Delivery Systems and Benefits a. For beneficiaries who elect to receive health home services, the Health Home Care Coordinator will perform a comprehensive in-person health screening and work with the beneficiary to complete a Health Action Plan within 90 days of the date when the Lead Entity was notified of the beneficiary’s health home eligibility.
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Delivery Systems and Benefits. For beneficiaries who elect to receive health home services, the Health Home Care Coordinator will perform a comprehensive in-person health screening and work with the beneficiary to complete a Health Action Plan within 90 days of the date when the Lead Entity was notified of the beneficiary’s health home eligibility. Beneficiary Participation on Governing and Advisory Boards: As part of the Demonstration, CMS and the State shall require Health Home Networks to establish mechanisms to ensure meaningful beneficiary input processes and the involvement of beneficiaries in planning and process improvements. This will be addressed in the State’s qualification process for Health Home Networks. In addition, the State will provide avenues for ongoing beneficiary or beneficiary advocates to provide input into the Demonstration model, including participation in the Service Experience Team (SET). The SET works in partnership with the State to promote choice, quality of life, health, independence, safety, and active engagement to program improvement and development. The SET consists of up to 12 clients representing a diverse cross-section of geography, gender and programs being utilized, three to five Advocacy Representatives, a Tribal Representative, and State staff. Feedback collected by the State will be shared with Health Home Networks and will be part of the State’s process improvement efforts. Readiness Review: See Section III for discussion of Readiness Review. Monitoring: Intentionally Left Blank Quality Management: See Section IV.J for additional detail. Financing and Payment: See Sections IV.I and IV.J for additional detail. Evaluation: Intentionally Left Blank DEFINITIONS (APPENDIX 1 of the MOU): The following terms are added: Region 1: The 37 original counties in which the Demonstration began operating in 2013, specifically: Adams, Asotin, Benton, Chelan, Clallam, Clark, Columbia, Cowlitz, Douglas, Ferry, Franklin, Garfield, Grant, Grays Harbor, Island, Jefferson, Kitsap, Kittitas, Klickitat, Lewis, Lincoln, Xxxxx, Okanogan, Pacific, Pend Oreille, Pierce, San Xxxx, Skagit, Skamania, Spokane, Stevens, Thurston, Wahkiakum, Walla Walla, Whatcom, Whitman, and Yakima counties Region 2: King and Snohomish counties Intentionally Left Blank As of July 1, 2013, in conjunction with the approved Health Home SPA #13-0008, the Demonstration began operating in the following 14 counties: Coverage Area 4: Pierce County Coverage Area 5: Clark, Cowlitz, Klickitat, Skamania,...
Delivery Systems and Benefits. The Demonstration will not fundamentally change benefits packages, choice of providers and plans for Beneficiaries, or the ways in which the MSHO Plans contract with either the State and CMS. However, MSHO is an important vehicle for wider adoption of delivery system reforms throughout Minnesota. Building on provider contracting arrangements under MSHO and its current Medicaid Health Care Home benefit, the State will promote relationships between MSHO Plans and providers called Integrated Care System Partnerships (ICSPs). The goals of these ICSPs are to improve coordination between Medicare and Medicaid services and, ultimately, to help Beneficiaries remain in their homes or choice of community settings and improve health outcomes in all settings. The State has developed a range of ICSP arrangements based on provider interest and capacity, as well as geographic and demographic factors. The State’s MSHO contracts outline the following models: Model 1. Health Care Home-based Virtual Integrated Care System Partnerships (Virtual ICSPs). Minnesota created Health Care Homes (HCHs) to provide payments to primary care providers that would incent better coordination of the entire spectrum of care provided to an individual. Building on the current all-payer HCH requirements in Minnesota, under the Demonstration the State and MSHO Plans will identify options for increasing coordination among MSHO Plans and the plan care coordinators, contracted clinics, and practitioners certified as health care homes, as well as with other contracted providers. Model 2. HCH or HCH alternative based primary, acute, and/or long term care ICSPs. This model builds on the State’s HCH approach to further integrate primary and long term care coordination and delivery. New contract requirements require each MSHO plan to submit proposals for ICSPs to the State for review and to implement new arrangements no later than January 2014. About 20 ICSP proposals are expected. The ICSPs will also allow plans to strengthen and revise current primary care partnerships already existing within the MSHO Plans. The new contracting requirements tie provider performance to a range of financial metrics including pay for performance goals, performance pools, and total cost of care systems with risk/gain parameters. These arrangements facilitate the integration of HCH coordination provided by primary care providers with other all care coordination provided under the Medicaid acute and long term care and Me...
