Targeted Case Management for Individuals with Serious Mental Illness

General Policy

Targeted case management is a service that assists Medicaid members in the target group to gain access to needed medical, social, educational, and other services. The overall goal of the service is not only to help Medicaid members access needed services, but to ensure that services are coordinated among all agencies and providers involved.

Authority

The Consolidated Omnibus Budget Reconciliation Act (P.L. 99-272, COBRA) added targeted case management to the list of optional services which can be provided under the State Medical Plan.

Target Group

1. This target group is comprised of Medicaid members with serious mental illness and includes adults with serious mental illness and children with serious emotional disorders, and individuals with substance use disorders (including their Medicaid-eligible children who are at risk for the development of a substance use disorder).
2. Currently, Utah Medicaid also covers targeted case management to the following target groups or case management through the following home and community-based (HCBS) waivers:

   Targeted Case Management Target Groups
   Early Childhood (Ages 0-4)
   Pregnant Members

   HCBS Waivers (Providing Case Management Services)

   1. Physical Disabilities Waiver
   2. Community Supports Waiver for Individuals with Intellectual Disabilities or Other Related Conditions
   3. New Choices Waiver (for individuals who are deinstitutionalized)
   4. Waiver for Individuals Age 65 or Older
   5. Waiver for Technology-Dependent Children
   6. Acquired Brain Injury Waiver
   7. Medically Complex Children’s Waiver
   8. Community Transitions Waiver
   9. Limited Supports Waiver

There are separate rules and provider manuals to address the scope of services and reimbursement methods for the other case management groups. Since a Medicaid member may qualify for targeted or waiver case management services under other case management groups, it is imperative that before providing targeted case management services under this targeted case management program, the case manager determine if other agencies are already providing targeted or waiver case management for the client to ensure there is no duplication of case management activities.

Definitions

Centers for Medicare and Medicaid Services (CMS) means the agency within the federal Department of Health and Human Services that administers the Medicare and Medicaid programs, and works with states to administer the Medicaid program.

DHHS means the Utah Department of Health and Human Services.

Division of Integrated Healthcare (DIH) means the organizational unit in DHHS that administers the Medicaid program in Utah.  Before July 1, 2022, this was the Division of Medicaid and Health Financing in the Utah Department of Health.  Beginning July 1, 2022, this is the Division of Integrated Healthcare in DHHS.

Division of Occupational and Professional Licensing (DOPL) means the division within the Utah State Department of Commerce responsible for occupational and professional licensing.

Early Periodic Screening Diagnosis and Treatment (EPSDT) program. All Medicaid members birth through age twenty who have Traditional Medicaid qualify for EPSDT services. 19 and 20 year old members who have Non-Traditional Medicaid do not qualify for EPSDT services.

Healthy Outcomes Medical Excellence Program (HOME) means the program operated by the University of Utah, means a voluntary managed care program for Medicaid members who have a developmental disability and mental health or behavioral challenges. HOME is a coordinated care program that provides to its enrollees, medical services, mental health/substance use disorder services and targeted case management services. When Medicaid members enroll in HOME, they are removed from their PMHP and physical health plan enrollment, if enrolled.

Health Plan means a federally defined plan under contract with the DHHS to provide specified physical health care services to Medicaid members enrolled in the plan.

Institution for Mental Diseases (IMD) means, pursuant to 42 CFR §435.1010, a hospital, nursing facility, or other institution of more than 16 beds that is primarily engaged in providing diagnosis, treatment or care of persons with mental diseases, including medical attention, nursing care and related services. Whether an institution is an institution for mental diseases is determined by its overall character as that of a facility established and maintained primarily for the care and treatment of individuals with mental diseases, whether or not it is licensed as such. An institution for the mentally retarded is not an institution for mental diseases.

Prepaid Mental Health Plan (PMHP) means the mental health and substance use disorder managed care plan operating under the authority of the Department of Health and Human Service's 1915(b) waiver. 

SUMH means the Office of Substance Use and Mental Health in the Division of Integrated Healthcare.

