Care Management Programs a. We have established (and from time to time establish) various Member-focused health education and information programs as well as benefit Utilization Management Programs and utilization review programs. These voluntary programs, collectively called the Care Management Programs, are designed to:
i. provide you with information that will help you make more informed decisions about your health;
ii. help us facilitate the management and review of the coverage and benefits provided under our policies; and
iii. present opportunities as explained below, to mutually agree upon alternative benefits for cost-effective medically appropriate Health Care Services.
b. Please note that we reserve the right to discontinue or modify our Prior Authorization requirements and any Care Management Programs at any time without your consent.
Care Management Programs. We have established (and from time to time establish) various Member- focused health education and information programs as well as benefit Utilization Management Programs and utilization review programs. These voluntary programs, collectively called the Care Management Programs, are designed to:
a. provide you with information that will help you make more informed decisions about your health;
b. help us facilitate the management and review of the coverage and benefits provided under our policies; and
c. present opportunities as explained below, to mutually agree upon alternative benefits for cost-effective medically appropriate Health Care Services.
Care Management Programs. We understand special health needs and are prepared to help you manage any that you may have. Our Care Management services can help with complex medical or behavioral health needs. If you qualify for Care Management, we will partner you with a care manager. Care managers are registered nurses or social workers that are specially trained to help you:
Care Management Programs. In accordance with 5101:3-26-03.1(A)(8), MCPs must offer and provide care management services which coordinate and monitor the care of members who require high-cost and/or extensive services. The MCP’s care management program must also include a Children with Special Health Care Needs component as specified below.
i. Each MCP must inform all members and contracting providers of the MCP’s care management services.
ii. Children with Special Health Care Needs (CSHCN): CSHCN are a particularly vulnerable population which often have chronic and complex medical health care conditions. In order to ensure compliance with the provisions of 42 CFR 438.208, each MCP must establish a CSHCN component as part of the MCP’s care management program. The MCP must establish a process for the timely identification, completion of a comprehensive health assessment, and providing appropriate care management services for any CSHCN. CSHCN are defined as children age 17 and under who are pregnant, and members under 21 years of age with one or more of the following: -Asthma -HIV/AIDS -A chronic physical, emotional or mental condition for which they are receiving treatment or counseling -Supplemental security income (SSI) for a health-related condition -A current letter of approval from the Bureau of Children with Medical Handicaps (BCMH), Ohio Department of Health
Care Management Programs. In accordance with 5101:3-26-03.1(A)(8), MCPs must offer and provide care management services which coordinate and monitor the care of members with special health care needs.
i. Each MCP must inform all members and contracting providers of the MCP’s care management services.
ii. The MCP’s care management program must include, at a minimum, the following components:
