A targeted case management program is available for developmentally disabled (DD) individuals who are enrolled in AHCCCS but do not qualify for ALTCS.  Case managers employed by the Department of Economic Security, Division of Developmental Disabilities provide intervention to meet the needs of this population.

Other case management services are included in health plan benefits.

Certain Indian tribes have signed Intergovernmental Agreements with AHCCCS to deliver case management services and to provide directly or arrange for HCBS to Native Americans who reside on reservations.

The targeted case management program is reimbursed according to the AHCCCS Fee Schedule, or a negotiated rate.

Other case management services are included in the capitated rate paid to health plans for enrolled members.

A physician must prescribe targeted case management (but physicians are not responsible for case management services nor must they supervise them). 

Recipients eligible for this service are:

• Recipients younger than 21 who are referred as a result of a EPSDT screening;
• Recipients younger than 21 who are eligible for early intervention or who have developmental disabilities;
• Recipients age 60 and older;
• Recipients older than 20 who have developmental disabilities; and
• Case management for Medicaid-eligible pregnant women.

Targeted case management is limited to in-state providers only.

Providers of targeted case management to children younger than 21 who are not eligible for DDS must be an MSW, RN, LPN, LSW, Licensed Psychiatric Technician Nurse, or a master’s degree certified School Guidance Counselor, School Psychologist Specialist or Special Education Supervisor.

A targeted case manager may have a maximum active caseload of 70 Medicaid recipients at one time.

Reimbursement is based on the lesser of the billed amount or the Medicaid maximum allowable for each procedure.

Targeted case management services must be billed on a per unit basis.  One unit equals 15 minutes.

There are two types of case management benefits to serve Medi-Cal recipients.  The Targeted Case Management program serves individuals who would benefit from a case manager’s direct support to ensure the person receives appropriate care and to encourage the person to follow an established plan of care.  See next column for eligible groups.

The Medical Case Management (MCM) program provides short-term case management to Medi-Cal beneficiaries who have no other health care coverage. Individuals eligible for MCM services generally have complex, chronic and/or catastrophic medical conditions. MCM assists in planning the discharge from an acute hospital to a home setting. MCM typically approves home health care services and other related medical services. MCM staff follow-up with the Medi-Cal beneficiary to ensure services are meeting their needs.  

The following groups are eligible for Targeted Case Management:

• Individuals age 18 and older who are in frail health and who would otherwise need institutional care;
• Individuals age 18 and older who are on probation and who have medical and/or mental needs;
• Individuals age 18 and older who are unable to handle personal, medical or other affairs or who are under a conservator;
• Persons who have been identified as needing public health case management such as women, infants, children, pregnant women, persons with HIV/AIDS or reportable communicable diseases, persons who use medical technological devices, and persons with multiple diagnoses;
• Individuals who need outpatient clinic services and case management who have not followed a medical regime; and
• Individuals who have language barriers or other communication barriers that result in difficulties complying with a medical plan.

There is a separate case management program called California Children Services (CCS) for children under age 21 who are residentially, financially and medically eligible.  Eligible children are required by law to be referred to this program.

These services are reimbursed according to the Medi-Cal fee schedule.  DHS establishes rates for each provider type on a fee-for-service basis.

Case management services are provided to individuals with developmental disabilities and to those who are mentally ill.  Specific criteria must be met with regard to enrollment in specific programs and institutionalization.
Case management consists of at least one activity every other month by the community centered board which is providing services.

Only designated Community Centered Boards may be reimbursed for targeted case management for individuals with developmental disabilities.
Only community mental health centers and clinics designated by the Department of Institutions and licensed by the Department of Health are reimbursed for case management services for mentally ill Medicaid clients.

For individuals with developmental disabilities, reimbursement is as follows:

1. Services provided to individuals who are eligible for targeted cae management for 16 days or more within any calendar month are reimbursed for two units of service.
2. Services provided to individuals who are eligible for targeted case management services for 15 days or less within any calendar month are reimbursed for one unit of service.

Reimbursement for services provided to mentally ill individuals is on a prospective basis in accordance with federal requirements.

Case management services are covered for the following special populations:

• Chronically mentally ill; and
• Developmentally disabled.

These services are reimbursed at per diem rates.  Only state-funded providers are eligible for reimbursement.

