| (a) Case management contacts on behalf of any eligible
child under age 21 are subject to this subchapter, regardless of the
family's ability to pay.
(b) Case management means services provided under this
subchapter to help BCVDD Program-eligible children gain access to
medical, social, educational, vocational, and other appropriate services
to help them reach or maintain an optimal level of functioning in
a community-based setting. Case management includes:
(1) coordinating the performance of evaluations and
assessments including eye exams, eye specialty exams, and/or exams
under anesthesia; arranging for other medical or nonmedical diagnostics;
helping the family understand the results of diagnostic examinations;
and communicating the results of diagnostic evaluations and assessments
to educators and other professionals involved with the child;
(2) facilitating the development, review, and evaluation
of the family service plan in accordance with §106.1427 of this
subchapter (relating to Assessment) and DARS DBS procedures; the plan
is based on the child's applicable history and identified needs, the
parent's input, and the results of all evaluations and assessments;
(3) helping the family identify available service providers
and making appropriate referrals to obtain services from medical,
social, and educational providers to address identified needs and
achieve goals;
(4) following up with the family to help with timely
access to services, to discuss the disposition of the referral with
the family, and to determine if the services have met the child's
needs;
(5) monitoring and reassessing the delivery and effectiveness
of services through contacts with the child, family members, school
staff members, and service providers as frequently as necessary and
at least annually to determine if:
(A) services are being provided in accordance with
the family service plan;
(B) services are adequate; and
(C) when the child has new needs or there are changes
in the needs of the child, the family service plan and service arrangements
are adjusted to address the identified needs;
(6) facilitating the child's transition to educational,
habilitative, or vocational services as appropriate;
(7) documenting all case management activities, the
child's and family's response to case management, whether the child
and family have declined any services in the plan, and coordination
with other case management providers.
(c) Case management may be delivered face-to-face or
by telephone.
(1) Contacts are billable when the interaction:
(A) is with an eligible child, and/or the child's parent,
the child's caregiver, or other people directly related to identifying
the eligible child's needs;
(B) helps the eligible child access services;
(C) identifies needs and supports to help the eligible
child obtain services;
(D) provides the BCVDD Program Specialist with useful
feedback; or
(E) alerts the BCVDD Program Specialist to changes
in the eligible child's needs.
(2) Contacts are billable to the family according to §106.1463
of this subchapter (relating to Case Management Reimbursement Charges).
(d) Case management services are not billable to Medicaid
when another payor is liable for payment or when case management services
are associated with the proper and efficient administration of the
state plan. Case management services associated with the following
are not payable as optional case management services under Medicaid
and may not be billed to families of children not receiving Medicaid:
(1) Medicaid eligibility determinations and redeterminations;
(2) Medicaid eligibility intake processing;
(3) Medicaid preadmission screening;
(4) prior authorization for Medicaid services;
(5) required Medicaid utilization review;
(6) Texas Health Steps program administration;
(7) Medicaid "lock-in" provided for under the Social
Security Act, §1915(a);
(8) services that are an integral or inseparable part
of another Medicaid service;
(9) outreach activities that are designed to locate
people who are potentially eligible for Medicaid; and
(10) any medical evaluation, examination, or treatment
billable as a distinct Medicaid-covered benefit.
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| Source Note: The provisions of this §359.117 adopted to be effective June 13, 2013, 38 TexReg 3810; transferred effective February 1, 2022, as published in the January 7, 2022 issue of the Texas Register, 47 TexReg 35 |
