Common use of Care Management Clause in Contracts

Care Management. a. The Health Plan shall be responsible for the management of medical care and continuity of care for all Enrollees. The Health Plan shall maintain written Case Management and continuity of care protocols that include the following minimum functions: (1) Appropriate referral and scheduling assistance of Enrollees needing specialty health care/Transportation Services, including those identified through Child Health Check-Up Program (CHCUP) Screenings; (2) Determination of the need for Non-Covered Services and referral of the Enrollee for assessment and referral to the appropriate service setting (to include referral to WIC and Healthy Start) utilizing assistance as needed by the area Medicaid office; (3) Case Management follow-up services for Children/Adolescents, who the Health Plan identifies through blood Screenings as having abnormal levels of lead; (4) Coordinated Hospital/institutional discharge planning that includes post-discharge care, including skilled, short-term, skilled nursing facility care, as appropriate; and (5) A mechanism for direct access to specialists for Enrollees identified as having special health care needs, as is appropriate for their condition and identified needs. (6) The Health Plan shall have an outreach program and other strategies for identifying every pregnant Enrollee. This shall include case management, claims analysis, and use of health risk assessment, etc. The Health Plan shall require its participating Providers to notify the Health Plans of any Medicaid Enrollee who is identified as being pregnant. (7) Documentation of referral services in Enrollees’ Medical Records, including results. (8) Monitoring of Enrollees with ongoing medical conditions and coordination of services for high utilizers such that the following functions are addressed as appropriate: acting as a liaison between the Enrollee and Providers, ensuring the Enrollee is receiving routine medical care, ensuring that the Enrollee has adequate support at home, assisting Enrollees who are unable to access necessary care due to their medical or emotional conditions or who do not have adequate community resources to comply with their care, and assisting the Enrollee in developing community resources to manage the Enrollee’s medical condition. (9) Documentation of emergency care encounters in Enrollees’ Medical Records with appropriate medically indicated follow-up. (10) Coordination of hospital/institutional discharge planning that includes post-discharge care, including skilled short-term rehabilitation, and skilled nursing facility care, as appropriate. (11) Share with other MCOs, PIHPs, and PAHPs serving the Enrollee the results of its identification and assessment of any Enrollee with special health care needs so that those activities need not be duplicated. (12) Ensure that in the process of coordinating care, each Enrollee's privacy is protected consistent with the confidentiality requirements in 45 CFR parts 160 and 164. 45 CFR Part 164 specifically describes the requirements regarding the privacy of individually identifiable health information.

Care Management. a. The Health Plan shall be responsible for the management of medical care and continuity of care for all Enrollees. The Health Plan shall maintain written Case Management and continuity of care protocols that include the following minimum functions: (1) a. Appropriate referral and scheduling assistance of Enrollees needing specialty health care/Transportation Servicesservices, including those identified through Child Health Check-Up Program (CHCUP) Screenings;. (2) b. Determination of the need for Non-Covered Services and referral of the Enrollee for assessment and referral to the appropriate service setting (to include referral to WIC and Healthy Start) utilizing assistance as needed by the area Medicaid office;. (3) c. Case Management follow-up services for Children/Adolescentschildren, who the Health Plan identifies through blood Screenings as having abnormal levels of lead;. (4) d. Coordinated Hospital/institutional discharge planning that includes post-discharge care, including skilled, short-term, skilled nursing facility care, as appropriate; and. (5) e. A mechanism for direct access to specialists for Enrollees identified as having special health care needs, as is appropriate for their condition and identified needs. (6) f. The Health Plan shall have an outreach program and other strategies for identifying every pregnant Enrollee. This shall include case management, claims analysis, and use of health risk assessment, etc. The Health Plan shall require its participating Providers to notify the Health Plans of any Medicaid Enrollee who is identified as being pregnant. (7) g. Documentation of referral services in Enrollees’ Medical Recordsmedical records, including results. (8) h. Monitoring of Enrollees with ongoing medical conditions and coordination of services for high utilizers such that the following functions are addressed as appropriate: acting as a liaison between the Enrollee and Providers, ensuring the Enrollee is receiving routine medical care, ensuring that the Enrollee has adequate support at home, assisting Enrollees who are unable to access necessary care due to their medical or emotional conditions or who do not have adequate community resources to comply with their care, and assisting the Enrollee in developing community resources to manage the Enrolleemember’s medical condition. (9) i. Documentation of emergency care encounters in Enrollees’ Medical Records records with appropriate medically indicated follow-up. (10) j. Coordination of hospital/institutional discharge planning that includes post-discharge care, including skilled short-term rehabilitation, and skilled nursing facility care, as appropriate. (11) k. Share with other MCOs, PIHPs, and PAHPs serving the Enrollee the results of its identification and assessment of any Enrollee enrollee with special health care needs so that those activities need not be duplicated. (12) l. Ensure that in the process of coordinating care, each Enrollee's privacy is protected consistent with the confidentiality requirements in 45 CFR parts 160 and 164. 45 CFR Part 164 specifically describes the requirements regarding the privacy of individually identifiable health information.