Case management services are covered as part of the HCBS waivers, the Smart Start program, Part C program, child mental health services and the Delaware Healthy Children’s Program (DHCP).

It is part of the MCO requirement to provide case management services under the Diamond State Health Plan (DSHP) for the Smart Start Program, Part C Program and child mental health services.

It is part of the MCO requirement to provide case management services under the Delaware Healthy Children’s Program (DHCP).

Case management is only reimbursed through MCOs for recipients other than waiver participants.

HCBS waiver recipients are exempt from MCO coverage.  Case management services provided through the Elderly and Disabled HCBS waiver and the Assisted Living Medicaid waiver are considered an administrative cost and DMAP is not billed separately.  HCBS AIDS/HIV and HCBS MR waiver providers are reimbursed for case management services an established rate using a HCPCS procedure code. 

Targeted case management programs:

• Department of Health (DOH) Children’s Medical Services (CMS) clients.  Medicaid reimburses DOH CMS clinic staff for case management services.
• Mental Health Targeted Case Management (for recipients who are enrolled in a Department of Children and Families mental health target program).

Under the CMS  program, Medicaid reimbursement for individual mental health case management services is limited to 86 hours per individual case manager, per month, per recipient.  Reimbursement for intensive, team case management services is limited to 12 hours per day, per recipient.  Only one claim for all cumulative units that occurred during the day is reimbursed per individual case manager, per recipient.

Under the Mental Health TCM program, Medicaid will reimburse up to 344 units of children’s or adult mental health TCM per month, per recipient and up to 48 units of intensive team services per recipient, per day, per case management team.

Medicaid reimburses the provider an established fee based on a unit of service for each allowable case management service.  A unit is from one to 15 minutes.
Case management services provided by CMS must be adjusted annually to their actual cost.

Mental health TCM services are reimbursed in time increments.  Fifteen minutes equal one unit of service.  If multiple units are provided on the same day, the actual time spend must be totaled and rounded up to the nearest 15-minute increment.  The provider may not round up each service episode to the nearest 15-minute increment prior to summing the total.

The following Targeted Case Management programs are available:

• At-Risk of Incarceration Case Management -- For children under age 21 who are emotionally disturbed (including behaviorally dysfunctioning), or substance abusing, who are at-risk of incarceration;
• Child Protective Services Case Management – For children from birth to age 18 who have been placed in foster care or are receiving Child Protective Services necessary to protect them from abuse, neglect or exploitation;
• Adult Protective Services Case Management – For Medicaid members age 18 and older who meet special conditions (e.g., imminent risk of abuse, etc.)
• Adult with AIDS Case Management – For adults (age 21+) with AIDS or symptomatic HIV at greatest risk of hospitalization
• Children At Risk Case Management -- For children under age 21 in targeted areas. 
• Perinatal Case Management – for pregnant women.

If a Medicaid member is enrolled in more than one Targeted Case Management (TCM) program, the case managers from both TCMs must collaborate to determine which TCM will be most appropriate in meeting the needs of the member.  Duplication of services may not occur.  Only one TCM provider will be reimbursed per month for TCM services.

At Risk of Incarceration Case Management – Reimbursed on a fee-for-service basis, billed monthly on the CMS-1500 form.  Payment is limited to the lesser of the submitted charge or established fee based on the actual cost of providers.

Child and Adult Protective Services – Reimbursement rates are established based on cost as determined by the quarterly Social Services Random Moment Sample Study.  Procedure code Y5170 is used for billing and documentation services.  At least one of the following ICD-9 codes must appear on the claim form:  V61.9, V62.89 or V62.9.  The reimbursement rate for Y5170 is $195.

Adult AIDS – Paid on fee-for-service basis.  Codes are:

• Y5100-New client comprehensive assessment ($126)
• Y5101-Extended follow-up ($84)
• Y5102-Brief follow-up ($42)

Children At Risk – Reimbursed on a fee-for-service basis.

Perinatal Case Management is reimbursed on a fee-for-service basis.*

*Refer to Crosswalk from local to national codes (required under HIPAA) for new codes.

Targeted Case Management is offered to the following populations:

• Individuals who have developmental disabilities or are mentally retarded;
• Individuals who are considered, “Severely Disabled Mentally Ill”;
• Infants and toddlers ages 0 to 3 who have special needs.

Case management services include case assessment, case planning and ongoing monitoring and service coordination.

