Archived Questions and Answers

Targeted Case Management (TCM)

Table of Contents

  1. Will children´s case management providers have the option to become Health Home network partners?
  2. What was the rationale for including targeted case management (TCM) programs to become Health Homes?
  3. Will TCM programs that either become Health Home leads or Health Home network partners be able to keep their TCM slots and bill Medicaid directly for them?
  4. If a converted OMH TCM provider receives a referral to serve a Medicaid-eligible enrollee that is seriously and persistently mentally ill (SPMI), can the converted TCM provider place the individual in one of their legacy converted TCM slots (if available) and bill Medicaid directly for Health Home services at the legacy TCM rate? Can the provider continue to fill TCM legacy slots with people who are Health Home participants and bill Medicaid directly at the present TCM rates?
  5. If a Health Home assigns a member to a TCM provider are services billed at the legacy rate or the Health Home rate?
  6. Can you explain more about how the OMH TCM programs transitioned into the Health Home care coordination role?
  7. Will TCM programs be expected to provide only Health Home care management, or will TCM programs continue to need to meet specified requirements (e.g., OMH required four face–to–face encounters per month per ICM, array of services from regulations, etc.).
  8. What is to become of those currently served by TCMs who are not Medicaid eligible?
  9. TCM providers will bill for and receive their provider–specific per–member per month (PMPM) legacy rate. Will legacy providers be required to provide an administrative percentage of this rate to the Health Home and the Managed Care Health Plan?
  10. What is the role of the County Single Point of Access (SPOA)? Are Health Homes able to assign individuals directly to OMH TCM programs without regard to County SPOA committees?
  11. If a Health Home assigns a non–TCM member to a TCM provider can the Health Home bill?
  12. How will TCM providers expand the number of Health Home clients they are eligible to serve and maintain the previous care management relations with their converting TCM clients they currently serve?
  13. ACT teams provide case management services as do PROS service providers. Are these service providers included as members of Health Homes provider networks or are their functions being carried out by the Health Home? Is there a potential for duplicate billing for case management services by ACT teams, PROS, and Health Homes? If so, how will this be addressed under the current model?
  14. Have OMH Intensive Case Management (ICM) programs been converted to Health Home services?
  15. There had been some preliminary discussions about granting Health Home access to PSYCKES data, but we haven´t heard anything further about it for a while. We hope this is still under consideration because it could be such a valuable tool for Health Home Care Managers. We´d appreciate any information you can provide about the status of this request.
  16. Is it true that services provided to members in legacy slots paid for by OMH TCM legacy rates must meet the current ICM guidelines and the Health Home slots are the only ones exempt from ICM regulations? If that is true then do the care coordinators have to meet current qualifications?
  17. How would Medicaid ineligible AOT clients be served in a Health Home?
  18. If a member transitions from a Health Home to an Assertive Community Treatment program are they discharged from the Health Home?

Back to current Q&As

1. Will children´s case management providers have the option to become Health Home network partners?

Requirements for Health Homes to serve children are still under development, Children previously served by HIV COBRA case management may continue to be served. Other children´s programs will convert to Health Home services once the Health Home network requirements for children have been developed. For additional information see (insert link to Children´s HH webpage)

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2. What was the rationale for including targeted case management (TCM) programs to become Health Homes?

Targeted case management programs were uniquely positioned to apply to be designated as Health Homes or convert to network partners providing Health Home care management because they have a wealth of experience in providing comprehensive case management and extensive community supports to help meet the complex needs of their clients.

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3. Will TCM programs that either become Health Home leads or Health Home network partners be able to keep their TCM slots and bill Medicaid directly for them?

TCM programs that convert to Health Home care management are being allowed to bill directly for both existing slots (known as legacy slots) and new members (also known as expansion slots). TCM slots are billed at a legacy rate established for each provider. Providers must bill for any slots above the legacy cap at the Health Home rates, currently the option to bill legacy rates and to bill directly is in place until December 31, 2014.

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4. If a converted OMH TCM provider receives a referral to serve a Medicaid–eligible enrollee that is seriously and persistently mentally ill (SPMI), can the converted TCM provider place the individual in one of their legacy converted TCM slots (if available) and bill Medicaid directly for Health Home services at the legacy TCM rate? Can the provider continue to fill TCM legacy slots with people who are Health Home participants and bill Medicaid directly at the present TCM rates?

Converted OMH TCM programs or COBRA TCM programs can use either legacy or expansion slots for members that meet their legacy diagnostic criteria and can also place new Health Home members into available converted TCM legacy slots. Converting TCM programs and MATS programs can bill eMedNY directly for both legacy and expansion slots. Payment will be at the TCM rate for a specified period. Click here for updated information.

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5. If a Health Home assigns a member to a TCM provider are services billed at the legacy rate or the Health Home rate?

