Common use of Disease Management (DM Clause in Contracts

Disease Management (DM. The HMO must provide, or arrange to have provided to Members, comprehensive disease management services consistent with state statutes and regulations. Such DM services must be part of person-based approach to DM and holistically address the needs of persons with multiple chronic conditions. The HMO must develop and implement DM services that relate to chronic conditions that are prevalent in HMO Program Members. In the first year of operations, STAR, STAR+PLUS and CHIP HMOs must have DM Programs that address Members with chronic conditions to be identified by HHSC and included within the Uniform Managed Care Manual. HHSC will not identify the Members with chronic conditions. The HMO must implement policies and procedures to ensure that Members that require DM services are identified and enrolled in a program to provide such DM services. The HMO must develop and maintain screening and evaluation procedures for the early detection, prevention, treatment, or referral of participants at risk for or diagnosed with chronic conditions identified by HHSC and included within the Uniform Managed Care Manual. The HMO must ensure that all Members identified for DM are enrolled into a DM Program with the opportunity to opt out of these services within 30 days while still maintaining access to all other Covered Services. The DM Program(s) must include: 1. Patient self-management education; 2. Provider education; 3. Evidence-based models and minimum standards of care; 4. Standardized protocols and participation criteria; 5. Physician-directed or physician-supervised care; 6. Implementation of interventions that address the continuum of care; 7. Mechanisms to modify or change interventions that are not proven effective; and 8. Mechanisms to monitor the impact of the DM Program over time, including both the clinical and the financial impact. The HMO must maintain a system to track and monitor all DM participants for clinical, utilization, and cost measures. The HMO must provide designated staff to implement and maintain DM Programs and to assist participating Members in accessing DM services. The HMO must educate Members and Providers about the HMO’s DM Programs and activities. Additional requirements related to the HMO’s Disease Management Programs and activities are found in the HHSC Uniform Managed Care Manual.

Disease Management (DM. The HMO must provide, or arrange to have provided to Members, comprehensive disease management services consistent with state statutes and regulations. Such DM services must be part of person-based approach to DM and holistically address the needs of persons with multiple chronic conditions. The HMO must develop and implement DM services that relate to chronic conditions that are prevalent in HMO Program Members. In the first year of operations, STAR, STAR+PLUS and CHIP HMOs must have DM Programs that address Members with chronic conditions to be identified by HHSC and included within the Uniform in HHSC’sUniform Managed Care Manual. HHSC will not identify the individual Members with chronic conditions. The HMO must implement policies and procedures to ensure that Members that require DM services are identified and enrolled in a program to provide such DM services. The HMO must develop and maintain screening and evaluation procedures for the early detection, prevention, treatment, or referral of participants at risk for or diagnosed with the chronic conditions identified by HHSC and included within in the Uniform Managed Care Manual. The HMO must ensure that all Members identified for DM are enrolled into a DM Program with the opportunity to opt out of these services within 30 days while still maintaining access to all other Covered Services. For all new Members not previously enrolled in the HMO and who require DM services, the HMO must evaluate and ensure continuity of care with any previous DM services in accordance with the requirements in the Uniform Managed Care Manual. The DM Program(s) must include: 1. Patient self-management education; 2. Provider education; 3. Evidence-based models and minimum standards of care; 4. Standardized protocols and participation criteria; 5. Physician-directed or physician-supervised care; 6. Implementation of interventions that address the continuum of care; 7. Mechanisms to modify or change interventions that are not proven effective; and 8. Mechanisms to monitor the impact of the DM Program over time, including both the clinical and the financial impact. The HMO must maintain a system to track and monitor all DM participants for clinical, utilization, and cost measures. The HMO must provide designated staff to implement and maintain DM Programs and to assist participating Members in accessing DM services. The HMO must educate Members and Providers about the HMO’s DM Programs and activities. Additional requirements related to the HMO’s Disease Management Programs and activities are found in the HHSC Uniform Managed Care Manual.