These services are not available to individuals enrolled in HMOs.

Individuals receiving services under the HCBS waiver programs are eligible to receive non-duplicative case management services as targeted case management services.

Case managers providing services to individuals with developmental disabilities and/or mentally retarded must meet the state civil service requirements for the titles of Social Worker III or IV, or Registered Professional Nurse III or IV, or the definition of Qualified Mental Retardation Professional.

Case managers providing services to individuals who are severely disabled mentally ill must meet the state civil service requirements for the titles of Social Worker III or IV, Registered Professional Nurse III or IV, Case Manager I, II, III, IV or V, or Qualified Mental Health Professional.

Case managers providing services to infants and toddlers with special needs must meet the state civil service requirements for the titles Social Worker III or IV, Registered Professional Nurse III or IV, or Qualified Care Coordinator.

Reimbursement rates for targeted case management services are established by the Department of Human Services.

Reimbursement for case assessment and case planning is limited to no more than one each for a recipient in a calendar year unless the recipient requires a reassessment due to a major change in level of functioning due to health, socio-emotional or environmental factors, in which case a second assessment or case plan may be reimbursed.
Reimbursement for ongoing monitoring and service coordination is limited to one claim for each recipient per month, and is only for the services rendered by or under the supervision of the recipient’s designated case manager.

Family Case Management – All infants and pregnant women who are enrolled in medical assistance programs are referred to the Department of Human Services (DHS) for family case management. 

Case management services are also provided to high-risk infants up to age two who are:

• Identified through Illinois Department of Public Health’s Adverse Pregnancy Outcome Reporting System (APORS); or
• Wards of Illinois Department of Children and Family Services (DCFS) identified as high risk children.

These services are reimbursed according to the Medicaid Fee Schedule for case management.

Case management services are covered for the following populations:

• Individuals infected with HIV;
• Pregnant women;
• Individuals age 18 or older identified as seriously mentally ill or seriously emotionally disturbed;
• Children under age 18 who are determined to be seriously emotionally handicapped;
• Individuals age 18 or older who are determined to have a substance-related disorder;
• Children under age 18 who determined to have a substance-related disorder; and
• Infants and toddlers with developmental disabilities.

Components of case management:

• Identification and outreach;
• Individual assessment;
• Service planning;
• Implementation;
• Monitoring of service delivery and utilization; and
• Reassessment.

The supervising physician or Health Service Provider in Psychology (HSPP) bears the ultimate responsibility for certifying the diagnosis and plan of treatment for community mental health rehabilitation services.

Program for infants and toddlers with developmental disabilities is called First Steps Early Intervention.

Reimbursement is based on the lower of the provider’s submitted charge or the established statewide Resource Based Relative Value Scale (RBRVS) fee schedule allowance for the service.

Case management services are covered for:

• Medicaid recipients age 18 or older and have a primary diagnosis of mental retardation, developmental disability or chronic mental illness;
• Medicaid recipients under age 18 receiving Home and Community Based Services (HCBS) Mental Retardation (MR) waiver services;
• Medicaid recipients under age 18 with a primary diagnosis of mental retardation or developmental disability who reside in a child welfare decategorization county under certain conditions.

Case management services require prior authorization from the fiscal agent.  Reauthorization is required on an annual basis.

Residents of Intermediate Care Facilities for the Mentally Retarded (ICF/MR) are not eligible to receive case management services, except for qualified discharge planning activities provided within 30 days of discharge.

The basis of payment for case management services is a monthly payment per enrollee.  The monthly payment is established on the basis of cost information submitted to the Medicaid fiscal agent, and is an average cost per recipient.

Providers are required to submit a projected cost report by July 1 of each year.  This form is used to establish a projected rate for the new fiscal year.

Individualized planning and coordination is provided for the following defined groups:

• MR/DD Waiver Individuals;
• Infants/toddlers with special needs;
• High-risk pregnant women;
• HIV infected individuals;
• EPSDT recipients on MR/DD Waiver waiting list; and
• First time mothers.

Children under age 21 who are on the MR/DD Waiver waiting list are eligible for special case management services.

Case management services are reimbursed at a flat monthly rate billed for each participant.
Direct service providers are reimbursed according to the Medicaid Fee Schedule in the appropriate provider manual.  For services provided by a subcontractor agency, the enrolled direct service provider must reimburse the subcontractor according to the terms of the contract and retain the administrative costs.

