Coordination of Care. (a) The MA Dual SNP is responsible for coordinating the delivery of all benefits covered by both Medicare and Medicaid for Dual Eligible Members and Other Dual SNP Members who are eligible for LTSS including when benefits are delivered via Medicaid fee-for-service, making reasonable efforts to coordinate Medicare Advantage benefits provided by the MA Dual SNP with LTSS provided through Texas Health and Human Services Commission and the STAR+PLUS HMOs. Coordination of Care must include the following for these members:
(1) identify providers of covered Medicaid LTSS in the Texas service areas identified in Attachment A, Proposed MA Product Service Areas;
(2) help access needed Medicaid LTSS, to the extent they are available to the member;
(3) help coordinate the delivery of Medicaid LTSS and Medicare benefits and services; and
(4) provide training to its Network Providers regarding Medicaid LTSS so that they may help members receive needed LTSS that are not covered by Medicare. The MA Dual SNP must inform Network Providers of the Medicare benefits and Medicaid LTSS available to Dual Eligible Members and Other Dual SNP Members.
(b) The MA Dual SNP’s Coordination of Care efforts for LTSS may include protocols for working with STAR+PLUS service coordinators or HHSC caseworkers, as well as protocols for reciprocal referral and communication of data and clinical information regarding Dual Eligible Members with the coordinators and caseworkers.
(c) MA Dual SNPs that are not designated as HIDE-SNPs by CMS must provide timely notification of all admissions to a hospital and SNF to the STAR+PLUS MCO via a secure file transfer. The file shall be organized and populated in accordance with the template provided by HHSC. For the purposes of this section, timely notification is defined as no later than two business days from which the MA Dual SNP becomes aware that a High Risk Dual Eligible Member has been admitted. If the MA Dual SNP delegates responsibility for information sharing to its contracted hospitals and SNFs, the MA Dual SNP will require its contracted hospitals and SNFs meet the same information sharing requirements on admissions as required of the MA Dual SNP by this Agreement. The MA Dual SNP retains ultimate responsibility for compliance with the information sharing requirements in this Agreement.
(d) The MA Dual SNP is responsible for the coordination of both Medicare and Medicaid benefits, regardless of whether a Dual Eligible Member is enrolled with the ...
Coordination of Care. 7.1. CONTRACTOR shall ensure that all care, treatment and services provided pursuant to this Agreement are coordinated among all providers who are serving the client, including all other SMHS providers, as well as providers of Non-Specialty Mental Health Services (NSMHS), substance use disorder treatment services, physical health services, dental services, regional center services and all other services as applicable to ensure a client-centered and whole- person approach to services.
7.2. CONTRACTOR shall ensure that care coordination activities support the monitoring and treatment of comorbid substance use disorder and/or health conditions.
7.3. CONTRACTOR shall include in care coordination activities efforts to connect, refer and link clients to community-based services and supports, including but not limited to educational, social, prevocational, vocational, housing, nutritional, criminal justice, transportation, childcare, child development, family/marriage education, cultural sources, and mutual aid support groups.
7.4. CONTRACTOR shall engage in care coordination activities beginning at intake and throughout the treatment and discharge planning processes.
7.5. To facilitate care coordination, CONTRACTOR will request a 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 of Care. The PH-MCO must coordinate care for its Members. The PH-MCO must provide for seamless and continuous coordination of care across a continuum of services for the Member with a focus on improving health care outcomes. The continuum of services may include the In-Plan comprehensive service package, out-of-plan services, and non-MA covered services provided by other community resources such as: • Nursing Facility Care • Intermediate Care Facility for the Intellectually Disabled/Other Related Conditions • Residential Treatment Facility • Acute Psychiatric Facilities • Extended and Extended Acute Psychiatric Facilities • Non-Hospital Residential Detoxification, Rehabilitation, and Half- Way House Facilities for Drug/Alcohol Dependence/ Addiction • Opioid Use Disorder Centers of Excellence • Aging Well PA/Level of Care Assessment and Pre-admission Screening Requirements • Juvenile Detention Centers • Children in Substitute Care Transition • Adoption Assistance for Children and Adolescents • Services to Dual Eligibles Under the Age of Twenty-one • Transitional Care Homes • Medical Xxxxxx Care Services • Early Intervention Services (note the PH-MCO must refer for Early Intervention Services any of its Members who are children from birth to age three (3) who are living in residential facilities. “Children living in residential facilities” describes children who are in a 24-hour living setting in which care is provided for one or more children.) • The OBRA waiver, a home-and-community-based waiver program for individuals who have a severe developmental physical disability requiring an Intermediate Care Facility/Other Related Conditions (ICF/ORC) level of care • Intellectual Disabilities Services (note the PH-MCO is responsible to ensure a family with a child who has or is at risk of a developmental delay is referred to the County Intellectual Disabilities office for a determination of eligibility for home and community-based services, including children living in residential facilities as described above.) • Home-and Community-Based Waiver for Persons with Intellectual Disabilities • Children in Residential Facilities • Home-and Community-Based Waiver for Persons with Autism The PH-MCO must provide the necessary related services for Members in facilities as described in Exhibit O, Description of Facilities and Related Services. Out-of-Plan Services are described in Exhibit P, Out-of-Plan Services. Recipient coverage rules are outlined in Exhibit BB, PH-MCO Recipient ...
