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    Targeted Case Management Program Questions and Answers

    What is case management?

    Case management is a service which provides targeted medical assistance clients with access to comprehensive medical and social services to encourage the cost effective use of medical care and community resources, while ensuring the client's freedom of choice and promoting the well-being of the individual.

    Who makes up the target group?

    Individuals with Acquired Immune Deficiency Syndrome (AIDS) or Symptomatic Human Immune Deficiency Virus (HIV) disease who are receiving medical assistance benefits. Certain groups such as State Blind and Healthy Horizons are excluded.

    Why was this group selected?

    Experience indicates that proper and timely attention to medical and related social problems can reduce the incidence of hospitalization and decrease the need for extensive medical intervention.

    What does the Department of Public Welfare mean by symptomatic HIV disease?

    • Tested positive for HIV through standard, medically accepted procedures; and
    • Has a documented history of at least one symptom of HIV disease.

    Who is eligible for case management services?  

    With the exception of medical assistance recipients who are enrolled in a Health Maintenance Organization (HMO), HealthChoices or a Medical Assistance Hospice Program, all categorically and medically needy recipients who fall into the AIDS target group are eligible for case management services.

    What is a case manager?

    A case manager is a coordinator and facilitator of necessary medical and social services. It is the case manager's role to locate appropriate resources and assist the client in gaining access to needed services. (A case manager will not be reimbursed for providing direct services to clients).

    What qualifies an individual to be a case manager?

    A case manager must:

    • Have one year of case management experience.
    • Meet the following criteria:
      • Bachelor or Master of Social Work;
      • Bachelor or Master of Social Science;
      • Bachelor of Science in Nursing or equivalent nursing degree; or
      • Registered nurse licensed in Pennsylvania with one year experience working with the target group, and a combination of 12 semester hours in psychology, or other social welfare courses.
    • Have documented case management training which includes college credit, workshop certificates, formal in or out-service training, or on-the-job training.
    • Be enrolled in the Medical Assistance Program.

    What are some of the services provided by the case manager?

    • Screening - evaluating to determine if the recipient is an appropriate candidate for case management services.
    • Assessing - identifying the recipient's medical and social needs and the appropriate services to meet those needs. Based on the medical treatment plan established by the client's physician, the client and case manager will develop realistic goals.
    • Developing and Implementing a Service Coordination Plan (SCP) - the case manager, with the cooperation of the client and the client's family, will develop an action plan that specifies concrete activities to be completed in order to achieve the client's goals.
    • Linking and Coordinating Services - locating resources and making referrals or arrangements for treatment and support services related to the SCP.
    • Facilitating - acting as a resource person to resolve access problems that may arise while implementing the SCP.
    • Monitoring - insuring the appropriate quantity, quality, and effectiveness of services in accordance with the SCP.
    • Reassessing - conferring with the client and physician and reviewing the SCP periodically, as required by the Department, to ensure that services provided are consistent with the needs and goals of the client. 

    How are case managers paid?

    The case manager submits invoices, on a monthly basis, directly to the Case Management Section and is paid through PROMISe™ (Provider Reimbursement and Operations Management Information System).

    What are the reimbursement rates for case managers?

    The case manager is paid in 15-minute units at:

    • 1 unit = 15 minutes = $7.50
    • 2 units = 30 minutes = $15.00
    • units = 45 minutes = $22.50
    • 4 units = 60 minutes = $30.00 

    What is the role of the physician in the Case Management Program?

    The physician assesses the client's need for case management services, informs the client of the availability of such services, develops a medical plan of care for each client, certifies the client's diagnosis, and may refer the client directly to the Case Management Section.

    May case managers be employed by other entities or must they be self-employed?

    Case managers may be self-employed or employed by a hospital, social service agency, a home health agency, or a private agency. If a case manager is employed by, and providing case management services through one of these agencies, payment may be assigned to the agency if it is enrolled in Medical Assistance.

    How are case managers assigned?

    Case managers are not assigned. Each client has the freedom to select any enrolled case manager in his or her geographic area. Upon request, the Department of Public Welfare will provide a list of available case managers to assist clients in the selection process.

    Can a client change case manager?

    Yes. The client has the right to change case manager; however, a Change/Discontinuance of Case Management Services Form must be submitted to the Department 30 days prior to the change. A new Case Management Agreement Form co-signed by the new case manager must be submitted after the change is approved.

    Is case management mandatory for the target group?

    No. The client is free to choose case management. The client may also drop out of the Case Management Program at any time by completing the proper form and submitting it to the Department of Public Welfare. If the client decides to return to the Case Management Program, the client may return immediately to the same case manager. If the client chooses another case manager, the client must submit a request for the desired change.

    Is there a limit on the number of clients that a case manager may serve at any given time?

    Yes. A case manager may provide services for a maximum of 25 medical assistance clients. The case manager may not use this limit to discriminate against any race, color, religion, or group.

    What can a client do if he/she is denied case management services?

    The client has the right to appeal to the Department of Public Welfare if denied case management services. The Case Management Section will review the appeal. If the denial is upheld, the appeal will be referred to the Department's Office of Hearings and Appeals for appropriate action.

    Whom do I contact if I need more information on the Case Management Program?

    The Case Management telephone number is 717-772-6295. The mailing addressing is:

    Provider and Member Services Section
    P. O. Box 8044
    Harrisburg, PA 17105-8044