Targeted Case Management is covered for the following populations:

• Adults with mental retardation;
• Individuals with HIV;
• Infants and children, birth through age 5, with or at risk for developmental delays;
• Families of children who are abused or neglected or who are at risk of abuse or neglect;
• Children and young adults who are in the care or custody of DHS or of an agency of another state and placed in Maine, and families of children who are receiving post-adoption services;
• Adults in need of protective services;
• Children and adolescents with emotional disturbance, behavioral disorder, mental illness, mental retardation or pervasive developmental disorder;
• Children and adolescents with serious emotional disturbance, ages 11 through 17 residing in Cumberland County;
• Juveniles referred or under supervision of juvenile case workers;
• Pregnant and/or postpartum women and/or those at risk for inadequate parenting;
• Adults with long term care needs;
• Residents of Kennebec, Somerset, Androscoggin, Sagadahoc, Waldo, Penobscot, Knox, Cumberland, York and Lincoln Counties;
• Individuals with Psychoactive Substance Dependence;
• Residents of Franklin, Oxford and Androscoggin Counties;
• Children and adolescents exhibiting high risk behaviors that may result in social, emotional or academic failure, ages 5 to 21 attending a school administrative unit or a private school approved for the provision of special education and supportive services in Maine;
• Families of children who are participating the Healthy Families Benefit; and
• Disease Case Management Program (diabetes and asthma);
• Children and adolescents exhibiting high risk behaviors that may result in social, emotional or academic failure, ages 5 to 21 attending a school administrative unit or a private school approved for the provision of special education and supportive services in Maine;
• Families of children who are participating the Healthy Families Benefit; and
• Disease Case Management Program (diabetes and asthma).

No Special Considerations

Reimbursement for covered services shall be made in accordance with Chapter III, Section 13, Allowances for Case Management Services.
Payment will be made under this Section of the Maine Medical Assistance Manual for case management services provided to an eligible member at any given point in time so long as the service provided does not duplicate service provided by another case manager (see Section 13.04).

Providers of case management services for adults in need of long-term care shall be reimbursed according to the rate of reimbursement negotiated and developed by the Bureau of Elder and Adult Services and approved by the Bureau of Medical Services.

Targeted case management services are provided to individuals infected with HIV/AIDS.

Setting of service – staffed congregate, residential housing programs that meet the Department of Public Health’s AIDS Bureau funding requirements.

The national procedure code for Targeted Case Management is T1017 – Targeted Case Management, Each 15 Minutes.  This code is for services to Mass Health members who have been diagnosed with AIDS and who are living in congregate AIDS housing.
The maximum number of units that can be billed for each member per day is four. 

Case management services are provided to children in foster care, persons with mental illness, children in school-based services, and children with developmental disabilities. Children in Maternal Support services (MSS) programs can also be covered for case management. Children’s Special Health Care Services (CSCHS) also covers case management services for children who have chronic illnesses or disabling conditions if the needs are complex.

CHCHS services must relate to a plan of care. Case managers providing these services have to be RNs.

Pre-paid health plans may include case management and supports coordination services that are provided in any setting or location that the individual prefers. The populations served by pre-paid health plans include: persons with mental illness, persons with developmental disabilities, children with serious emotional disturbance, and persons with substance-abuse disorders.

Targeted case management services, each fifteen minutes are listed under T1017, the national HCPCS code for school-based services. In addition, code 99361 is listed under physician/psychiatrist school based services. This is a case management code described as: “medical conference by a physician with an interdisciplinary team of health professionals--approximately 30 minutes.  Designated case managers have to either be RNs or in the field of special education. (Refer to Michigan Medicaid Provider Manual-SBS) for details.

Targeted case management services are provided to:

• Seriously and persistently mentally ill patients; and
• Children under age 21 who are at risk of placement or in placement, at risk of maltreatment or experiencing maltreatment, or in need of protection or services.

Tuberculosis Case Management – Case management services are furnished to assist persons infected with TB in gaining access to needed medical services, including assessing the need for medical services to treat tuberculosis, developing a plan of care addressing those needs, assisting in accessing medical services identified in the care plan and monitoring compliance with the care plan to ensure completion of tuberculosis therapy.

