TMPPM 2008 > Texas Medicaid Services > Mental Health (MH) Mental Retardation (MR) > Benefits and Limitations

32.3 Benefits and Limitations

32.3.1 Service Coordination and Case Management

The Texas Medicaid Program provides the following service coordination and case management services:

•Service coordination for people with mental retardation or related condition (adult or child) per consumer, per month.

•Case management for people with serious emotional disturbance (child, 3-17 years of age).

•Case management for people with severe and persistent mental illness (adult, 18 years of age and older)

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An MR service coordination reimbursable contact is the provision of a service coordination activity by an authorized service coordinator during a face-to-face meeting with an individual eligible for service coordination. To bill and be paid for one unit of service coordination per month, at least one face-to-face meeting between the service coordinator and the eligible individual must occur during the month billed.

An MH case management reimbursable contact is the provision of a case management activity by an authorized case manager during a face-to-face meeting with an individual authorized to receive that specific type of case management. A billable unit of case management is 15 continuous minutes of contact.

Service coordination and case management services are not reimbursable when provided to a client eligible for Medicaid and receiving services through the Home and Community-Based Services (HCS) waiver. These services are included in the waiver. Claims submitted to TMHP for people receiving services under the HCS waiver are identified quarterly by DADS and payments are recouped.

The Texas Medicaid Program must not be billed for service coordination or case management services provided to people who are residents or inpatients of:

•Nursing facilities (for people not mandated by the Omnibus Budget Reconciliation Act [OBRA] of 1987).*

•Intermediate care facilities for mental retardation (ICF-MR).*

•State MR facilities.*

•State MH facilities.

•Title XIX participating hospitals including general medical hospitals.

•Private psychiatric hospitals.

•Medicaid-certified residence not already specified.

•Institutions for mental diseases such as a hospital, nursing facility, or other institution of more than 16 beds primarily engaged in providing diagnosis, treatment, or care of people with mental diseases including medical attention, nursing care, and related services.

•Jail or public institution.

*A contact by the service coordinator to assist in discharge planning from some of the above may be reimbursed, if provided within 180 days before discharge. Service coordination services provided to people who are on predischarge furlough to the community from a nursing facility, intermediate care facility, or state MR facility may be reimbursed. Service coordination services provided to people who are on trial placement from a state MR facility to the community may be reimbursed if the person remains eligible for Medicaid upon release from the facility and receives regular Medicaid coverage.

The Texas Medicaid Program must not be billed for MH case management services provided before the establishment of a diagnosis of mental illness and authorization of services.

Refer to: "Managed Care" for more information or contact the client's BHO. Do not bill TMHP for MH case management services rendered to NorthSTAR clients.