Appendix 6

Materials for Pennsylvania Leadership Workshop 2

Pennsylvania Second Roundtable on Children’s Health and Managed Care
Topic: Care Coordination for Children with Special Health Care Needs
May 10, 2005

Goal of the roundtable: To begin development of a uniform care coordination approach for
children with special health care needs (CSHCN).

Whether Medicaid/EPSDT “case-management,” Title V CSHCN “care coordination,” the SCHIP
program, an AAP medical home project, or managed care strategies, Pennsylvania can do more to assist
families in meeting the needs of their children, linking across service delivery systems, and managing
care to reduce unnecessary spending. This Roundtable is focused on identifying strategies to improve
cross-system supports and build a common framework for serving CSHCN.

There is no single definition of children with special health care needs that is commonly accepted.
Definitions vary among States (e.g., definitions used by a state Title V agency may vary from that used by
the same state's Medicaid agency). For this Roundtable discussion, CSHCN are defined as: “Children
who have or are at increased risk for chronic physical, developmental, behavioral, or emotional conditions
and who also require health and related services of a type or amount beyond that required by children
generally.”¹ This definition is broad, incorporating children with a range of conditions and risk.

Recent national data and special initiatives across the country indicate the following:

• An estimated 12.8 percent – 9.4 million – children under age 18 in the United States have special
  health care needs, and CSHCN needs are present in 20 percent of U.S. households with children.
• On average, parents rated the severity of their children’s conditions as 4.2. This average rating
  was higher for CSHCN in families with incomes below the poverty level (5.3) and lower among
  CSHCN in families with incomes of 400 percent of poverty or more (3.5).
• Among children with special health care needs living in poverty, 40 percent need emotional,
  behavioral, or developmental services, compared to 23 percent in higher-income families.
• Findings from a national survey indicate that 8 percent of parents cited financial problems as the
  main reason that health care for their CSHCN had been delayed or forgone in the previous 12
  months.
• For pediatrics, the standard of care for children with special health care needs is that of a
  “medical home” – an approach to providing care that is accessible, family-centered,
  comprehensive, continuous, coordinated, compassionate, and culturally competent.
• Pilot projects coordinated by the Center for Health Care Strategies found that: overlapping care
  coordination programs led to increased costs and confusion, specific screening tools and
  protocols were effective, and effective education and informing for parents was essential.

This document was prepared for the Second Roundtable on Children’s Health and Managed Care to be held on May 10, 2005 in Harrisburg, Pennsylvania. The more than 35 senior policy makers and professionals attending the workshop will discuss approaches to care coordination for children enrolled in Medicaid and SCHIP health plans. These documents have not been endorsed by Federal or State officials. The workshop was based on work by Johnson Group Consulting and the George Washington University (GWU). This work is being conducted with support from the Maternal and Child Health Bureau (MCHB), Health Resources and Services Administration (HRSA), U.S. Department of Health and Human Services. Thanks to the Pennsylvania Perinatal Partnership and other volunteer leaders on the steering committee that designed this Roundtable.

Summary of the Second Pennsylvania Roundtable on Child Health and Managed Care: Care
Coordination for Children with Special Health Care Needs

Welcome and Introductions

The meeting began with a welcome from Cheryl Squire-Flint, Healthy Start Pittsburgh, and Pat Yoder,
Chester County Health Department, representing the Pennsylvania Perinatal Partnership and local public
health leadership in maternal and child health. They described how this second roundtable was designed
as a follow-up to the first roundtable held in March 2004. The agenda for the day was designed to offer an
array of perspectives on strategies for enhancing care coordination for CSHCN.

The next speaker, representing the Pennsylvania Secretary of Health, was Melita Jordan, director of the
Bureau of Family Health and the designate Title V program director for Pennsylvania. Ms. Jordan
described the Title V mission and Federal-State partnership. More specifically, she described the
mandate under Title V to designate 30 percent of the State’s block grant allocation to serving children
with special health care needs and their families. In Pennsylvania, program activities include:
comprehensive specialty care, Parent-to-Parent support groups, a medical home initiative, and other
projects and services. In terms of direct medical services, the State supports staff in each of the six
community health districts. Ms. Jordan also reported on the results of a study by Health Systems
Research, which found that: a) those covered by Medicaid faced access problems outside urban areas; b)
no mechanisms exist to link various systems of care; c) provider payments and continuity of care continue
to be important issues; and d) older CSHCN are more likely to lack access to care and need more
transition assistance.