Tuberculosis case management services are covered if provided by a certified public health nurse, employed by a community health board. 

Payment rate is established in Minnesota Rules, part 9505.0491.

Use code X5698 for Tuberculosis case management. (Refer to HIPAA state crosswalk for new code. This was a local code and the crosswalk would have the current code.)

Case management services are provided to the following Medicaid populations:

• Adults and children at risk of abuse, neglect or exploitation (according to established criteria); these are individuals who are mentally ill, emotionally disturbed, substance abusers or have developmental disabilities.
• Individuals infected with HIV/AIDS.

For services provided to adults and children at risk of abuse, neglect or exploitation, providers must have a Master of Social Work degree or a Bachelor of Social Work degree, or be a social worker who meets the state requirements for Social Worker II classification.  Individuals receiving these services cannot be institutionalized or be receiving services through home and community-based waiver programs.

Individuals with HIV/AIDS may not be institutionalized or be receiving services through home and community-based waiver programs.

Case management services do not require Carolina ACCESS PCP referral.

Reimbursement for case management providers is the same per unit rate (one unit = 15 minutes) for all providers and is determined annually by DMA.

Case management services are covered for adults with mental retardation.  These services include coordinating access to needed medical, social, educational or other services.

Under FFS, case management services are reimbursed according to the Nebraska Medicaid Practitioner Fee Schedule.

Targeted case management is available for the following populations:

• Severe Emotionally Disturbed (SED) Children;
• Seriously Mentally Ill (SMI) persons;
• Developmentally Delayed Infants and Children;
• Mentally Retarded;
• Juveniles on Probation (JPS);
• Child Protective Services (CPS); and
• Blind and Visually Impaired Persons.

These services are reimbursed the lower of billed charges OR the fixed fee established in the Medicaid Fee Schedule.

Case management of advance care planning and directives (CM-ACPD) for individuals with severe illnesses – Includes case management services for individuals enrolled in Medicaid who have been diagnosed as being severely ill, i.e., diagnosed with an illness or medical condition that is expected to result in continuous deterioration and death within approximately two years.

Examples:

• Cancer
• End Stage Cardio-Pulmonary Disease
• Alzheimer’s Disease and Related Disorders
• End Stage Cardiac Disease
• AIDS
• Post Cerebrovascular Accident (Stroke)
• End Stage Renal Disease
• Parkinson’s Disease
• Amyotrophic Lateral Sclerosis (Lou Gehrig’s Disease)

CM-ACPD is a covered service when it is provided by agencies that are enrolled in the NH Medicaid program, licensed as a home health agency by the state in they practice, and are certified Medicare hospice providers.

Payment is made in accordance with fee schedules developed by DHHS for the individual services provided.

Called “Care Management” services.

Specific care management services include:

• Pregnancy services including HealthStart program,
• EPSDT services and coordination for children with elevated blood lead levels,
• Mental health/substance abuse services coordination,
• HIV/AIDS services coordination, and
• Dental services for enrollees with developmental disabilities.
• Other diagnoses where appropriate or requested by provider or patient.

HMOs must have a case/care management component.

HMOs must establish linkages with Ryan White CARE Act grantees for care management services either through a contract, MOA or other cooperative working agreement approved DMAHS.

Reimbursement for case management services not provided under managed care and is provided according to the Medicaid physician fee schedule.

The following types of case management programs are available:

• Abused and neglected adults;
• Chronically mentally ill;
• Developmentally disabled adults;
• EPSDT children;
• Families First;
• Maternal and child care;
• Medically at-risk children;
• Traumatic brain injury; and
• Multiple specialties.

Case management agencies must have a letter of designation showing that the agency is government, Indian tribal government, Indian Health Services or an FQHC.  Agencies must also be certified by either CYFD or DOH.

Reimbursement for these services is made at the lesser of:

• Billed charges; or
• MAD fee schedule for the specific service or procedure.

Defined in the NYS Code of Rules and Regulations as “those services which will assist persons eligible for medical assistance to obtain needed medical, social, psychosocial, educational, financial and other services.”  These services “are meant to assist persons identified as high users of services, or as having problems accessing medical care or services, or as belonging to certain age, diagnostic or specialized program groups, on a statewide basis or limited to persons residing in definable geographic areas.”

