On December 4, CMS published an interim final rule clarifying the definition of case management and targeted case management (TCM) services for which states may receive Medicaid payment. Implementing Section 6052 of the Deficit Reduction Act of 2005, passed in response to concerns over improper billing and duplicate payments, the rule newly defines case management and TCM services to include only "those activities that help an individual gain access to needed medical, social, educational, and other services." CMS specifies that federal matching funds are not available for "activities that are an integral component of another covered Medicaid service" (for example, case management of medical services that are also managed by an individual’s managed care plan), or for "services that involve the direct delivery of underlying medical, educational, social, or other services to which an eligible individual has been referred." FFP may be available for these direct services, such as performance of diagnostic tests, counseling services, etc., if they are covered under another Medicaid service category.
CMS would also specifically exclude federal matching payments for:
- Transportation services and day care services meant to enable beneficiaries to access needed services;
- Activities that constitute the administration of foster care programs or other nonmedical programs, including guardianship, legal services and special education services not included in individualized education plans or family services plans; and
- Case Management or TCM services to individuals under the age of 65 who reside in an institution for mental diseases (IMD).
Furthermore, FFP would only be available for the cost of case management or TCM services if there are no other third parties liable to pay for those services, including reimbursement under medical, social, or educational programs.
According to CMS, these clarifications would save the Medicaid program $1.280 billion from Fiscal Years 2008 to 2012. Comments on the rule are due February 4, 2008. The rule will become effective March 3, 2008.
The full text of the rule is available online at http://a257.g.akamaitech.net/7/257/2422/01jan20071800/edocket.access.gpo.gov/2007/pdf/07-5903.pdf.
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