Representing the Pennsylvania Department of Public Welfare (DPW), Suzanne Campbell, told the group
that that DPW welcomed ideas for improving service delivery. She also encouraged the group to think
about ways to increase efficiencies in the current budget climate.

Perspectives on the Challenge

Kate Maus, MCH leader for the Philadelphia Department of Public Health, described her experiences in
coordinating resources for CSHCN at the local level. For example, care coordinators in Philadelphia have
to manage: the interface among five tertiary care hospitals, multiple specialty physicians, Medicaid
eligibility staff; multiple health care coordination projects, and managed care special needs units, as well
as providers from mental health, education, early intervention, childcare, and child welfare systems. Ms.
Maus described the contrast between what exists today and the dream of family-centered care. She
described the vision of parents of children with special needs as: “Nothing about me without me.”

Speaking as an affected and concerned parent of a child with special health care needs, Melissa Parsons
described the challenges she faces in coordinating care across medical and social systems for a young
child with a chromosomal disorder that affects multiple body systems. Despite ongoing support from
Healthy Start, Mrs. Parsons has faced challenges throughout her child’s first two years, negotiating
through multiple surgeries, eleven doctors, many specialty evaluations, early intervention services, and
related support services.

Panel Presentations on Program Models in Pennsylvania

• SECCS Grant, Barbara Caboot, Department of Health – All State Title V programs
  have used State Early Childhood Care Systems (SECCS) grant funding to plan for improved
  linkages among early childhood health, welfare, and education systems. Pennsylvania, now in
  the second year of the planning phase, has done a gap analysis. Other potential future activities
  include: development of a system and/or finance map, implementation of integrated programs or
  funding strategies, and reorganization of administrative functions for early childhood programs.
  Efforts to better integrate care coordination for CSHCN could be a focus for future efforts.
• Medical Home Initiative - Alan Kohrt, MD, and Molly Gato, PA Chapter, American
  Academy of Pediatrics – The American Academy of Pediatrics has advanced principles for
  providing a medical home to every child with special health care needs. HRSA’s Maternal and
  Child Health Bureau (MCHB) and States have supported model program initiatives to advance
  the concept of a medical home. Dr. Kohrt described the current efforts in this State. In
  Pennsylvania, 26 physician (pediatrician) practices currently are implementing the medical home
  model in the context of learning collaborative. Additional practices are being added
  incrementally. Each practice identifies a family partner, quality improvement team leader, and
  care coordinator who work together to change practice behavior. For 16 of these practices, such
  efforts are supported by small grants ($5,000 - $10,000). Molly Gato described how outcomebased
  data are being collected (through a new time-tracking form and a patient database) for the
  purpose of evaluating change. The medical home model is central to the discussion and design of
  a more uniform approach to care coordination for CSHCN.
• HIV/AIDS Case Management Model – Dorothy Mann, Family Planning Council –
  Lessons learned from the HIV-AIDS program case-management approach operating in
  Philadelphia since the 1980s are useful in the context of care coordination for CSHCN. Ms.
  Mann described how the State uses standardized qualifications to certify case managers, who, in
  turn, can be hired by local service agencies. In Southeastern Pennsylvania, three managed care
  organizations contract with these local service agencies, despite the fact that they could opt to do
  this case management internally. Ms. Mann described this HIV/AIDS case management as
  tailored to individual needs and functioning as care coordination for outpatient services. Current
  reimbursement is $35 per hour, with case managers carrying an average caseload of 25
  individuals/families. No evaluation of the HIV model has been conducted.
• Assessment of Office-based vs. Community-based Care Coordination – Ed Spahr,
  MD, Department of Health – Dr. Spahr described the medical home training project operated
  by the Department of Health. He also discussed the attributes of office-based versus communitybased
  approaches to care coordination. Finally, he stressed the importance of measuring family
  satisfaction, including measures to capture perceptions of the degree to which care coordination
  results in services that are family centered, culturally competent, and well coordinated.
• Current Managed Care Contracts – Allison McCanemy, Department of Public
  Welfare – In Pennsylvania, as in most States, Medicaid uses several types of managed care
  arrangements, including full-risk capitated HMOs and primary care case management (PCCM).
  DPW has contracts with private consultants to implement chronic disease management projects,
  which include asthma in children. These projects are designed to test the impact of a system of
  rewards and incentives for improved quality and effectiveness in chronic disease management.
  In addition, Ms. McCanemy said, in the context of full-risk contracts, Medicaid managed care
  organizations have responsibility for operating “special needs” case management/care
  coordination units. Questions have been raised about the role of these units, that is, whether they
  are charged with family-focused care coordination or plan-focused cost containment. Also,
  anecdotal evidence suggests that some families mistrust these HMO-operated units.
• Care Coordination Model – Loware Holiman, Department of Insurance – The
  Department of Insurance (DOI) operates the State Children’s Health Insurance Program (SCHIP)
  plan in Pennsylvania, which is designed similar to a standard Blue Cross/Blue Shield private plan.
  Ms. Holiman reported that SCHIP does not currently use a care coordination model and lacks
  data to monitor such services. The State’s SCHIP plan does use HEDIS indicators and data to
  monitor program/plan performance. Right now, DOI is investigating the higher than average use
  of Emergency Room services by covered children. They also have survey data indicating that 92
  percent of children in SCHIP have an identified regular source of care (a doctor or a nurse).