Care Management. a. The Contractor will offer Care Management services to all Enrollees as needed, and will develop, maintain, and monitor a care plan for all Enrollees to support health and wellness, ensure effective linkages and coordination between the PCP and other Health Plan Care Professionals and providers and services, and to coordinate the full range of medical and behavioral health services, preventive services, medications, LTSS, social supports, Telemedicine services and enhanced benefits as needed, both within and outside the Contractor. Care Management services include ICM for community-based LTSS Enrollees and non-LTSS high-risk Enrollees. Care Management services also include care coordination services for individuals with more limited Care Management needs and transition coordination for Enrollees in nursing facilities who have an opportunity for discharge to the community. All Care Management services will be person-centered and will be delivered to Enrollees according to their strength-based needs and preferences. Enrollees will be encouraged to participate in decision making with respect to their care. If an Enrollee is unable to be reached after three attempts, or they choose not to participate, then a care plan is not required. At least annually, the Contractor shall attempt to reach Enrollees whom they were unable to reach or who chose to not participate in care planning and offer care management services and the development of a care plan. The Contractor shall have effective systems, policies, procedures and practices in place to identify Enrollees in need of Care Management services, including an early warning system and procedures that xxxxxx proactive identification of high-risk Enrollees and to further identify Enrollees’ emerging needs. A determination of which Enrollees are at high risk will be made by the Contractor as a result of either its predictive modeling results or a CFNA, as described in Section 2.6.2. Enrollees who are determined to be at high-risk and eligible for ICM may include, but not be limited to, individuals with complex medical conditions and/or social support needs that may lead to: the need for high-cost services; deterioration in health status; or institutionalization. The Contractor shall have effective systems, policies, procedures, and practices in place to identify Enrollees in need of Home Stabilization Services. The Contractor is required to coordinate with the out-of-plan Home Stabilization Service providers as part of the Enrollee’s ICP and other care plans (e.g., LTSS Care Plan). Care Coordinators should ensure that Enrollees receive aftercare follow-up when transitioning from a higher level of care. Care Management services will assist Enrollees to obtain needed medical, behavioral health, prescription and non-prescription drugs, community-based or facility-based LTSS, social, educational, psychosocial, financial and other services in support of the ICP or general Enrollee goals, irrespective of whether the needed services are covered under the Capitation Payment to the Contractor under this Demonstration. Care Management services are planned and provided based on opportunities to deliver quality-based outcomes such as: improved/maintained functional status, improved/maintained clinical status, enhanced quality of life, Enrollee satisfaction, adherence to the ICP, improved Enrollee safety, cost savings, wellness, and Enrollee autonomy. Care Management services include supports available to all Enrollees, at the level needed to effectively support each Enrollee. The Contractor shall develop and implement cost effective Care Management strategies that improve or maintain the level of quality by using payment incentives among other tools. The Contractor’s payment, measurement and incentive strategies shall include strategies that decrease avoidable hospitalizations and emergency room utilization, and reduce nursing facility admissions and lengths of stay, with a focus on high utilizers and promotion of community-based care or the least restrictive setting possible. For LTSS, the Contractor shall implement a conflict free Care Management system that complies with the following characteristics: 2.5.4.6.1. There is separation of eligibility determination from direct services provision. Eligibility for services is established separately from the provision of services, so assessors do not feel pressure to make Enrollees eligible to increase business for their organization. Eligibility is determined by an entity or organization that has no fiscal relationship to the Enrollee; 2.5.4.6.2. Funding levels for the Enrollee will be established using a tool reviewed and approved by RI EOHHS. 