(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.

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