Common use of Assignment of Risk Levels Clause in Contracts

Assignment of Risk Levels. The Contractor shall develop a Care Management program that addresses the varying needs and differing levels of Care Management needs for Members. Based on the Health Risk Screening, the Contractor’s Care Management program must provide for the completion of a detailed health risk assessment for Members, which includes an assessment of and assignment to risk stratification levels (e.g., low, medium, high) which determine the intensity of interventions and follow-up care that is required for each Member. The Contractor shall prioritize and assign Members to low, medium, or high levels based on the identified risk and level of need. Members who have high costs or potentially high costs or otherwise qualify, include but are not limited to pregnant women under twenty-one (21), high risk pregnancies, serious and persistent behavioral health conditions, and infants and toddlers with established risk for developmental delays, shall be assigned to the medium or high risk level and receive Care Management services. Members with less intensive needs will be assigned to the low risk level and shall have access to Care Management teams. The Care Manager must contact the Member via telephone or face-to-face interview to assess the Member’s Care Management needs. This detailed health risk assessment must evaluate the Member’s medical condition(s), including physical, behavioral, social and psychological needs. The goal of this assessment is to confirm the Member’s need for Care Management, identify the Member’s existing and /or potential health care needs, determine the types of services needed by the Member and begin the development of the treatment plan. The Contractor will determine the need for an onsite visit at the Member’s residence to complete this assessment. This detailed health risk assessment must occur within thirty (30) calendar days for Members newly assigned to the High or Medium risk levels as a result of the Health Risk Screening, referral and/or predictive modeling. The detailed health risk assessment must be reviewed by a qualified health professional appropriate for the Member’s health condition. The detailed health risk assessment shall address the following, at a minimum: a. Identification of the severity of the Member’s conditions/disease state; b. Evaluation of co-morbidities, or multiple complex health care conditions; c. Demographic information (including ethnicity, education, living situation/housing, legal status, employment status; and d. The Member’s current treatment Providers and treatment plan, if available. The treatment plan for the Member must be completed within thirty (30) days of the completion of the detailed health risk assessment, if appropriate. The Contractor shall conduct initial and ongoing predictive modeling to identify and evaluate the Member’s risk level, which must incorporate the use of pharmacy utilization data. In addition, in consideration of the fact complete claims data may not be available for the MississippiCAN population, particularly for Members new to the program, the Contractor must propose other analyses used to identify and stratify Members who may be in need of Care Management services. Whenever available, the Contractor shall use findings from an initial Health Risk Screening for new Members. The Contractor shall report on the number of Members for whom they attempted to conduct a Health Risk Screening, the number of Members who could not be reached, and the findings from the Health Risk Screenings for those Members whom the Contractor was able to assess. The Contractor shall report this information as part of the Care Management Reports. Additionally, Members may be considered for receiving Care Management services, through Provider referral, State Agency referral and Member self-referral. At a minimum, the Contractor shall provide Care Management services to all Members identified with the following chronic conditions: diabetes, asthma, hypertension, obesity, congestive heart disease, and organ transplants. Following the health risk assessment, the Contractor shall update the risk level assignment when there has been a change in the health status, needs, or a significant health care event relevant to the Member’s risk level assignment. The Contractor must receive Division approval for other analysis used to identify Member’s risk level prior to use. The Contractor shall modify its approach upon Division request. Additionally, the Contractor shall provide alternate solutions if the implemented approach does not achieve the targeted outcomes and savings over time. All Members shall have access to the Care Management Team and the Contractor must provide all Members with information on how to contact this Team through the Contractor Member Information Packet.

