Oregon Health Authority
Health Systems Division: Medical Assistance Programs - Chapter 410
Division 138
TARGETED CASE MANAGEMENT
410-138-0060
Targeted Case Management Program — Provider Requirements
(1) This rule is in effect for services rendered retroactive to July 1, 2009, except for the TCM Asthma/Heathy Homes Program that is retroactive to July 1, 2010; Babies First!, CaCoon, and Nurse-Family Partnership for services rendered effective January 1, 2017; and NNHV approved by CMS effective July 1, 2019.
(2) TCM Public Health Nurse Home Visiting (Babies First!, CaCoon, NNHV, and Nurse-Family Partnership) targeted case managers may be an employee of a Local County Health Department or other public or private agency contracted by a Local Public Health Authority with the demonstrated ability to meet all state and federal laws governing the participation of providers in the state Medicaid program and the ability to provide data to the Maternal and Child Health (MCH) Data System. TCM services provided under the Universally Offered Newborn Nurse Home Visiting Program as defined in Public Health 333, Division 6 Newborn Nurse Home Visiting must be provided by certified providers.
(3) TCM Asthma/Healthy Homes, Early Intervention/Early Childhood Special Education (EI/ECSE), and Human Immunodeficiency Virus (HIV) provider organizations shall be unit of government providers. TCM EI/ECSE providers may also be a subcontractor of a government entity.
(4) TCM Substance Abusing Pregnant Women and Substance Abusing Parents with Children Under Age 18 provider organizations shall be locally based agencies.
(5) TCM Federally Recognized Tribal Governments providers shall be Indian Health Services/638 facilities.
(6) All providers shall demonstrate the ability to provide all core elements of case management services including:
(a) Comprehensive assessment, which may include triage and environmental assessment of client needs;
(b) Reassessment of the client’s status and needs annually or more frequently with a significant change in the client’s condition;
(c) Development and periodic revision of a comprehensive care and service plan;
(d) Referral and linking/coordination of services;
(e) Ongoing monitoring and follow-up of referral and related services;
(f) A financial management capacity and system that provides documentation of services and costs and provides computerized tracking and monitoring to assure adequate follow-up and avoid duplication.
(7) Except for Federally Recognized Tribal Governments and the Newborn Nurse Home Visiting Program, the TCM provider shall provide the non-federal matching share from public funds in compliance with OAR 410-138-0005.
(8) If the provider is a subcontractor of a governmental entity, the governmental entity shall make the non-federal matching share with public fund payments in compliance with OAR 410-138-0005.
(9) All program providers shall demonstrate the following TCM experience and capacity:
(a) Understanding and knowledge of local and state resources and services available to the target population;
(b) Demonstrated case management experience in coordinating and linking community resources as required by the target population;
(c) Demonstrated and documented experience providing services for the target population;
(d) An administrative capacity to ensure quality of services in accordance with state and federal requirements;
(e) A financial management capacity and system that provides documentation of services and costs;
(f) Capacity to document and maintain client case records in accordance with state and federal requirements, including requirement for recordkeeping on OAR 410-138-0007 and 410-120-1360; confidentiality requirements in ORS 192.518–192.524,179.505 and 411.320; and HIPAA Privacy requirements applicable to case management services;
(g) A sufficient number of staff to meet the case management service needs of the target population;
(h) Demonstrated ability to meet all state and federal laws governing the participation of providers in the state Medicaid program; and
(i) Enrolled as a TCM provider with the Authority and meeting the requirements set forth in the provider enrollment agreement.
(10) TCM Asthma/Healthy Homes Program case managers shall possess the following additional qualifications:
(a) A current active Oregon registered nurse (RN) license; or
(b) A registered environmental health specialist; or
(c) An asthma educator certified by the National Asthma Education and Prevention Program; or
(d) A community health worker certified by the Stanford Chronic Disease Self-Management Program; or
(e) A case manager working under the supervision of a licensed registered nurse or a registered environmental specialist.
(11) The TCM case managers for the Public Health Nurse Home Visiting, Babies First!, CaCoon, and Nurse-Family Partnership programs:
(a) May be an employee of a local county health department or other public or private agency contracted by a Local Public Health Authority;
(b) Shall be a licensed registered nurse with experience in community health, public health, or child health nursing; and
(c) May be a community health worker, family advocate, or promotora working under the plan developed by a licensed registered nurse. The minimum qualifications of the Community Health Workers, Family Advocates, or Promotoras are as follows:
(A) High School Graduate or GED with additional course work in human growth and development, health occupations, or health education; and
(B) Two years’ experience in public health, mental health, or alcohol drug treatment settings; or
(C) Any satisfactory combination of experience and training that demonstrates the ability to perform case management duties;
(D) The case manager shall work under the policies, procedures, and protocols of the state MCH Section.
