Policy Resources: Targeted Case Management, CMS Interim Final Rule

Ensuring adequate financing for the treatment and rehabilitation services that member agencies provide is the fundamental service that the National Council provides to its members. In that spirit, this page presents an initial summary of the Interim Final Rule released by the Centers for Medicare and Medicaid Services regarding the provision of case management and Targeted Care Management in Medicaid.

National Council staff are in active dialogue with mental health, disability, Medicaid, and legal experts in an attempt to analyze and prepare a response to this regulation. The National Council shares this summary with its membership in an attempt to alert you to potential issues raised in the regulations and to hear your questions and concerns with the rule.

The National Council recently hosted a Town Hall Meeting for members on this issue. During this call, National Council staff offered an overview of the Interim Final Rule and answered questions from members.

In the Interim Final Rule, the Centers for Medicare and Medicaid Services indicate that there is a 60-day window for submitting comments. However, it must be noted that this regulation is being published as an Interim Final Rule, meaning that it will go into effect 90 days after being published.

The National Council will take significant action to limit any possible negative effect of these new rules. CMS estimates that as a result of this rule, Federal Medicaid spending on case management and targeted case management services will be reduced by $1,280 million between FY 2008 and FY 2012.

The Interim Final Rule was published on December 4, 2007.

The preamble begins by explaining that “case management is commonly understood to be an activity that assists individuals in gaining access to necessary care and services appropriate to their needs …In the context of this regulation, it is the individual’s access to care and services that is the subject of this management – not the individual.”

It should also be noted that the definition of case management in the Deficit Reduction Act was effective January 1, 2006. The provisions of this rule are effective 90 days after the date of publication of this rule (December 4, 2007). The complete definition is found at the end of this document.

While the rest of this document provides more detail, we will summarize the major changes contained in the Interim Final Rule:

Medicaid beneficiaries receiving case management can have only one plan and one 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, such as Rehabilitative Services, if the case manager meets the provider qualifications.

Specific Provisions

440.169 Case Management Services

This section provides definition of case management and Targeted Case Management. Additionally, it provides clarification regarding case management activities for individuals transitioning to a community setting from an institutional setting:

Persons between the ages of 22 and 64, residing in an IMD, or who are in a public institution are excluded from this case management activity;

If the institutional stay was 180 days or longer, than the services may be provided in the last 60 days of that period;

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

Payment for these case management 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 is clarifying that case management services are only provided to individuals in the community, or transitioning to the community. However, these requirements may provide onerous to community providers as discharge delays or other factors outside the control of the community provider may affect reimbursement. It is also not clear how community providers will document that all of these conditions have been met in order to claim FFP.

Comprehensive Assessment

CMS is requiring that the assessment performed by the case manager address: all areas of need, the individual’s strengths and preferences, and consider the individual’s physical and social environment. CMS further clarifies that performance of a comprehensive assessment can minimize the need for an individual to be covered under multiple case management plans and have multiple case managers, and can reduce the likelihood of service duplication and inefficiencies.

Periodic assessment needs to occur at least once a year.

The individual [Medicaid recipient] cannot be required to receive services from a particular provider – or from any provider – if the individual chooses. If the individual declines services listed in the care plan, this must be documented in the case records.

In the Interim Final Rule, CMS provides the following as a partial list of activities that qualify as case management activities:

Assessment of an eligible individual to to determine service needs;
Development of a specific care plan based on the information collected through an assessment;
Referral and related activities to help an individual obtain needed services; and
Monitoring and follow-up activities.

Further, case management does not include the direct services, program, or activity to which the individual is linked.

Case management services must be provided by a single Medicaid case management provider. Thus, when an individual could be served by more than one targeted case management plan amendment (for example when the individual has both mental retardation and a mental illness) a decision must be made concerning the appropriate target group so that the individual will have one case management provider.

CMS intends to provide for a delayed compliance date so that States will have a transition period of the lesser of 2 years or 1 year after close of the first regular session of the State Legislature that begins after this regulation becomes final before it will take enforcement action on the requirement for one case manager to provide comprehensive services to individuals.

441.18 Case Management Services

(1) Beneficiaries cannot be forced to use certain providers, therefore, except for Targeted Case Management Services for individuals with development disabilities, or mental illness, individuals eligible to receive case management (or TCM) must be free to choose their case management provider from those that qualify.

If the case manager also provides other services under the plan, the State must ensure that a conflict of interest does not exist that will result in the case manager making self-referrals.

Case management does not include the actual direct services that an individual obtains. For this reason, if a case manager provides a direct service - such as counseling - during the course of a case management visit, the direct service cannot be reimbursed as part of the State’s case management service. This service may be covered under another Medicaid service category, such as rehabilitation services, if the service is covered under the State plan, the case manager is also a qualified provider of that service, and the individual chooses to receive the service from the case manager.

The performance of diagnostic tests is also a direct service and therefore not covered as part of case management.

(2) States cannot use case management to restrict access to other Medicaid services.

(3) States cannot compel an individual to receive case management, condition receipt of case management services on the receipt of other services, or condition receipt of other Medicaid services on receipt of case management (or TCM).

(6) States must prohibit providers of case management services from exercising the State agency’s authority to authorize or deny the provision of other Medicaid services.

