Enrollees with Special Health Care Needs Sample Clauses

Enrollees with Special Health Care Needs. Enrollees including, at a minimum, those who have or are at increased risk to have chronic physical, developmental, or behavioral health condition(s); require an amount or type of services beyond those typically required for individuals of similar age; and may receive these services from an array of public and/or private providers across health, education and social systems of care.
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Enrollees with Special Health Care Needs. Enrollees who meet the following characteristics:
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Enrollees with Special Health Care Needs. 36.1 Individuals with Special Health Care Needs (ISHCN) A. Children in/or receiving Xxxxxx Care or adoption assistance; B. Blind/Disabled Children under age 19 and Related Populations eligible for SSI; C. Adults over the age of 65; D. Homeless (upon identification); E. Individuals with chronic physical health illnesses; F. Individuals with chronic behavioral health illnesses; G. Children receiving EPSDT Special Services. The Contractor shall develop and distribute to ISHCN Members caregivers, parents and/or legal guardians, information and materials specific to the needs of the member, as appropriate. This information shall include health educational material as appropriate to assist ISHCN and /or caregivers in understanding their chronic illness. The contractor shall have in place policies governing the mechanisms utilized to identify, screen and assess individuals with special health care needs. The Contractor will produce a treatment plan for enrollees with special health care needs who are determined through assessment to need a course of treatment or regular care monitoring. The Contractor shall develop practice guidelines and other criteria that consider that needs of ISHCN and provide guidance in the provision of acute and chronic physical and behavioral health care services to this population.
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Enrollees with Special Health Care Needs. Enrollees who face physical, behavioral or environmental challenges daily that place at risk their health and ability to fully function in society. This includes individuals with intellectual disabilities or related conditions; individuals with serious chronic illnesses, such as human immunodeficiency virus (HIV), schizophrenia or degenerative neurological disorders; individuals with disabilities resulting from many years of chronic illness such as arthritis, emphysema or diabetes; children/adolescents and adults with certain environmental risk factors such as homelessness or family problems that lead to the need for placement in xxxxxx care; and all enrollees in LTC Managed Care Plans.
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Enrollees with Special Health Care Needs. The Contractor shall implement mechanisms to comprehensively assess each enrollee identified as having special health care needs to identify any ongoing special conditions of the enrollee that require a course of treatment or regular care monitoring. The Contractor shall offer case management to all enrollees with SHCN regardless of information gathered through this comprehensive assessment, the HNA, or predictive modeling.
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Enrollees with Special Health Care Needs. Individuals of any age with a behavioral health disability, physical disability, developmental disability, or other circumstances that place their health and ability to fully function in society at risk, requiring individualized care approaches. Enrollees with Special Health Care Needs shall include any enrollees who:  have complex needs such as multiple chronic conditions, co-morbidities, and co-existing functional impairments;  are at high risk for admission/readmission to a hospital within the next six (6) months;  are at high risk of institutionalization;  have been diagnosed with a Serious Emotional Disturbance, a Severe and Persistent Mental Illness, or a Substance Use Disorder, or otherwise have significant behavioral health needs;  are homeless as defined in Section 330(h)(5)(A) of the Public Health Services Act and codified by the US Department of Health and Human Services in 42 U.S.C. 254(b);  are women with high-risk pregnancies;  have been recently incarcerated and are transitioning out of custody;  are at high risk of inpatient admission or Emergency Department visits, including certain enrollees transitioning care across acute hospital, chronic disease and rehabilitation hospital or nursing facility setting;  are members of the DOJ Agreement Target Population; or  receive care from other state agency programs, including but not limited to programs through OJJ, DCFS, or OPH.
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Enrollees with Special Health Care Needs. Enrollees who meet the following characteristics: Have complex or chronic medical needs requiring specialized health care services, including persons with multiple chronic conditions, co-morbidities, and/or co-existing functional impairments, and including persons with physical, mental/substance use, and/or developmental disabilities, such as persons with cognitive, intellectual, mobility, psychiatric, and/or sensory disabilities described below: Cognitive Disability – a condition that leads to disturbances in brain functions, such as memory, orientation, aware ness, perception, reasoning, and judgment. Many conditions can cause cognitive disabilities, including but not limited to Alzheimer’s disease, bipolar disorder, Xxxxxxxxx disease, traumatic injury, stroke, depression, alcoholism, and chronic fatigue syndrome. Intellectual Disability – is a disability characterized by significant limitations both in intellectual functioning and in adaptive behavior that affect many everyday social and practical skills. Mobility Disability - an impairment or condition that limits or makes difficult the major life activity of moving a person’s body or a portion of his or her body. “Mobility disability” includes, but is not limited to, orthopedic and neuro-motor disabilities and any other impairment or condition that limits an individual’s ability to walk, maneuver around objects, ascend or descend steps or slopes, and/or operate controls. An individual with a mobility disability may use a wheelchair or other assistive device for mobility or may be semi-ambulatory. Psychiatric Disability – a mental disorder that is a health condition characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning. Examples include, but are not limited to, depression, bipolar disorder, anxiety disorder, schizophrenia, and addiction. Sensory Disability - any condition that substantially affects hearing, speech, or vision. Are children/adolescents who have, or are at increased risk for, chronic physical, developmental, behavioral, or emotional conditions and who also require health and related services of a type and amount beyond that required by children generally; Are at high risk for admission/readmission to a 24-hour level of care within the next six months; Are at high risk of institutionalization; Have been diagnosed with a Serious Emotional Disturbance, a Severe and Persistent Mental Illness, or a substan...
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Related to Enrollees with Special Health Care Needs

