Care Management Requirements for Sample Clauses

Care Management Requirements for. All Members 1. Information Sharing for New Members HMOs must have policies and procedures to utilize member-specific information provided by DHS to prevent duplication of activities and as input into any needs stratification or care plan development activities. This may include results of any screens completed by the member, claims/encounter history, FFS prior authorization data, high-risk pregnancy indicators, and upcoming non-emergency medical transportation trips. (Pursuant to 42 CFR § 438.208(b)(4)) HMOs must also follow information sharing as written under Art. VII, F, 7. 2. Screening Requirements Pursuant to 42 CFR § 438.208(b)(3), the HMO must make a best effort to conduct an initial screening of each member’s needs, within 90 days of HMO enrollment for all new members, including subsequent attempts if the initial attempt to contact the member is unsuccessful. New members include those that were previously enrolled in the HMO but re-enroll in the HMO at least six months after their last disenrollment. See Sections B and C of this Article for BadgerCare Plus and SSI specific screening requirements. 3. Primary Care Provider Assignment Per Art. VII, C, HMOs are encouraged to assist members in identifying a primary care provider. This identification should be a part of the initial member screening process. 4. Care Coordination Requirements for all Members The HMO must coordinate and provide Medicaid-covered, medically necessary services to members in accordance with the needs identified in the initial screen. The HMO care coordinator or other professional staff shall follow-up regularly with the member to determine if services provided best address their needs. Per 42 CFR § 438.208(b)(2), the HMO must coordinate the services it provides to members: a. Between settings of care, including appropriate discharge planning for hospital or institutional stays. Upon notification of a change in setting of care, the HMO is responsible for coordination with the hospital or institution staff. b. With services provided by another HMO. c. With services a member receives through Medicaid Fee-for-Service. d. With services a member receives through community and social support providers. More information and requirements on care coordination can be found in Art. VII, F. 5. Members with Special Needs A more specific model for all SSI members can be found in Art. III, C. However, for other individuals deemed to be a member with special needs, the following is required: