Section 3 - Participation and Program Requirements...Section 3-Participation and Program Requirements . 3-3 . June 2019. E. Maternal Child Health Program, F. Employment and Human Services

Medi-Cal Targeted Case Management

Provider Manual SECTION 3

Participation and Program Requirements

Table of Contents

Subject Page Overview 3-1 Program Requirements 3-1

Freedom of Choice 3-1 Fee Mechanism 3-1 Third Party Liability 3-1 Care Coordination to Prevent Duplication with Other Programs 3-2 1915(c) Home and Community-Based Services (HCBS) Waiver 3-2

Medi-Cal Managed Care 3-2 Other Programs 3-2

TCM Encounter 3-3 TCM Encounter Log 3-3 TCM Encounter Log Requirements 3-3

Required Information for the TCM encounter log 3-3 Reconciling TCM Encounter Log to the TCM System 3-4 TCM Encounter Rate 3-5

Quality Assurance 3-5 Non-Claimable Operating Costs 3-5 Subcontractors 3-5

TCM Program Participation Requirements Checklist 3-6 Host County / DHCS Contract 3-6 Host County / LGA Contract 3-6 Participation Requirements 3-7

Provider Participation Agreement 3-7 Ensuring Non-Duplication 3-7 Medi-Cal Disclosure Statement – Form 6207 3-7 Medi-Cal Provider Enrollment Agreement – Form 6208 3-7

Memorandum Of Understanding 3-8 Annual Participation Prerequisite 3-8

Adding a New Target Population 3-9 Performance Monitoring Plan (PMP) 3-9

Non-Duplication of Services 3-9 Managed Care Non-Duplication of Services 3-10 Lead Case Manager Non-Duplication of Services 3-11

Office of Inspector General Reviews 3-11 LGA Signature Authority Request 3-11 LGA Profile Request 3-11 Fee Mechanism 3-11 Subprogram Codes 3-12

TCM Program Withdrawal and Enrollment and/or Re-enrollment 3-12 LGA Participation Withdrawal from the TCM Program Form 3-12 LGA Participation Enrollment and/or Re-Enrollment in the TCM Program Form

3-13

1915(c) Home and Community-Based Services (H C B S) Waiver

T C M EncounterT C M Encounter LogT C M Encounter Log Requirements

Reconciling T C M Encounter Log to the T C M SystemT C M Encounter Rate

T C M Program Participation Requirements ChecklistHost County / D H C S ContractHost County / L G A Contract

Performance Monitoring Plan (P M P)

L G A Signature Authority RequestL G A Profile Request

T C M Program Withdrawal and Enrollment and/or Re-enrollmentL G A Participation Withdrawal from the T C M Program FormL G A Participation Enrollment and/or Re-Enrollment in the T C M Program Form

TCM PROVIDER MANUAL - Participation and Program Requirements

Section 3- Participation and Program Requirements 3-1

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I. OVERVIEW

To participate in the Targeted Case Management (TCM) program a Local Government Agency (LGA) must meet all of the following:

• Have a fully executed TCM Provider Participation Agreement (PPA), • Complete a TCM Annual Participation Prerequisite (APP), • Participate in TCM Time Survey Training and Documentation (refer to section 4), • Complete the annual TCM Cost Report (refer to section 5), and • Maintain supporting documentation to substantiate the TCM services provided

(refer to Section 9).

II. PROGRAM REQUIREMENTS

1. Freedom of Choice

Section 1902(a)(23) of the Social Security Act allows beneficiaries to obtain services from any qualified Medicaid provider that provides the services to them as specified in 42 Code of Federal Regulations (CFR) Section 431.51(a)(1). Additionally, 42 CFR Section 441.18(a)(1) states that, in providing TCM services, individuals will be allowed free choice of providers. The LGA must document that the eligible individual is aware of and understands their freedom of choice options. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in the State Plan (Attachment 4.19-B).

2. Fee Mechanism

Since Medi-Cal is the payer of last resort, a fee mechanism must be in place to ensure that all other possible payment sources have been considered prior to using Medi-Cal as a payment source for TCM services.

Payment for TCM services under 42 CFR Section 441.18(a)(4) must not be duplicate payments made to public agencies or private entities under other program authorities for the same purposes. In general, payment may not be made for services which another payer is liable or for which no payment liability is incurred. Similarly, separate payment cannot be made for similar services, which are an integral and inseparable part of another Medicaid covered service.

3. Third Party Liability

Since Medi-Cal is the payer of last resort, LGAs must determine if eligible individuals have health insurance coverage other than Medi-Cal for comprehensive case management services. LGAs may only provide and claim for TCM services to the extent those services are not covered by any other insurance the eligible individuals may have. If an eligible individual does have other insurance coverage, the insurance information

T C M PROVIDER MANUAL - Participation and Program Requirements

To participate in the Targeted Case Management (T C M) program a Local Government Agency (L G A) must meet all of the following:

Have a fully executed T C M Provider Participation Agreement (P P A),

Complete a T C M Annual Participation Prerequisite (A P P),

Participate in T C M Time Survey Training and Documentation (refer to section 4),

Complete the annual T C M Cost Report (refer to section 5), and

Maintain supporting documentation to substantiate the T C M services provided (refer to Section 9).

Section 1902(a)(23) of the Social Security Act allows beneficiaries to obtain services from any qualified Medicaid provider that provides the services to them as specified in 42 Code of Federal Regulations (C F R) Section 431.51(a)(1). Additionally, 42 C F R Section 441.18(a)(1) states that, in providing T C M services, individuals will be allowed free choice of providers. The L G A must document that the eligible individual is aware of and understands their freedom of choice options. Eligible individuals will have free choice of any qualified Medicaid provider within the specified geographic area identified in the State Plan (Attachment 4.19-B).

Since Medi-Cal is the payer of last resort, a fee mechanism must be in place to ensure that all other possible payment sources have been considered prior to using Medi-Cal as a payment source for T C M services. Payment for T C M services under 42 C F R Section 441.18(a)(4) must not be duplicate payments made to public agencies or private entities under other program authorities for the same purposes. In general, payment may not be made for services which another payer is liable or for which no payment liability is incurred. Similarly, separate payment cannot be made for similar services, which are an integral and inseparable part of another Medicaid covered service.

Since Medi-Cal is the payer of last resort, L G As must determine if eligible individuals have health insurance coverage other than Medi-Cal for comprehensive case management services. L G As may only provide and claim for T C M services to the extent those services are not covered by any other insurance the eligible individuals may have. If an eligible individual does have other insurance coverage, the insurance information

Since Medi-Cal is the payer of last resort, LGAs must determine if eligible individuals Since Medi-Cal is the payer of last resort, L G As must determine if eligible individuals have health insurance coverage have health insurance coverage other than Medi-Cal for comprehensive case other than Medi-Cal for comprehensive case management services. L G As may only provide and claim for T C M management services. LGAs may only provide and claim for TCM services to the extent services to the extent those services are not covered by any other insurance the eligible individuals may have. If an those services are not covered by any other insurance the eligible individuals may have. eligible individual does have other insurance coverage, the insurance information If an eligible individual does have other insurance coverage, the insurance information and the extent of the coverage for case management services must be documented in client case notes. Section 3- Participation and Program Requirements June 2019 3-1



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and the extent of the coverage for case management services must be documented in client case notes.

4. Care Coordination to Prevent Duplication with Other Programs

Prior to and during the course of providing TCM services, the TCM case manager must be vigilant and coordinate with other providers to prevent duplication of services.

a. 1915(c) Home and Community-Based Services (HCBS) Waiver

LGAs cannot claim encounters for TCM services provided to clients enrolled in any Section 1915(c) HCBS Waiver program. However, once a client is dis-enrolled from a Section1915(c) HCBS Waiver program, TCM services may be claimed. In these cases, evidence of client Section 1915(c) HCBS Waiver status contemporaneous with the provision of TCM service must be documented in the client case notes.

For more information regarding the 1915(c) HCBS Waiver please click on the following link: https://dds.ca.gov/Waiver/Home.cfm.

b. Medi-Cal Managed Care

The Medi-Cal 2020 Waiver and the related Medi-Cal Managed Care Expansion requires broader Medi-Cal managed care health plan (MCP) responsibility for care coordination and case management services for beneficiaries. This includes coordination and referral of resources for client social support issues.

To implement a collaborative approach between the TCM program and MCPs, LGAs in all Medi-Cal Managed Care counties are required to enter into a Memorandum of Understanding (MOU) with each MCP. Participation in the TCM program is contingent upon signing an MOU. These MOUs will serve to define the responsibilities and coordination requirements between the TCM program and MCPs.

c. Other Programs

A case manager is expected to coordinate with all agencies and programs that provide services to the client to ensure non-duplication of services.

Other programs that provide case management include, but are not limited to, the following:

A. California Children's Services (CCS), B. AIDS Program, C. Mental Health TCM, D. Childhood Lead Team,


Prior to and during the course of providing T C M services, the T C M case manager must be vigilant and coordinate with other providers to prevent duplication of services.

1915(c) Home and Community-Based Services (H C B S) Waiver:

L G As cannot claim encounters for T C M services provided to clients enrolled in any Section 1915(c) H C B S Waiver program. However, once a client is dis-enrolled from a Section 1915(c) H C B S Waiver program, T C M services may be claimed. In these cases, evidence of client Section 1915(c) H C B S Waiver status contemporaneous with the provision of T C M service must be documented in the client case notes.For more information regarding the 1915(c) H C B S Waiver please click on the following

Medi-Cal 2020 Waiver and the related Medi-Cal Managed Care Expansion requires Medi-Cal managed care health plan (M C P) responsibility for care coordination case management services for beneficiaries. This includes coordination and referral resources for client social support issues. implement a collaborative approach between the T C M program and M C Ps, L G As all Medi-Cal Managed Care counties are required to enter into a Memorandum of (M O U) with each M C P. Participation in the T C M program is contingent signing an M O U. These M O Us will serve to define the responsibilities and requirements between the T C M program and M C Ps.

California Children's Services (C C S),

A I D S Program,

Mental Health T C M,

California Children's Services (CCS),

AIDS Program,

Mental Health TCM,

Childhood Lead TeamMaternal Child Health Program,Employment and Human Services Program, andAdult and Aging Services Program.

https://dds.ca.gov/Waiver/index.cfm



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E. Maternal Child Health Program, F. Employment and Human Services Program, and G. Adult and Aging Services Program.

5. TCM Encounter

An "encounter" is defined as a face-to-face contact or a telephone contact in lieu of a face-to-face contact when environmental considerations preclude a face-to-face encounter for the purpose of rendering one or more TCM service components by a case manager.

a. TCM Encounter Log

LGAs are required to maintain a TCM encounter log to keep a list of all the encounters (claimable and un-claimable client interactions) in their jurisdiction. The LGA Coordinator must use the encounter log information to enter/upload encounters into the TCM System and submit invoices based on the date of service and target population. The TCM System verifies the following information:

• Medi-Cal eligibility of TCM encounters through the Medi-Cal Eligibility

Data System (MEDS), • Duplicative encounters, • Invoices submitted within the 12 month claiming deadline, and • Valid case manager National Provider Identifier (NPI).

After the TCM System completes all appropriate verifications on the encounter information, DHCS staff further verifies the claims (invoices submitted by the LGAs) to either approve or deny them. The information reported in the TCM System is used to develop the TCM Cost Report.

i. TCM Encounter Log Requirements

The TCM encounter log is used by the LGA to record the necessary information required to compile the LGA’s claim for federal reimbursement. (Note that the TCM encounter log does not supplant the need for detailed client case records.)

1) Required Information for the TCM encounter log includes:

• The client’s first and last name, • The client’s date of birth. (Refer to Section 8 for more information), • The client’s Medi-Cal number, Beneficiary Identification Number, or Social

Security number,


T C M Encounter

An "encounter" is defined as a face-to-face contact or a telephone contact in lieu of a face-to-face contact when environmental considerations preclude a face-to-face for the purpose of rendering one or more T C M service components by a manager.

L G As are required to maintain a T C M encounter log to keep a list of all the encounters (claimable and un-claimable client interactions) in their jurisdiction. The L G A Coordinator must use the encounter log information to enter/upload encounters into the T C M System and submit invoices based on the date of service and target population.The T C M System verifies the following information:

Medi-Cal eligibility of T C M encounters through the Medi-Cal Eligibility Data System (M E D S),

Duplicative encounters,

Invoices submitted within the 12 month claiming deadline, and

Valid case manager National Provider Identifier (N P I).

