Or. Admin. Code § 410-138-0005 - [Effective until 4/19/2025] Payment for Targeted Case Management Services Eligible for Federal Financial Participation
(1) This rule is
to be used in conjunction with Targeted Case Management (TCM) rules OAR
410-138-0000 through
410-138-0009 and
410-138-0390 and the Division 's
General Rules chapter 410, division 120.
(2) The TCM services rules are designed to
assist the TCM provider organizations in matching state and federal funds for
TCM services defined by Section 1915(g) of the Social Security Act,
42 USC §
1396n(g). Providers of
Tribal TCM, Newborn Nurse Home Visiting Program, and Nurse Family Partnership
Program are exempt from cost-sharing requirements to pay non-federal matching
funds.
(3) Payment shall be made to
the TCM provider enrolled with the Authority as a unit of government provider
meeting the requirements set forth in the provider enrollment
agreement.
(4) Signing the provider
enrollment agreement sets forth the relationship between the State of Oregon,
the Authority, and the TCM provider and constitutes agreement by the TCM
provider to comply with all applicable Authority rules and federal and state
laws and regulations.
(5) The TCM
provider shall bill according to administrative rules in chapter 410, division
138 and the TCM supplemental information. Payments shall be made using the
Medicaid Management Information System (MMIS), and the TCM provider shall
retain the full payment for covered services provided. The TCM provider shall
have a Trading Partner Agreement with the Authority prior to submission of
electronic transactions.
(6) TCM
authorized under these rules is a cost-sharing (Federal Financial Participation
(FFP) matching) program in which the TCM provider as a public entity, unit of
government , shall pay the non-federal matching share of the amount of the TCM
claims, calculated using the Federal Medical Assistance Percentage (FMAP) rates
in effect during the quarter when the TCM claims will be paid:
(a) The TCM provider's non-federal matching
share means the public funds share of the Medicaid payment amount. Pursuant to
the Social Security Act, 42
CFR 433.51, public funds may be considered as
the state's share in claiming federal financial participation, if the public
funds meet the following conditions:
(A) The
public funds are transferred to the Authority from public entities that are
units of government;
(B) The public
funds are not federal funds, or they are federal funds authorized by federal
law to be used to match other federal funds; and
(C) All sources of funds shall be allowable
under the Social Security Act 42 CFR 433 Subpart B;
(b) The unit of government TCM provider shall
pay the non-federal matching share to the Authority in accordance with OAR
410-120-0035.
(7) Before the Authority pays for
TCM claims, the Authority shall receive the corresponding local match payment
as described in this rule. Failure to timely pay the non-federal matching funds
to the Authority will delay payment.
(8) The Authority shall not be financially
responsible for payment of any claim that CMS disallows under the Medicaid
program. If the Authority has previously paid the TCM provider for any claim,
which CMS disallows, the TCM provider shall reimburse the Authority the amount
of the claim that the Authority has paid to the TCM provider, less any amount
previously paid by the unit of government TCM provider to the Authority for the
non-federal match portion for that claim.
(9) Providers shall only bill Medicaid for
allowable activities in the TCM program that assist individuals eligible under
the Medicaid State Plan to gain access to needed medical, social, educational,
and other services. One or more of the following allowable activities shall
occur before billing:
(a)
Assessment ;
(b) Development of a
care plan ;
(c) Referral and follow
up; and
(d) Monitoring and follow
up.
(10) TCM claims may
not duplicate payments made to:
(a) Public
agencies or private entities for any other case management activities or direct
services provided under the State Plan or OHP, through fee for service, managed
care, or other contractual arrangement, that meet the same need for the same
client at the same point in time;
(b) A TCM provider by program authorities
under different funding authority than OHP, including but not limited to other
public health funding;
(c) A TCM
provider for administrative expenditures reimbursed under agreement with the
Authority or any other program or funding source.
(11) Medicaid is only liable for the cost of
otherwise allowable case management services if there are no other third
parties liable to pay. However, while schools are legally liable to provide
IDEA-related health services at no cost to eligible children, Medicaid
reimbursement is available for these services because section 1903(c) of the
Act requires Medicaid to be primary to the U.S. Department of Education for
payment for covered Medicaid services furnished to a child with a disability.
These services may include health services included in a child's Individualized
Education Program (IEP) or Individual Family Service Plan (IFSP) under the
IDEA. Payment for those services that are included in the IEP or IFSP may not
be available when those services are not covered Medicaid services.
(12) The Authority's acceptance of cost data
provided by provider organizations for the purpose of establishing rates paid
for TCM services does not imply or validate the accuracy of the cost data
provided.
(13) Reimbursement is
subject to all rules and laws pertaining to federal financial
participation.
Notes
Statutory/Other Authority: ORS 413.042 & 414.065
Statutes/Other Implemented: ORS 414.065
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