The targeted groups for case management in New York are:

• Foster children;
• Prenatal Care Assistance Program (PCAP) – see below under “Extended Services for Pregnant Women”;
• Seriously and Persistently Mentally Ill;
• Developmentally Disabled;
• Pregnant women and infants in high infant mortality areas;
• Pregnant and parenting teens;
• Children ages 0 to 2 who are enrolled in the Early Intervention program; and
• Individuals with HIV/AIDS.

Qualified providers are: facilities licensed or certified under NYS law or regulation, health care or social work professionals licensed or certified in accordance with NYS law, State and local governmental agencies, and home health agencies certified under NYS law. 

Authorization by the social services district or by another State agency empowered by the commissioner is required prior to provision of case management services.  No single authorization for a recipient to receive case management services will exceed 12 months.

Rates, fees or amounts reimbursed for case management services are to be determined utilizing cost estimates included in the provider’s proposal and any other data and information deemed appropriate, and are subject to the approval of the Division of the Budget.
Documentation of the basis for case management reimbursement rates, fees or amounts including the qualifications of staff providing case management services must accompany the provider’s proposal.
No payment to the provider of case management services can be made for authorized services unless such claim is supported by documentation of the time spent in providing services to each recipient.
Payment for case management services may be made on the basis of units of service provided at a particular skill level (i.e., payment per hour or per visit), on a capitated basis (i.e., payment of a flat fee per month or per day for each person eligible for medical assistance in the program, although varied amounts or levels of service may be required), or on such other payment basis as may be approved by the department.

Targeted case management is provided to Children with Special Health Care Needs (CSHCN), especially those with high-risk and chronic conditions such asthma, teen pregnancy and HIV/AIDS.
The Primary Alternative Care and Treatment (PACT) is a case management program for recipients who have exceed the utilization criteria for prescribing physicians, number of office visits and drug use. 

The CSHCN program was developed by the Bureau of Managed Health Care, which monitors MCP delivery of these services and performance.

If enrolled in PACT, clients are asked to select a primary physician to make referrals and a primary pharmacy to dispense all medications.  Any physician who is a Medicaid provider may become an enrollee’s primary physician/case manager. 

These services are billed at the lesser of billed charges of the Medicaid maximum contained in the Ohio Medicaid Fee Schedule.

These services are included in the Managed Care Plan (MCP) capitated rates for Medicaid recipients who are enrolled in MCPs.

Each primary physician may bill the department for a monthly case management fee for each month a PACT client is assigned to him/her.  This fee is not available to primary pharmacies, clinics, FQHCs, or to any other provider, including providers rendering services to an enrolled client on an emergency or referral basis.

Case management services are covered for the following groups:

• Chronically and/or severely mentally ill adults;
• Children under 21 who are at risk of out-of-home placement due to psychiatric or substance abuse problems;
• First time mothers and their infants/children;
• Developmentally delayed infants and toddlers, ages 0 to 3 (Early Intervention Case Management Services);
• High risk pregnant women;
• Individuals infected with TB.

There is also a school-based targeted case management program.   Other targeted case management programs serve the following Medicaid populations:

• Mentally retarded individuals;
• Children under age 18 in emergency, temporary or permanent custody or supervision of the DHS; and
• Children under age 18 who are at risk of or in the temporary custody or supervision of the Office of Juvenile Affairs.

Case management services provided to the chronically and/or severely mentally ill, as well as children under 21 at risk of out-of-home placement due to psychiatric or substance problems are provided by case management agencies that are certified by the Department of Mental Health and Substance Abuse.

Providers of case management services to first time mothers must be certified by the Maternal and Child Health Service Division of the OK Department of Health.  Providers must be RNs and have completed the initial phase of training for case management for first time mothers, and be enrolled for any subsequent phases of required training.

Early Intervention Case Management Services are provided by specialized case managers certified by the Oklahoma State Department of Education.

Case management services provided to high-risk pregnant women are provided by agencies certified by the Oklahoma State Health Department.

Case management services provided to individuals with TB are provided by case managers certified by the Oklahoma State Department of Health.

For mentally ill adults, prospective payment rates are used.  These rates are calculated using an RVU schedule and one of two conversion factors (one public, one private).

For at-risk children under 21, prospective rates are established using RVUs and a single conversion factor.

For first time mothers, reimbursement is made for one case management service per day provided during the pre and postnatal period and first two years of the infant/child’s life.  Case management services are limited to five services per month.

