Iowa requires quarterly monitoring to assure the following conditions are met:

Services are being furnished in accordance with the individual’s comprehensive service plan;

Services in the comprehensive service plan are adequate; and

If there are changes in the needs or status of the individual, necessary adjustments are made to the comprehensive service plan and to service arrangements with providers.

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Contacts

• With respect to contacts with individuals who are not eligible for medical assistance under the State plan, CMS clarified the following:

Considered an allowable case management activity, when the purpose of the contact is directly related to the management of the eligible individual’s care.

Not considered allowable an allowable case management activity if such contacts relate directly to the identification and management of the non-eligible or non-targeted individual’s needs and care.

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Transition Services

• IFC provides clarification regarding case management activities for individuals transitioning to a community setting from an institutional setting:

If the institutional stay was 180 days or longer, then the services may be provided in the last 60 days of the period.

If the institutional placement was less than 180 days, then case management can be provided only in the last 14 days of the placement.

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Transition Services

• Payment for transition services will only be made when all of the following criteria are met:

The individual has left the institution, Is enrolled with the community case management provider, And receiving medically necessary services in the

community.

• CMS has clarified that case management services are only provided to individuals in the community, or transitioning to the community.

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Billable Activities

• Services identified under the service definitions are billable if they meet one of the following criteria:

Face-to-face contacts with the eligible individual. Collateral contacts made to persons on behalf of the eligible

individual. May include contacts with persons such as other service providers, friends, landlords, etc..

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Non-Billable Activities

• Medicaid case management services do not include payment for the provision of direct services (medical, educational,social, vocational, transportation, or housing) to which the Medicaid eligible individual has been referred.

For example, if a child has been referred to a State foster care program, activities performed by the foster care case worker that relate directly to the provision of foster care services cannot be covered as case management.These activities are a component of the overall foster care service to which the child has been referred, they do not qualify as case management.

Transportation services meant to enable beneficiaries to access needed services.

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Non-Billable Activities

• Contacts with non-eligibles and non-targeted individuals that relate directly to the identification and management of the non-eligible or non-targeted individual’s needs and care cannot be billed to Medicaid.

• Case manager transportation services (i.e. visit consumer at the doctor’s office).

• Case management services for persons between the ages of 22 and 64, residing in a institution for mental disease (IMD), or who are in a public institution.

• Documentation time (service plan, monitoring, notes, etc.)

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Summary of Activities

Billable

• Face-to-face contacts with the eligible individual

• Collateral contacts made to persons on behalf of the eligible individual

• Contacts with non-eligibles and non-targeted individuals that relate directly to the management of the eligible individual’s care

• Transition services when specified criteria are met

Non-Billable• Provision of direct services (medical,

educational,social, vocational, transportation, or housing) to which the Medicaid eligible individual has been referred

• Documentation time (service plan, monitoring, notes, etc.)

• Case manager transportation services• Case management services for persons

between the ages of 22 and 64, residing in a institution for mental disease (IMD), or who are in a public institution

• Contacts with non-eligibles and non-targeted individuals that relate directly to the identification and management of the non-eligible or non-targeted individual’s needs

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Billable Units Report (BUR)

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Purpose

• The Billable Units Report (BUR) captures how case management staff spend their time

• Distinguishes between billable and non-billable case management units.

• Used to calculate the number of 15-minute units to report on the Financial and Statistical report.

• Providers may use their own form but must include required elements.

• Iowa Medicaid Enterprise has developed a BUR to use if providers do not want to develop their own.

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Required Elements

• The following elements must be included on the BUR: Date Begin Time End Time Patient ID Total minutes Billable minutes Non-billable minutes Billable activity description

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Implementation Process

• Begin tracking billable units on the BUR effective November 1, 2008, and continue through April 30, 2009.

• At the end of each month add up total billable hours and divide by 15 to calculate the number of 15 minute units.

Use standard rounding rules.

• Use the BUR information to complete the projected Financial and Statistical Report due to the IME on June 1, 2009, to develop a projected 15-minute unit rate.

• Continue completing the BUR on a monthly basis.

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Questions