After the T C M System completes all appropriate verifications on the encounter D H C S staff further verifies the claims (invoices submitted by the L G As) either approve or deny them. The information reported in the T C M System is to develop the T C M Cost Report.

T C M Encounter Log Requirements

The T C M encounter log is used by the L G A to record the necessary information required to compile the L G A’s claim for federal reimbursement. (Note that the T C M encounter log does not supplant the need for detailed client case records.)

i. TCM Encounter Log Requirements



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• The date of the TCM service (encounter), • The name of the provider agency, • The name and NPI number of the case manager, and • The location of the encounter.

For clients residing in institutions, the TCM encounter log must include the following in addition to the above stated requirements:1

• The location of the service (home, office, other, or type of institution; for example: Board and Care, Intermediate Care Facility, Hospital, Nursing Facility, Psychiatric Facility, Institutions for Mental Diseases, etc.) and

• The client’s admission and discharge date from an institution.

For the purpose of developing the TCM Cost Report accurately, it is necessary to maintain a log of all TCM encounters for both Medi-Cal and non-Medi-Cal clients. A separate log may be maintained to record encounters for clients for whom reimbursement will not be claimed through the TCM program.

2) Reconciling the TCM Encounter Log to the TCM System

LGAs must reconcile their TCM encounter log to the data in the TCM System for the following three encounter categories. (Encounters will be identified in these three categories after they have been entered into the TCM System.) This is a necessary step to accurately complete the TCM Cost Report.

a. Claimable TCM Medi-Cal Only Encounters: Encounters include all

TCM Medi-Cal encounters with a claimable status.

b. Non-claimable TCM Medi-Cal Only Encounters: Encounters consist of TCM Medi-Cal encounters that are not claimable through the TCM program. For example: a TCM Medi-Cal encounter that is reimbursed through a 1915(c) HCBS Waiver would not be a claimable TCM encounter due to duplication of services. Include this encounter in the TCM encounter log.

c. TCM Non-Medi-Cal Encounters: Encounters received a non-eligible status

due to Medi-Cal ineligibility.

Note: To ensure accuracy, all TCM encounters classified above shall be included in the TCM encounter log. The encounter log should be reconciled and updated once payments are received.

1 When TCM clients reside in nursing facilities, hospitals, convalescent homes, or other facilities that are not their private residence, TCM case managers must make good faith effort, as specified in their Performance Monitoring Plan, not to claim for services that have already been provided.


The date of the T C M service (encounter),

The name of the provider agency,

The name and N P I number of the case manager, and

For the purpose of developing the T C M Cost Report accurately, it is necessary to maintain a log of all T C M encounters for both Medi-Cal and non-Medi-Cal clients. A separate log may be maintained to record encounters for clients for whom reimbursement will not be claimed through the T C M program.

Reconciling the T C M Encounter Log to the T C M System

L G As must reconcile their T C M encounter log to the data in the T C M System for the following three encounter categories. (Encounters will be identified in these three categories after they have been entered into the T C M System.) This is a necessary step to accurately complete the T C M Cost Report.

Claimable T C M Medi-Cal Only Encounters: Encounters include all T C M Medi-Cal encounters with a claimable status.

Non-claimable T C M Medi-Cal Only Encounters: Encounters consist of T C M Medi-Cal encounters that are not claimable through the T C M program. For example: a T C M Medi-Cal encounter that is reimbursed through a 1915(c) H C B S Waiver would not be a claimable T C M encounter due to duplication of services. Include this encounter in the T C M encounter log.T C M Non-Medi-Cal Encounters: Encounters received a non-eligible status due to Medi-Cal ineligibility.

Note: To ensure accuracy, all T C M encounters classified above shall be included in the the T C M encounter log. The encounter log should be reconciled and updated once payments are received.

1 When T C M clients reside in nursing facilities, hospitals, convalescent homes, or other facilities that are not their private residence, T C M case managers must make good faith effort, as specified in their Performance Monitoring Plan, not to claim for services that have already been provided.

1 When TCM clients reside in nursing facilities, hospitals, convalescent homes, or other facilities that 1 When TCM clients reside in nursing facilities, hospitals, convalescent homes, or other facilities that are not their private residence, TCM case managers must make good faith effort, as specified are not their private residence, TCM case managers must make good faith effort, as specified in their in their Performance Monitoring Plan, not to claim for services that have already been provided. Performance Monitoring Plan, not to claim for services that have already been provided.

Reconciling the TCM Encounter Log to the TCM System

LGAs must reconcile their TCM encounter log to the data in the TCM System for the LGAs must reconcile their TCM encounter log to the data in the TCM System for the following three encounter categories. (Encounters will be identified in these three following three encounter categories. (Encounters will be identified in these three categories after categories after they have been entered into the TCM System.) This is a necessary they have been entered into the TCM System.) This is a necessary step to accurately complete step to accurately complete the TCM Cost Report. the TCM Cost Report.



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3) TCM Encounter Rate

For more information about how the TCM encounter rate is created, refer to Section 5 of this Manual.

6. Quality Assurance

Each LGA participating in the TCM program shall have a Quality Assurance (QA) process. QA refers to administrative and procedural activities implemented systematically to assure that the requirements and goals of the TCM program are met. It is the systematic measurement, comparison with a standard, monitoring of processes or an associated feedback loop that promotes programmatic compliance.

7. Non-Claimable Operating Costs

Claimable operating costs are costs other than salaries, benefits, travel and training that are necessary for the proper and efficient administration of the TCM program. DHCS will reimburse the LGA for claimable operating costs. DHCS will not reimburse the LGA for non-claimable operating costs on the TCM Cost Report and must reclassify those costs as Non-TCM costs. Examples of non-claimable operating costs are listed below but are not limited to the following:

• Malpractice insurance • Equipment used for providing direct services • Medical supplies • Drugs and medications • Costs of elected officials and their related costs • Costs for lobbying activities

Note: The repair and maintenance of lab equipment such as an x-ray machine are not valid claimable costs.

8. Subcontractors

A subcontractor is a Community Based Organization (CBO) or Local Public Entities (LPE) contracting with the LGA for the provision of TCM services.

