Assignment to Care Coordination Levels. 4.4.3.1 The HRA shall determine if a Member requires a CNA to determine if the Member should be assigned to Care Coordination level two (2) or level three (3). 4.4.3.2 Within seven (7) Calendar Days of completion of the HRA, Members who have been identified as needing a Comprehensive Needs Assessment shall be informed of such action. If the Member is enrolled in a Health Home, refer to Agreement Section 4.13.2. 4.4.3.3 Within ten (10) Calendar Days of completion of the HRA, Members requiring a Comprehensive Needs Assessment shall receive: 4.4.3.3.1 Contact information for the CONTRACTOR’s Care Coordination unit; 4.4.3.3.2 The name of the assigned care coordinator (if applicable); and 4.4.3.3.3 A time frame during which the Member can expect to be contacted by the Care Coordination unit or individual care coordinator to complete the Comprehensive Needs Assessment. 4.4.3.4 Members who are identified as NOT needing a Comprehensive Needs Assessment shall be monitored by the Care Coordination unit according to the provisions in Section 4.4.4 of this Agreement. 4.4.3.5 Care Coordination Level Two (2) and Level Three (3). For Members meeting one of the indicators below, the CONTRACTOR shall conduct a Comprehensive Needs Assessment (further explained in section 4.4.5 of this Agreement) to determine whether the Member should be in Care Coordination level two (2) or level three (3): 4.4.3.5.1 Is a high-cost user as defined by the CONTRACTOR; 4.4.3.5.2 Is in out-of-State medical placements; 4.4.3.5.3 Is a dependent child in out-of-home placements; 4.4.3.5.4 Is a transplant patient; 4.4.3.5.5 Is identified as having a high risk pregnancy; Section 4.4.3.5.5.1 4.4.3.5.5.1 Pregnant Members eighteen (18) years of age and younger 4.4.3.5.6 Has a Behavioral Health diagnosis including substance abuse that adversely affects the Member’s life; 4.4.3.5.7 Is medically fragile; 4.4.3.5.8 Is designated as ICF/MR/DD; 4.4.3.5.9 Has frequent emergency room use, defined as two (2) or more emergency room visits in a six (6) month period; 4.4.3.5.10 Has an acute or terminal disease; 4.4.3.5.11 Is readmitted to the hospital within thirty (30) Calendar Days of discharge; 4.4.3.5.12 Has other indicators as prior approved by HSD; 4.4.3.5.13 Is a Medically Frail adult member; 4.4.3.5.14 Has mild cognitive deficits requiring prompting or cueing; 4.4.3.5.15 Has co-morbid health conditions; 4.4.3.5.16 Requires assistance with two (2) or more ADLs or IADLs living in the community; and 4.4.3.5.17 Has poly-pharmaceutical use, defined as simultaneous use of six (6) or more medications from different drug classes and/or simultaneous use of three (3) or more medications from the same drug class.
Appears in 13 contracts
Samples: Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement, Medicaid Managed Care Services Agreement
