Effective Date of Disenrollment. All HCA approved disenrollment requests shall be effective on or before the first Calendar Day of the second month following the month of the request for disenrollment unless otherwise indicated by HCA. In all instances, the effective date shall be indicated on the termination record sent by HCA to the CONTRACTOR. The CONTRACTOR shall immediately update its enrollment roster based on any changes made in accordance with this Section 4.3 of this Agreement. In accordance with NMAC 8.308.7.10.a, the CONTRACTOR shall not, under any circumstances, disenroll a Member. HCA retains the sole authority to disenroll a Member from the CONTRACTOR and from the Turquoise Care program. The CONTRACTOR shall not request disenrollment because of a change in the Member’s health status, because of their utilization of medical or Behavioral Health services, their diminished mental capacity, or uncooperative or disruptive behavior resulting from their special needs (except when their continued enrollment seriously impairs the CONTRACTOR’s ability to furnish services to either that particular Member or other Members). Care Coordination General The CONTRACTOR shall provide Care Coordination that complies with 42 C.F.R. § 438.208 and all requirements set forth in this Agreement. The CONTRACTOR’s Care Coordination program must be designed to cover a wide spectrum of episodic and chronic health care conditions for Members including those in the top ten percent of cost of Members, including those with special health care needs, with an emphasis on addressing health disparities, facilitating care transitions, helping Members with care navigation, removing barriers to care, proactive health promotion, health education, and disease management. The CONTRACTOR shall provide Care Coordination in consultation with a Member’s treatment team and direct engagement with Members resulting in improved Physical and Behavioral Health outcomes. The CONTRACTOR shall ensure those activities are performed by Care Coordinators who have expertise in Member self-management approaches, Member advocacy, navigating complex systems and communicating with a wide spectrum of professional and laypersons, including family members, physicians, specialists, and other health care professionals. The CONTRACTOR shall ensure that performing Care Coordination requirements does not impede a Member’s ability to timely access necessary services. The CONTRACTOR’s Care Coordination program must reflect the following principles: Person-Centered – Care Coordination supports the Member’s choices and goals through an approach that is individualized, Trauma-informed, and Culturally Competent; Holistic – Care Coordination assesses and addresses the Member’s Physical Health needs, Behavioral Health needs, and social needs that impact health outcomes; Strengths-based – Care Coordination leverages the strengths of the CONTRACTOR (e.g., expertise, data, information systems) and community-based resources (e.g., providers with whom Members have established relationships, individuals who work in the communities in which Members reside, local organizations that support Members’ social needs) in coordination with an individual Member’s strengths, needs, and preferences; and Well-coordinated – Care Coordination provides clear and timely communication between and among Providers, Members, Member-serving systems, and individuals involved in the care and treatment of the Member in order to identify the Member’s needs, identify and secure access to necessary resources and services, and monitor and adjust resources and services as necessary to meet the Member’s needs. Care Coordination may be provided to a Member by or through the CONTRACTOR using one (1) of the Care Coordination models offered by the CONTRACTOR. The CONTRACTOR may offer one (1) or more of the following three (3) models: CONTRACTOR-Driven, Full Delegation, or Shared Functions Models of Care Coordination. In addition, the CONTRACTOR must offer the Full Delegation Model of Care Coordination for all prenatal and Postpartum Members. The CONTRACTOR shall promote, support, and expand the availability and use of the Full Delegation Model and the Shared Functions Model (when offered) of Care Coordination. The CONTRACTOR shall ensure its Members’ Care Coordination needs are met regardless of the model of Care Coordination used to provide Care Coordination to a Member. For those that decline Care Coordination, if their circumstances change, the Contractor is required to offer Care Coordination again upon change in circumstance (e.g. entering into auto-assigned category such as pregnant member). The CONTRACTOR shall expand the availability and use of CHWs to perform Care Coordination activities through its Full Delegation Model and Shared Functions Model (when offered) of Care Coordination. In order to assist Care Coordination to meet the holistic needs of Members, including the social needs that impact Member health outcomes, the CONTRACTOR shall enter into written agreements with community based organizations that offer resources necessary to address HRSNs. In providing Care Coordination to its Members, the CONTRACTOR shall ensure that each Member’s privacy is protected consistent with the State and federal confidentiality requirements, including those listed in 45 C.F.R. § 160 and § 164 and 42 C.F.R. § 2.
