OHCA Policies and Rules

Search Entire Policy
OHCA Policies and Rules Main Page

Part 97      TARGETED CASE MANAGEMENT SERVICES FOR MEMBERS UNDER TWENTY-ONE YEARS OF AGE AT RISK OF INVOLVEMENT WITH OR IN THE TEMPORARY CUSTODY OR SUPERVISION OF THE OKLAHOMA OFFICE OF JUVENILE AFFAIRS (OJA)

317:30-5-970.Eligible providers

[Revised 09-14-2020]
(a) Case management agency qualifications. As the provider agency, the Oklahoma Office of Juvenile Affairs (OJA) must meet applicable state and federal laws governing the participation of providers in the Medicaid program. The Office of Juvenile Affairs Targeted Case Management (OJATCM) program must:

(1) Be available to all eligible members;

(2) Be delivered on a statewide basis with procedures that assure twenty-four (24) hour availability, the protection and safety of recipients, and continuity of services without duplication;

(3) Ensure compliance with federal and state mandates and regulations related to serving the targeted population are met in a consistent and uniform manner;

(4) Meet applicable state and federal laws governing the participation of providers in the Medicaid program, including, but not limited to, the ability to meet federal and state requirements for documentation billing and audits;

(5) Demonstrate that its staff has experience working with the target population and a minimum of five (5) years' experience in providing all core elements of case management including:

(A) Individual strengths and needs assessment;

(B) Needs-based service planning;

(C) Service coordination and monitoring; and

(D) Ongoing assessment and treatment plan revision.

(6) Have adequate administrative capacity to fulfill state and federal requirements;

(7) Have financial management capacity and systems that provide documentation of services and costs in accordance with Generally Accepted Government Auditing Standards (GAGAS);

(8) Have the capacity to document and maintain individual case records in accordance with state and federal requirements;

(9) Have a minimum of five (5) years' experience in providing and meeting the case management and service needs of the target population;

(10) Have responsibility for planning and coordinating statewide juvenile justice and delinquency prevention services in accordance with Title 10A of the Oklahoma Statutes (O.S.), Section ( ' ) 2-2-102; and

(11) Have the ability to evaluate the effectiveness, accessibility, and quality of targeted case management (TCM) services on a community-wide basis.

(b) Interagency agreement. An agreement between the Oklahoma Health Care Authority (OHCA) and OJA for TCM services must be in effect before Medicaid reimbursement can be made for compensable services.

(c) Case manager qualifications. A targeted case manager for the OJATCM program must:

(1) Be employed by OJA;

(2) Possess a minimum of a bachelor's degree in a behavioral science, or a bachelor's degree and one (1) year of professional experience in juvenile justice or a related field;

(3) Possess knowledge of:

(A) Laws, regulations, legislation, policies, and procedures as they pertain to the State's administration of juvenile justice and the investigation of juvenile delinquency;

(B) Community resources;

(C) Human developmental stages, developmental disorders, and social work theory and practices;

(D) Adverse childhood experiences and the impact of trauma on the developing brain;

(E) The risk and protective factors of child delinquency;

(F) Solution-focused practices and the critical role protective factors play in intervention planning;

(G) Sensitivity of cultural diversity; and

(H) Clinical and counseling techniques and treatment of juvenile delinquency;

(4) Possess skills in:

(A) Crisis intervention;

(B) Gathering necessary information to determine the needs of the child;

(C) Casework management;

(D) Courtroom testimony, terminology, and procedures;

(E) Effective communication;

(F) Developing, evaluating, and modifying, as appropriate, intervention planning on an ongoing basis;

(G) Establishing and maintaining supportive relationships with children and their families;

(H) Assisting children and families to access needed resources and supports; and

(I) Working with courts and law enforcement entities; and

(5) Have the ability to access multi-disciplinary staff, when needed. This includes, at a minimum, medical professionals and a child protective services social worker.



317:30-5-971.Coverage by category
[Revised 09-14-2020]

The target group includes individuals under twenty-one (21) years of age involved in, or at serious risk of involvement with, the juvenile justice system, as provided in Article II of the Oklahoma Juvenile Code. The target group includes individuals, under twenty-one (21) years of age, who have been temporarily placed in OJA custody or supervision or who are voluntarily supervised by OJA to prevent further involvement with the juvenile justice system. The target group may include individuals, under twenty-one (21) years of age, who are assessed as at risk of abuse or neglect as defined in Title 10A of the Oklahoma Statutes (O.S.), Section ( ' ) 1-1-105. The target group does not include those who are involuntarily in secure custody of law enforcement or judicial systems, except individuals who meet Medicaid criteria for inpatient care as defined in ' 435.1010 of Title 42 of the Code of Federal Regulations.

(1) Adults.  There is no coverage for adults age twenty-one (21) and older.

(2) Children.  Payment is made for services to members under the age twenty-one (21).