Lunchtime Presentation: What can we learn from other states?

Kay Johnson, Johnson Group Consulting

Ms. Johnson gave a presentation about what other States are doing to improve care coordination for
CSHCN, particularly through the lens of Medicaid and Medicaid managed care. She briefly described
other States approaches, particularly SECCS planning grants and AAP/MCHB medical home initiatives,
stating that Pennsylvania has undertaken many of the same projects and activities as other States. For
example, North Carolina and other States have developed data collection and referral forms similar to the
one being tested in pediatric practices in Pennsylvania. Other States, such as Colorado and Connecticut
have used their SECCS planning process and medical home initiatives to achieve greater coordination and
support services for CSHCN. Ms. Johnson also set out a framework for thinking about these issues. She
clarified that Medicaid does not finance a category called “care coordination” but does have several types
of case management benefit categories that States can use. One important category is “targeted case
management,” which is an optional benefit category financed at the State’s medical assistance matching
rate. Other categories are administrative case management, which qualify for the 50/50 administrative
matching rate. Both categories may be or have been used by other States to finance support services for
CSHCN. This is only possible, however, where clear definitions and specific dollars have been
identified. Ms. Johnson concluded by encouraging the group to acknowledge that lack of shared
definitions (and not financing) were the greatest obstacles to achieving their goal of better integrated care
coordination for CSHCN.

[D]

Summary of Discussion regarding Care Coordination for CSHCN

1. Participants discussed the need to define and achieve greater consensus on the vision for what
   they are hoping to achieve through care coordination.
2. The characteristics of care coordination they envisioned would ideally:
   - make one individual the primary point of contact;
   - assign one individual to each family as the primary care coordinator;
   - be responsible for cross-system linkages;
   - use existing resources;
   - provide more than just benefits management;
   - offer a variety of entry points;
   - be independent (of providers or payors);
   - be able to be varied by intensity & need (not one size fits all);
   - link to medical home (e.g., through paper reports, co-location); and
   - have accountability (e.g., data reporting, grievance procedures).
3. The group also identified a basic set of principles, including many often cited as essential for
   CSHCN and their families and other desirable characteristics more related to public
   administration. They suggested services should be: safe, effective, efficient, timely, equitable,
   unduplicated, family-driven and family-centered, and culturally competent.
4. The Roundtable participants discussed the need for a shared definition of care
   coordination/case management for CSHCN. In order to be useful for policy and finance
   discussions, this definition must be one that can be operationalized and would include:
   - provider qualifications;
   - certification standards;
   - outcome and process measures/benchmarks;
   - criteria for service eligibility (i.e., which children/families have need for this service).
5. The group also saw a need to quantify the need and assess gaps in funding and services.
   Specific questions that need to be addressed include: a) how many children by age, type of
   condition/severity, and level of need of family, b) how many dollars are now being spent on care
   coordination for CSHCN, and c) how many existing providers are available to deliver these
   services?