Qualified Targeted Case Management Providers

1. Qualified providers of targeted case management services to members in this target group are employed by or under contract with one of the following:
   1. a local mental health and/or substance abuse authority (usually PMHP contractors);
   2. a local authority’s designated mental health and substance use disorder services provider (usually PMHP contractors);
   3. the Department of Health and Human Services; or
   4. a program providing Medicaid-covered services, including targeted case management services for individuals with serious mental illness, under the authority of 1915(a) of the Social Security Act (i.e., HOME). Providers authorized under Section 1915(a) of the Social Security Act provide targeted case management services only to Medicaid members enrolled in the 1915(a) program.
2. Primary providers of targeted case management services are:
   1. licensed social service worker under supervision of a licensed mental health therapist identified in paragraph A.1 of Chapter 1-5 who is qualified to provide supervision;
   2. individual who has obtained a qualifying bachelor’s degree and is actively engaged in meeting DOPL requirements to obtain license as a social service worker in accordance with state law, and is under supervision of a licensed mental health therapist identified in C. 1 below who is qualified to provide supervision;
   3. licensed advanced substance use disorder counselor (ASUDC) or licensed substance use disorder counselor (SUDC) under the general supervision of a licensed mental health therapist identified in C.1 of this Chapter;
   4. licensed certified advanced substance use disorder counselor (CASUDC) or licensed certified advanced substance use disorder counselor intern (CASUDC-I) under direct supervision of a licensed mental health therapist identified in C.1 of this Chapter, or a licensed ASUDC who are qualified to provide supervision;
   5. licensed certified substance use disorder counselor (CSUDC) or licensed certified substance use disorder counselor intern (CSUDC-I) under direct supervision of a licensed mental health therapist identified in C.1 of this Chapter, a licensed ASUDC or a licensed SUDC who are qualified to provide supervision;
   6. licensed registered nurse;
   7. licensed practical nurse under the supervision of a licensed registered nurse or a licensed mental health therapist identified in C. 1 of this Chapter;

   8. individual who is not licensed who is at least 18 years old and under the supervision of an individual identified in C.1., C.2., or C.3.b. of this Chapter, a licensed social service worker or a licensed registered nurse; or a licensed ASUDC or licensed SUDC when targeted case management services are provided to individuals with a substance use disorder.

      Non-licensed individuals must complete the training curriculum and certification requirements specified in Chapter 1-5;

   9. registered nursing student engaged in activities constituting the practice of a regulated occupation or profession while in training in a recognized school approved by DOPL to the extent the activities are supervised by qualified faculty, staff, or designee and the activities are a defined part of the training program; or

   10. individual enrolled in a qualified substance use disorder counselor education program, exempted from licensure in accordance with Section 58-1-307 of the Utah Code and under DOPL-required supervision.

3. In addition to the primary service providers specified in B. above, individuals in C.1., C.2., and C.3., below, may also provide this service:

   1. Licensed mental health therapist practicing within the scope of practice defined in the individual’s respective licensing act and licensed under Title 58-60, Mental Health Professional Practice Act, as:

      1. physician and surgeon or osteopathic physician engaged in the practice of mental health therapy;
      2. advanced practice registered nurse (APRN), specializing in psychiatric mental health nursing;
      3. APRN intern specializing in psychiatric mental health nursing;
      4. psychologist qualified to engage in the practice of mental health therapy;
      5. certified psychology resident qualifying to engage in the practice of mental health therapy under the supervision of a licensed psychologist;
      6. physician assistant specializing in mental health care in accordance with Section 58- 70a- 501 of the Utah Code;
      7. clinical social worker;
      8. certified social worker or certified social worker intern;
      9. marriage and family therapist;
      10. associate marriage and family therapist;
      11. clinical mental health counselor; or
      12. associate clinical mental health counselor .
   2. An individual working within the scope of their license in accordance with Title 58 of the Utah Code:
      1. licensed physician and surgeon or osteopathic physician regardless of specialty;
      2. licensed APRN regardless of specialty working within the scope of the Nurse Practice Act and competency;
      3. licensed APRN intern regardless of specialty working within the scope of the Nurse Practice Act and competency;  or
      4. other medical practitioner licensed under state law, most commonly licensed physician assistants regardless of specialty when practicing within the physician assistant’s skills and scope of competence;
   3. An individual exempted from licensure as a mental health therapist:
      1. in accordance with Section 58-1-307 of the Utah Code, a student engaged in activities constituting the practice of a regulated occupation or profession while in training in a recognized school approved by DOPL to the extent the activities are supervised by qualified faculty, staff, or designee and the activities are a defined part of the training program; or
      2. in accordance with Subsection 58-61-307(2)(h) of the Utah Code, an individual who was employed as a psychologist by a state, county or municipal agency or other political subdivision of the state prior to July 1, 1981, and who subsequently has maintained employment as a psychologist in the same state, county, or municipal agency or other political subdivision while engaged in the performance of his official duties for that agency or political subdivision.

Supervision (when applicable) of individuals above must be provided in accordance with requirements set forth in Title 58 of the Utah Code, and the applicable profession’s practice act rule as set forth by the Utah Department of Commerce and found at the Department of Administrative Services, Division of Administrative Rules, at: https://rules.utah.gov/publications/utah-adm-code.

