Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 138 - TARGETED CASE MANAGEMENT › Section 410-138-0000 - Targeted Case Management Definitions

Current through Register Vol. 63, No. 7, July 1, 2024
The following definitions apply to OAR 410-138-0000  through
				410-138-0420:
(1) "Assessment" means
			 the act of gathering information and reviewing historical and existing records
			 of an eligible client in a target group to determine the need for medical,
			 educational, social, or other services. To perform a complete assessment, the
			 case manager shall gather information from family members, medical providers,
			 social workers, and educators, if necessary.
(2) "Care Plan" means a Targeted Case
			 Management (TCM) Care Plan that is a multidisciplinary plan that contains a set
			 of goals and actions required to address the medical, social, educational, and
			 other service needs of the eligible client based on the information collected
			 through an assessment or periodic reassessment.
(3) "Case Management" means services
			 furnished by a case manager to assist individuals eligible under the Medicaid
			 State Plan Amendment (SPA) in gaining access to and effectively using needed
			 medical, social, educational, and other services (such as housing or
			 transportation) in accordance with
			 42 CFR
			 441.18. See also the definition for Targeted
			 Case Management.
(4) "Centers for
			 Medicare and Medicaid Services (CMS)" means the federal agency under the U.S.
			 Department of Health and Human Services that provides the federal funding for
			 Medicaid and the Children's Health Insurance Program (CHIP).
(5) "Children and Youth with Special Health
			 Care Needs (CYSHCN)" means those children and youth who have or are at
			 increased risk for a chronic physical, developmental, behavioral, or emotional
			 condition and who also require health and related services of a type or amount
			 beyond that required by children generally.
(6) "Department" means the Department of
			 Human Services (Department).
(7)
			 "Division" means the Oregon Health Authority's Health Systems
			 Division.
(8) "Duplicate Payment"
			 means more than one payment made for the same services to meet the same need
			 for the same client at the same point in time.
(9) "Early Childhood Special Education
			 (ECSE)" means free, specially designed instruction to meet the unique needs of
			 a preschool child with a disability, three years of age until the age of
			 eligibility for public school, including instruction in physical education,
			 speech-language services, travel training, and orientation and mobility
			 services. Instruction is provided in any of the following settings: home,
			 hospitals, institutions, special schools, classrooms, and community childcare
			 or preschool settings.
(10) "Early
			 Intervention (EI)" means services for preschool children with disabilities from
			 birth until three years of age, including Indian children and children who are
			 homeless and their families.
(11)
			 "Early Intervention/Early Childhood Special Education (EI/ECSE) Services" means
			 services provided to a preschool child with disabilities, eligible under the
			 Individuals with Disabilities Education Act (IDEA) from birth until they are
			 eligible to attend public school, pursuant to the eligible child's
			 Individualized Family Service Plan (IFSP).
(12) "EI/ECSE Case Manager (i.e., service
			 coordinator)" means an employee of the EI/ECSE contracting or subcontracting
			 agency meeting the personnel standards requirements in OAR 581-015-2900. The
			 EI/ECSE case manager serves as a single point-of-contact and is responsible for
			 coordinating all services across agency lines for the purpose of assisting an
			 eligible client to obtain needed medical, social, educational, developmental,
			 and other appropriate services (such as housing or transportation) identified
			 in the eligible client's care plan in coordination with the client's
			 IFSP.
(13) "EI/ECSE TCM Program"
			 means a service under the State Plan and includes case management services
			 furnished to eligible EI/ECSE preschool children age 0-5 with disabilities,
			 assisting them to gain access to needed medical, social, educational,
			 developmental, and other appropriate services (such as housing or
			 transportation) in coordination with their IFSP. EI/ECSE TCM providers shall
			 meet the criteria for the provision of special education programs approved by
			 the State Superintendent of Public Instruction qualifying such programs for
			 state reimbursement under OAR 581-015-2710  EI/ECSE and shall be contractors
			 with the Oregon Department of Education in the provision of EI/ECSE services or
			 be sub-contractors with such a contractor. Medicaid reimbursement for EI/ECSE
			 TCM services is available only to eligible clients in the target group and does
			 not restrict an eligible client's free choice of providers.
(14) "Eligible Client" means an individual
			 who is found eligible for Medicaid or the Children's Health Insurance Program
			 (CHIP) by the Oregon Health Authority (Authority) and eligible for case
			 management services (including TCM services) as defined in the Medicaid State
			 Plan at the time the services are furnished.
(15) "Federal Financial Participation (FFP)"
			 means the portion paid by the federal government to states for their share of
			 expenditures for providing Medicaid services. FFP was created as part of the
			 Title XIX, Social Security Act of 1965. There are two objectives that permit
			 claims under FFP. They are:
(a) To assist
			 individuals eligible for Medicaid to enroll in the Medicaid program;
			 and
(b) To assist individuals on
			 Medicaid to access Medicaid providers and services. The second objective
			 involves TCM.