Appears in 2 contracts
Samples: Managed Care Services Agreement, Managed Care Services Agreement
Effective Date of Disenrollment. All HCA HSD approved disenrollment requests shall be effective on or before the first Calendar Day of the second month following the month of the request for disenrollment unless otherwise indicated by HCAHSD. In all instances, the effective date shall be indicated on the termination record sent by HCA HSD to the CONTRACTOR. The CONTRACTOR shall immediately update its enrollment roster based on any changes made in accordance with this Section 4.3 of this Agreement. In accordance with NMAC 8.308.7.10.a, the CONTRACTOR shall not, under any circumstances, disenroll a Member. HCA retains the sole authority to disenroll a Member from the CONTRACTOR and from the Turquoise Care program. The CONTRACTOR shall not request disenrollment because of a change in the Member’s health status, because of their utilization of medical or Behavioral Health services, their diminished mental capacity, or uncooperative or disruptive behavior resulting from their special needs (except when their continued enrollment seriously impairs the CONTRACTOR’s ability to furnish services to either that particular Member or other Members). Care Coordination General The CONTRACTOR shall provide Care Coordination that complies with 42 C.F.R. § 438.208 and all requirements set forth in this Agreement. The CONTRACTOR’s Care Coordination program must be designed to cover a wide spectrum of episodic and chronic health care conditions for Members including those in the top ten percent of cost of Members, including those with special health care needs, with an emphasis on addressing health disparities, facilitating care transitions, helping Members with care navigation, removing barriers to care, proactive health promotion, health education, and disease management. The CONTRACTOR shall provide Care Coordination in consultation with a Member’s treatment team and direct engagement with Members resulting in improved Physical and Behavioral Health outcomes. The CONTRACTOR shall ensure those activities are performed by Care Coordinators who have expertise in Member self-management approaches, Member advocacy, navigating complex systems and communicating with a wide spectrum of professional and laypersons, including family members, physicians, specialists, and other health care professionals. The CONTRACTOR shall ensure that performing Care Coordination requirements does not impede a Member’s ability to timely access necessary services. The CONTRACTOR’s Care Coordination program must reflect the following principles: Person-Centered – Care Coordination supports the Member’s choices and goals through an approach that is individualized, Trauma-informed, and Culturally Competent; Holistic – Care Coordination assesses and addresses the Member’s Physical Health needs, Behavioral Health needs, and social needs that impact health outcomes; Strengths-based – Care Coordination leverages the strengths of the CONTRACTOR (e.g., expertise, data, information systems) and community-based resources (e.g., providers with whom Members have established relationships, individuals who work in the communities in which Members reside, local organizations that support Members’ social needs) in coordination with an response to individual Member’s strengths, needs, Member needs and preferences; and Well-coordinated – Care Coordination provides clear and timely communication between and among Providers, Members, Member-serving systems, and individuals involved in the care and treatment of the Member in order to identify the Member’s needs, identify and secure access to necessary resources and services, and monitor and adjust resources and services as necessary to meet the Member’s needs. Care Coordination may be provided to a Member by or through the CONTRACTOR using one (1) of the Care Coordination models offered by the CONTRACTOR. The CONTRACTOR may offer one (1) or more of the following three (3) models: CONTRACTOR-Driven, Full Delegation, or Shared Functions Models of Care Coordination. In addition, the CONTRACTOR must offer the Full Delegation Model of Care Coordination for all prenatal and Postpartum Members. The CONTRACTOR shall promote, support, and expand the availability and use of the Full Delegation Model and the Shared Functions Model (when offered) Models of Care Coordination. The CONTRACTOR shall ensure its Members’ Care Coordination needs are met regardless of the model of Care Coordination used to provide Care Coordination to a Member. For those that decline Care Coordination, if their circumstances change, the Contractor is required to offer Care Coordination again upon change in circumstance (e.g. entering into auto-assigned category such as pregnant member). The CONTRACTOR shall expand the availability and use of CHWs to perform Care Coordination activities through its Full Delegation Model and Shared Functions Model (when offered) Models of Care Coordination. In order to assist Care Coordination to meet the holistic needs of Members, including the social needs that impact Member health outcomes, the CONTRACTOR shall enter into written agreements with community based organizations that offer resources necessary to address HRSNs. In providing Care Coordination to its Members, the CONTRACTOR shall ensure that each Member’s privacy is protected consistent with the State and federal confidentiality requirements, including those listed in 45 C.F.R. § 160 and § 164 and 42 C.F.R. § 2.
