Medicaid Targeted Case Management for the Child Welfare Population
What is Targeted Case Management (as an allowable Medicaid service)?
Targeted Case Management (TCM) is the provision of case management, defined as services which assist eligible individuals in gaining access to needed medical, social, educational and other services, to a "targeted" population such as child welfare, foster care, adoption.
Targeted Case Management includes:
It is important to note that TCM is assessment and facilitation of meeting service needs, not the provision of the called-for services.
- assessing the child's needs;
- arranging for the delivery of needed services as defined in the assessment;
- assisting the child and his/her family in accessing the needed services;
- tracking the child's progress by making referrals, tracking appointments, following up on services rendered, periodically reassessing the child's needs;
- advocating on behalf of the child;
- consulting with service providers or collateral contacts in determining the status or progress of the child's plan; and,
- arranging for crisis assistance, such as making arrangements for emergency referrals, coordinating other needed emergency services.
What are the President's proposals related to Targeted Case Management services?
The President's FY 2006 budget includes proposals to:
- Restrict the use of TCM to provide services to children in the child welfare system.
- Cap the federal matching rate of TCM to 50%. Currently the federal share of TCM is matched at a state's FMAP rate that varies from 50% in one state to nearly 80% in another state. Nine states, and the District of Columbia currently receive a federal matching rate for TCM that is higher than 70%.
What action is Congress taking this year?
Congress passed a FY 2006 Budget Resolution earlier this year that requires that reconciliation legislation be prepared by September 16, 2005, that reduces federal spending by a total of $35 billion over five years. The budget resolution specifically calls on Congress to enact $10 billion in cuts to Medicaid and other entitlement or mandatory programs. Congress may choose to achieve these cost savings by incorporating the Administration's proposals on TCM.
How does TCM differ from Case Management that is a component of other Medicaid covered mental health services?
Specific Medicaid covered mental health services may include case management as a component of the delivery of a particular mental health service. To receive case management, the recipient has to be receiving that particular service. TCM, on the other hand, allows a defined population to receive case management as a service in and of itself.
Defining a target group allows case management to be provided to a broader population than would be covered under a specific service, yet it limits the provision of the service to the defined group, thus limiting the exposure of the state Medicaid program. For those states that cover TCM, the state Medicaid plan must address the target group, areas of the state in which services will be provided, comparability of services, definition of services, qualifications of providers, free choice of providers and assurance that payment for case management services under the plan does not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.
Why have states chosen to provide TCM as a covered service for the child welfare population (child welfare being broadly defined as child protective services children, children in out-of-home care, and children being adopted)?
Much of the work with or on behalf of children in the child welfare arena is that which is described in the list of TCM activities--assessing service need, accessing those services, following-up, coordination among service providers, etc. To the extent this activity enhances the child's condition and/or reduces the likelihood that more intensive, more expensive Medicaid covered services will be needed in the future, it offers a cost benefit, particularly with the history of child welfare children being frequent users of Medicaid covered services.
Are there other benefits, besides potential cost saving, associated with TCM?
There are conditions associated with covered Medicaid services that add value to the provision of the service. Generally, there are requirements about: the qualifications of the individuals who can provide the service; the level of service that must be provided; and,the documentation of the activity. All of these requirements strengthen the service delivery system.
What is the fiscal benefit of TCM for the state child welfare agency?
The activities associated with TCM are necessary activities that child welfare staff performs for all cases regardless of how the cost is covered. Primarily, a state that has TCM as a covered Medicaid service and that claims Title IV-E Administration utilizes three funding options: recover part of the cost from Medicaid (i.e., TCM billing); recover part of the cost from Title IV-E administration claiming; or fund the entire cost with state general revenue. TCM is fiscally advantageous for states because: (a) children in child protective service cases may be included as part of the target group in TCM, but they are excluded from Title IV-E administration because they are not in foster care; (b) of those children in foster care, more children are Medicaid eligible than are Title IV-E eligible; and (c) in many states the federal match rate for Medicaid is greater than the 50% federal match rate for Title IV-E.
Is it 'double-dipping' if a state is claiming TCM for its child welfare population and also claiming Title IV-E Admin (which includes case management)?
First, it must be remembered that TCM being claimed for a child welfare population may be (according to the state's definition of the target group) a much broader population than those children in out-of-home care.
Secondly, many of the children in out-of-home care are not Title IV-E eligible (almost half the children in out-of-home care nationwide are ineligible for Title IV-E); thus, they are not eligible to receive Title IV-E reimbursed case management services.
Finally, states have mechanisms to separate out case management activity on behalf of Title IV-E eligible children from targeted case management activity for non-Title IV-E eligible children in foster care. Thus, states can appropriately claim either TCM or Title IV-E case management and not make duplicate claims for the same service to the same child.
Is TCM a part of the reimbursement that a foster parent receives?
No. Foster parents receive reimbursement for providing room and board for the children in their care. TCM is not a part of room and board.
For further information, please contact John Sciamanna, 202/639-4919, or Tim Briceland Betts, 202/942-0256.
Child Welfare League of America
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