 

317:30-5-971.1.Description of targeted case management (TCM) services

[Issued 09-14-2020]
(a) Definition. In accordance with Section (
' ) 440.169(b) of Title 42 of the Code of Federal Regulations (C.F.R.), TCM services are defined as services furnished to assist individuals, eligible under the Oklahoma Medicaid State Plan, in gaining access to needed medical, social, educational, and other services. TCM includes providing services that are directly related to identifying the individual's needs and care, for the purposes of helping the individual access services; identifying needs and supports to assist the individual in obtaining services; providing case managers with useful feedback, and alerting case managers to changes in the individual's needs [42 C.F.R. 440.169(e)]. TCM includes the following assistance:

(1) Comprehensive assessment and periodic reassessment of an individual's needs, to determine the need for any medical, educational, social, or other services.

(A) All members are assessed using comprehensive, evidence-based, risk/needs assessment tools at the beginning of case assignment.

(B) Comprehensive, evidence-based, risk/needs assessment tools are used to measure multiple areas or domains in the lives of the members and then linking that information to case planning.

(C) Any area showing a moderate to high-risk/need/strength score could result in additional goals and action steps documented within the individualized treatment plan.

(D) In addition to the initial assessment, each member is assessed, at least once every six (6) months. Assessment activities include:

(i) Taking member history;

(ii) Identifying and documenting the member's needs; and

(iii) Gathering information from family members, medical providers, social workers, educators (if necessary), and other applicable sources to form a complete assessment of the member.

(E) Should behavior shifts or life-changing events occur prior to six (6) months, the member is reassessed and the individualized treatment service plan is adjusted to reflect identified needs. Any needed changes in services, service providers, treatment type, frequency, or duration may be adjusted at this time.

(2) Development (and periodic revision) of a specific individualized treatment service plan is based on the information collected through the assessment that:

(A) Specifies the goals and actions to address the medical, social, educational, and other services needed by the individual;

(B) Includes activities such as ensuring the active participation of the individual, and working with his or her authorized health care decision maker and others to develop those goals; and

(C) Identifies a course of action to respond to the assessed needs of the individual.

(3) Referral and related activities (such as scheduling appointments for the member) to help the individual obtain needed services, including activities that help link the member with medical, social, educational providers, or other programs and services that are capable of providing needed services to address identified needs and achieve goals specified in the treatment service plan.

(4) Monitoring and follow-up activities necessary to ensure the individualized treatment service plan is implemented and adequately addresses the individual's needs.

(A) The targeted case manager visits with the child at least once each month, face to face, and/or weekly (via telephone) to review progress as outlined within the individualized treatment service plan. The targeted case manager must visit with the parent or legal guardians monthly. The targeted case manager maintains consistent contact with the service providers to remain up to date on the child's treatment and progress.

(B) The frequency and type of visits may be adjusted or revised to better meet the needs of the child.

(C) Monitoring and follow-up activities may be conducted as frequently as necessary, including at least one (1) annual monitoring, to determine whether the following conditions are met:

(i) Services are being furnished in accordance with the member's treatment service plan;

(ii) Services in the treatment service plan are adequate; and

(iii) Changes in the needs or status of the member are reflected in the treatment service plan. Monitoring and follow-up activities include making necessary adjustments in the treatment service plan and service arrangements with providers.

(b) Non-covered services. TCMdoes not include:

(1) Physically escorting or transporting a member to scheduled appointments or staying with the member during an appointment;

(2) Monitoring financial goals;

(3) Providing specific services such as shopping or paying bills; and/or

(4) Delivering bus tickets, nutritional services, money, etc.

(c) Non-duplication of services. Consistent with 42 C.F.R. ' 441.18(a)(4), payment for case management or TCM services shall not duplicate payments made to public agencies or private entities under the Oklahoma Medicaid State Plan or other program authorities.

(d) Individuals eligible for Part B of Medicare. Case management services provided to Medicare eligible recipients are filed directly with the fiscal agent.

317:30-5-972.Reimbursement

[Revised 09-14-2020]
(a) Targeted case management (TCM) services will be reimbursed pursuant to the methodology described in the Oklahoma Medicaid State Plan.

(b) The reimbursement methodology is based upon qualifying costs for the eligible population from the Cost Allocation Plan. The TCM unit rate is a prospective flat rate based on a qualifying TCM contact with the member in the target population or with some other person on behalf of the member during the claim period.

 

317:30-5-973.Billing

[Revised 09-14-2020]
   Billing for case management services must be submitted, ensuring no duplication of services, and in accordance with state and federal requirements, reflective of guidelines found at Oklahoma Administrative Code (OAC) 317:30-3-11, 317:30-3-11.1, and 317:30-3-20.



317:30-5-974.Documentation of records

[Revised 09-14-2020]
(a) The Oklahoma Office of Juvenile Affairs (OJA) must maintain case records that document for all members receiving targeted case management (TCM) as follows:

(1) The name of the member;

(2) The dates of the case management services;

(3) The name of the OJA as the provider agency (if applicable) and the person providing the case management service;

(4) The nature, content, units of the case management services received, and whether goals specified in the treatment service plan have been achieved;

(5) Whether the member has declined services in the treatment service plan;

(6) The need for, and occurrences of, coordination with other case managers;

(7) A timeline for obtaining needed services; and

(8) A timeline for reevaluation of the plan.

(b) All case management services rendered must be reflected by documentation in the records. All TCM units provided to the member must be documented by the case manager on the electronic case management system designated by OJA.



Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.