It depends on whether the legacy provider, who is now part of a Health Home, has a legacy slot available to accept this member. If the provider is below its slot limit, the provider can place the member in a legacy slot and bill for this member directly under the legacy TCM rate. If the TCM provider does not have an available TCM slot, but is still accepting new members, then the member is billed under the Health Home rate. In either case the TCM provider bills directly for a specified period, currently until December 31, 2014.

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6. Can you explain more about how the OMH TCM programs transitioned into the Health Home care coordination role?

OMH TCM providers became care management network partners under one or more Health Homes. Once the TCM provider starts billing the Health Home rate codes they are no longer subject to TCM regulations. Health Homes will develop their own policies for the role of care management partners. As part of Health Homes, care coordination will benefit from being connected to a larger service network.

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7. Will TCM programs be expected to provide only Health Home care management, or will TCM programs continue to need to meet specified requirements (e.g., OMH required four face–to–face encounters per month per ICM, array of services from regulations, etc.).

Once a TCM program converts to Health Home services (is billing Health Home/OMH/TCM rates) they are no longer subject to TCM rules and regulations. HIV COBRA programs converted to Health Home services once they engaged with a lead Health Home, and accepted Health Home assigned clients.

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8. What is to become of those currently served by TCMs who are not Medicaid eligible?

Healthcare for the underinsured and uninsured is a big problem both nationally and statewide. Access to Medicaid and commercial health insurance will improve with the advent of the Health Insurance Exchange. That being said, only Medicaid eligible individuals can participate in Health Homes. OMH has and will continue to provide State Aid funding for non–eligible individuals to receive care management.

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9. TCM providers will bill for and receive their provider–specific per–member per month (PMPM) legacy rate. Will legacy providers be required to provide an administrative percentage of this rate to the Health Home and the Managed Care Health Plan?

Health Home, legacy providers and Managed Care Plans will need to negotiate administrative fees as part of their Administrative Services Agreements (ASAs) arrangements. The State has suggested, based on the amount of administrative costs built into the Health Home PMPM that administrative fees be 3% of the PMPM, although some agreements call for a flat fee, which usually ranges from $10–$12 per member per month.

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10. What is the role of the County Single Point of Access (SPOA)? Are Health Homes able to assign individuals directly to OMH TCM programs without regard to County SPOA committees?

SPOAs will continue to play a role in assigning patients to TCM programs. Health Homes will need to work with their local SPOA in making some of these determinations.

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11. If a Health Home assigns a non–TCM member to a TCM provider can the Health Home bill?

No, TCMs bill for both TCM legacy slots and non–TCM slots (new Health Home or expansion slots).

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12. How will TCM providers expand the number of Health Home clients they are eligible to serve and maintain the previous care management relations with their converting TCM clients they currently serve?

It is the State´s intention to not disrupt care management relationships that are working; therefore the State is allowing converting TCM programs to keep their members. It will be up to transitioning TCM programs and Health Homes how best to adjust staffing levels and balance their case loads. At least initially many case managers´ caseloads will not change until the members who are being served require different levels of services. Ultimately decisions about how to balance case loads and assign members to case managers will be left to the care management agencies and the Health Home, acting in partnership with their local government unit.

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13. ACT teams provide case management services as do PROS service providers. Are these service providers included as members of Health Homes provider networks or are their functions being carried out by the Health Home? Is there a potential for duplicate billing for case management services by ACT teams, PROS, and Health Homes? If so, how will this be addressed under the current model?

See the OMH website for guidance.

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14. Have OMH Intensive Case Management (ICM) programs been converted to Health Home services?

OMH ICMs are included in Health Home partner networks.

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15. There had been some preliminary discussions about granting Health Home access to PSYCKES data, but we haven´t heard anything further about it for a while. We hope this is still under consideration because it could be such a valuable tool for Health Home Care Managers. We´d appreciate any information you can provide about the status of this request.

OMH and DOH have finalized a process that will allow Health Home care managers to access PSYCKES. Some of the Health Home network partners such as clinics may already have access to PSYCKES. New users will be added once system updates have been made. Click here to view Health Home Work Groups, Learning Collaborative and Webinars.

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16. Is it true that services provided to members in legacy slots paid for by OMH TCM legacy rates must meet the current ICM guidelines and the Health Home slots are the only ones exempt from ICM regulations? If that is true then do the care coordinators have to meet current qualifications?

No. Once an OMH TCM program converts to Health Homes (is billing Health Home Service rates/OMH/TCM rates) all slots are no longer subject to OMH TCM rules and regulations. Each Health Home determines and defines the qualifications required for their care managers.

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17. How would Medicaid ineligible AOT clients be served in a Health Home?

Medicaid ineligible clients cannot participate in Health Homes. OMH provides funding for ineligible Medicaid clients through State aid.

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18. If a member transitions from a Health Home to an Assertive Community Treatment program are they discharged from the Health Home?

Individuals in ACT receive case management services. The Department and OMH have developed a process for integrating the two programs. The guidance can be found on the OMH website.

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