Section 1: Overview of Medicaid and Case Management for Children and Pregnant Women

Eligibility for Case Management for Children and Pregnant Women (CPW) Services

CPW is a Medicaid benefit that helps eligible clients gain access to necessary services. In addition, CPW is:

  • A component of Texas Health Steps, which provides healthcare for children birth through age 20 who have Medicaid.

  • Comprehensive and family-centered, addressing a range of needs related to the client’s health condition/health risk or high-risk condition.

To be eligible for CPW services a client must:

  • Be eligible for Medicaid services in Texas;
  • Need assistance gaining access to necessary medical, social, educational and other services related to their health condition/health risk or high-risk condition; and
  • Desire to receive case management services.

The client must meet all four requirements

1. Medicaid Eligible

The client must be eligible for Medicaid but does not have to be enrolled in Medicaid at the time of intake. Visits are not billable if:

  • The client is not eligible for Medicaid.
  • The client, parent or guardian does not follow through with applying for Medicaid.
  • The client is an inpatient at a hospital or other treatment facility.

2. Health Condition/Health Risk and High-Risk Condition

  • A health condition and a health risk apply to children birth through age 20.
  • High-risk condition applies to pregnant women of any age.

3. Needs Help Accessing Services

Clients also must need assistance accessing medical, social, educational or other services related to their health condition/health risk or high-risk condition. Needs must be current and not anticipatory.

4. Desires Case Management Services

A final eligibility requirement is that clients must want help accessing services related to their health condition/health risk or high-risk condition.


Clients with Health Conditions or Risks

As a case manager, you are responsible for:

  • Gathering information to determine whether a health condition or health risk exists.
  • Eliciting information to determine whether the health condition or health risk results in a limitation of function.
Children with a Health Condition or Health Risk
  • Age birth through 20; and
  • a health condition or health risk: a diagnosed or undiagnosed behavioral health or medical condition, illness, injury or disability; and
  • results in a limitation of function, activity or social role as compared to healthy peers of the same age.

Note

There is no standard list of diagnoses or conditions that qualify a child for case management services.

The limitation must be in the general area of physical, cognitive, emotional or social development.

Pregnant Women with High-Risk Conditions
  • A pregnant woman of any age; and
  • A pregnant woman with at least one high-risk medical or psychosocial condition; and
  • A pregnant woman who places herself and her fetus(es) at greater-than-average risk for complications during pregnancy, delivery or following birth.
  • A woman with a high-risk condition during pregnancy can continue to receive case management services 12 months postpartum.

Note

There is no standard list of diagnoses or conditions that qualify a pregnant woman for case management services.

The woman is not eligible for case management services if the delivery occurs prior to intake.


Give It Some Thought


Eligibility Flow Sheet for Fee-for-Service Clients

eligilibility flow chart