The following are the essential components of Case Management for Children and Pregnant Women services and an explanation of billable components.

1. (1) Intake--A case manager's visit with a client, family, or guardian that includes the case manager collecting demographic information, health information, and other information relevant to determining the client's eligibility.

2. (2) Comprehensive visit--A required visit conducted by a case manager face-to-face with a client, family, or guardian that includes the case manager completing the following:

   1. (A) Family Needs Assessment. A comprehensive assessment completed by a case manager to determine a client's need for any medical, educational, social, or other services required to address the client's short- and long-term health and well-being. A case manager must document this assessment on a Family Needs Assessment form, which must include:

      1. (i) taking a client's history;
      2. (ii) identifying the client's needs, assessing and addressing family issues that impact the client's health condition, health risk, high-risk condition, or nonmedical needs; and
      3. (iii) gathering information from other sources, such as family members, medical providers, social workers, and educators, if necessary, to form a complete assessment of the client.

   2. (B) Service Plan. A plan for case management services completed by a case manager with a client or the client's parent or legal guardian that determines a planned course of action based on the information collected through the assessment required in paragraph (2)(A) of this section. A case manager must document the Service Plan on a Service Plan form, which must:

      1. (i) include activities and goals developed by the client in consultation with the case manager to address the medical, social, educational, and other services needed by the client;
      2. (ii) identify a course of action to respond to the assessed needs of the client, including identifying the individual responsible for contacting the appropriate service providers, and designating the time frame within which the client should access services; and
      3. (iii) be dated and signed by the Medicaid provider.

3. (3) Referral and related activities. To help manage a client's care, a case manager making referrals and conducting related activities, such as scheduling appointments for the client, conducting collateral contacts with a non-eligible individual that are directly related to identify and help the client obtain needed services and link the client with:

   1. (A) medical, social, and educational providers; and
   2. (B) other programs and services that can provide services the client needs.

4. (4) Follow-up visits by a case manager.

   1. (A) A case manager must make a follow-up visit:

      1. (i) as frequently as necessary to ensure a client's Service Plan is implemented and adequately addresses the client's needs;
      2. (ii) annually for a client who is eligible for case management for longer than 12 consecutive months; and
      3. (iii) as needed during the eligible postpartum period for a client who is a pregnant woman with a high-risk condition who may also have nonmedical needs.

   2. (B) During a follow up visit, a case manager must:

      1. (i) determine if:

         1. (I) services have been furnished to a client in accordance with the client's Service Plan; and
         2. (II) services in the initial Service Plan are adequate to address the client's needs; and
      2. (ii) complete a Service Plan Addendum form if the case manager identifies there has been a change in the client's needs or status and the initial Service plan needs to be revised.
5. (5) The essential components of Case Management for Children and Pregnant Women services that are eligible for Medicaid reimbursement are the comprehensive visit and each follow-up visit performed in accordance with this section.

6. (6) Case management services are not reimbursable if the services are provided:

   1. (A) to a client who does not meet the client eligibility requirements in §257.5 of this subchapter (relating to Client Eligibility);
   2. (B) to a client who has already received another case management service on the same day from the same billing provider; or
   3. (C) when a client is an inpatient at a hospital or other treatment facility.

Source Note:The provisions of this §257.11 adopted to be effective May 29, 2025, 50 TexReg 3129.