A LGA may subcontract with other entities to provide TCM services on behalf of the LGA. The subcontractor must agree that it will perform TCM services and will ensure that expenditures are allowable and meet all federal requirements for the provision of TCM services. The subcontract must contain language that the subcontractor will comply with the same conditions described in the TCM PPA between the LGA and DHCS, the State Plan, and this Manual.


T C M Encounter Rate

For more information about how the T C M encounter rate is created, refer to Section 5 of this Manual.

Each L G A participating in the T C M program shall have a Quality Assurance (Q A) process. Q A refers to administrative and procedural activities implemented systematically to assure that the requirements and goals of the T C M program are met. It is the systematic measurement, comparison with a standard, monitoring of processes or an associated feedback loop that promotes programmatic compliance.

Claimable operating costs are costs other than salaries, benefits, travel and training that are necessary for the proper and efficient administration of the T C M program. D H C S will reimburse the L G A for claimable operating costs. D H C S will not reimburse the L G A for non-claimable operating costs on the T C M Cost Report and must reclassify those costs as Non-T C M costs. Examples of non-claimable operating costs are listed below but are not limited to the following:

A subcontractor is a Community Based Organization (C B O) or Local Public Entities (L P E) contracting with the L G A for the provision of T C M services.

A L G A may subcontract with other entities to provide T C M services on behalf of the L G A. The subcontractor must agree that it will perform T C M services and will ensure that expenditures are allowable and meet all federal requirements for the provision of T C M services. The subcontract must contain language that the subcontractor will comply with the same conditions described in the T C M P P A between the L G A and D H C S, the State Plan, and this Manual.

7. Non-Claimable Operating Costs

A LGA may subcontract with other entities to provide TCM services on behalf of the LGA. The A LGA may subcontract with other entities to provide TCM services on behalf of the LGA. The subcontractor must agree that it will perform TCM services and will ensure subcontractor must agree that it will perform TCM services and will ensure that expenditures are that expenditures are allowable and meet all federal requirements for the provision of allowable and meet all federal requirements for the provision of TCM services. The subcontract TCM services. The subcontract must contain language that the subcontractor will must contain language that the subcontractor will comply with the same conditions described in comply with the same conditions described in the TCM PPA between the LGA and the TCM PPA between the LGA and DHCS, the State Plan, and this Manual. DHCS, the State Plan, and this Manual.



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III. TCM PROGRAM PARTICIPATION REQUIREMENTS CHECKLIST

The TCM program requirements checklist is designed to assist LGAs to ensure that the requirements to participate in the TCM program are met for each fiscal year.

The TCM program requirements checklist can be found on the TCM website: http://www.dhcs.ca.gov/provgovpart/Pages/TCM.aspx

IV. Host County / DHCS Contract

Per Title 22 of the California Code of Regulations (22 CCR) Section 51185(c), the “Host County” refers to an LGA designated by all TCM program participants, to be the administrative and fiscal intermediary between DHCS and all participating LGAs.

DHCS shall perform administrative activities, including technical support, processing claims, and program monitoring for LGAs participating in the TCM, pursuant to Welfare and Institutions (WIC) Section 14132.44. Annually, DHCS determines the staffing requirements upon which the DHCS projected costs are based. The projected costs include the anticipated salaries, benefits, overhead, operating expenses, and equipment necessary to administer the TCM program.

As authorized by WIC sections 14132.44 and 14132.47, the purpose of the Host County/DHCS contract between the Host County and DHCS is for the host county to reimburse DHCS (through participation fees) for providing administrative services for the implementation of the TCM program. Administrative services include activities such as processing of TCM claims; the host county shall act as the host entity for the LGAs that administer the County Based Medi-Cal Administrative Activities and TCM programs.

V. Host County / LGA Contract

Per 22 CCR Section 51492.2(c), LGAs shall designate a host county. Each participating LGA shall deposit an annual participation fee to the host county, for each LGAs portion of the costs described in subsection (b), through a mechanism agreed to by DHCS and LGAs.

A host county/LGA contract will be in place with the host county. The contract amount covers the cost of administering the LGA TCM program. The host county will pass these costs on to the other LGAs participating in the TCM program. These costs are reimbursed to the host county through participation fees. DHCS does not calculate this fee. The host county/LGA contract specifies the responsibility of the host county, the contracted LGA, and includes the scope of work.

Furthermore, the host county contract requires the host county to submit invoices and collect the portion of the payment from each LGA for the Local Host Services (LHS)


T C M PROGRAM PARTICIPATION REQUIREMENTS CHECKLIST

The T C M program requirements checklist is designed to assist L G As to ensure that the requirements to participate in the T C M program are met for each fiscal year.

The T C M program requirements checklist can be found on the T C M website:

Host County / D H C S Contract

Per Title 22 of the California Code of Regulations (22 C C R) Section 51185(c), the “Host County” refers to an L G A designated by all T C M program participants, to be the administrative and fiscal intermediary between D H C S and all participating L G As.

D H C S shall perform administrative activities, including technical support, processing claims and program monitoring for L G As participating in the T C M, pursuant to Welfare Institutions (W I C) Section 14132.44. Annually, D H C S determines the staffing upon which the D H C S projected costs are based. The projected costs the anticipated salaries, benefits, overhead, operating expenses, and necessary to administer the T C M program.

As authorized by W I C sections 14132.44 and 14132.47, the purpose of the Host County/D H C S contract between the Host County and D H C S is for the host county to reimburse D H C S (through participation fees) for providing administrative services for the implementation of the T C M program. Administrative services include activities such as processing of T C M claims; the host county shall act as the host entity for the L G As that administer the County Based Medi-Cal Administrative Activities and T C M programs.

Host County / L G A Contract

Per 22 C C R Section 51492.2(c), L G As shall designate a host county. Each participating L G A shall deposit an annual participation fee to the host county, for each L G As portion of the costs described in subsection (b), through a mechanism agreed to by D H C S and L G As.

A host county/L G A contract will be in place with the host county. The contract amount covers the cost of administering the L G A T C M program. The host county will pass these costs on to the other L G As participating in the T C M program. These costs are reimbursed to the host county through participation fees. D H C S does not calculate this fee. The host county/L G A contract specifies the responsibility of the host county, the contracted L G A, and includes the scope of work.