Coordination of Care. The Contractor will ensure coordination of care of all covered benefits under this Agreement including those provided for children, adolescents and adults for RIte Care, Rhody Health Partners and the Affordable Care Act Adult Expansion Populations. Coordination of care includes identification and follow-up of members with significant health and social needs that are at high risk of poor health outcomes, ensuring coordination of services and appropriate referral and follow-up. In particular, the Contractor will ensure coordination between medical services and behavioral health services required by the members. The Contractor will provide a care coordination program designed to help members who may or may not have a chronic disease, but have acute physical health, behavioral health, or social needs that impact health status and/or are at risk of further exacerbation of their illness. When the members need warrants immediate attention, care coordination will ensure access to primary care and behavioral health services. The goal of care coordination is to reduce the impact of any adverse outcome. Care coordination services are short term and time limited and should not be confused with intensive care management and/or other interventions. Services may include assistance with making or keeping needed medical or behavioral health appointments, hospital discharge planning, health coaching, and referrals related to the member’s immediate needs. Members are identified for care coordination because their needs do not meet the level of intensive care management as defined in this contract. The Contractor will develop guidelines for care coordination that will be submitted to EOHHS for review and approval. The Contract will have approval from the EOHHS for any subsequent changes prior to implementation of said changes. The Contractor will demonstrate the link to other Contractor systems such as quality, member services, utilization review, and appeals and grievances. For member who are identified as having special health care needs, the Contractor will: • Approve care plans in a timely manner if the Contractor’s approval is required. • Ensure that care plans are developed in accordance with applicable state quality assurance and utilization review standards. • Ensure that care plans are reviewed upon reassessment of functional need, at least every twelve (12) months, or when the member’s circumstances or needs change significantly, or at the request of the member. As ...
Coordination of Care. (a) The MA Dual SNP is responsible for coordinating the delivery of all benefits covered by both Medicare and Medicaid for Dual Eligible Members, and Other Dual SNP Members who are eligible for LTSS, including when benefits are delivered via Medicaid fee-for-service. The MA Dual SNP must make reasonable efforts to coordinate Medicare Advantage benefits provided by the MA Dual SNP with LTSS provided through Texas Health and Human Services Commission and the STAR+PLUS MCOs. Coordination of Care must include the following for these members:
(1) identify providers of covered Medicaid LTSS in the Texas service areas identified in Attachment C, Proposed MA Product Service Areas;
(2) help access needed Medicaid LTSS, to the extent they are available to the member;
(3) help coordinate the delivery of Medicaid LTSS and Medicare benefits and services; and
(4) provide training to its Network Providers regarding Medicaid LTSS so that they may help members receive needed LTSS that are not covered by Medicare. The MA Dual SNP must inform Network Providers of the Medicare benefits and Medicaid LTSS available to Dual Eligible Members and Other Dual SNP Members. rdination of Care efforts for LTSS may include protocols for working with STAR+PLUS service coordinators or HHSC caseworkers, as well as protocols for reciprocal referral and communication of data and clinical information regarding Dual Eligible Members with the coordinators and caseworkers.
Coordination of Care. A. The Contractor shall implement procedures to deliver care to and coordinate services for all of its beneficiaries. (42 C.F.R. § 438.208(b).) These procedures shall meet Department requirements and shall do the following:
1) Ensure that each beneficiary has an ongoing source of care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the services accessed by the beneficiary. The beneficiary shall be provided information on how to contact their designated person or entity. (42 C.F.R. § 438.208(b)(1).)