2.5.4.6.3. A plan of supports and services will be developed based on the Enrollee’s assessed needs. 2.5.4.6.4. Individuals performing LTSS evaluations and assessments and developing LTSS Care Plans cannot be related by blood or marriage to the Enrollee or any of the Enrollee’s paid caregivers, financially responsible for the management Enrollee, or empowered to make financial or health-related decisions on behalf of medical care the Enrollee. 2.5.4.6.5. In circumstances in which one entity is responsible for providing Care Management and continuity service delivery, appropriate safeguards and firewalls must be in place to mitigate risk of care for all Enrolleespotential conflict. 2.5.4.6.6. The Health Plan shall maintain written Case requirement to provide conflict free Care Management and continuity of care protocols that include the following minimum functions: (1) Appropriate referral and scheduling assistance of Enrollees needing specialty health care/Transportation Services, including those identified through Child Health Check-Up Program (CHCUP) Screenings; (2) Determination of the need for Non-Covered Services and referral of the Enrollee for assessment and referral is not intended to the appropriate service setting (to include referral to WIC and Healthy Start) utilizing assistance as needed by the area Medicaid office; (3) Case Management follow-up services for Children/Adolescents, who the Health Plan identifies through blood Screenings as having abnormal levels of lead; (4) Coordinated Hospital/institutional discharge planning that includes post-discharge hinder or prohibit accountable care, including skilledvalue-based, short-term, skilled nursing facility care, as appropriate; and (5) A mechanism for direct access to specialists for Enrollees identified as having special health care needs, as is appropriate for their condition and identified needsor other alternative payment strategies. (6) The Health Plan shall have an outreach program and other strategies for identifying every pregnant Enrollee. This shall include case management, claims analysis, and use of health risk assessment, etc. The Health Plan shall require its participating Providers to notify the Health Plans of any Medicaid Enrollee who is identified as being pregnant. (7) Documentation of referral services in Enrollees’ Medical Records, including results. (8) Monitoring of Enrollees with ongoing medical conditions and coordination of services for high utilizers such that the following functions are addressed as appropriate: acting as a liaison between the Enrollee and Providers, ensuring the Enrollee is receiving routine medical care, ensuring that the Enrollee has adequate support at home, assisting Enrollees who are unable to access necessary care due to their medical or emotional conditions or who do not have adequate community resources to comply with their care, and assisting the Enrollee in developing community resources to manage the Enrollee’s medical condition. (9) Documentation of emergency care encounters in Enrollees’ Medical Records with appropriate medically indicated follow-up. (10) Coordination of hospital/institutional discharge planning that includes post-discharge care, including skilled short-term rehabilitation, and skilled nursing facility care, as appropriate. (11) Share with other MCOs, PIHPs, and PAHPs serving the Enrollee the results of its identification and assessment of any Enrollee with special health care needs so that those activities need not be duplicated. (12) Ensure that in the process of coordinating care, each Enrollee's privacy is protected consistent with the confidentiality requirements in 45 CFR parts 160 and 164. 45 CFR Part 164 specifically describes the requirements regarding the privacy of individually identifiable health information.