Delivery Systems and Benefits. The Demonstration will not fundamentally change benefits packages, choice of providers and plans for Beneficiaries, or the ways in which the MSHO Plans contract with either the State and CMS. However, MSHO is an important vehicle for wider adoption of delivery system reforms throughout Minnesota. Building on provider contracting arrangements under MSHO and its current Medicaid Health Care Home benefit, the State will promote relationships between MSHO Plans and providers called Integrated Care System Partnerships (ICSPs). The goals of these ICSPs are to improve coordination between Medicare and Medicaid services and, ultimately, to help Beneficiaries remain in their homes or choice of community settings and improve health outcomes in all settings. The State has developed a range of ICSP arrangements based on provider interest and capacity, as well as geographic and demographic factors. The State’s MSHO contracts outline the following models: strengthen and revise current primary care partnerships already existing within the MSHO Plans. The new contracting requirements tie provider performance to a range of financial metrics including pay for performance goals, performance pools, and total cost of care systems with risk/gain parameters. These arrangements facilitate the integration of HCH coordination provided by primary care providers with other all care coordination provided under the Medicaid acute and long term care and Medicare.
Delivery Systems and Benefits.
1. STAR+PLUS MMP Service Capacity: CMS and the State shall contract with STAR+PLUS MMPs that demonstrate the capacity to provide, directly or by subcontracting with other qualified entities, the full continuum of Medicare and Medicaid covered services to enrollees, in accordance with this MOU, CMS guidance, and the three-way contract. Medicare covered benefits shall be provided in accordance with 42 CFR §422 and 42 CFR §423 et seq. Medicaid covered benefits shall be provided in accordance with 42 CFR §438, unless waived by the state’s existing THTQIP section 1115(a) demonstration, and with the requirements in the approved Medicaid State Plan, including any applicable State Plan amendments and/or section 1115(a) demonstrations, and in accordance with the requirements specified by the Texas Uniform Managed Care Contract, STAR+PLUS Expansion Contract, 1 TAC Chapter § 353, STAR+PLUS handbook, and Uniform Managed Care Manual, and this MOU. In accordance with the three-way contract and this MOU, CMS and the State may choose to allow for greater flexibility in offering flexible benefits that exceed those currently covered by either Medicare or Medicaid, as discussed in Appendix 7. CMS, the State, and STAR+PLUS MMPs will ensure that beneficiaries have access to an adequate network of medical, behavioral health, pharmacy, and LTSS providers that are appropriate and capable of addressing the needs of this diverse population, as discussed in more detail in Appendix 7.
2. STAR+PLUS MMP Risk Arrangements: CMS and the State shall require each STAR+PLUS MMP to provide a detailed description of its risk arrangements with providers under subcontract with the plan. This description shall be made available to enrollees upon request. It will not be permissible for any incentive arrangements to include any payment or other inducement that serves to withhold, limit, or reduce necessary medical or non-medical services to enrollees.
3. STAR+PLUS MMP Financial Solvency Arrangements: CMS and the State, through the Texas Department of Insurance (TDI), have established a financial solvency standard for all STAR+PLUS MMPs, as articulated in Appendix 7.
Delivery Systems and Benefits