Discussion of Opportunities for Action
The Roundtable participants discussed two types of next steps. First, the group “brainstormed” about
what type of activities might continue the momentum generated during the Roundtable and lead to
progress in improving care coordination for CSHCN. The main ideas were:

• prepare a fact sheet summarizing the current situation and making the case for change;
• prepare a more detailed analysis that states the “business case;”
• continue meetings to respectfully discuss differences in models and in purposes of care
  coordination/case management. This is an essential step toward reaching consensus on a working
  definition;
• conduct a needs/gap analysis, particularly focusing on current spending and provider capacity;
  develop a consensus definition;
• develop guidelines and/or a provider handbook that can be used to increase knowledge and
  change practices;
• develop a core, common training curriculum;
• write and execute interagency agreements that support better integrated care coordination (e.g.,
  billing codes, shared staff, pooled training funds, common definitions);
• develop a model for tiered billing, based on severity of need or intensity of services;
  convene additional State-level meetings to discuss and continue progress;
• encourage local meetings (particularly if tools such as a fact sheet, training materials, or
  guidelines can be shared).
• Finally, several members of this leadership group agreed to take future steps to advance the day’s
  work.

Handout for the Second Pennsylvania Roundtable

Extracted sections from the GWU Purchasing Specifications.

Purchasing Specifications for Children with Special Health Care Needs

Extracted Sections related to Care Coordination for CSHCN

… §104. Care Coordination Services

Commentary: The following illustrative language assumes that the Purchaser wishes to provide care
coordination services to children with special health care needs through the contracting MCOs in which
they are enrolled. It should be noted that States are not required to offer care coordination services to
Medicaid beneficiaries generally or to this population in particular, and some States do not cover these
services for this population. In addition, not all MCOs are organized to provide care coordination services
to children with special health care needs or other enrolled populations through separate care
coordinators; instead, they rely upon the treating physician to perform care coordination functions. Finally,
if a State Medicaid program elects to cover care coordination services for this population, it may also elect
to "carve out" such services from its purchasing agreements with MCOs and provide them on a fee-forservice
basis through the State Title V agency or other State or local agencies, or through private
organizations. For a review of the care coordination models used by Colorado, Delaware, New Mexico,
Oregon, and Washington, see Rosenbach and Young, Care Coordination in Medicaid Managed Care: A
Primer for States, Managed Care Organizations, Providers, and Advocates (March 2000) www.chcs.org.
The federal Medicaid statute and implementing regulations do not contain a “care coordination services”
category. Thus, it is not possible to state with certainty that the care coordination services set forth in the
following illustrative language would qualify for federal Medicaid matching funds. That determination can
be made only by HCFA. HCFA's published guidance on coverage of case management services is set
forth in State Medicaid Manual at §4302¹⁶, www.hcfa.gov/pubforms/pub45pdf/smm4t.htm.

(a) In General — Contractor shall comply with the requirements of this section relating to:
(1) assignment or selection of a care coordinator (as defined in §108(b)) under subsection (b);
and
(2) the duties of the care coordinator (as defined in §108(b)) under subsection (d).
Commentary: The following illustrative language assumes that the family or caregiver of an enrolled child
with special health care needs has the option of refusing to accept a care coordinator for the child. It also
assumes that the family or caregiver has the option of declining to accept the particular care coordinator
that Contractor wishes to assign to the child. The language would not, however, require Contractor to hire
or subcontract with any particular care coordinator in order to meet the wishes of the family or caregiver.
The family or caregiver’s choice would be limited to those care coordinators (including a primary care
provider, if the family or caregiver so chooses) available within Contractor’s provider network under §204.

