Children with Medical Complexity Targeted Case Management

The purpose of this program is to establish coverage and reimbursement of Targeted Case Management (TCM) services for children with medical complexity (CMC). CMC are a subset of children with special health care needs and have significant medical conditions that involve multiple organ systems. As a result of these conditions, families face substantial health needs. Intensive care coordination is proven to be an effective strategy for addressing the challenges faced by this population. 

Beneficiary Eligibility Requirements: 

The CMC TCM services are voluntary services available to children under 21 years of age who are determined dually eligible for Children's Special Health Care Services (CSHCS) and Medicaid (Title V/XIX), are enrolled in the CSHCS program only (Title V only) or are eligible for Medicaid (Title XIX) or Children’s Health Insurance Program (CHIP).

Children with Medical Complexity (CMC) must:

• Meet all the following chronicity, complexity, and fragility criteria:
• have at least one CSHCS medically eligible condition that involves three or more organ systems; have functional limitations and are technologically dependent; and/or a transplant candidate; AND
• receive treatment from three or more medical and/or surgical specialties at a hospital or medical university.

• Meet at least one of the following utilization criteria during the previous 12 months:
• one or more hospital admissions, with at least one hospital stay of five or more days; OR
• ten or more visits with a medical or surgical specialist at a pediatric specialty clinic.

Beneficiaries who are too young to have met the utilization criteria may be eligible if they meet the above-stated chronicity, complexity, and fragility criteria and both of the following: a stay in the hospital totaling five or more days; AND clinicians’ anticipation that the beneficiary will be an intensive user of health resources.

The CMC TCM core team verifies client eligibility.

Core Services/Key Aspects: 

Eligible beneficiaries work with a multi-disciplinary care team of providers to receive the core elements of TCM services:

• A comprehensive assessment with the entire core team to determine the beneficiary’s needs. There is a limit of one comprehensive assessment every year.
• The development of and updates to a written, person-centered care plan that includes goals, actions, and timelines to address the medical, social, educational, and any other identified need.
• Ongoing monitoring and follow-up activities, including actions and contacts necessary to ensure the care plan is implemented. Also, referral and care coordination services to support the beneficiary in obtaining needed services. These services include face-to-face, telephone, or written contacts with, or on behalf of, the beneficiary. This comprehensive set of services is available to clients/families 24/7 and must be completed at least once per month. 
• CMC team works to navigate and integrate care across systems; intervene proactively for the family to prevent health crises and/or reduce their impact; and promote self-care skills and independence.

CMC TCM Case Management Entity Qualifications:

• Must be a Michigan Medicaid-enrolled organization qualified to provide CMC TCM services.
• All case management entities must be certified by MDHHS before providing CMC TCM services.
• Must obtain a separate National Provider Identifier (NPI) number to enroll and submit claims specifically for the CMC TCM services.

Approved Case Management Entities

Mott Children’s Hospital – Partners for Children

Additional Resources

CMC TCM provider handbook (coming soon)

CMC TCM program application form

CMC TCM NPI authorization form

CMC TCM NPI deauthorization form

CMC TCM informed consent form

CMC TCM policy