Reimbursement for early intervention case management services is based on a unit of service of 10 minutes.  Reimbursement is at a rate of $4.17 per 10 minutes.  The procedure code is W4558.

For high-risk pregnant women, reimbursement is made for one case management service per day provided during the pre and postnatal period at the rate of $30.06.  Case management services are limited to seven services per pregnancy.  Procedure code W4652 must be used on the CMS 1500.

Reimbursement for TB is based on 30 minute increments at the rate of $30.03 per unit and the procedure code is W4800.

Case management is a covered service, regardless of provision through health plans, PCCM program or FFS.  Prepaid health plans must ensure provision of case management services whether capitated or non-capitated (this includes FCHPs and MHOs).
Case management services include a comprehensive, ongoing assessment of medical, dental or mental health needs plus the development and implementation of a plan to obtain needed services that are capitated or non-capitated, and follow-up, as appropriate, to assess the impact of care.

Exceptional Needs Care Coordination for Aged, Blind and Disabled individuals is a service available through FCHPs that is separate from and in addition to case management services.

Case management is covered by OMAP as FFS if not contracted for by individual health plans.
FCHPs may optionally contract for maternity case management services.
MHOs provide case management for capitated and non-capitated mental health services as defined in the Administrative Rules.

Expands perinatal services to include management of health, economic, social and nutritional factors through the end of pregnancy and a two month postpartum period.

Maternity case managers must be currently licensed as a physician, PA, NP, Certified Nurse Midwife, Direct Entry Midwife, Social Worker or a Registered Nurse with a minimum of two years related and relevant work experience.

Nutritional counselors must be registered dieticians or have a bachelor’s degree in nutrition related field with two years of related work experience.

Services are over and above medical management of pregnant clients.

Intensive nutritional counseling services are covered.

FCHPs may optionally contract for maternity case management services.  Those that choose to do so receive an additional capitation amount that varies by eligibility category.  No plans elected to provide this service for FY 2002.

OMAP forms 2470, 2471 or 2472 must be used for maternity case management documentation.

Reimbursement is made according to the level of case management that is delivered.  These codes and explanations are found in the Medical Surgical Provider Guide.

Targeted Case Management (TCM) Services in Pennsylvania are provided to:

• Categorically and medically needy recipients who have contracted AIDS or symptomatic HIV;
• Categorically needy adult recipients with severe and persistent mental illness and children with a severe mental illness or emotional disturbance; and
• Those pregnant women with a high incidence of medical and/or social problems that could constitute a serious hazard and may result in complication, prolonged hospitalization or death of the mother and/or the fetus.

Pennsylvania has also included in their state plan targeted case management services for eligible recipients with mental retardation.

The state has established a certification procedure for case managers. 

The Department of Public Welfare’s coverage for TCM services is limited to a specified number of hours per 30-day period as determined by the Department as appropriate for the specific target group, and included in the MA Program Fee Schedule.  Payment will be made for TCM services provided by only one MA case manager per recipient for a given period of time determined by the Department.

Targeted Case Management programs:

• Adult Mental Health
• Early Intervention Services
• Adolescent Pregnancy Program Special Education Services
• Lead Program
• Head Start
• Child Development Center Program
• Services for the Blind and Visually Impaired
• HIV/AIDS Program
• RI Family Court Program

There are specific requirements for providers serving each population.

Case management services are reimbursed according to the Rhode Island Medical Assistance Fee Schedule.

Targeted to individuals of any age with mental retardation or mental illness; services intended to help obtain medical, social, educational and other services; also services for infants and toddlers with developmental disabilities (early childhood intervention service coordination), high risk pregnant women and infants, blind and visually impaired children, children up to age 20 in foster care, or those who receive in-home services or adoption assistance; elderly or disabled who receive services From the Department of Protective and Regulatory Services.

The State requires that a provider apply for, and receive, additional and separate provider status for case management services. However, many case management service claims, including EPSDT, are made directly to NHIC, and providers need not enroll with STAR and STAR+PLUS plans.

Typical components of service: initial risk assessment; individual service plan development; comprehensive risk assessment; service plan implementation; monitoring and reassessment.