Care Management. a. The Contractor will offer Care Management services to all Enrollees as needed, and will develop, maintain, and monitor a care plan for all Enrollees to support health and wellness, ensure effective linkages and coordination between the PCP and other Health Plan Care Professionals and providers and services, and to coordinate the full range of medical and behavioral health services, preventive services, medications, LTSS, social supports, Telemedicine services and enhanced benefits as needed, both within and outside the Contractor. Care Management services include ICM for community-based LTSS Enrollees and non- LTSS high-risk Enrollees. Care Management services also include care coordination services for individuals with more limited Care Management needs and transition coordination for Enrollees in nursing facilities who have an opportunity for discharge to the community. All Care Management services will be person-centered and will be delivered to Enrollees according to their strength-based needs and preferences. Enrollees will be encouraged to participate in decision making with respect to their care. If an Enrollee is unable to be reached after three attempts, or they choose not to participate, then a care plan is not required. At least annually, the Contractor shall attempt to reach Enrollees whom they were unable to reach or who chose to not participate in care planning and offer care management services and the development of a care plan. The Contractor shall have effective systems, policies, procedures and practices in place to identify Enrollees in need of Care Management services, including an early warning system and procedures that xxxxxx proactive identification of high-risk Enrollees and to further identify Enrollees’ emerging needs. A determination of which Enrollees are at high risk will be made by the Contractor as a result of either its predictive modeling results or a CFNA, as described in Section 2.6.2. Enrollees who are determined to be at high-risk and eligible for ICM may include, but not be limited to, individuals with complex medical conditions and/or social support needs that may lead to: the need for high-cost services; deterioration in health status; or institutionalization. The Contractor shall have effective systems, policies, procedures, and practices in place to identify Enrollees in need of Home Stabilization Services. The Contractor is required to coordinate with the out-of- plan Home Stabilization Service providers as part of the Enrollee’s ICP and other care plans (e.g., LTSS Care Plan). Care Coordinators should ensure that Enrollees receive aftercare follow-up when transitioning from a higher level of care. Care Management services will assist Enrollees to obtain needed medical, behavioral health, prescription and non-prescription drugs, community-based or facility-based LTSS, social, educational, psychosocial, financial and other services in support of the ICP or general Enrollee goals, irrespective of whether the needed services are covered under the Capitation Payment to the Contractor under this Demonstration. Care Management services are planned and provided based on opportunities to deliver quality-based outcomes such as: improved/maintained functional status, improved/maintained clinical status, enhanced quality of life, Enrollee satisfaction, adherence to the ICP, improved Enrollee safety, cost savings, wellness, and Enrollee autonomy. Care Management services include supports available to all Enrollees, at the level needed to effectively support each Enrollee. The Contractor shall develop and implement cost effective Care Management strategies that improve or maintain the level of quality by using payment incentives among other tools. The Contractor’s payment, measurement and incentive strategies shall include strategies that decrease avoidable hospitalizations and emergency room utilization, and reduce nursing facility admissions and lengths of stay, with a focus on high utilizers and promotion of community-based care or the least restrictive setting possible. For LTSS, the Contractor shall implement a conflict free Care Management system that complies with the following characteristics: 2.5.4.6.1. There is separation of eligibility determination from direct services provision. Eligibility for services is established separately from the provision of services, so assessors do not feel pressure to make Enrollees eligible to increase business for their organization. Eligibility is determined by an entity or organization that has no fiscal relationship to the Enrollee; 2.5.4.6.2. Funding levels for the Enrollee will be established using a tool reviewed and approved by RI EOHHS. 2.5.4.6.3. A plan of supports and services will be developed based on the Enrollee’s assessed needs. 2.5.4.6.4. Individuals performing LTSS evaluations and assessments and developing LTSS Care Plans cannot be related by blood or marriage to the Enrollee or any of the Enrollee’s paid caregivers, financially responsible for the management Enrollee, or empowered to make financial or health-related decisions on behalf of medical care and continuity of care the Enrollee. 