Coordination and Continuity of Care. 18.7.1 Contractor shall comply with the care and coordination requirements established by the County and per 42 C.F.R. § 438.208.
18.7.2 Contractor shall ensure that all care, treatment, and services provided pursuant to this Agreement are coordinated among all providers who are serving the client. Coordination and continuity of care procedures shall meet the following requirements:
18.7.2.1 Ensure that each client has an ongoing source of care appropriate to their needs and a person or entity formally designated as primarily responsible for coordinating the services accessed by the client. The client shall be provided information on how to contact their designated person or entity.
18.7.2.2 All services provided to clients shall be coordinated:
18.7.2.2.1 Between settings of care, including appropriate discharge planning for short-term and long-term hospital and institutional stays.
18.7.2.2.2 With the services the client receives from any other managed care organization.
18.7.2.2.3 With the services the client receives in FFS Medi-Cal.
18.7.2.2.4 With the services the client receives from community and social support providers.
18.7.3 Share with other providers serving the client, as allowed by regulations, the results of any identification and assessment of that client’s needs to prevent duplication of those activities.
18.7.4 Ensure that each provider furnishing services to clients maintains and shares, as appropriate, a client health record in accordance with professional standards.
18.7.5 Ensure that in the process of coordinating care, each client’s privacy is protected in accordance with the privacy requirements in 45 C.F.R. Parts 160 and 164 subparts A and E and 42 C.F.R. Part 2, to the extent that they are applicable.
18.7.6 Contractor shall engage in care coordination activities beginning at intake and throughout the treatment and discharge planning processes.
18.7.7 To facilitate care coordination, Contractor will request a 42 CFR Part 2, HIPAA and California law compliant client authorization to share client information with and among all other providers involved in the client’s care, in satisfaction of state, and federal privacy laws and regulations.
Coordination and Continuity of Care. A. The Contractor shall assure coordination and continuity of care within the standards prescribed by 42 CFR 438.208.
1) The Contractor shall coordinate the services that the Contractor either furnishes or arranges to be furnished to the beneficiary with services that the beneficiary receives from any other Medi-Cal managed care plan or subcontractor in accordance with 42 CFR 438.208(b)(2).
2) The Contractor shall ensure that, in the course of coordinating care, each beneficiary's privacy is protected in accordance with all federal and state privacy laws, including but not limited to 45 CFR 160 and 164, to the extent that such provisions are applicable.
3) The Contractor shall enter into a Memorandum of Understanding (MOU) with any Medi-Cal managed care plan serving the Contractor’s beneficiaries in accordance with 42 CFR 438.208.
a) The Contractor shall notify the DHCS in writing if the Contractor is unable to enter into an MOU or if an MOU is terminated, providing a description of the Contractor’s good faith efforts to enter into or maintain the MOU. The contractor shall monitor the effectiveness of its MOU with Physical Health Care Plans.
4) Pursuant to 42 CFR 438.208(b)(1), (2), and (3), the Contractor must implement procedures to:
a) Ensure that each beneficiary has an ongoing source of primary care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the health care services furnished to the beneficiary;
b) Coordinate the services the Contractor furnishes to the beneficiary with the services the beneficiary receives from any other health plan;
c) Share with other health plans serving the beneficiary the results of its identification and assessment of any beneficiary with special health care needs (as defined by DHCS) so that those activities need not be duplicated; and
d) At State discretion, exceptions may exist for health plans that serve dually eligible beneficiaries.
5) Beneficiaries with special health care needs:
a) For beneficiaries determined to need a course of treatment or regular care monitoring, the Contractor shall have a mechanism in place to allow beneficiaries to directly access a specialist, as appropriate, for the beneficiary’s condition and identified needs.
b) The Contractor shall implement mechanisms to assess each Medicaid beneficiary identified as having special health care needs in order to identify any ongoing special conditions of the beneficiary that require a ...
Coordination and Continuity of Care. 1. In addition to meeting the coordination and continuity of care requirements set forth in Article II.E.3, the Contractor shall develop a care coordination plan that provides for seamless transitions of care for beneficiaries with the DMC-ODS system of care. Contractor is responsible for developing a structured approach to care coordination to ensure that beneficiaries successfully transition between levels of SUD care (i.e. withdrawal management, residential, outpatient) without disruptions to services.
2. In addition to specifying how beneficiaries will transition across levels of acute and short-term SUD care without gaps in treatment, the Contractor shall ensure that beneficiaries have access to recovery supports and services immediately after discharge or upon completion of an acute care stay, with the goal of sustained engagement and long- term retention in SUD and behavioral health treatment.
3. Contractor shall enter into a Memorandum Of Understanding (MOU) with any Medi-Cal managed care plan that enrolls beneficiaries served by the DMC-ODS. This requirement may be met through an amendment to the Specialty Mental Health Managed Care Plan MOU.
i. The following elements in the MOU should be implemented at the point of care to ensure clinical integration between DMC-ODS and managed care providers:
a. Comprehensive substance use, physical, and mental health screening.
b. Beneficiary engagement and participation in an integrated care program as needed;
c. Shared development of care plans by the beneficiary, caregivers and all providers;
d. Collaborative treatment planning with managed care;
e. Delineation of case management responsibilities;
f. A process for resolving disputes between the county and the Medi-Cal managed care plan that includes a means for beneficiaries to receive medically necessary services while the dispute is being resolved;
g. Availability of clinical consultation, including consultation on medications;
h. Care coordination and effective communication among providers including procedures for exchanges of medical information;
i. Navigation support for patients and caregivers; and
j. Facilitation and tracking of referrals between systems including bidirectional referral protocol.
Coordination and Continuity of Care. A. The Contractor shall assure coordination and continuity of care within the standards prescribed by 42 CFR 438.208.
B. The Contractor shall coordinate the services that the Contractor either furnishes or arranges to be furnished to the beneficiary with services that the beneficiary receives from any other Medi-Cal managed care plan or Contractor in accordance with 42 CFR 438.208(3)(b)(2).
C. The Contractor shall ensure that, in the course of coordinating care, each beneficiary’s privacy is protected in accordance with all federal and state privacy laws, including but not limited to 45 CFR 160 and 164, to the extent that such provisions are applicable.
Coordination and Continuity of Care. 5.3.19.1 Each provider furnishing services to CHIP Members must maintain and share, as appropriate, the CHIP Member’s health record in accordance with professional standards.
5.3.19.2 Preferred Provider must, when appropriate, interact with a CHIP Member’s PCP for prompt treatment, coordination of care or referral for other identified services that are not the responsibility of the Preferred Provider.
5.3.19.3 Highmark and Preferred Provider will jointly identify the services to be delivered and Highmark and Preferred Provider will monitor the quality of the services delivered.
5.3.19.4 Highmark and Preferred Provider shall work cooperatively to establish programmatic responsibility for each CHIP Member.
5.3.19.5 Preferred Provider may be called upon to serve on interagency teams when requested by DHS.
5.3.19.6 PCPs shall interact for prompt treatment, coordination of care, or referral of CHIP Members for other identified services that are not the responsibility of Preferred Provider.
5.3.19.7 Highmark will provide training and consultations to facilitate continuity of care and the cost-effective use of resources.
5.3.19.8 Preferred Provider and Highmark agree to make mutual intensive outreach efforts to CHIP Members identified as needing service.
5.3.19.9 Preferred Provider, Highmark, and PCPs agree to communicate on an ongoing basis; exchange relevant enrollment and individual health related information; and coordinate service needs. Highmark will monitor such activity pursuant to this Agreement.