Furthermore, the host county contract requires the host county to submit invoices and collect the portion of the payment from each L G A for the Local Host Services (L H S)

Furthermore, the host county contract requires the host county to submit invoices and Furthermore, the host county contract requires the host county to submit invoices and collect the collect the portion of the payment from each LGA for the Local Host Services (LHS) portion of the payment from each L G A for the Local Host Services (LHS) projected administrative costs, for which each participating LGA is liable. Funds are to be remitted projected administrative costs, for which each participating LGA is liable. Funds are to be remitted to DHCS by the host county within sixty (60) days of receipt of the DHCS to DHCS by the host county within sixty (60) days of receipt of the DHCS invoice.

https://www.dhcs.ca.gov/provgovpart/Pages/TCM.aspx



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projected administrative costs, for which each participating LGA is liable. Funds are to be remitted to DHCS by the host county within sixty (60) days of receipt of the DHCS invoice.

VI. Participation Requirements

1. Provider Participation Agreement For a LGA to participate in the TCM program and to claim reimbursement for Medicaid TCM services, federal regulations require that an agreement be in place between the single state agency (DHCS) responsible for administering the Medicaid program (Medi- Cal) and the agency (LGA) to whom any administrative responsibilities have been delegated. In California, the agreement between DHCS and the LGA is referred to as the TCM Evergreen PPA.

Prior to 2017, the PPA was a five-year agreement between DHCS and the LGA. In

2017, the PPA transitioned to an evergreen agreement. The purpose of the PPA is to establish the responsibilities of both the qualified LGA and DHCS in providing TCM services. The mutual objectives of the LGA and DHCS are defined in 42 United States Code Section 1396n (g) (2). All LGAs must abide by the executed PPA as it permits.

a. Ensuring Non-Duplication of Services

Methods for delivering TCM services vary from program to program; therefore, it is the responsibility of the LGA to design and implement a countywide system to prevent duplication of services and to ensure coordination and continuity of care among case management providers, including 1915(c) HCBS Waivers and all other programs or waivers that provide case management. Each LGA will be required to certify each year, in a manner prescribed by DHCS (the TCM Performance Monitoring Plan (PMP)), that such a plan of coordination is in place (refer to the PMP subsection).

b. Medi-Cal Disclosure Statement – Form 6207

Every applicant or provider must complete and submit a current Medi-Cal Disclosure Statement (DHCS 6207) as part of a complete application package for enrollment, continued enrollment, or certification as a Medi-Cal provider. This document must be completed and signed by an authorized signer and shall be submitted with the PPA as an exhibit to DHCS.

c. Medi-Cal Provider Enrollment Agreement – Form 6208

The Medi-Cal Provider Enrollment Agreement (Form 6208) serves as an agreement between the LGA and the DHCS to provide Medi-Cal services within the county. This document must be completed, notarized, and signed by an authorized signer and shall be submitted with the PPA as an exhibit to DHCS.


projected administrative costs, for which each participating L G A is liable. Funds are to be remitted to D H C S by the host county within sixty (60) days of receipt of the D H C S invoice.

For a L G A to participate in the T C M program and to claim reimbursement for Medicaid T C M services, federal regulations require that an agreement be in place between the single state agency (D H C S) responsible for administering the Medicaid program (Medi- Cal) and the agency (L G A) to whom any administrative responsibilities have been delegated. In California, the agreement between D H C S and the L G A is referred to as the T C M Evergreen P P A.

Prior to 2017, the P P A was a five-year agreement between D H C S and the L G A. In 2017, the P P A transitioned to an evergreen agreement. The purpose of the P P A is to establish the responsibilities of both the qualified L G A and D H C S in providing T C M services. The mutual objectives of the L G A and D H C S are defined in 42 United States Code Section 1396n (g) (2). All L G As must abide by the executed P P A as it permits.

Methods for delivering T C M services vary from program to program; therefore, it is the responsibility of the L G A to design and implement a countywide system to prevent duplication of services and to ensure coordination and continuity of care among case management providers, including 1915(c) H C B S Waivers and all other programs or waivers that provide case management. Each L G A will be required to certify each year, in a manner prescribed by D H C S (the T C M Performance Monitoring Plan (P M P)), that such a plan of coordination is in place (refer to the P M P subsection).

Every applicant or provider must complete and submit a current Medi-Cal Disclosure Statement (D H C S 6207) as part of a complete application package for enrollment, continued enrollment, or certification as a Medi-Cal provider. This document must be completed and signed by an authorized signer and shall be submitted with the P P A as an exhibit to D H C S.

b. Medi-Cal Disclosure Statement – Form 6207



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2. Memorandum Of Understanding

LGAs are required to implement a MOU with MCPs serving beneficiaries in the same county as the LGA when the LGA is in a Geographic Managed Care, Two-Plan Managed Care, Regional Model, Imperial Model, San Benito Model, or County Organized Health System in accordance with State issued policy directives, including PPLs, and federal directives. The MOU will serve to define the respective responsibilities between LGAs and MCPs and must include coordination protocols to ensure non-duplication of services provided to beneficiaries in common. Although the APP/PMP lists descriptions of similar non-duplication of services techniques as the MOU, the MOU contains a separate TCM requirement than the APP/PMP. All documents are required to be on file with DHCS.

3. Annual Participation Prerequisite

The APP provides DHCS with TCM participation information to ensure compliance with regulations and to develop the TCM program encounter and cost projections. The APP provides the following information and forms:

• LGA’s intent to participate in TCM. • LGA’s target population(s) participation for the following State Fiscal Year (SFY). • LGA’s target population program encounter and cost projections, • Supplemental information for each CBO and LPE subcontracted for the provision

of TCM services as applicable, • Subprogram codes assigned to participating provider agencies, • TCM System LGA Profile Request form which is used to update and verify the

accuracy of the information on file for each LGA within the TCM System (form(s) must be submitted every year),

• TCM System Invoice Signature Authority Request Form, which is used to update and accurately verify the validity of authorized signers of invoices submitted for claiming (new form(s) must be submitted every year),

• Performance Monitoring Plan, • LGA Time Survey Frequency, and • Proof (screenshots) displaying verification of case managers not on the Office of

Inspector General (OIG) List of Excluded Individuals and Entities (LEIE).

LGAs intending to participate in the TCM program must submit a completed APP to [email protected] by March 31 of each SFY. Because the LGA Coordinator is required to submit the APP to DHCS via e-mail, the e-mail will function as the LGA Coordinator’s signature. LGAs will not be able to participate in the TCM target populations for the following SFY if the required documentation is not received prior to March 31.