(b) Assignment or Selection of Care Coordinator
(1) In General
(A) Contractor shall, within [ ] days of the date described in paragraph (5), notify in writing
the family or caregiver of an enrolled child with special health care needs (as defined in
§108(c)) of the identity of the care coordinator that Contractor proposes to assign to the
child to furnish care coordination services under subsection (d).
(B) This paragraph shall not be construed to require Contractor to assign to a child a care
coordinator who does not participate in Contractor’s provider network under §204(e) or
with whom Contractor does not have an out-of-network arrangement under §204(f).
(2) Option to Receive Care Coordination Services from Primary Care Provider¹⁷ —
Contractor shall allow the family or caregiver of an enrolled child with special health care needs to
select as the child’s care coordinator a primary care provider participating in Contractor’s provider
network who is willing to assume the responsibilities enumerated under subsection (d) with
respect to the child.
(3) Option to Receive Care Coordination Services from Care Coordinator — Contractor shall
allow the family or caregiver of an enrolled child with special health care needs to receive care
coordination services from a care coordinator (as defined in §108(b)) other than a primary care
provider if the care coordinator is selected by the child’s primary care provider in consultation with
the child’s family or caregiver.
(4) Option to Refuse a Care Coordinator — Contractor shall not assign an enrolled child with
special health care needs to a care coordinator (as defined in §108(b)) unless the child’s family or
caregiver (or, in the case of an adolescent, the adolescent):
(A) agrees in writing to receive care coordination services under this section from a care
coordinator; and
(B) has selected a care coordinator under paragraph (2) or consulted with a primary care
provider under paragraph (3).
(5) Date — The date described in this paragraph is the earlier of:
(A) the effective date of enrollment of the child; or
(B) the date on which the enrolled child has been identified as a child with special health
care needs (as defined in §108(c)) by a provider participating in Contractor's provider
network (whether or not such provider is the child’s primary care provider).
(6) Responsibilities of Care Coordinator — If a care coordinator has been selected by or
assigned to an enrolled child or the child’s family or caregiver under paragraphs (2) and (3),
Contractor shall ensure that the care coordinator carries out the duties required under subsection
(d).
(c) Use of State Title V CSHCN Program Personnel
(1) Option — Contractor may meet the requirements of subsection (b) through the use of care
coordinators (as defined under §108(b)) affiliated with [drafter insert name of State Title V
CSHCN Agency].

