Disease Management. If you have a chronic condition such as asthma, coronary heart disease, diabetes, congestive heart failure, and/or chronic obstructive pulmonary disease, we’re here to help. Our tools and information can help you manage your condition and improve your health. You may also be eligible to receive help through our care coordination program. This voluntary program is available at no additional cost you. To learn more about disease management, please call (000) 000-0000 or 0-000-000-0000. Our entire contract with you consists of this agreement and our contract with your employer. Your ID card will identify you as a member when you receive the healthcare services covered under this agreement. By presenting your ID card to receive covered healthcare services, you are agreeing to abide by the rules and obligations of this agreement. Your eligibility for benefits is determined under the provisions of this agreement. Your right to appeal and take action is described in Appeals in Section 5. This agreement describes the benefits, exclusions, conditions and limitations provided under your plan. It shall be construed under and shall be governed by the applicable laws and regulations of the State of Rhode Island and federal law as amended from time to time. It replaces any agreement previously issued to you. If this agreement changes, an amendment or new agreement will be provided.
Disease Management. The Contractor shall offer, at minimum, asthma, depression, pregnancy, ADHD, autism/pervasive developmental disorder, COPD, coronary artery disease, chronic kidney disease, congestive heart failure, HIV, Hepatitis C and diabetes disease management programs for eligible Hoosier Healthwise members. Members with excessive utilization or under-utilization for conditions other than those listed shall also be eligible for the disease management services described in this section. Members with these conditions should be identified through the health needs screening tool described in Section 4.2.3 and by identification of conditions based on claims. The Contractor shall make a spectrum of disease management tools available to the population, including population-based interventions, care management and complex case management, as described below. All care and case management programs should identify psychosocial issues of the members that may contribute to poor health outcomes and provide appropriate support services for addressing such issues. The Contractor shall submit quarterly reports to OMPP regarding the selection criteria, strategies, outcomes and efficacy of these and any other disease management programs offered by the Contractor. The quarterly reports shall include participation rates and utilization and cost statistics of both total members enrolled in the disease management programs. All disease management programs must encourage compliance with national care guidelines (e.g., American Diabetic Association) and incentivize healthy member behaviors. All members shall be sent population-based disease management materials (e.g., educational fliers, screening reminders, etc.). OMPP believes that the Contractor’s disease management programs will serve as a critical area for pursuing continuous innovation in improving member health status, and disease management programs may be subject to onsite visits or external quality reviews. OMPP reserves the right to require the Contractor to have disease management programs for additional conditions in the future. OMPP will provide three (3) months advance notice to the Contractor if OMPP decides to add new diseases to the disease management program requirements. The Contractor is encouraged to offer additional disease management programs beyond those required in the Scope of Work. If the Contractor provides additional disease management programs, the Contractor shall also provide annual updates to OMPP documenting ...
Disease Management. Disease management is a set medically necessary interventions designed to improve and maintain the health of Medicaid Managed Care Members. Disease management includes the coordination, monitoring, and education of Members to maximize appropriate self-management. The CONTRACTOR shall:
4.2.8.1. Comply with physical and Behavioral Health disease management and Care Management/Coordination provisions set forth in Section 4 and Section 5 of this contract and other relevant Department manuals and guides.
Disease Management. If you have a chronic condition such as asthma, coronary heart disease, diabetes, congestive heart failure, and/or chronic obstructive pulmonary disease, we’re here to help. Our tools and information can help you manage your condition and improve your health. You may also be eligible to receive help through our care coordination program. This voluntary program is available at no additional cost you. To learn more about disease management, please call (000) 000-0000 or 0-000-000-0000. This is a legal agreement between you and Blue Cross & Blue Shield of Rhode Island (BCBSRI). Your ID card will identify you as a member when you receive the healthcare services covered under this agreement. By presenting your ID card to receive covered healthcare services, you are agreeing to abide by the rules and obligations of this agreement. Your eligibility for benefits is determined under the provisions of this agreement. This agreement is issued based on your application and payment of premium. Your right to appeal and take action is described in Appeals in Section 5. You hereby expressly acknowledge your understanding that this contract is solely between you and BCBSRI. BCBSRI is an independent corporation operating under a license from the Blue Cross and Blue Shield Association (“the Association"), an association of independent Blue Cross and Blue Shield plan, permitting us to use the Blue Cross and Blue Shield Service Marks. We are not contracting as the agent of the Association. You further acknowledge and agree that you have not entered into this contract based upon representations by anyone other than us and that no person, entity or organization other than us shall be held accountable or liable to you for any of our obligations to you under this contract. This paragraph shall not create any additional obligations on our part other than those obligations created under other provisions of this agreement. This agreement describes the benefits, exclusions, conditions and limitations provided under your plan. It shall be construed under and shall be governed by the applicable laws and regulations of the State of Rhode Island and federal law as amended from time to time. It replaces any agreement previously issued to you. If this agreement changes, an amendment or new agreement will be provided.