L G A’s intent to participate in T C M.

L G A’s target population(s) participation for the following State Fiscal Year (S F Y).

L G A’s target population program encounter and cost projections,

Supplemental information for each C B O and L P E subcontracted for the provision of T C M services as applicable,

L G As are required to implement a M O U with M C Ps serving beneficiaries in the same county as the L G A when the L G A is in a Geographic Managed Care, Two- Plan Managed Care, Regional Model, Imperial Model, San Benito Model, or County Organized Health System in accordance with State issued policy directives, including P P Ls, and federal directives. The M O U will serve to define the respective responsibilities between L G As and M C Ps and must include coordination protocols to ensure non-duplication of services provided to beneficiaries in common. Although the A P P/P M P lists descriptions of similar non-duplication of services techniques as the M O U, the M O U contains a separate T C M requirement than the A P P/P M P. All documents are required to be on file with D H C S.

Subprogram codes assigned to participating provider agencies,

T C M System L G A Profile Request form which is used to update and verify the accuracy of the information on file for each L G A within the T C M System (form(s) must be submitted every year),

T C M System Invoice Signature Authority Request Form, which is used to update and accurately verify the validity of authorized signers of invoices submitted for claiming (new form(s) must be submitted every year),

Performance Monitoring Plan,

The A P P provides D H C S with T C M participation information to ensure compliance with regulations and to develop the T C M program encounter and cost projections. The A P P provides the following information and forms:

Proof (screenshots) displaying verification of case managers not on the Office of Inspector General (O I G) List of Excluded Individuals and Entities (L E I E).

L G As intending to participate in the T C M program must submit a completed A P P to

by March 31 of each S F Y. Because the L G A Coordinator is required to submit the A P P to D H C S via e-mail, the e-mail will function as the L G A Coordinator’s signature. L G As will not be able to participate in the T C M target populations for the following S F Y if the required documentation is not received prior to March 31.

[email protected]



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a. Adding A New Target Population If a LGA would like to add a target population not previously participated in prior to the SFY, the LGA must list the target population on the Participation Tab worksheet in the APP document. Once the APP has been submitted, DHCS will update the Attachment 4.19-B for the appropriate target population.

Note: If the LGA’s name is not listed on the ‘Areas of State in which services will be provided (Section 1915(g) (1) of the Act)’ of each of the target population of current service, LGAs are not approved to claim FFP for that particular target population.

b. Performance Monitoring Plan The TCM PMP is required under Title 22 CCR Section 51271(a). The PMP helps to ensure statewide non-duplication of payments, non-duplication of services, and a more efficient use of agency resources in meeting needs. The PMP must include protocols and procedures for coordination and continuity of care among providers for Medi-Cal beneficiaries who are eligible to receive TCM services from two or more providers. LGAs that participate in and claim through the TCM program and other programs providing case management services must include, in their PMP, a description of the systematic controls that are in place to ensure non-duplication of services.

i. Non-Duplication of Services

The potential duplication of case management services reimbursed through a Medi-Cal and/or non-Medi-Cal payer may occur with, and is not limited to, the five TCM target populations. LGAs that participate in the TCM program must include in their PMP a description of the systematic controls that ensure non-duplication of TCM services:

• LGAs will communicate with MCPs at least once every six months for clients with

open medical issues needing case management. o LGA TCM case managers will contact the client’s MCP case manager or

other appropriate contact to discuss client medical issues and/or related social support issues.

o Coordination will include, at a minimum, all medical issues and all social support related issues identified by the MCP and/or by the LGA TCM program.

• LGA case managers will obtain and review the MCP’s member care plan. • LGA case managers will notify the MCP that the client is receiving TCM services

and has identified a social support issue(s) that may impede the implementation of the MCP care plan.

• All other Medi-Cal programs and waivers that provide case management services to clients in their LGA (e.g., California Children’s Services, Mental Health TCM, Childhood Lead Team, etc.).


If a L G A would like to add a target population not previously participated in prior to theS F Y, the L G A must list the target population on the Participation Tab worksheet in theAPP document. Once the APP has been submitted, D H C S will update the Attachment4.19-B for the appropriate target population.

Note: If the L G A’s name is not listed on the ‘Areas of State in which services will beprovided (Section 1915(g) (1) of the Act)’ of each of the target population of currentservice, L G As are not approved to claim F F P for that particular target population.

The T C M P M P is required under Title 22 C C R Section 51271(a). The P M P helps to ensure statewide non-duplication of payments, non-duplication of services, and a more efficient use of agency resources in meeting needs. The P M P must include protocols and procedures for coordination and continuity of care among providers for Medi-Cal beneficiaries who are eligible to receive T C M services from two or more providers. L G As that participate in and claim through the T C M program and other programs providing case management services must include, in their P M P, a description of the systematic controls that are in place to ensure non-duplication of services.

The potential duplication of case management services reimbursed through a Medi- Cal and/or non-Medi-Cal payer may occur with, and is not limited to, the five T C M target populations. L G As that participate in the T C M program must include in their P M P a description of the systematic controls that ensure non-duplication of T C M services:

Non-Duplication of Services

L G A case managers will obtain and review the M C P’s member care plan.

L G A case managers will notify the M C P that the client is receiving T C M services and has identified a social support issue(s) that may impede the implementation of the M C P care plan.

All other Medi-Cal programs and waivers that provide case management services to clients in their L G A (e.g., California Children’s Services, Mental Health T C M, Childhood Lead Team, etc.).

L G As will communicate with M C Ps at least once every six months for clients withopen medical issues needing case management.

L G A T C M case managers will contact the client’s M C P case manager orother appropriate contact to discuss client medical issues and/or related social support issues.

Coordination will include, at a minimum, all medical issues and all socialsupport related issues identified by the M C P and/or by the L G A T C Mprogram.

LGA TCM case managers will contact the client’s MCP case manager or other appropriate contact to discuss client medical issues and/or related social support issues.

Coordination will include, at a minimum, all medical issues and all social support related issues identified by the MCP and/or by the LGA TCM program.

TGA case managers will obtain and review the MCP’s member care plan.

TGA case managers will notify the MCP that the client is receiving TCM services and has identified a social support issue(s) that may impede the implementation of the MCP care plan.

