Common use of Coordination and Continuity of Care Clause in Contracts

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 course of treatment or regular care monitoring. The assessment mechanisms must: i. Use appropriate health care professionals; ii. Assess the quality and appropriateness of care furnished to beneficiaries with special health care needs. c) The Contractor shall produce a treatment plan for beneficiaries determined to need a course of treatment or regular care monitoring, the treatment plan must be: i. Developed by the beneficiary’s primary care provider with beneficiary participation, and in consultation with any specialists caring for the beneficiary; ii. Approved by the entity in a timely manner, if this approval is required; and iii. In accordance with any applicable State quality assurance and utilization review standards. d) Pursuant to 42 CFR 438.206(b)(2), the Contractor shall ensure that female beneficiaries have direct access to a women's health specialist within the network for covered care necessary to provide women's routine and preventive health care services. This is in addition to the beneficiaries designated source of primary care if that source is not a women's health specialist. B. Care Coordination within DMC-ODS levels of care 1) 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. C. 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 can be met through an amendment to the Specialty Mental Health Managed Care Plan MOU. 1) 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, including ASAM Level 0.5 SBIRT services; 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 438.208.438.208.‌ 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).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.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.Plans.‌ 4) Pursuant to 42 CFR 438.208(b)(1), (2), and (3), the Contractor must implement procedures to: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: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.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 course of treatment or regular care monitoring. The assessment mechanisms must:must:‌ i. Use appropriate health care professionals; ii. Assess the quality and appropriateness of care furnished to beneficiaries with special health care needs. c) The Contractor shall produce a treatment plan for beneficiaries determined to need a course of treatment or regular care monitoring, the treatment plan must be:be:‌ i. Developed by the beneficiary’s primary care provider with beneficiary beneficiary‌ participation, and in consultation with any specialists caring for the beneficiary; ii. Approved by the entity in a timely manner, if this approval is required; and iii. In accordance with any applicable State quality assurance and utilization review standards. d) Pursuant to 42 CFR 438.206(b)(2), the Contractor shall ensure that female beneficiaries have direct access to a women's health specialist within the network for covered care necessary to provide women's routine and preventive health care services. This is in addition to the beneficiaries designated source of primary care if that source is not a women's health specialist.specialist.‌ B. Care Coordination within DMC-ODS levels of carecare‌ 1) 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.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.treatment.‌ C. 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 can be met through an amendment to the Specialty Mental Health Managed Care Plan MOU.MOU.‌ 1) 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:providers:‌ a) Comprehensive substance use, physical, and mental health screening, including ASAM Level 0.5 SBIRT services;services;‌ b) Beneficiary engagement and participation in an integrated care program as needed;needed;‌ c) Shared development of care plans by the beneficiary, caregivers and all providers;providers;‌ d) Collaborative treatment planning with managed care;care;‌ e) Delineation of case management responsibilities;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;resolved;‌ g) Availability of clinical consultation, including consultation on medications;medications;‌ h) Care coordination and effective communication among providers including procedures for exchanges of medical information;information;‌ i) Navigation support for patients and caregivers; andand‌ j) Facilitation and tracking of referrals between systems including bidirectional referral protocol.protocol.‌