Targeted Case Management

Case Management Defined

Case Management refers to those services provided by professional mental health staff for the purpose of monitoring and assisting clients in their over-all life situations including gaining access to needed medical, social, educational and other services necessary to meet basic human needs. These services may include, but are not necessarily limited to:

Maintaining up-to-date assessments and evaluations necessary for establishing eligibility for services
Participating in the treatment planning process and monitoring client progress in meeting the goals and objectives of the plan
Locating, coordinating and monitoring all necessary medical, educational, vocational, social and psychiatric services
Assisting in development and execution of a plan for assuring income maintenance
Assisting in development of appropriate social networks
Assistance with other activities necessary to maintain psychiatric stability in a community-based setting

Adolescent Pregnancy Program

Introduction

The “target” group for this amendment consists of pregnant or parenting adolescents (defined as individuals who have not attained age twenty) or the children of pregnant or parenting adolescents who:

Meet the criteria for services provided under the Adolescent Parenting Program of the Department of Human Services, and
Are receiving case management services from providers in the State of Rhode Island who are certified and under contract with the Department of Human Services to provide adolescent parenting services pursuant to established state regulations, and
Are eligible for and receiving Title XIX Medicaid coverage as categorically needy, and
Are eligible for the Early and Periodic Screening, Diagnosis and Treatment (EPSDT) program, and
Are pregnant or parenting and at risk.

Covered Services

Services are covered for categorically needy recipients only, and for EPSDT.

The following table lists all covered services for Adolescent Pregnancy services. The table shows the procedure code, service description and if the service requires prior authorization (Y-yes or N-no).

Prodedure CodeDescriptionPA

X0376Non-Medical Case Management Adolescent Pregnancy, Per MonthN

Limitations

Covers children to twenty years of age.

If an individual is receiving case management from more than one source, the first billing submitted is paid, all others will be denied. Only one case manager is allowed per recipient. (For example, if a child in Head Start is also in special education, only one case manager should oversee both.)

Patient Liability

There is no recipient co-pay or patient liability for adolescent pregnancy services.

Participating providers are exempt from billing any third party resources, including Medicare, for adolescent pregnancy services provided to Medicaid recipients.

Provider Participation

The overall case management program at each provider agency must be directed by a qualified professional of the Adolescent Parenting Project or by a person possessing equivalent experience in working with adolescent parents.

Each staff member providing case management services must have at least an Associate’s Degree in the social sciences, or equivalent experience, or a combination thereof.

Each staff member must receive specialized training, including a complete orientation to the community services/agencies in Rhode Island as well as meeting all other requirements specified by contract with the Department of Human Services Adolescent Parenting Project.

Lead Program

Introduction

This target group consists of eligible individuals under age 21 who:

Are eligible for the Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) program.
Have been determined to have an elevated screening or diagnostic blood level of greater than 15vgm%.
Age 0 through 6 years or who are developmentally delayed.

Covered Services

Services are covered for categorically and medically needy recipients.

Services are covered for EPSDT recipients

The following table lists all covered services for Lead Program services. The table shows the procedure code, service description and if the service requires prior authorization (Y-yes or N-no).

Procedure CodeDescriptionPA

T1029Comprehensive Environmental Lead

Investigation, not including laboratoryN

Limitations

Medical Case Management cannot be billed for individuals who are enrolled in a managed care program.

Patient Liability

Covers children birth to 20 years of age. There is no recipient co-pay or patient liability for Lead Program services.

Participating providers are exempt from billing any third party resources, including Medicare, for lead investigation services provided to Medicaid recipients.

Provider Participation

The overall case management program will be directed by individuals who meet the criteria established by the Rhode Island Department of Health (RIDOH). Each staff member providing case management services must meet the criteria as established by RIDOH.

Services For The Blind And Visually Impaired Program

Introduction

Target group 13 consists of recipients who:

Are blind or visually impaired
Are not eligible for Vocational Rehabilitation services due to age or other criteria.

Covered Services

Services are covered for categorically and medically needy recipients

Services are covered for EPSDT.

The following table lists all covered services for the Blind And Visually Impaired Program services. The table shows the procedure code, service description and if the service requires prior authorization (Y-yes or N-no).

Procedure CodeDescriptionPA

X0620Non-Medical Case Management: Services for the Blind and Visually Impaired Program (SBVI)N

Limitations

Medical Targeted Case Management cannot be billed for individuals who are enrolled in a managed care program.

Patient Liability

There is no recipient co-pay or patient liability for Blind and Visually Impaired Program services.

Participating providers are exempt from billing any third party resources, including Medicare, for Blind and Visually Impaired services provided to Medicaid recipients.

Provider Participation

The overall case management program will be directed by qualified individuals who meet the criteria established by DHS. Each staff member providing case management services must meet the criteria as established by DHS.

HIV/AIDS Program

Introduction

The “target” group for this amendment shall be individuals who:

Have a documented HIV infection and/or a diagnosis of AIDS.
Are receiving case management services from providers who are licensed by the Department of Health and provide service under contract to the Department of Health.
Are eligible for Title XIX Medicaid Coverage either as categorically eligible or medically needy only.

Covered Services

Services are covered for categorically and medically needy recipients.

Services are covered for EPSDT.

The following table lists all covered services for HIV/AIDS Program services. The table shows the procedure code, service description and if the service requires prior authorization (Y-yes or N-no).

Procedure CodeDescriptionPA

X0377Non-Medical Case Management: HIV - Per 1/4 Hour UnitN

Limitations

Medical Targeted Case Management cannot be billed for individuals who are enrolled in a managed care program.

Patient Liability

There is no recipient co-pay or patient liability for HIV/AIDS Program services.

Participating providers are exempt from billing any third party resources, including Medicare, for HIV/AIDS Program services provided to Medicaid recipients

Provider Participation

The overall case management program at each provider agency must be directed by a registered nurse or equivalent health care professional with at least two years experience in the delivery of case management services. All services shall be delivered in accordance with the requirements specified by contract with the Department of Health.