Appears in 1 contract
Samples: Managed Care Services Agreement
Effective Date of Disenrollment. All HCA approved disenrollment requests shall be effective on or before the first Calendar Day of the second month following the month of the request for disenrollment unless otherwise indicated by HCA. In all instances, the effective date shall be indicated on the termination record sent by HCA to the CONTRACTOR. The CONTRACTOR shall immediately update its enrollment roster based on any changes made in accordance with this Section 4.3 of this Agreement. In accordance with NMAC 8.308.7.10.a, the CONTRACTOR shall not, under any circumstances, disenroll a Member. HCA retains the sole authority to disenroll a Member from the CONTRACTOR and from the Turquoise Care program. The CONTRACTOR shall not request disenrollment because of a change in the Member’s health status, because of their utilization of medical or Behavioral Health services, their diminished mental capacity, or uncooperative or disruptive behavior resulting from their special needs (except when their continued enrollment seriously impairs the CONTRACTOR’s ability to furnish services to either that particular Member or other Members). Care Coordination General The CONTRACTOR shall provide Care Coordination that complies with 42 C.F.R. § 438.208 and all requirements set forth in this Agreement. The CONTRACTOR’s Care Coordination program must be designed to cover a wide spectrum of episodic and chronic health care conditions for Members including those in the top ten percent of cost of Members, including those with special health care needs, with an emphasis on addressing health disparities, facilitating care transitions, helping Members with care navigation, removing barriers to care, proactive health promotion, health education, and disease management. The CONTRACTOR shall provide Care Coordination in consultation with a Member’s treatment team and direct engagement with Members resulting in improved Physical and Behavioral Health outcomes. The CONTRACTOR shall ensure those activities are performed by Care Coordinators who have expertise in Member self-management approaches, Member advocacy, navigating complex systems and communicating with a wide spectrum of professional and laypersons, including family members, physicians, specialists, and other health care professionals. The CONTRACTOR shall ensure that performing Care Coordination requirements does not impede a Member’s ability to timely access necessary services. The CONTRACTOR’s Care Coordination program must reflect the following principles: Person-Centered – Care Coordination supports the Member’s choices and goals through an approach that is individualized, Trauma-informed, and Culturally Competent; Holistic – Care Coordination assesses and addresses the Member’s Physical Health needs, Behavioral Health needs, and social needs that impact health outcomes; Strengths-based – Care Coordination leverages the strengths of the CONTRACTOR (e.g., expertise, data, information systems) and community-based resources (e.g., providers with whom Members have established relationships, individuals who work in the communities in which Members reside, local organizations that support Members’ social needs) in coordination with an individual Member’s strengths, needs, and preferences; and Well-coordinated – Care Coordination provides clear and timely communication between and among Providers, Members, Member-serving systems, and individuals involved in the care and treatment of the Member in order to identify the Member’s needs, identify and secure access to necessary resources and services, and monitor and adjust resources and services as necessary to meet the Member’s needs. Care Coordination may be provided to a Member by or through the CONTRACTOR using one (1) of the Care Coordination models offered by the CONTRACTOR. The CONTRACTOR may offer one (1) or more of the following three (3) models: CONTRACTOR-Driven, Full Delegation, or Shared Functions Models of Care Coordination. In addition, the CONTRACTOR must offer the Full Delegation Model of Care Coordination for all prenatal and Postpartum Members. The CONTRACTOR shall promote, support, and expand the availability and use of the Full Delegation Model and the Shared Functions Model (when offered) of Care Coordination. The CONTRACTOR shall ensure its Members’ Care Coordination needs are met regardless of the model of Care Coordination used to provide Care Coordination to a Member. For those that decline Care Coordination, if their circumstances change, the Contractor is required to offer Care Coordination again upon change in circumstance (e.g. entering into auto-assigned category such as pregnant member). The CONTRACTOR shall expand the availability and use of CHWs to perform Care Coordination activities through its Full Delegation Model and Shared Functions Model (when offered) of Care Coordination. In order to assist Care Coordination to meet the holistic needs of Members, including the social needs that impact Member health outcomes, the CONTRACTOR shall enter into written agreements with community based organizations that offer resources necessary to address HRSNs. In providing Care Coordination to its Members, the CONTRACTOR shall ensure that each Member’s privacy is protected consistent with the State and federal confidentiality requirements, including those listed in 45 C.F.R. § 160 and § 164 and 42 C.F.R. § 2.
Appears in 1 contract
Samples: Services Agreement