2.5.4.6.5. In circumstances in which one entity is responsible for all Enrollees. The Health Plan shall maintain written Case providing Care Management and continuity service delivery, appropriate safeguards and firewalls must be in place to mitigate risk of care protocols that include the following minimum functions: (1) Appropriate referral and scheduling assistance of Enrollees needing specialty health care/Transportation Services, including those identified through Child Health Check-Up Program (CHCUP) Screenings; (2) Determination of the need for Non-Covered Services and referral of the Enrollee for assessment and referral to the appropriate service setting (to include referral to WIC and Healthy Start) utilizing assistance as needed by the area Medicaid office; (3) Case Management follow-up services for Children/Adolescents, who the Health Plan identifies through blood Screenings as having abnormal levels of lead; (4) Coordinated Hospital/institutional discharge planning that includes post-discharge care, including skilled, short-term, skilled nursing facility care, as appropriate; and (5) A mechanism for direct access to specialists for Enrollees identified as having special health care needs, as is appropriate for their condition and identified needspotential conflict. (6) The Health Plan shall have an outreach program and other strategies for identifying every pregnant Enrollee. This shall include case management, claims analysis, and use of health risk assessment, etc. The Health Plan shall require its participating Providers to notify the Health Plans of any Medicaid Enrollee who is identified as being pregnant. (7) Documentation of referral services in Enrollees’ Medical Records, including results. (8) Monitoring of Enrollees with ongoing medical conditions and coordination of services for high utilizers such that the following functions are addressed as appropriate: acting as a liaison between the Enrollee and Providers, ensuring the Enrollee is receiving routine medical care, ensuring that the Enrollee has adequate support at home, assisting Enrollees who are unable to access necessary care due to their medical or emotional conditions or who do not have adequate community resources to comply with their care, and assisting the Enrollee in developing community resources to manage the Enrollee’s medical condition. (9) Documentation of emergency care encounters in Enrollees’ Medical Records with appropriate medically indicated follow-up. (10) Coordination of hospital/institutional discharge planning that includes post-discharge care, including skilled short-term rehabilitation, and skilled nursing facility care, as appropriate. (11) Share with other MCOs, PIHPs, and PAHPs serving the Enrollee the results of its identification and assessment of any Enrollee with special health care needs so that those activities need not be duplicated. (12) Ensure that in the process of coordinating care, each Enrollee's privacy is protected consistent with the confidentiality requirements in 45 CFR parts 160 and 164. 45 CFR Part 164 specifically describes the requirements regarding the privacy of individually identifiable health information.

Care Management. a. The Contractor will offer Care Management services to all Enrollees as needed, and will develop, maintain, and monitor a care plan for all Enrollees to support health and wellness, ensure effective linkages and coordination between the PCP and other Health Plan Care Professionals and providers and services, and to coordinate the full range of medical and behavioral health services, preventive services, medications, LTSS, social supports, Telemedicine services and enhanced benefits as needed, both within and outside the Contractor. Care Management services include ICM for community-based LTSS Enrollees and non- LTSS high-risk Enrollees. Care Management services also include care coordination services for individuals with more limited Care Management needs and transition coordination for Enrollees in nursing facilities who have an opportunity for discharge to the community. All Care Management services will be person-centered and will be delivered to Enrollees according to their strength-based needs and preferences. Enrollees will be encouraged to participate in decision making with respect to their care. The Contractor shall have effective systems, policies, procedures and practices in place to identify Enrollees in need of Care Management services, including an early warning system and procedures that xxxxxx proactive identification of high-risk Enrollees and to further identify Enrollees’ emerging needs. A determination of which Enrollees are at high risk will be made by the Contractor as a result of either its predictive modeling results or a CFNA, as described in Section 2.6.2. Enrollees who are determined to be at high-risk and eligible for ICM may include, but not be limited to, individuals with complex medical conditions and/or social support needs that may lead to: the need for high-cost services; deterioration in health status; or institutionalization. The Contractor shall have effective systems, policies, procedures, and practices in place to identify Enrollees in need of Home Stabilization Services. The Contractor is required to refer these Enrollees to the RI EOHHS designee for Home Stabilization Services and will be required to coordinate with the out-of-plan Home Stabilization Service providers as part of the Enrollee’s ICP and other care plans (e.g., LTSS Care Plan). The Contractor will be required to report on this at an interval defined by RI EOHHS. Care Coordinators should ensure that Enrollees receive aftercare follow-up when transitioning from a higher level of care. Care Management services will assist Enrollees to obtain needed medical, behavioral health, prescription and non-prescription drugs, community-based or facility-based LTSS, social, educational, psychosocial, financial and other services in support