In addition, all individuals providing targeted case management services must know Medicaid regulations pertaining to targeted case management as described in this provider manual.

Targeted Case Management Training Curriculum

1. To meet the SUMH’s training  standards and become certified to provide targeted case management services, all non-licensed  individuals will be required to:
   1.  successfully complete the SUMH’s training curriculum and pass a written examination which tests basic knowledge, attitudes, ethics, and skills related to the provision of targeted case management services; and
   2. successfully complete the SUMH’s targeted case management practicum requirement.
2. To continue to be a qualified provider of targeted case management services, the individual must successfully complete the SUMH’s recertification requirements.

Client Rights

1. Targeted case management services cannot be used to restrict the client’s access to other services available under the Utah Medicaid State Plan.
2. The client (or the client’s guardian if applicable) must voluntarily choose targeted case management services, and be given a choice in the selection of their targeted case manager. Clients can also choose to discontinue targeted case management services at any time.
3. The case manager will not condition receipt of targeted case management services on the receipt  of other Medicaid-covered services, or condition receipt of other Medicaid-covered services on  receipt of targeted case management services.
4. Targeted case management clients will have free choice of any qualified Medicaid providers of other medical care unless restricted due to enrollment in a Health Plan, the PMHP, or a program providing services authorized under 1915(a) of the Social Security Act (i.e., HOME).

Substance Use Disorder (SUD) Treatment in Licensed SUD Residential Treatment Programs (ASAM Levels 3.1, 3.3, 3.5, 3.7) and Mental Health Treatment in Licensed Mental Health Residential Treatment Programs

When SUD residential treatment programs and mental health residential treatment programs are reimbursed on a per diem bundled payment basis in accordance with Chapter 2-13, Substance Use Disorder (SUD) Treatment in Licensed SUD Residential Treatment Programs (ASAM Levels 3.1, 3.3, 3.5, 3.7), and Chapter 2-17, Mental Health Treatment in Licensed Mental Health Residential Treatment Programs, of the Utah Medicaid Provider Manual for Rehabilitative Mental Health and Substance Used Disorder Services, targeted case management services are included in the per diem bundled payment and cannot be reported separately.

Scope of Service

 Covered Services / Activities

1. Targeted case management is a service that assists Medicaid members in the target group to gain access to needed medical, social, educational, and other services. The overall goal of the service is not only to help Medicaid members to access needed services, but to ensure that services are coordinated among all agencies and providers involved.

   Individuals who are employed by or contracted with an entity specified in Chapter 1-5, A. solely or as part of their duties to provide targeted case management services, may assist clients to gain access to needed medical services, including rehabilitative mental health/substance use disorder services provided by that entity.

   The entity’s providers (e.g., physicians, mental health therapists, nurses, etc.) who provide rehabilitative mental health/substance use disorder services to clients in accordance with Chapter 2 of the Utah Medicaid Provider Manual for Rehabilitative Mental Health and Substance Use Disorder Services or other medical services, may not report day-to-day discussions with other internal treatment providers regarding coordination of their respective services as targeted case management. These discussions are considered an integral part of the entity’s services delivery. (See Chapter 2-2, N. below.)

2. Medicaid reimbursement for targeted case management is dictated by the nature of the activity and the purpose for which the activity was performed. When reported in amounts that are reasonable (given the needs and condition of the particular client), the following activities/services are covered by Medicaid under targeted case management:

   1. assessing the client to determine service needs, including activities that focus on needs identification, to determine the need for any medical, educational, social, or other services. Assessment activities include: taking client history, identifying the needs of the client and completing related documentation, gathering information from other sources such as family members, medical providers, social workers, other providers, and educators, if necessary, to form a complete assessment of the client;

   2. developing a written, individualized, and coordinated case management service plan based on the information collected through an assessment that specifies the goals and actions to address the medical, social, educational, and other services needed by the client, with input from the client, the client’s authorized health care decision maker, and others (e.g., the client’s family, other agencies, etc.) knowledgeable about the client’s needs, to develop goals and identify a course of action to respond to the assessed needs of the client;

   3. referral and related activities to help the client obtain needed services, including activities that help link the client with medical (including mental health and substance use disorder), social, educational providers or other programs and services that are capable of providing needed services, such as making referrals to providers of needed services and scheduling appointments for the client;

   4. assisting the client to establish and maintain eligibility for entitlements;

   5. coordinating the delivery of services to the client, including EPSDT well-child health exams and follow-up (see the Utah Medicaid Provider Manual for EPSDT Services);