2) Coordinate the services the Contractor furnishes to the beneficiary between settings of care, including appropriate discharge planning for short term and long-term hospital and institutional stays. Coordinate the services the Contractor furnishes to the beneficiary with the services the beneficiary receives from any other managed care organization, in FFS Medicaid, from community and social support providers, and other human services agencies used by its beneficiaries. (42 C.F.R. § 438.208(b)(2)(i)-(iv), Cal. Code Regs., tit. 9 § 1810.415.)
3) The Contractor shall share with the Department or other managed care entities serving the beneficiary the results of any identification and assessment of that beneficiary’s needs to prevent duplication of those activities. (42 C.F.R. § 438.208(b)(4).)
4) Ensure that each provider furnishing services to beneficiaries maintains and shares, as appropriate, a beneficiary health record in accordance with professional standards. (42 C.F.R. § 438.208(b)(5).)
5) 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 C.F.R. § 160 and § 164, subparts A and E, to the extent that such provisions are applicable. (42 C.F.R. § 438.208(b)(6).)
Coordination of Care. Contractor shall provide coordination of care assistance to Prospective Enrollees to access a PCP or WHCP, or to continue a course of treatment, before Contractor’s coverage becomes effective, if requested to do so by Prospective Enrollees, or if Contractor has knowledge of the need for such assistance. The Care Coordinator assigned to the Prospective Enrollee shall attempt to contact the Prospective Enrollee no later than two (2) Business Days after the Care Coordinator is notified of the request for coordination of care.
Coordination of Care. 1. To coordinate care and deliver quality health care to the MCO’s Enrollees by providing all necessary information to the Medicaid Program, its authorized agents, the Administrative Services Organizations with which the Department contracts and to any other entity as directed by the Department, in accordance with applicable federal and state confidentiality laws and regulations.
2. For Enrollees with behavioral health conditions, coordination of care should include but not be limited to:
a. Participation in monthly collective MCO medical directors’ meetings and one-on-one MCO meetings with the ASO for care coordination,
b. Cooperation with the Department’s high utilizer pilot program,
c. Assistance with the development and coordination of appropriate treatment plans for Enrollees,
d. Provider education and promotion for the Screening, Brief Intervention, and Referral to Treatment (SBIRT) process,
e. Provider education about the substance use release of information (ROI) process under 42 CFR, Part 2, and
f. Provider education for Enrollee identification and referrals to the ASO or core service agencies for behavioral health services,
3. To implement procedures to deliver care to and coordinate services for all Enrollees. These procedures must do the following:
a. Ensure that each Enrollee has an ongoing source of care appropriate to his or her needs and a person or entity formally designated as primarily responsible for coordinating the services accessed by the Enrollee (e.g., a primary care provider);
b. Provide the Enrollee with information on how to contact their designated person or entity;
c. Coordinate the services the MCO furnishes to the Enrollee:
i. Between settings of care, including appropriate discharge planning for short term and long-term hospital and institutional stays;
ii. With the services the Enrollee receives from any other MCO;
iii. With the services the Enrollee receives in FFS Medicaid; and
iv. With the services the Enrollee receives from community and social support providers.
d. Make a best effort to conduct an initial screening of each Enrollee's needs, within 90 days of the effective date of enrollment for all new Enrollees, including subsequent attempts if the initial attempt to contact the Enrollee is unsuccessful;
e. Share with the Department or other MCOs serving the Enrollee the results of any identification and assessment of that Enrollee's needs to prevent duplication of services or benefits;
f. Use CRISP to identify new E...
Coordination 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
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. The Contractor shall require the subcontractor to include in its contracts with all network providers the following elements which should be implemented at the point of care to ensure clinical integration:
i. Comprehensive substance use, physical, and mental health screening.
ii. Beneficiary engagement and participation in an integrated care program as needed.
iii. Shared development of care plans by the beneficiary, caregivers, and all providers.
iv. Collaborative treatment planning with managed care.
v. Delineation of case management responsibilities.
vi. A process for resolving disputes between the Contractor and the Medi-Cal managed care plan that includes a means for beneficiaries to receive medically necessary services while the dispute is being resolved.
vii. Availability of clinical consultation, including consultation on medications.
viii. Care coordination and effective communication among providers including procedures for exchanges of medical information.
ix. Navigation support for patients and caregivers.
x. Facilitation and tracking of referrals between systems including bidirectional referral protocol.
Coordination of Care. The Contractor must provider coordination of care to Individuals in with complex needs.