(2) Written Agreement — If Contractor elects to use care coordinators under paragraph (1),
Contractor shall enter into a written agreement with [drafter insert name of State Title V CSHCN
Agency] under §206(b)(3).…
(d) Responsibilities of Care Coordinator¹⁸ — Contractor shall ensure that, in the case of an enrolled
child with special health care needs (as defined under §108(c)) who has selected a care coordinator
under subsection (a), the care coordinator, consistent with §107(b) relating to utilization management,
shall:
(1) make every effort to meet with the family or caregiver of the child, in person or by telephone,
within [ ] days of being assigned, in order to learn about the child’s diagnosis and treatment needs
and the needs of the family or caregiver in supporting the child;
(2) assist:
(A) the primary care provider in developing the child's care plan under §105(b)(1)(D); and
(B) the child (and the child’s family or caregiver) in understanding the contents of the
plan;
(3) assist the child in accessing items and services specified in the child’s care plan under §105
that are:
(A) the duty of Contractor under §103(a); and
(B) required under each of the following plans (if any) that has been developed for the
child:
(i) an IFSP (as defined in §108(g));
(ii) an IEP (as defined in §108(f));
(iii) a plan developed for the child by [drafter insert name of State child welfare
agency]; and
(iv) [drafter insert references to other applicable treatment plans];
(4) if requested by the child (or, except in the case of an adolescent, the child’s family or
caregiver), assist the child, in manner consistent with §209(d) (relating to confidentiality
protections), in accessing items and services that are specified in the child’s care plan under
§105 and are the responsibility of Purchaser under §103(b);
Commentary: The illustrative language in paragraph (5) assumes that the MCO's care coordinator has the
responsibility for assisting an enrolled child's family or caregiver in having payment made for services
covered under a State's Medicaid program that are not the duty of the MCO. Another approach would be
for the family or caregiver to be referred to appropriate State or local agencies.
(5) if requested by the child (or, except in the case of an adolescent, the child’s family or
caregiver), assist the child, in manner consistent with §209(d) (relating to confidentiality
protections), in accessing and identifying payment sources for items and services that are
specified in the child’s care plan under §105 and not the responsibility of Contractor under
§103(a) or Purchaser under §103(b);
66
(6) consistent with §203(f), assist the child in accessing pediatric specialists (as defined in
§108(j)) and other providers participating in Contractor’s provider network that are identified in the
child’s care plan under §105;
(7) refer the child to the [drafter insert reference to responsible agencies under Part B and Part C
of the Individuals with Disabilities Education Act, 20 U.S.C. §1400 et seq.] unless the child is
receiving services under an IEP (as defined in §108(f)) or an IFSP (as defined in §108(g));
(8) if appropriate, in the case of a child age 16 or older, refer the child to the State Vocational
Rehabilitation Agency under Title I of the Rehabilitation Act of 1973, 29 U.S.C. §720 et seq., 34
C.F.R. 300.347(b);
(9) facilitate, consistent with the confidentiality protections under §209, the exchange of
information and medical records among Contractor, the child’s primary care provider, and [drafter
insert reference to responsible agencies under Part B and Part C of the Individuals with
Disabilities Education Act, 20 U.S.C. §1400 et seq.];
(10) meet (in person or by telephone) with the child and the child’s family or caregiver in order to
track the child’s progress under the child’s care plan under §105 and, based on the experience of
the child and the child’s family or caregiver, make recommendations to the child’s primary care
provider with respect to updating the care plan under §105(b)(5);
(11) establish working arrangements with care coordinators or case managers (other than those
employed by, or under contract to, Contractor) who have responsibilities with respect to the child;
(12) assist the child (and the child’s family or caregiver) in:
(A) understanding the child’s entitlement to a fair hearing under 42 C.F.R. §430.220 and
to the continuation of services pending the fair hearing under 42 C.F.R. §430.230 and, in
the case of denial, termination, or reduction of items and services covered under §103(a),
in effectuating these entitlements; and
(B) accessing, under §209(c), Contractor’s grievance procedures and the State fair
hearing process;
(13) assist the child (and the child’s family or caregiver) in documenting, establishing, and
maintaining the child’s eligibility for [drafter insert reference to State Medicaid program], the
Supplemental Security Income (SSI) program under Title XVI of the Social Security Act, 42
U.S.C. §1381 et seq., and other public program benefits;
(14) inform the child's family or caregiver of the manner in which the child’s family or caregiver
may participate in:
(A) voluntary networks organized for mutual support by families or caregivers of children
with special health care needs; and
(B) the Family Advisory Board established and maintained by Contractor under
§101(d)(3); and
(15) in the case of a child with special health care needs who is an adolescent as defined
in §108(a), assist the adolescent in identifying and overcoming transitional issues relating
to accessing items and services described in paragraph (3).¹⁹

Handout for the Second Pennsylvania Roundtable
Medicaid Case Management: Examples*

* Table prepared by Kay Johnson for the Managed Care Technical Assistance Project, Second
Pennsylvania Roundtable on Child Health and Managed Care: Care Coordination for Children
with Special Health Care Needs

Definitions from Federal Regulation (www.cms.gov)

4-302. OPTIONAL TARGETED CASE MANAGEMENT SERVICES - BASIS, SCOPE
AND PURPOSE …

A. Background.--Case management is an activity which assists individuals eligible for Medicaid in
gaining and coordinating access to necessary care and services appropriate to the needs of an individual.
Prior to the enactment of P.L. 99-272, States could not provide case management as a distinct service
under Medicaid without the use of waiver authority. However, aspects of case management have been an
integral part of the Medicaid program since its inception. The law has always required interagency
agreements under which Medicaid patients may be assisted in locating and receiving services they need
when these services are provided by others. Prior to the enactment of P.L. 99-272, Federal financial
participation (FFP) for case management activities may be claimed in any of four basic areas:

1. Component of Another Service.--Case management may be provided as an integral and
inseparable part of another covered Medicaid service. An example of this type of case
management is the preparation of treatment plans by home health agencies. …separate
payment for the case management component cannot be made, but is included in the payment
made for the service at the Federal Medical Assistance Percentage (FMAP) rate.

2. Administration.--Case management may be provided as a function necessary for the proper
and efficient operation of the Medicaid State plan, as provided in §1903(a) of the Act. Activities
such as utilization review, prior authorization and nursing home preadmission screening may be
paid as an administrative expense. The payment rate is either the 50 percent matching rate or the
75 percent FFP rate for skilled professional medical personnel, when the criteria in 42 CFR
432.50 are met.