   6. contacting non-eligible or non-targeted individuals when the purpose of the contact is directly related to the management of the client’s care. For example, family members may be able to help identify needs and supports, assist the client to obtain services, provide case managers with useful feedback and alert them to changes in the client’s status or needs;

   7. instructing the client or caretaker, as appropriate, in independently accessing needed services;

   8. monitoring and follow-up activities, including activities and contacts that are necessary to ensure the targeted case management service plan is effectively implemented and adequately addressing the needs of the client, which activities may be with the client, family members, providers or other entities, and conducted as frequently as necessary to help determine such matters as whether services are being furnished in accordance with the client’s case management service plan, whether the services in the case management service plan are adequate, whether there are changes in the needs or status of the client, and if so, making necessary adjustments in the case management service plan and service arrangements with providers; and

   9. monitoring the client’s progress and continued need for targeted case management and other services.

3. Covered targeted case management services provided to Medicaid members transitioning to a community setting will be made available for up to 30 consecutive days of a covered stay in a medical institution.

Non-Covered Services / Activities

In accordance with CMS guidelines, the following services and activities are not considered targeted case management and may not be reported as targeted management services:

1. documenting targeted case management services - with the exception of the time spent  developing the written needs assessment, service plan, and 180-day service plan review - is not  reimbursable as targeted case management. (See Chapter 3-2, Required Documentation.)

2. teaching, tutoring, training, instructing, or educating the client or others, except in so far as the activity is specifically designed to assist the client, parent, or caretaker to independently obtain needed services for the client.

   For example, assisting the client to complete a homework assignment, creating chore or behavioral charts and other similar materials for clients or families, or instructing a client or family member on nutrition, budgeting, cooking, parenting skills or other skills development is not reimbursable as targeted case management;

3.  directly assisting with personal care or activities of daily living (bathing, hair or skin care, eating, etc.) or instrumental activities of daily living (assisting with budgeting, cooking, shopping, laundry, home repairs, apartment hunting, moving residences, or acting as a protective payee) are not reimbursable activities under targeted case management;
4. performing routine services including courier services. For example, running errands or picking up and delivering food stamps or entitlement checks are not reimbursable as targeted case management;
5. direct delivery of an underlying medical, educational, social or other service to which the client has been referred, or provision of a Medicaid-covered service. For example, providing medical and psycho-social evaluations, treatment, therapy and counseling that are otherwise reportable under other categories of service (e.g., services described in the Utah Medicaid Provider Manual for Rehabilitative Mental Health and Substance Use Disorder Services), are not reimbursable as targeted case management;

6. direct delivery of foster care services, including but not limited to research gathering and completion of documentation required by the foster care program, assessing adoption placements, recruiting or interviewing potential foster care placements, serving legal papers, home investigations, providing transportation, administering foster care subsidies or making foster care placement arrangements.

   Children in state custody (foster care) have DHHS case workers. When DHHS case workers refer a child to a local mental health and/or substance abuse authority/PMHP or to the local authority’s designated mental health and substance use disorder services provider/PMHP, the purpose is for the provision of rehabilitative services outlined in the Utah Medicaid Provider Manual for Rehabilitative Mental Health and Substance Use Disorder Services.

   Therefore, there should be few circumstances where the local mental health and/or substance abuse authority/PMHP or the local authority’s designated mental health and substance use disorder services provider/PMHP would also provide targeted case management services to a child in state custody.

   If the local mental health and/or substance abuse authority/PMHP or the local authority’s designated mental health and substance use disorder services provider/PMHP determines there is a case management need, this should be communicated to the child’s DHHS case manager. If the DHHS case manager agrees that the treatment provider also should provide some of the targeted case management services the child requires, and the services will not constitute the direct delivery of foster care services as specified in the first paragraph of this subsection F, then the entity may do so. This agreement must be clearly documented in the child’s targeted case management record;

7. time spent traveling to the client’s home or other location where a covered case management activity will occur is not reimbursable, nor is time spent transporting a client or a client’s family members;

8. providing services for or on behalf of other family members that do not directly assist the client to access needed services. For example, counseling the client’s sibling or helping the client’s parent obtain a mental health service are not reimbursable as targeted case management;

9. recruitment activities in which the center or case manager attempts to contact potential members of service are not reimbursable as targeted case management;

10. time spent assisting client to gather evidence for a hearing with DIH or participating in a hearing as a witness is not reimbursable as targeted case management;

11. time spent coordinating between case management team members for a client is a non-reportable activity;

12. when there is a failed face-to-face or telephone contact, time spent leaving a note or message noting the failed attempt is not reimbursable as targeted case management; and

13. in accordance with Chapter 2-1, A., time spent by two or more treatment providers of an entity specified in Chapter 1-5, A., arranging or coordinating their treatment services, and indirect activities of the entity (i.e., supervision of treatment providers, and interdisciplinary team conferences for the development of rehabilitative treatment plans) may not be reported as targeted case management activities.