All other Medi-Cal programs and waivers that provide case management services to clients in their LGA (e.g., California Children’s Services, Mental Health TCM, Childhood Lead Team, etc.).



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• List all 1915(c) HCBS Waivers (e.g., AIDs Waiver, In-Home Operations Waiver,

Developmentally Disabled Waiver, etc.). • Provide the procedures and steps used to identify TCM clients receiving services

through other Medi-Cal programs or Waiver by verbally asking clients if other case management services are being received.

• It is strongly recommended that TCM programs identify contacts within their counties for any other Medi-Cal programs or waiver programs with whom to check client participation. Evidence of client status in regard to other programs or waivers must be documented in client case notes. This may include provider agency directives to case managers or other such internal documents.

• If a client participates in other programs or a waiver is identified, LGAs must follow the detailed specific methods to coordinate which should be specified in the procedures in their existing PMP. These procedures may include such elements as specific program contacts for other specific programs, frequency of contacts, protocols for coordination, etc. All such coordination must be documented in client case notes.

• Identify specific procedures to ensure non-duplication of services. ii. Managed Care Non-Duplication of Services

To prevent duplication of services, a LGA must have coordination of care between the TCM program and the MCPs, which include County Organizational Health System, Geographic Managed Care, Two-Plan Model, Regional Model, Imperial Model, and the San Benito Model. The PMP must include, at a minimum, procedures for LGAs to coordinate with MCPs to ensure non-duplication of services:

• Annually provide MCPs with the TCM target populations in which the

LGA participates, including the TCM target population definition(s). • Identify TCM clients who are assigned to MCPs to assist TCM programs

and MCPs in meeting coordination requirements by querying TCM clients. • Refer any client with an open TCM case to the client’s MCP care

coordinator when the TCM case manager identifies client medical needs. • Coordinate with the client’s MCP when the client’s medical needs are not

being addressed in a timely or effective manner as determined by the TCM case manager from monitoring the client condition and/or progress.

• Provide MCPs with client status updates when a TCM assessment is performed. • Provide direction to MCPs when referring clients to TCM if the client meets the

definition of the target populations the LGA participates in and when the MCP identifies a non-medical need and/or other issue where TCM may be beneficial.

• The MCPs shall collaborate with the TCM program for referrals when the client requires services not covered by the MCP. All such coordination must be described and documented in TCM client case notes.


List all 1915(c) H C B S Waivers (e.g., A I Ds Waiver, In-Home Operations Waiver,Developmentally Disabled Waiver, etc.).

Provide the procedures and steps used to identify T C M clients receiving services through other Medi-Cal programs or Waiver by verbally asking clients if other case management services are being received.

It is strongly recommended that T C M programs identify contacts within theircounties for any other Medi-Cal programs or waiver programs with whom tocheck client participation. Evidence of client status in regard to other programs orwaivers must be documented in client case notes. This may include provideragency directives to case managers or other such internal documents.

If a client participates in other programs or a waiver is identified, L G As mustfollow the detailed specific methods to coordinate which should be specified inthe procedures in their existing P M P. These procedures may include suchelements as specific program contacts for other specific programs, frequency ofcontacts, protocols for coordination, etc. All such coordination must bedocumented in client case notes.

To prevent duplication of services, a L G A must have coordination of care between the T C M program and the M C Ps, which include County Organizational Health System, Geographic Managed Care, Two-Plan Model, Regional Model, Imperial Model, and the San Benito Model. The P M P must include, at a minimum, procedures for L G As to coordinate with M C Ps to ensure non-duplication of services:

Annually provide M C Ps with the T C M target populations in which the L G A participates, including the T C M target population definition(s).Identify T C M clients who are assigned to M C Ps to assist T C M programs and M C Ps in meeting coordination requirements by querying T C M clients.Refer any client with an open T C M case to the client’s M C P care coordinator when the T C M case manager identifies client medical needs.Coordinate with the client’s M C P when the client’s medical needs are not being addressed in a timely or effective manner as determined by the T C M case manager from monitoring the client condition and/or progress.Provide M C Ps with client status updates when a T C M assessment is performed.

Provide direction to M C Ps when referring clients to T C M if the client meets the definition of the target populations the L G A participates in and when the M C P identifies a non-medical need and/or other issue where T C M may be beneficial.The M C Ps shall collaborate with the T C M program for referrals when the client requires services not covered by the M C P. All such coordination must be described and documented in T C M client case notes.



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iii. Lead Case Manager Non-Duplication of Services

When there are multiple case managers, one must assume the role of the lead case manager in order to avoid duplications of services. The lead case manager will be responsible for communicating with the other case managers when developing, implementing, and monitoring a client’s care plan. The TCM case managers must communicate regularly relative to the needs of their mutual TCM client.

c. Office of Inspector General Reviews To verify that each case manager is not on the OIG LEIE database exclusion list, annually the LGAs must search the LEIE online database which can be found at the website: https://exclusions.oig.hhs.gov. LGAs will search for each case manager by first and last name and take a screenshot of the page verifying that each case manager is not an excluded provider, and therefore, has passed the OIG LEIE database check.

DHCS will maintain copies of the above verification in the LGA’s file. LGAs will not be able to participate in the TCM program for the SFY if the required documentation is not received annually.

d. LGA Signature Authority Request

The LGA Signature Authority Request form provides the names of all individuals authorized to review, approve, and sign on behalf of the LGA when submitting TCM program invoices, forms, etc.

Note: This form must be included with the electronic submission of the APP package (this form must be submitted annually).The Signature Authority Request form can be found on the TCM website: http://www.dhcs.ca.gov/provgovpart/Pages/TCM.aspx

e. LGA Profile Request

The LGA Profile Request form is used to obtain, update, and verify a LGA’s pertinent information (such as name, address, etc.) on file for each of the participating LGAs in the automated TCM System.

Note: This form must be included with the electronic submission of the APP package (this form must be submitted annually).The LGA Profile Request can be found on the TCM website: http://www.dhcs.ca.gov/provgovpart/Pages/TCM.aspx

f. Fee Mechanism

LGAs must have an established fee mechanism specific to TCM services that may include a sliding fee schedule based on income. The fee mechanism may vary by program and must include instructions as to how it will be used.


When there are multiple case managers, one must assume the role of the lead casemanager in order to avoid duplications of services. The lead case manager will beresponsible for communicating with the other case managers when developing,implementing, and monitoring a client’s care plan. The T C M case managers mustcommunicate regularly relative to the needs of their mutual T C M client.