(7) States must require providers to maintain case records for all individuals receiving case management that document the following:

(i) the name of the individual

(ii) the dates of case management services

(iii) the name of the provider agency and the name of the person providing case management services

(iv) the nature, content, units of case management services received and whether goals specified in the care plan have been achieved

(v) whether the individual has declined services in the care plan

(vi) the need for, and occurrences of, coordination with other case managers

(vii) a timeline for obtaining needed services

(viii) a timeline for reevaluation of the plan

(8) States must submit State Plan Amendment(s) in order to be in compliance with these new rules. These State Plan Amendments (SPAs) must specify a number of things, including the payment methodology in units that do not exceed 15 minutes.

Case management services that are integral to other programs are not covered, including:

Child welfare/child protective services: the Interim Final Rule specifies that "...case management activities included under therapeutic foster care programs will be subject to this payment exclusion since these activities are inherent to the foster care program."

Probation and Parole

Guardianship

Special education: the Interim Final Rule makes an exception only for "...case management that is included in an individualized education program or individualized family service plan consistent with section 1903(c) of the Act."

In each of these cases, Medicaid beneficiaries who are receiving these other services can still qualify for case management if they fall within the respective target group for that service.

Sec. 6052. Reforms of Case Management and Targeted Case Management

(a) IN GENERAL.—Section 19 15(g) of the Social Security Act (42 U.S.C. 1396n(g)(2)) is amended by striking paragraph (2) and inserting the following:

‘‘(2) For purposes of this subsection:

‘‘(A)(i) The term ‘case management services’ means services which will assist individuals eligible under the plan in gaining access to needed medical, social, educational, and other services. ‘‘(ii) Such term includes the following:

‘‘(I) Assessment of an eligible individual to determine service needs, including activities that focus on needs identification, to determine the need for any medical, educational, social, or other services. Such assessment activities include the following:

‘‘(aa) Taking client history.

‘‘(bb) Identifying the needs of the individual, and completing related documentation.

‘‘(cc) 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 individual.

‘‘(II) Development of a specific care plan based on the information collected through an assessment, that specifies the goals and actions to address the medical, social, educational, and other services needed by the eligible individual, including 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 such goals and identify a course of action to respond to the assessed needs of the eligible individual.

‘‘(III) Referral and related activities to help an individual obtain needed services, including activities that help link eligible individuals with medical, social, educational providers or other programs and services that are capable of providing needed services, such as making referrals to providers for needed services and scheduling appointments for the individual.

‘‘(IV) Monitoring and follow-up activities, including activities and contacts that are necessary to ensure the care plan is effectively implemented and adequately addressing the needs of the eligible individual, and which may be with the individual, family members, providers, or other entities and conducted as frequently as necessary to help determine such matters as—

‘‘(aa) whether services are being furnished in accordance with an individual’s care plan;

‘‘(bb) whether the services in the care plan are adequate; and

‘‘(cc) whether there are changes in the needs or status of the eligible individual, and if so, making necessary adjustments in the care plan and service arrangements with providers.

‘‘(iii) Such term does not include the direct delivery of an underlying medical, educational, social, or other service to which an eligible individual has been referred, including, with respect to the direct delivery of foster care services, services such as (but not limited to) the following:

‘‘(I) Research gathering and completion of documentation required by the foster care program.

‘‘(II) Assessing adoption placements.

‘‘(III) Recruiting or interviewing potential foster care parents.

‘‘(IV) Serving legal papers.

‘‘(V) Home investigations.

‘‘(VI) Providing transportation.

‘‘(VII) Administering foster care subsidies.

‘‘(VIII) Making placement arrangements.

‘‘(B) The term ‘targeted case management services’ are case management services that are furnished without regard to the requirements of section 1902(a)(1) and section 1902(a)(10)(B) to specific classes of individuals or to individuals who reside in specified areas.

‘‘(3) With respect to contacts with individuals who are not eligible for medical assistance under the State plan or, in the case of targeted case management services, individuals who are eligible for such assistance but are not part of the target population specified in the State plan, such contacts—

‘‘(A) are considered an allowable case management activity, when the purpose of the contact is directly related to the management of the eligible individual’s care; and

‘‘(B) are not considered an allowable case management activity if such contacts relate directly to the identification and management of the noneligible or nontargeted individual’s needs and care.

‘‘(4)(A) In accordance with section 1902(a)(25), Federal financial participation only is available under this title for case management services or targeted case management services if there are no other third parties liable to pay for such services, including as reimbursement under a medical, social, educational, or other pro-gram.

‘‘(B) A State shall allocate the costs of any part of such services which are reimbursable under another federally funded program in accordance with OMB Circular A–87 (or any related or successor guidance or regulations regarding allocation of costs among federally funded programs) under an approved cost allocation program.

‘‘(5) Nothing in this subsection shall be construed as affecting the application of rules with respect to third party liability under programs, or activities carried out under title XXVI of the Public Health Service Act or by the Indian Health Service.’’.

(b) REGULATIONS.—The Secretary shall promulgate regulations to carry out the amendment made by subsection (a) which may be effective and final immediately on an interim basis as of the date of publication of the interim final regulation. If the Secretary provides for an interim final regulation, the Secretary shall provide for a period of public comments on such regulation after the date of publication. The Secretary may change or revise such regulation after completion of the period of public comment.

EFFECTIVE DATE.—The amendment made by subsection (a) shall take effect on January 1, 2006.

The direct delivery of an underlying medical, educational, social, or other service to which an eligible individual has been referred is not reimbursable as case management.

Medicaid payment (FFP) will not be available for these activities.

Print Page \| Email Page

Real Stories National Council member organizations across the country work hard to give nearly 6 million adults, children, and families with mental illnesses and addiction disorders a chance to recover and lead productive lives. Read their stories

Policy Resources: Targeted Case Management, CMS Interim Final Rule

Specific Provisions

Real Stories