(12) The TCM case managers for the Newborn Nurse Home Visiting Program must be a licensed registered nurse and an employee of a certified NNHV provider as defined in Public Health 333, Division 6 Universally Offered Newborn Nurse Home Visiting Program. The case manager shall work under the policies, procedures, and protocols of the state MCH Section.
(13) Additional qualifications for TCM EI/ECSE provider organizations include the following:
(a) TCM EI/ECSE providers shall meet the criteria to administer the provision of EI and ECSE within selected service areas designated by the Oregon Department of Education, qualifying such programs for state reimbursement under EI/ECSE Programs (OAR 581-015-2700 through 581-015-2910);
(b) Shall be contractors with the Oregon Department of Education in the provision of EI/ECSE services or sub-contractors with such a contractor and shall meet the following qualifications:
(A) Demonstrated case management experience in conjunction with service coordination under OAR 581-015-2840 specified on a child’s Individualized Family Service Plan (IFSP) for coordinating and linking such community resources as required by the target population; and
(B) Capacity to document and maintain individual case records in accordance with confidentiality requirements in the Individuals with Disabilities Education Act, ORS 192.518–192.524, 179.505, and 411.320, and HIPAA Privacy requirements in 45 CFR 160 and 164, if applicable.
(14) Qualifications for TCM EI/ECSE Supervisors of EI/ECSE service coordinators of targeted case management services shall:
(a) Possess a minimum of a master’s degree in early childhood special education, or a related field and have three years of experience with infants, toddlers, young children, and families;
(b) Hold a Teacher Standard and Practices Commission (TSPC) administrative endorsement or within 12 months of employment, complete authorization as an Early Childhood Supervisor under OAR 581-015-2910; and
(c) Have a professional development plan based on the content of the EI/ECSE competencies.
(15) Qualifications of EI and ECSE Specialists performing case management/Targeted Case Management services shall:
(a) Possess a minimum of a baccalaureate degree in early childhood, special education or a related field;
(b) Have a professional development plan based on the content of the EI/ECSE competencies; and
(c) Hold one of the following credentials:
(A) TSPC licensure or endorsement in EI/ECSE;
(B) TSPC licensure or endorsement in a related field; or
(C) Within 12 months of employment, authorization as an Early Childhood Specialist under OAR 581-15-2905.
(16) Qualifications of EI and ECSE Related services personnel shall possess a minimum of a baccalaureate degree and a valid license necessary to practice in Oregon. Related services personnel who also provide service coordination as outlined in OAR 581-015-2840 shall have:
(a) TSPC licensure in their area of discipline; or
(b) State licensure in their area of discipline; and
(c) A professional development plan based on the content of the EI/ECSE competencies;
(d) Knowledge and understanding of the Individuals with Disabilities Education Act (IDEA);
(e) Knowledge and understanding of the nature and scope of services available under the Oregon EI/ECSE programs.
(17) In addition to the above, all shall be employees of the ODE, its contractors or subcontractors, and shall have demonstrated knowledge and understanding about:
(a) The ODE EI/ECSE programs OAR 581-015-2700 through 581-015-2910, including these rules and the applicable Medicaid State Plan Amendment;
(b) Case Management experience in conjunction with service coordination under OAR 581-015-2840 for coordinating and linking such community resources as required by the target population to assist clients in gaining access to needed medical, social, educational, developmental, and other appropriate services in coordination with the eligible child’s IFSP;
(c) The Individuals with Disabilities Education Act (IDEA);
(d) The nature and scope of services available under the Oregon EI/ECSE program, including the TCM services, and the system of payments for services and other pertinent information.
(18) TCM HIV providers shall have the financial management capacity and system that provides documentation of services and costs and is able to generate quarterly service utilization reports that can be used to monitor services rendered against claims submitted and paid. The service utilization reporting requirements are as follows:
(a) Report on the number of unduplicated clients receiving services during the reporting period;
(b) Report on the number of full time equivalent (FTE) case managers providing services during the reporting period; and
(c) Report on the number of distinct case management activities performed during the reporting period (Triage Assessments, Comprehensive Assessments, Re-Assessments, Care Plan Development, Referral and Related Services, and Monitoring Follow-Up) along with the total number of 15-minute increments associated with each activity category.