Limitations on Reimbursable Services

1. The agency may report the covered services and activities specified in Chapter 2-1, B. only if:
   1. the services and activities are identified in the targeted case management service plan;
   2. the time spent in the service or activity involves a face-to-face encounter, telephone or written communication with the client, family, caretaker, service provider, or other individual with a direct involvement in providing or assuring the client obtains the necessary services documented in the targeted case management service plan;
   3. there are no other third parties liable to pay for such services, including reimbursement under a medical, social, education, or other program;
   4. activities are not an integral and inseparable component of another covered Medicaid service; and
   5. activities do not constitute the direct delivery of underlying medical, education, social, or other services to which an eligible individual has been referred including foster care programs.‎
2. The agency may not report the covered services and activities specified in Chapter 2-1 if no payment liability is incurred. Reimbursement is not available for services provided free-of-charge to non-Medicaid members.
3. Payment for targeted case management services may not duplicate payments made to public agencies or private entities under other program authorities for this same purpose.

4. Team Case Management

   Targeted case management services provided to a client by more than one targeted case manager employed by or under contract with the same entity are reimbursable only under the following conditions:

   1. all targeted case managers on the team meet the qualifications described in Chapter 1 - 5;
   2. all targeted case managers on the team coordinate with one another to ensure only necessary, appropriate, and unduplicated case management services are delivered by all team members;
   3. time spent by two or more targeted case managers on the team in the same targeted case management activity may be reported by one case manager team member only; and
   4. the client is informed of and understands the roles of the team members.

Record Keeping

General Requirements

The case management record must be maintained on file in accordance with any federal or state law or state administrative rules, and made available for state or federal review, upon request.

Required Documentation

The following documents must be contained in each client's case file:

1. a written individualized needs assessment which documents the client's need for targeted case management services;
2. a written, individualized targeted case management service plan that identifies the services (i.e., medical, social educational, and other services) the client is to receive, who will provide them, and a general description of the targeted case management activities needed to help the client obtain or maintain these services; and
3. a written review of the service plan, at a minimum every 180-days, summarizing the client’s progress toward targeted case management service plan objectives. The service plan review must be completed within the month due, or more frequently as required by the client’s condition. If changes are required in the written service plan, a revised service plan must also be developed.

The case manager must develop and maintain sufficient written documentation for each unit of targeted case management services reported.

Record:

For each date of service, documentation must include:

1. date, start and stop time and duration of each service;
2. setting in which the service was rendered (when via telehealth, the provider setting and notation that the service was provided via telehealth);
3. at the end of the day, total number of minutes of targeted case management services based on the rules specified in the ‘Unit’ section below;
4. at a minimum, one note summarizing all of the targeted case management activities performed during the day, or a separate note summarizing each targeted case management activity. Notes must document how the activities relate to the targeted case management service plan and be sufficient to support the number of units reported; and
5. signature and licensure or credentials of the individual who rendered the targeted case management service(s).

Unit:

T1017 - Targeted Case Management for Clients with Mental Health Disorders - per 15 minutes

H0006 - Targeted Case Management for Clients with Substance Use Disorders - per 15 minutes

1. When reporting these procedure codes, follow the rules specified below for converting the total duration of targeted case management services provided in a day to the specified unit.
2. The number of 15-minute units of service reported cannot exceed four units in an hour and cannot exceed in total billings in a day, the number of hours the case manager worked (e.g., eight-hour work day).
3. If the total duration of targeted case management activities provided in a day total less than 15 minutes, then there must be a minimum of eight minutes in order to report one 15-minute unit.

4. If the total duration of targeted case management activities provided in a day are in excess of 60 minutes, divide the total number by 15 to determine the number of 15-minute units that can be reported. If there are minutes left over, apply the following rules:

   1-7 minutes equal 0 units; and

   8-15 minutes equals one 15-minute unit.

   For example, the targeted case manager performed five separate targeted case management activities for the client during the day for a total duration of 70 minutes. When divided by 15 this would result in five units of service.

5. A range of dates should not be reported on a single line of a claim (e.g., listing on the claim the 1st through the 30th or 31st as the service date). Each date of service should be reported on a separate line of the claim.

Procedure Codes for Targeted Case Management for the Seriously Mentally Ill

For each date of service, enter the appropriate five-digit procedure code as indicated below:

 

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