To verify that each case manager is not on the O I G L E I E database exclusion list,annually the L G As must search the L E I E online database which can be found at the

L G As will search for each case manager by firstand last name and take a screenshot of the page verifying that each case manager isnot an excluded provider, and therefore, has passed the O I G L E I E database check.

D H C S will maintain copies of the above verification in the L G A’s file. L G As will not be able to participate in the T C M program for the S F Y if the required documentation is not received annually.

L G A Signature Authority Request

The L G A Signature Authority Request form provides the names of all individuals authorized to review, approve, and sign on behalf of the L G A when submitting T C M program invoices, forms, etc.

Note: This form must be included with the electronic submission of the A P P package(this form must be submitted annually).The L G A Profile Request can be found on theT C M website

L G A Profile Request

The L G A Profile Request form is used to obtain, update, and verify a L G A’s pertinent information (such as name, address, etc.) on file for each of the participating L G As in the automated T C M System.

This form must be included with the electronic submission of the A P P package form must be submitted annually).The L G A Profile Request can be found on TCM website:

LG As must have an established fee mechanism specific to T C M services that may include a sliding fee schedule based on income. The fee mechanism may vary by program and must include instructions as to how it will be used.

https://exclusions.oig.hhs.gov/





June 2019

For more details on Fee Mechanisms please see the Program Requirements heading within this Section.

g. Subprogram Codes All TCM encounters entered into the TCM System require a subprogram code associated with the LGA, including CBOs, subcontracted public agencies, etc.

The Subprogram Codes tab of the APP worksheet lists the required information that TCM analysts use to update LGA Profiles in the TCM System for the next SFY. Each of the columns listed below must be completed:

• Provider Agency - For each target population used by the LGA, list the provider

agency names in the provider agency column on the left side of the worksheet. o For example: County Health Care Services.

• Name of Subdivision Providing Services – For example: Public Health Department.

• Subprogram code – LGAs will create their own subprogram codes (DHCS does not create them for the counties). The subprogram codes shall be four characters long (numbers, letters, or a mixture of both numbers and letters).

o For Example: 1234 or CH01. • Target Population – List the target populations in which your county participates

in, per each of the provider agencies: o For example: List 14, 15, and 17, if your county only participates within

those three target populations. o List all of the provider agencies for each of the target populations.

• Agency Type – CBO, LPE, LGA.

LGAs can add subprogram codes to their LGA profile in the TCM System by completing the subprogram codes tab in the APP worksheet and submit it to DHCS with their APP submission.

LGAs that exceed the space provided in their subprogram codes tab in the APP worksheet can use the Subprogram Codes worksheet that can be found on the TCM website. This Subprogram Codes worksheet is also used to submit additional subprogram codes throughout the year. To update subprogram codes after the submission of the APP, LGAs must submit the Subprogram Codes worksheet through e-mail to [email protected].

4. TCM Program Withdrawal and Enrollment and/or Re-enrollment

a. LGA Participation Withdrawal from The TCM Program Form This form is to be used by LGAs to initiate withdrawal from the TCM program. LGAs must also meet the termination notice requirements outlined in the PPA and must


All T C M encounters entered into the T C M System require a subprogram code associated with the L G A, including C B Os, subcontracted public agencies, etc.

The Subprogram Codes tab of the A P P worksheet lists the required information that T C M analysts use to update L G A Profiles in the T C M System for the next S F Y. Each of the columns listed below must be completed:

Agency Type – C B O, L P E, L G A.

Provider Agency - For each target population used by the L G A, list the provider agency names in the provider agency column on the left side of the worksheet.

Subprogram code – L G As will create their own subprogram codes (D H C S doesnot create them for the counties). The subprogram codes shall be four characterslong (numbers, letters, or a mixture of both numbers and letters).

For Example: 1234 or C H 01.

L G As can add subprogram codes to their L G A profile in the T C M System by completingthe subprogram codes tab in the A P P worksheet and submit it to D H C S with their A P Psubmission.

L G As that exceed the space provided in their subprogram codes tab in the A P Pworksheet can use the Subprogram Codes worksheet that can be found on the T C Mwebsite. This Subprogram Codes worksheet is also used to submit additionalsubprogram codes throughout the year. To update subprogram codes after thesubmission of the A P P, L G As must submit the Subprogram Codes worksheet through

T C M Program Withdrawal and Enrollment and/or Re-enrollment

L G A Participation Withdrawal from The T C M Program Form

This form is to be used by L G As to initiate withdrawal from the T C M program. L G As must also meet the termination notice requirements outlined in the P P A and must

Agency Type – CBO, LPE, LGA.

[email protected]



June 2019

submit a final Cost Report with their withdrawal requests. The LGA Coordinator must sign the form in blue ink and return it to the address provided on the form or e-mail it to [email protected] before July 1 of each year, if applicable.

Note: • LGAs who withdraw from the TCM program must submit a Cost Report.

The withdrawal from the TCM program Request form can be found on the TCM website: http://www.dhcs.ca.gov/provgovpart/Pages/TCM.aspx

b. LGA Participation Enrollment and/or Re-Enrollment In The TCM Program Form The LGA will use this form to formally enroll or re-enroll in the TCM program. The LGA Coordinator must sign the form in blue ink and return it to the address provided on the form or e-mail it to [email protected] before December 31.

Note: For new TCM enrollment, DHCS must be contacted for additional information. The LGA does not need to complete this form if continuing TCM participation.


submit a final Cost Report with their withdrawal requests. The L G A Coordinator must sign the form in blue ink and return it to the address provided on the form or e-mail it to

L G As who withdraw from the T C M program must submit a Cost Report.

The withdrawal from the T C M program Request form can be found on the T C M website:

L G A Participation Enrollment and/or Re-Enrollment In The T C MProgram Form

The L G A will use this form to formally enroll or re-enroll in the T C M program. The L G A Coordinator must sign the form in blue ink and return it to the address provided on the

Note: For new T C M enrollment, D H C S must be contacted for additional information. The L G A does not need to complete this form if continuing T C M participation.

[email protected]


[email protected]

Documents

Section 3 - Participation and Program Requirements...Section 3-Participation and Program Requirements . 3-3 . June 2019. E. Maternal Child Health Program, F. Employment and Human Services