1. What is Targeted Case Management (TCM)?
Targeted Case Management (TCM) is a service that helps individuals with mental health conditions access necessary medical, social, educational, and other supportive services. It involves assessing a client’s needs, creating a service plan, and coordinating care across different providers to enhance the individual’s functioning.
2. Who qualifies for mental health TCM services?
Individuals must be eligible for Medicaid and fall into specific target groups, such as children with serious emotional disturbances (SED) or adults with severe and persistent mental illnesses. The recipients must also lack a natural support system and need ongoing assistance to access required services.
3. What are the main responsibilities of a TCM provider?
A TCM provider is responsible for helping individuals gain access to necessary services, coordinating care, developing and monitoring service plans, advocating for the individual’s needs, and providing crisis intervention. They must ensure that services align with the recipient’s needs and goals, while also adhering to Medicaid rules and documentation requirements.
4. What training is required for case managers in TCM?
Case managers must complete training approved by Medicaid that includes core case management components like assessment, service planning, coordination, and monitoring. Other important topics include community resources, mental health treatment principles, medication management, and HIPAA compliance. Supervisors must also complete specialized training to oversee case managers.
5. How are children certified for mental health TCM services?
To certify a child for TCM, documentation must show that the child has a serious emotional disturbance requiring advocacy and service coordination. This certification must be completed within 30 days of the initial service and reviewed periodically to ensure the child continues to meet eligibility criteria.
6. What is the role of a case manager in the TCM program?
The case manager plays a critical role in conducting assessments, developing individualized service plans, linking clients to necessary resources, coordinating services, and monitoring the effectiveness of interventions. They are also responsible for regular follow-up and crisis intervention to ensure the client’s needs are met effectively.
7. What documentation is required for Medicaid TCM reimbursement?
Providers must maintain detailed case notes for every TCM service provided. This includes the case manager’s name, the recipient’s name, service dates and times, service locations, and a description of how the service supports the individual’s service plan. Failure to properly document services can result in denial of reimbursement.
8. How often should a service plan be updated?
Service plans should be updated at least every six months or whenever significant changes occur in the recipient’s condition. The plan must be reviewed to ensure that the goals and services are still appropriate for the recipient’s needs, with documentation to support ongoing or modified services.
9. What are the responsibilities of a TCM supervisor?
A TCM supervisor oversees case managers, ensuring they meet certification and training requirements. Supervisors are also responsible for reviewing and approving assessments and service plans, providing guidance to case managers, and documenting supervision activities. They must maintain up-to-date knowledge of Medicaid policies and ensure compliance.
10. What services are excluded from TCM coverage?
Medicaid does not cover direct therapeutic services like psychotherapy, medical services such as blood pressure checks, or administrative functions like checking Medicaid eligibility. Additionally, TCM services cannot be provided to individuals who are in nursing homes, jails, or institutions, except under special circumstances.
11. What is Intensive Case Management in TCM?
Intensive Case Management is a more hands-on service provided to individuals with severe and persistent mental illness. It includes a team approach where multiple case managers may be involved to ensure clients receive comprehensive, round-the-clock support to remain stable in their community and avoid hospitalization.
12. How is eligibility for Medicaid TCM certified?
Eligibility is certified through an assessment by a case manager and their supervisor, who document the recipient’s need for TCM services based on established criteria. This certification must be updated regularly to maintain Medicaid reimbursement.
13. Can Medicaid pay for case management services for individuals in residential programs?
In most cases, Medicaid does not cover TCM services for individuals in nursing homes, psychiatric facilities, or jails. However, limited exceptions exist, such as during discharge planning for individuals leaving certain types of facilities, provided it is part of an approved Medicaid program.
14. What happens if a child in TCM moves to a new district?
If a child relocates from one district to another where they were already receiving TCM services, they do not need to meet new eligibility criteria in the new district. However, this change must be documented in the child’s case record to maintain continuity of services.
15. How long can a recipient receive TCM services during a Medicaid 30-day certification?
Recipients can receive TCM services for up to 30 days without meeting full eligibility criteria if referred by Medicaid’s contracted utilization management vendor or admitted to an inpatient psychiatric unit. After 30 days, the recipient must meet the regular eligibility criteria to continue receiving services.
16. What is the role of natural support systems in TCM?
Natural support systems, such as family, friends, and community resources, play a crucial role in the success of TCM. Case managers work closely with these systems to ensure the recipient has the support they need to achieve their service plan goals and maintain stability in their living environment.
17. What types of services must be provided in TCM?
Services in TCM include assessing the recipient’s needs, developing a service plan, linking the recipient to necessary resources, advocating for services, coordinating care among different providers, and ongoing monitoring to ensure that the services are meeting the recipient’s goals.
18. Can TCM services be duplicated?
No, Medicaid will not reimburse for services that overlap or are duplicative of other case management services the recipient is already receiving. Case managers must coordinate services to avoid duplication and ensure efficient care delivery.
19. What is a Medicaid TCM service plan review?
A service plan review is a regular evaluation of a recipient’s service plan to ensure that the services, goals, and objectives remain appropriate. It must occur at least every six months or sooner if there are significant changes in the recipient’s needs. This process includes documentation and signatures from all parties involved.
20. What happens if a recipient no longer meets TCM eligibility?
If a recipient no longer meets the eligibility criteria for TCM services, the case manager must document the change in the recipient’s record, and Medicaid will stop reimbursing for services. This ensures that only individuals who truly need case management continue receiving services.