3.Section 1915(b) Waivers.--Case management may be provided in a waiver granted under
§1915(b) of the Act….

4.Section 1915(c) Waivers.--Case management may be provided as a service in a waiver granted
pursuant to §1915(c) of the Act....

… (2) For purposes of this subsection, the term ‘case management services’ means services which will
assist individuals eligible under the plan in gaining access to needed medical, social, educational, and
other services.

B. Legislation.--P.L. 99-272 adds case management to the list of optional services which may be
provided under Medicaid. Section 9508 of P.L. 99-272 adds a new subsection (g) to §1915 of the Act.
This subsection, as amended by P.L. 100-203, provides that:

"(g)(1) A State may provide, as medical assistance, case management services
under the plan without regard to the requirements of section 1902(a)(1) and
section 1902(a)(10)(B). The provision of case management services under this
subsection shall not restrict the choice of the individual to receive medical
assistance in violation of section 1902(a)(23). A State may limit the provision of
case management services under this subsection to individuals with acquired
immune deficiency syndrome (AIDS); or with AIDS-related conditions, or with
either, and a State may limit the provision of case management services under
this subsection to individuals with chronic mental illness. The State may limit the
case managers available with respect to case management services for eligible
individuals with developmental disabilities or with chronic mental illness in order to
ensure that the case managers for such individuals are capable of ensuring that
such individuals receive needed services.
…

4302.2 State Plan Amendment Requirements.--Any State plan amendment request to provide optional
case management services must address all of the requirements of this section.

6. Target Group.--Identify the target group to whom case management services will be provided.
   This targeting may be done by age, type or degree of disability, illness or condition (e.g., Acquired
   Immune Deficiency Syndrome (AIDS) or Chronic Mental Illness), or any other identifiable
   characteristic or combination thereof. The following examples are target groups currently
   receiving case management services under §1915(g) of the Act:
   • Developmentally disabled persons (as defined by the State);
   • Children between the ages of birth and up to age 3 who are experiencing developmental
     delays or disorder behaviors as measured and verified by diagnostic instruments and
     procedures;
   • Pregnant women and infants up to age 1;
   • Individuals with hemophilia;
   • Individuals 60 years of age or older who have two or more physical or mental diagnoses
     which result in a need for two or more services; and
   • Individuals with AIDS or HIV related disorders.
   
   In defining the target group, you must be specific and delineate all characteristics of the
   population.…
   
   NOTE: Although FFP may be available for case management activities that identify the specific services
   needed by an individual, assist recipients in gaining access to these services, and monitor to assure that
   needed services are received, FFP is not available for the cost of these specific services unless they are
   separately reimbursable under Medicaid. Also, FFP is not available for the cost of the administration of
   the services or programs to which recipients are referred….
   
7. Differentiation Between Targeted Case Management Services and Case Management Type
   Activities for Which Administrative Federal Match May Be Claimed.--You must differentiate between
   case management services which may properly be claimed at the service match under §1915(g) and
   case management activities which are appropriate for FFP at the administrative match under the State
   plan, based upon the appropriate criteria. These two payment authorities do not result in mutually
   exclusive types of services.
   
   There are certain case management activities which may appropriately be eligible for FFP at either the
   administrative or the service match rate. Examples of case management activities that may be claimed at
   either the administrative or the service match rate entail providing assistance to individuals to gain access
   to services listed in the State plan, including medical care and transportation. In cases where an activity
   may qualify as either a Medicaid service or an administrative activity, you may classify the function in
   either category. This decision must be made prior to claiming FFP because of the different rules which
   apply to each type of function under the Medicaid program.
   1. Case Management as a Service Under §1915(g).--FFP is available at the FMAP rate for
      allowable case management services under §1915(g) when the following requirements are met:
      Expenditures are made on behalf of eligible recipients included in the target group (i.e. there must
      be an identifiable charge related to an identifiable service provided to a recipient);
   • Case management services are provided as they are defined in the approved State plan;
   • Case management services are furnished by individuals or entities with whom the Medicaid
     agency has in effect a provider agreement;
   • Case management services are furnished to assist an individual in gaining or coordinating
     access to needed services…

   Because §1915(g) of the Act defines case management services as services which assist
   individuals eligible under the plan in gaining access to needed medical, social, educational, and
   other services, recipients may obtain access to services not included in the Medicaid State plan.
   The costs of case management services provided under §1915(g) that involve gaining access to
   non-Medicaid services are eligible for FFP at the service match rate.