of the ICP or general Enrollee goals, irrespective of whether the needed services are covered under the Capitation Payment to the Contractor under this Demonstration. Care Management services are planned and provided based on opportunities to deliver quality-based outcomes such as: improved/maintained functional status, improved/maintained clinical status, enhanced quality of life, Enrollee satisfaction, adherence to the ICP, improved Enrollee safety, cost savings, wellness, and Enrollee autonomy. Care Management services include supports available to all Enrollees, at the level needed to effectively support each Enrollee. The Contractor shall develop and implement cost effective Care Management strategies that improve or maintain the level of quality by using payment incentives among other tools. The Contractor’s payment, measurement and incentive strategies shall include strategies that decrease avoidable hospitalizations and emergency room utilization, and reduce nursing facility admissions and lengths of stay, with a focus on high utilizers and promotion of community-based care or the least restrictive setting possible. For LTSS, the Contractor shall implement a conflict free Care Management system that complies with the following characteristics: 2.5.4.6.1. There is separation of eligibility determination from direct services provision. Eligibility for services is established separately from the provision of services, so assessors do not feel pressure to make Enrollees eligible to increase business for their organization. Eligibility is determined by an entity or organization that has no fiscal relationship to the Enrollee; 2.5.4.6.2. Funding levels for the Enrollee will be established using a tool reviewed and approved by RI EOHHS. 2.5.4.6.3. A plan of supports and services will be developed based on the Enrollee’s assessed needs. 2.5.4.6.4. Individuals performing LTSS evaluations and assessments and developing LTSS Care Plans cannot be related by blood or marriage to the Enrollee or any of the Enrollee’s paid caregivers, financially responsible for the management Enrollee, or empowered to make financial or health-related decisions on behalf of medical care the Enrollee. 2.5.4.6.5. In circumstances in which one entity is responsible for providing Care Management and continuity service delivery, appropriate safeguards and firewalls must be in place to mitigate risk of care for all Enrolleespotential conflict. 2.5.4.6.6. The Health Plan shall maintain written Case requirement to provide conflict free Care Management and continuity of care protocols that include the following minimum functions: (1) Appropriate referral and scheduling assistance of Enrollees needing specialty health care/Transportation Services, including those identified through Child Health Check-Up Program (CHCUP) Screenings; (2) Determination of the need for Non-Covered Services and referral of the Enrollee for assessment and referral is not intended to the appropriate service setting (to include referral to WIC and Healthy Start) utilizing assistance as needed by the area Medicaid office; (3) Case Management follow-up services for Children/Adolescents, who the Health Plan identifies through blood Screenings as having abnormal levels of lead; (4) Coordinated Hospital/institutional discharge planning that includes post-discharge hinder or prohibit accountable care, including skilledvalue-based, short-term, skilled nursing facility care, as appropriate; and (5) A mechanism for direct access to specialists for Enrollees identified as having special health care needs, as is appropriate for their condition and identified needsor other alternative payment strategies. (6) The Health Plan shall have an outreach program and other strategies for identifying every pregnant Enrollee. This shall include case management, claims analysis, and use of health risk assessment, etc. The Health Plan shall require its participating Providers to notify the Health Plans of any Medicaid Enrollee who is identified as being pregnant. (7) Documentation of referral services in Enrollees’ Medical Records, including results. (8) Monitoring of Enrollees with ongoing medical conditions and coordination of services for high utilizers such that the following functions are addressed as appropriate: acting as a liaison between the Enrollee and Providers, ensuring the Enrollee is receiving routine medical care, ensuring that the Enrollee has adequate support at home, assisting Enrollees who are unable to access necessary care due to their medical or emotional conditions or who do not have adequate community resources to comply with their care, and assisting the Enrollee in developing community resources to manage the Enrollee’s medical condition. (9) Documentation of emergency care encounters in Enrollees’ Medical Records with appropriate medically indicated follow-up. (10) Coordination of hospital/institutional discharge planning that includes post-discharge care, including skilled short-term rehabilitation, and skilled nursing facility care, as appropriate. (11) Share with other MCOs, PIHPs, and PAHPs serving the Enrollee the results of its identification and assessment of any Enrollee with special health care needs so that those activities need not be duplicated. (12) Ensure that in the process of coordinating care, each Enrollee's privacy is protected consistent with the confidentiality requirements in 45 CFR parts 160 and 164. 45 CFR Part 164 specifically describes the requirements regarding the privacy of individually identifiable health information.