Questions and Answers

Case Management for Children and Pregnant Women


Question Answer
What is Case Management for Children and Pregnant Women? Case Management for Children and Pregnant Women is a Medicaid benefit. Through the program, case managers help families get medical services, school services, medical equipment and supplies and other services that are medically necessary.
Who can get case management?

Case managers can help children and young adults age 20 and younger who have a health condition or health risk who are covered by Medicaid. They also can help women of any age with a high risk pregnancy.  The person or family must need help getting services or they must be having trouble finding or connecting with the services that they need related to their health condition or health risk.

Does the person have to have a medical diagnosis to get case management services?

The person does not have to have a formal medical diagnosis.  If they have a health condition or health risk and needs related to that risk, they might be approved for services.

 Examples of health conditions:

This might be a disability that limits the child’s ability to function or do activities as well as kids of the same age. The health condition could also be a problem that requires special health-care needs. A few examples are asthma, cancer, cerebral palsy, cystic fibrosis, Down syndrome, diabetes, heart conditions, autism disorder, mental health or behavioral health issues or learning disabilities.

 Examples of health risks:

Children with a health risk don’t yet have a health condition or formal medical diagnosis. They may need services to prevent the child from developing a health condition or to prevent them from missing regular health care. For example, a health risk in a child may include high blood lead levels and developmental or nutrition issues. Also, any child who regularly misses health-care visits or does not follow through with referrals may also have a health risk.

 Examples of High Risk Pregnancies:

A high-risk pregnancy means there is a problem that could cause harm to the pregnant woman, to her baby, or both. Medical conditions, such as high blood pressure, premature labor, gestational diabetes or poor fetal growth may result in a high-risk pregnancy.  Social and behavioral issues, such as homelessness and drug or alcohol use may also make a pregnancy high-risk.

Who can refer someone to Case Management for Children and Pregnant Women?

Anyone can make a referral.
What happens after a referral is made for case management services?

After a referral is made to Texas Health Steps, staff will call the family to tell them more about case management.  If the family wants case management, the staff can help set up a meeting with a case manager or offer a list of case managers the family can contact.

Who are case managers?

Case managers are professionals. They are trained to help get families the services that they have trouble finding on their own. 

Case managers are either licensed social workers or Registered Nurses. They work on their own or are employed by schools, health departments, counseling agencies, health clinics or other types of agencies.

Case managers are available statewide.

What does the case manager do to help?

The case manager will meet with the person approved for Medicaid, the person’s parent or guardian.  They will do a full assessment to find out all of the needs a family might have related to the health condition. Then the case manager and family will make a service plan that addresses all the needs.  Case managers find local resources and follow up to make sure the family gets the services they need.

Examples of case management include:

  • Getting medical and dental services
  • Getting medical supplies and equipment
  • Working on school or education issues
What is an example of what a case manager does? A case manager worked with a family who has a 6-year-old with cerebral palsy and other health conditions. The child was not able to walk and had outgrown his wheelchair. The mother didn’t know how to get a new chair ordered. With the mother’s consent, the case manager contacted the child’s physical therapist at the school who also agreed the child needed a new wheelchair. The physical therapist and case manager worked together. They contacted the medical supply company that the mother had used before. They got the necessary paperwork from the child’s doctor, and the physical therapist did a seating evaluation. Because of the assistance of the case manager, the child now has a new wheelchair.
Can a case manager help someone find a doctor or dentist? If someone needs help finding routine medical needs, such as a doctor or dentist, you should refer that person to either the Texas Health Steps toll-free hotline at 1-877-847-8377 or the person’s managed care health plan.
Does a case manager provide education about treatment and services for a child recently diagnosed with a health condition? No. Since a child’s treatment and services are usually very specific to their particular health condition, the family should get information about their child’s treatment and services directly from the child’s health care provider.   A case manager cannot educate the family about the health condition but they may help by referring the parent or guardian to a health professional that can provide this education.
Does a case manager evaluate my child for a mental health or behavioral health condition, such as ADHD, ADD, Autism, Bipolar, etc.? No. A case manager does not conduct evaluations for mental health or behavioral health conditions but they may help by referring the parent or guardian to the primary care physician and/or a professional health-care provider that can do that kind of evaluation.
My child has a health condition and the health plan has denied therapies, equipment, supplies and treatment services. Can a case manager help with that? Yes. A case manager can work with the family, the health care provider and the health plan to ensure that the child has the services that are medically necessary.
How long does the case manager work with the client? The case manager gets approval for a number of visits based on the person’s level of need.  Once all person’s needs have been addressed the case manager will close the case.  If there are additional needs, the case manager may request more visits or reopen the case.
Who can the client call if there are concerns about the case management services? If the family has concerns about the case manager and/or case management services, the family can call Texas Health Steps toll free at 1-877-847-8377.
Do all of the members in the family need to be approved for Medicaid to receive case management services? No. Only the child (newborn through age 20) with the health condition or health risk or the woman of any age with a high risk pregnancy needs to have Medicaid coverage.
How do I make a referral for case management services? Call 1-877-847-8377 or complete and fax a Referral Form.
Last updated October 5, 2016