(19) TCM HIV case managers shall possess the following education and qualifications:
(a) A current active Oregon registered nurse (RN) license or Bachelor of Social Work, or other related health or human services degree from an accredited college or university; and
(b) Documented evidence of completing the Authority’s HIV Care and Treatment designated HIV Targeted Case Manager training and shall participate in the Authority’s on-going training for HIV targeted case managers. The training may either be provided by the Authority or be approved by the Authority and provided by the TCM provider organization.
(20) The TCM Substance Abusing Pregnant Women and Substance Abusing Parents with Children Under Age 18 case manager shall:
(a) Possess a combination of education and experience necessary to support case planning and monitoring. The case manager shall be able to demonstrate an understanding of issues relating to substance abuse and community supports;
(b) Demonstrate continuous sobriety under a nonresidential or independent living condition for the immediate past two years;
(c) Meet at least one of the following qualifications:
(A) Be a licensed Medical Provider, Qualified Mental Health Professional, or Qualified Mental Health Associate; or
(B) Possess certification as an Alcohol and Drug Counselor (CADC) level I, II, or III; or
(C) Complete a Peer Services Training Program following a curriculum approved by the Authority’s Addictions and Mental Health Division and be:
(i) A self-identified person currently or formerly receiving mental health services; or
(ii) A self-identified person in recovery from a substance use disorder who meets the abstinence requirements for recovering staff in alcohol and other drug treatment programs; or
(iii) A family member of an individual who is a current or former recipient of addictions or mental health services;
(d) Work under the supervision of a clinical supervisor. The clinical supervisor shall:
(A) Meet the requirements in Oregon administrative rule for alcohol and other drug treatment programs;
(B) Be certified or licensed by a health or allied provider agency to provide addiction treatment; and
(C) Possess one of the following qualifications:
(i) Five years of paid full-time experience in the field of alcohol and other drug counseling; or
(ii) A Bachelor’s degree and four years of paid full-time experience in the social services field with a minimum of two years of direct alcohol and other drug counseling experience; or
(iii) A Master’s degree and three years of paid full-time experience in the social services field with a minimum of two years of direct alcohol and other drug counseling experience;
(e) Satisfy continuing education requirements as specified by the agency providing clinical supervision specific to alcohol and other drug treatment; and
(f) Work in compliance with Medicaid policies, procedures, and protocols.
(21) A Federally Recognized Tribal Governments TCM provider shall be an organization certified as meeting the following criteria:
(a) A minimum of three years’ experience of successful work with Native American children, families, and elders involving a demonstrated capacity to provide all core elements of tribal case management including: assessment, case planning, case plan implementation, case plan coordination, and case plan reassessment;
(b) A minimum of three years case management experience in coordinating and linking community medical, social, educational, or other resources as required by the target population;
(c) Administrative capacity to ensure quality of services in accordance with tribal, state, and federal requirements; and
(d) Evidence that the TCM organization is a federally recognized tribe located in the State of Oregon.
(22) The following are qualifications of Tribal Case Managers within provider organizations:
(a) Completion of training in a case management curriculum;
(b) Basic knowledge of behavior management techniques, family dynamics, child development, family counseling techniques, emotional and behavioral disorders, and issues around aging;
(c) Skill in interviewing to gather data and complete needs assessment in preparation of narratives/reports, in development of service plans, and in individual and group communication;
(d) Ability to learn and work with state, federal and tribal rules, laws and guidelines relating to Native American child, adult, and elder welfare and to gain knowledge about community resources and link tribal members with those resources;
(e) Knowledge and understanding of these rules and the applicable Medicaid State Plan Amendment.
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
History:
DMAP 58-2022, amend filed 06/21/2022, effective 06/22/2022
DMAP 51-2021, temporary amend filed 12/28/2021, effective 01/01/2022 through 06/29/2022
DMAP 13-2020, amend filed 03/24/2020, effective 03/27/2020
DMAP 9-2017, f. 3-31-17, cert. ef. 4-1-17
DMAP 4-2017(Temp), f. 2-2-17, cert. ef. 2-10-17 thru 7-11-17
DMAP 2-2017(Temp), f. & cert. ef. 1-13-17 thru 7-11-17
DMAP 76-2016, f. 12-29-16, cert. ef. 1-1-17
DMAP 41-2010, f. 12-28-10, cert. ef. 1-1-11
DMAP 22-2010, f. 6-30-10, cert. ef. 7-1-10
OMAP 50-2004, f. 9-9-04, cert. ef. 10-1-04
HR 37-1994, f. 12-30-94, cert. ef. 1-1-95
HR 20-1992, f. & cert. ef. 7-1-92