Disease Management the Contractor’s ongoing services and assistance for specific disease and/or conditions. Services include specific interventions, education and outreach targeted to Enrollees with, or at risk for, these diseases or conditions. DSRIP Performance Year (“Performance Year”) –an administrative period related to DSRIP and related purposes. For Performance Year 0, the period commencing on the Contract Effective Date and ending December 31, 2017, unless otherwise specified by EOHHS. For other Performance Years, a twelve-month period commencing January 1 and ending December 31, unless otherwise specified by EOHHS. DSRIP Program’s State Accountability Protocols – the terms of financial accountability under Massachusetts’ DSRIP agreement with the federal government, determining the percent of Massachusetts’ DSRIP spending authority that is at risk based on state performance. DSTI Glide Path Payments – DSRIP payments made to the Contractor, as appropriate, to support the transition of Participating Safety Net Hospitals. Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) – the delivery of health care services to MassHealth Standard and CommonHealth Members under the age of 21, pursuant to 42 USC 1396d(a)(4), 42 CFR Part 441, Subpart B, 130 CMR 450.140-149 and § 1115 Medicaid Research and Demonstration Waiver. Effective Date of Disenrollment - up to 11:59 p.m. on the last day, as determined by EOHHS, on which the Contractor is responsible for providing the activities described in this Contract to an Enrollee, as further defined by EOHHS. Effective Date of Enrollment – as of 12:01 a.m. on the first day on which the Contractor is responsible for providing the activities described in this Contract to an Enrollee, as further defined by EOHHS. Emergency Services Programs (ESPs) – Medically necessary services provided through designated, contracted providers, and which are available seven (7) days per week, twenty-four (24) hours per day to provide treatment of any individual who is experiencing a mental health or substance use disorder crisis, or both. An ESP encounter includes, at a minimum, crisis assessment, intervention and stabilization. In addition to contracted ESPs, ESP Encounter services (not Youth Mobile Crisis Intervention services) may also be provided by outpatient hospital emergency departments as further directed by EOHHS. Enrollee – a Member enrolled with the Contractor, either by choice, or by assignment by XXXXX. A Member shall be considered an ...
Disease Management. A system of coordinated health care interventions and communications for populations with conditions in which Enrollee self-care efforts are significant.
Disease Management the Contractor’s disease or condition specific packages of ongoing services and assistance for specific disease and/or conditions. Services include specific interventions and education/outreach targeted to Enrollees with, or at risk for, these conditions. Division of Insurance (DOI) – The Massachusetts Division of Insurance. DMH – the Massachusetts Department of Mental Health.
Disease Management. 4.11.10.1 The Contractor shall develop disease management programs for individuals with Chronic Conditions. These programs must target the prevalent chronic diseases within the Contractor’s population.
4.11.10.2 The Contractor must notify DCH of the disease management programs it initiates and terminates and provide evidence, on an annual basis of the effectiveness of such programs for its enrolled members.
4.11.10.3 The Contractor must submit Quarterly status reports to DCH which include specified Disease Management Program data as described in Section 4.18.4.13 in addition to the annual report.
4.11.10.4 The Contractor will submit Quarterly reports to DCH which include specified Disease Management Program data as described in Section 4.18.4.13.
Disease Management. The Contractor must have and comply with written protocols to manage the care for Enrollees identified with congestive heart failure, chronic obstructive pulmonary disease, diabetes, and depression and a reporting system that produces clinical indicator data as required in Subsection 2.14(A)(2)&(4). The protocols must include the following:
a. Written practice guidelines, in accordance with accepted clinical practice, including diagnostic, pharmacological, and functional standards;
b. Measurement and distribution of reports relating to Contractor and PCP/PCT compliance with practice guidelines;
c. Educational programming for Enrollees and caregivers that emphasizes self-care and maximum independence;
d. Formal educational processes for clinical Providers in the best practices of managing the disease; and
e. Evaluation of effectiveness of each program by measuring outcomes of care.
Disease Management. The CONTRACTOR shall provide DM strategies to Members with identified chronic conditions as part of its Care Coordination processes and activities. The CONTRACTOR’s DM strategies must include at a minimum population identification/stratification, collaborative practice models, self-management education, evidence-based practice guidelines, process and outcomes measurements and internal quality improvement processes. The CONTRACTOR shall improve its ability to manage chronic illnesses/diseases/conditions through DM protocols. The CONTRACTOR shall: Participate in DM projects annually; and Provide comprehensive DM for a minimum of two (2) chronic disease states, one (1) applicable/relevant to the Adult population and one (1) to the pediatric population, using strategies consistent with nationally recognized DM guidelines, such as those available through the Agency for Healthcare Research and Quality (AHRQ), the National Quality Measures Clearinghouse (NQMC), or the Care Continuum Alliance). The CONTRACTOR's Care Coordination program description must describe the CONTRACTOR’s DM strategies, including, at a minimum, the CONTRACTOR’s approach to population identification/stratification, collaborative practice models, Member self-management education, evidence-based practice guidelines, process and outcomes measurements, and internal quality improvement processes.