Providers to individuals with mental illness or retardation are paid a statewide interim rate; after annual reimbursement period, each provider’s allowable costs are compared to interim payment and reconciliation is made up to 125% of the statewide rate. If provider’s costs are less than 95% of the interim rate, the provider must pay the difference between the provider’s costs and 95% of the statewide rate. For services to women and children, initial rates are set by the state, later a specified rate is established using cost-based prospective rates. Case management services are frequently “carved-out” from managed care, i.e. claims for services may be directly submitted to NHIC and are not included in the capitated payment.  Current rates for each service are listed in the Medicaid Provider Procedures Manual, under the appropriate section.

Targeted groups:

• Mentally ill with long term mental illness
• Individuals with mental retardation who live at home, in individualized residential facilities, or licensed and unlicensed community care homes that do not receive funding from Medicaid. 
• High risk children (IEP/IFSP)
• Families whose children are abused or neglected or suspected of being at imminent risk thereof; Children and adolescents who are in the care or custody of the Department of Social and Rehabilitation Services or of an agency in another state and placed in Vermont; and Families of children receiving post-adoption assistance 
• Pregnant and postpartum woman and infants through twelve months of age enrolled in the Vermont Department of Health, Healthy Babies Program
• Children ages 1-5 years who are at risk for unnecessary and avoidable medical interventions and who do not have another case management provider whose responsibility is to provide or coordinate the interventions included in this service.

Reimbursement basis is the lower of the provider’s charge or the Medicaid rate on file. 

The following case management programs are available:

• Maternity Support Services (MSS) – For eligible pregnant women through the maternity cycle. Includes community health nursing visits, nutrition visits, behavioral health visits and community health worker visits.
• Infant Case Management (ICM) – Part of MSS services to service high risk infants and their families.
• HIV/AIDS Case Management

Infant Case Management (ICM) is considered a family-based intervention.  Therefore the infant [and family] are only allowed one Title XIX Targeted Case Manager at a time.

Individuals enrolled in managed care are eligible for case management services outside their plan.  Providers should bill MAA directly.

MSS is reimbursed according to the Medicaid Fee Schedule (code T1023 HD).

ICM is reimbursed according to the Medicaid Fee Schedule (code T1017 HD).  One unit equals 15 minutes.

Travel expenses, charting time/documents, phone calls and mileage are included in the reimbursement rate for ICM.  For ICM, a maximum of 6 units may be billed per month and a maximum of 40 units may be billed during the 10 months (following the maternity cycle).

HIV/AIDS Case Management is reimbursed according to the Medicaid Fee Schedule (code T2022, modifiers U8 and U9).

TCM is available to the following populations:

• Persons age 65 or over;
• Persons with a diagnosis of Alzheimer’s disease or related dementia;
• Persons with a developmental disability
• Persons who are age 21 or older with a chronic mental illness;
• Persons with a physical or sensory disability;
• Persons having an alcohol or drug dependency;
• Persons diagnosed as having HIV infection;
• Persons who are severely emotionally disturbed and under age 21;
• Persons diagnosed with asthma and under age 21
• Persons infected with tuberculosis
• Women 45 to 64 years old
• Children enrolled in a Birth to 3 Program; and
• Families with a child(ren) under age 21 who is at risk of a physical, mental or emotional dysfunction.

These services may only be provided by certified case management agencies.

Wisconsin Medicaid covers case management services on a FFS basis for recipients enrolled in Medicaid-contracted HMOs.

The following special managed care program include case management as a covered service; therefore, case management may not be billed separately to Wisconsin Medicaid for individuals enrolled in these programs:

• Children Come First (CCF);
• Community Care for the Elderly;
• Community Health Partnership;
• Community Living Alliance;
• Elder Care Options; and
• Wraparound Milwaukee(WAM).

DHFS establishes contracted hourly rates for all covered services provided by certified case management agencies.  The contracted hourly rates are based on various factors, including a review of budgetary constraints and other relevant economic limitations.
Providers are required to bill their usual and customary charge.  For providers using a sliding fee scale, the usual and customary charge is the median of the provider’s charge for the service when provided to non-Medicaid patients.
For each covered service, DHFS pays the federal Medicaid share of the contracted hourly rate.  Medicaid reimbursement, less appropriate copayments and payments by other insurers will be considered payment in full.
Providers are reimbursed by Medicaid only for that portion of allowable costs for which federal financial participation (FFP) is available.  The State share shall come from non-federal funds available to case management agencies.