   Examples of case management services provided under §1915(g) of the Act may include
   assistance in obtaining Food Stamps, energy assistance, emergency housing, or legal services.
   All case management services provided as medical assistance pursuant to §1915(g) of the Act
   must be described in the State plan. In addition, they must be provided by a qualified provider as
   defined in the State plan.

   When case management is provided pursuant to §1915(g) of the Act, the service is subject to the
   rules pertaining to all Medicaid services. If you choose to cover targeted case management
   services under your State plan, as defined in §1915(g) of the Act, you cannot claim FFP at the
   administrative rate for the same types of services furnished to the same target group.

   2. Case Management as an Administrative Activity. ….
      …The following list of functions provides examples of activities which may properly be claimed as
      administrative case management activities, but not as targeted case management services. The
      omission of any particular function from this list does not represent a determination on HCFA’s
      part that the function is not necessary for the administration of the plan.
      • Medicaid eligibility determinations and redeterminations;
      • Medicaid intake processing;
      • Medicaid preadmission screening for inpatient care;
      • Prior authorization for Medicaid services and utilization review; and
      • Medicaid outreach (methods to inform or persuade recipients or potential recipients
        to enter into care through the Medicaid system).

   
   Because activities related to services which Medicaid does not cover are not considered
   necessary for the administration of the Medicaid plan, the accompanying costs are not eligible for
   Medicaid FFP at the administrative rate. For example… setting up an appointment with a
   Medicaid participating physician and arranging for transportation for a recipient may be
   considered case management administrative activities necessary for the proper and efficient
   administration of the Medicaid plan. However, arranging for baby sitting for a recipient’s child,
   although beneficial to the recipient, is not an activity for which administrative FFP can be
   claimed…. when a caseworker suspects that physical abuse of a recipient has occurred, the
   referral to medical care could be considered a reimbursable administrative activity under the
   Medicaid program. However, assisting the victim in obtaining emergency housing and legal
   services, although in the best interest of the recipient, is not an activity for which administrative
   FFP may be claimed….
   
   Administrative case management activities may be performed by an entity other than the single
   State agency. However, there must be an interagency agreement in effect…

8. Case Management Under the Early and Periodic Screening, Diagnostic and Treatment (EPSDT)
   Program.--Care coordination, including aspects of case management, has always been an integral
   component of the EPSDT program... Section 1905(r) requires that States provide any services included in
   §1905(a) of the Act, when medical necessity for the service is shown by an EPSDT screen, whether such
   services are covered under the State plan. While case management is required under the expanded
   EPSDT program when the need for the activity is found medically necessary, this does not mean
   §1915(g) targeted case management services. Therefore, when the need for case management activities
   is found to be medically necessary, the State has several options to pursue:
   1. Component of an Existing Service.--Case management services may be provided to persons
      participating in the EPSDT program by an existing service provider such as a physician or clinic
      referring the child to a specialist.
   2. Administration.--Case management services may be provided to EPSDT participants by the
      Medicaid agency or another State agency such as title V, the Health Department or an entity with
      which the Medicaid agency has an interagency agreement. Administrative case management
      activities must be found necessary for the proper and efficient administration of the State plan
      and therefore must be limited to those activities necessary for the proper and efficient
      administration of Medicaid covered services. FFP is available at the administrative rate.
   3. Medical Assistance.--Case management services may be provided under the authority of
      §1905(a)(19) of the Act. The service must meet the statutory definition of case management
      services, as defined by §1915(g) of the Act. Therefore, FFP is available for assisting recipients in
      gaining access to both Medicaid and non-Medicaid services. FFP for case management services
      furnished under §1905(a)(19) of the Act is available at the FMAP rate.

   Any combination of two or more of the above is possible, as long as FFP is not available for duplication of
   services.

¹ McPherson et al. A New Definition of Children with Special Health Care Needs. Pediatrics. 1998;102:137-140.