Assignment of Risk Levels. The Contractor shall develop a Care Management program that addresses the varying needs and differing levels of Care Management needs for Members. Based on the Health Risk Screening, the Contractor’s Care Management program must provide for the completion of a detailed health risk assessment for Members, which includes an assessment of and assignment to risk stratification levels (e.g., low, medium, high) which determine the intensity of interventions and follow-up care that is required for each Member. The Contractor shall prioritize and assign Members to low, medium, or high levels based on the identified risk and level of need. Members who have high costs or potentially high costs or otherwise qualify, include including but are not limited to pregnant women under twenty-one (21), high risk pregnanciesMembers with persistent and/or preventable inpatient readmissions, serious and persistent behavioral health Behavioral Health conditions, and infants and toddlers with established risk for developmental delays, shall be assigned to the medium or high risk level and receive Care Management services. Members with less intensive needs will be assigned to the low risk level and shall have access to Care Management teams. Contractor shall conduct predictive modeling upon initial Enrollment and at least monthly to identify and evaluate Member risk levels, which must incorporate the use of pharmacy utilization data. Contractor shall also consider Members for receiving Care Management through provider referral, State Agency referral, and Member self- referral. In addition, in consideration of the potential lack of complete claims or encounter data for the CHIP population prior to Enrollment with Contractor, particularly for Members new to CHIP, Contractor may use other analyses used to identify and stratify Members who may be in need of Care Management services. The Care Manager must may contact potentially medium- and high-risk Members and/or the Member Member’s guardian via telephone or face-to-face interview to assess administer the Member’s Care Management needsdetailed health risk assessment. This detailed health risk assessment must evaluate the Member’s medical condition(s), including physical, behavioral, social social, and psychological needs. The goal of this assessment is to confirm the Member’s need for Care Management, identify the Member’s existing and /or potential health care needs, determine the types of services needed by the Member Member, and begin the development of the Member’s treatment plan. The Contractor will determine the need for an onsite visit at the Member’s residence to complete this assessment. This detailed health risk assessment must occur within thirty (30) calendar days for Members newly assigned to the High identified as potentially high- or Medium medium-risk levels as a result of the Health Risk Screening, referral and/or predictive modeling. The detailed health risk assessment must be reviewed by a qualified health professional appropriate for the Member’s health condition. The detailed health risk assessment shall address the following, at a minimum: a. Identification of the severity of the Member’s conditions/disease statestate (e.g., medical, Behavioral Health, social), documentation of recent treatment history and current medications; b. Evaluation of co-morbidities, or multiple complex health care conditions; c. Demographic information (including ethnicity, education, living situation/housing, legal status, employment status); and d. The Member’s current treatment Providers providers and treatment plan, if available. The treatment plan for the Member must be completed within thirty (30) days of the completion of the detailed health risk assessment, if appropriate. The Contractor shall conduct initial and ongoing predictive modeling to identify and evaluate the Member’s risk level, which must incorporate the use of pharmacy utilization data. In addition, in consideration of the fact complete claims data may not be available for the MississippiCAN population, particularly for Members new to the program, the Contractor must propose other analyses used to identify and stratify Members who may be in need of Care Management services. Whenever available, the Contractor shall use findings from an initial Health Risk Screening for new Members. The Contractor shall report on the number of Members for whom they attempted to conduct a Health Risk Screening, the number of Members who could not be reached, and the findings from the Health Risk Screenings for those Members whom the Contractor was able to assess. The Contractor shall report this information as part of the Care Management Reports. Additionally, Members may be considered for receiving Care Management services, through Provider referral, State Agency referral and Member self-referral. At a minimum, the Contractor shall provide Care Management services to all Members identified with the following chronic conditions: diabetes, asthma, hypertension, obesity, congestive heart diseaseattention deficit hyperactivity disorder, and organ transplants. Following the detailed health risk assessment, the Contractor shall update the risk level assignment at least annually and when there has been a change in the health status, needs, or a significant health care event relevant to the Member’s risk level assignment. The Contractor must receive Division DOM approval for other analysis or methods used to identify or re-assess Member’s risk level thirty (30) calendar days prior to useuse by Contractor. The Contractor shall modify its approach upon Division DOM request. Additionally, the Contractor shall provide alternate solutions if the implemented approach does not achieve the targeted outcomes and savings over time. All Members shall have access to the Care Management Team team and the Contractor must provide all Members with information on how to contact this Team the Care Management team through the Contractor Member Information Packet.

Assignment of Risk Levels. The Contractor shall develop a Care Management program that addresses the varying needs and differing levels of Care Management needs for Members. Based on the Health Risk Screening, the Contractor’s Care Management program must provide for the completion of a detailed health risk assessment for Members, which includes an assessment of and assignment to risk stratification levels (e.g., low, medium, high) which determine the intensity of interventions and follow-up care that is required for each Member. The Contractor shall prioritize and assign Members to low, medium, or high levels based on the identified risk and level of need. Members who have high costs or potentially high costs or otherwise qualify, include but are not limited to Members with persistent and/or preventable inpatient readmissions, pregnant women under twenty-one (21), high risk pregnancies, serious and persistent behavioral health conditions, and infants and toddlers with established risk for developmental delays, shall be assigned to the medium or high risk level and receive Care Management services. Members being discharged from an acute inpatient psychiatric stay or PRTF shall be assigned to high risk level and receive Care Management services. Members with less intensive needs will be assigned to the low risk level and shall have access to Care Management teams. The Care Manager must contact the Member via telephone or face-to-face interview to assess the Member’s Care Management needs. This detailed health risk assessment must evaluate the Member’s medical condition(s), including physical, behavioral, social and psychological needs. The goal of this assessment is to confirm the Member’s need for Care Management, identify the Member’s existing and /or potential health care needs, determine the types of services needed by the Member and begin the development of the treatment plan. The Contractor will determine the need for an onsite visit at the Member’s residence to complete this assessment. This detailed health risk assessment must occur within thirty (30) calendar days for Members newly assigned to the High or Medium risk levels as a result of the Health Risk Screening, referral and/or predictive modeling. The detailed health risk assessment must be reviewed by a qualified health professional appropriate for the Member’s health condition. The detailed health risk assessment shall address the following, at a minimum: a. Identification of the severity of the Member’s conditions/disease state; b. Evaluation of co-morbidities, or multiple complex health care conditions; c. Demographic information (including ethnicity, education, living situation/housing, legal status, employment status; and d. The Member’s current treatment Providers and treatment plan, if available. The treatment plan for the Member must be completed within thirty (30) days of the completion of the detailed health risk assessment, if appropriate. The Contractor shall conduct initial and ongoing predictive modeling to identify and evaluate the Member’s risk level, which must incorporate the use of pharmacy utilization data. In addition, in consideration of the fact complete claims data may not be available for the MississippiCAN population, particularly for Members new to the program, the Contractor must propose other analyses used to identify and stratify Members who may be in need of Care Management services. Whenever available, the Contractor shall use findings from an initial Health Risk Screening for new Members. The Contractor shall report on the number of Members for whom they attempted to conduct a Health Risk Screening, the number of Members who could not be reached, and the findings from the Health Risk Screenings for those Members whom the Contractor was able to assess. The Contractor shall report this information as part of the Care Management Reports. Additionally, Members may be considered for receiving Care Management services, through Provider referral, State Agency referral and Member self-referral. At a minimum, the Contractor shall provide Care Management services to all Members identified with the following chronic conditions: diabetes, asthma, hypertension, obesity, congestive heart disease, and organ transplants. Following the health risk assessment, the Contractor shall update the risk level assignment when there has been a change in the health status, needs, or a significant health care event relevant to the Member’s risk level assignment. The Contractor must receive Division approval for other analysis used to identify Member’s risk level prior to use. The Contractor shall modify its approach upon Division request. Additionally, the Contractor shall provide alternate solutions if the implemented approach does not achieve the targeted outcomes and savings over time. All Members shall have access to the Care Management Team and the Contractor must provide all Members with information on how to contact this Team through the Contractor Member Information Packet.