  • HEALTH CARE PLANS ‌ Notwithstanding the references to the Pacific Blue Cross Plans in this article, the parties agree that Employers, who are not currently providing benefits under the Pacific Blue Cross Plans may continue to provide the benefits through another carrier providing that the overall level of benefits is comparable to the level of benefits under the Pacific Blue Cross Plans.

  • Extended Health Care Plan ‌ The Employer shall pay the monthly premium for regular employees entitled to coverage under a mutually acceptable extended health care plan.

  • Medicaid If and when the Resident’s assets/funds have fallen below the Medicaid eligibility levels, and the Resident otherwise satisfies the Medicaid eligibility requirements and is not entitled to any other third party coverage, the Resident may be eligible for Medicaid (often referred to as the “payor of last resort”). THE RESIDENT, RESIDENT REPRESENTATIVE AND SPONSOR AGREE TO NOTIFY THE FACILITY AT LEAST THREE (3) MONTHS PRIOR TO THE EXHAUSTION OF THE RESIDENT’S FUNDS (APPROXIMATELY $50,000) AND/OR INSURANCE COVERAGE TO CONFIRM THAT A MEDICAID APPLICATION HAS OR WILL BE SUBMITTED TIMELY AND ENSURE THAT ALL ELIGIBILITY REQUIREMENTS HAVE BEEN MET. THE RESIDENT, RESIDENT REPRESENTATIVE AND/OR SPONSOR AGREE TO PREPARE AND FILE AN APPLICATION FOR MEDICAID BENEFITS PRIOR TO THE

  • Medical Care Leave An Employee who is unable to make the necessary arrangements for maintenance of personal health care outside of scheduled work time, shall be granted time off with pay. Such time off shall not exceed sixteen (16) working hours per calendar year. Hours in excess of sixteen (16) hours per calendar year shall be deducted from the Employee's sick leave accumulation.

  • Medicare Parts A and B of the health care program for the aged and disabled provided by Title XVIII of the United States Social Security Act, as amended from time to time. [MEMBER]. An eligible person who is covered under this Contract (includes Covered Employee[ and covered Dependents, if any)].

  • Behavioral Health Services – Mental Health and Substance Use Disorder Inpatient - Unlimited days at a general hospital or a specialty hospital including detoxification or residential/rehabilitation per plan year. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Outpatient or intermediate careservices* - See Covered Healthcare Services: Behavioral Health Section for details about partial hospital program, intensive outpatient program, adult intensive services, and child and family intensive treatment. Preauthorization may be required for services received from a non-network provider. 0% - After deductible 40% - After deductible Office visits - See Office Visits section below for Behavioral Health services provided by a PCP or specialist. Psychological Testing 0% - After deductible 40% - After deductible Medication-assisted treatment - whenrenderedby a mental health or substance use disorder provider. 0% - After deductible 40% - After deductible Methadone maintenance treatment - one copayment per seven-day period of treatment. 0% - After deductible 40% - After deductible Outpatient - Benefit is limited to 18 weeks or 36 visits (whichever occurs first) per coveredepisode. 0% - After deductible 40% - After deductible In a physician's office - limited to 12 visits per plan year. 0% - After deductible 40% - After deductible Emergency room - When services are due to accidental injury to sound natural teeth. 0% - After deductible The level of coverage is the same as network provider. In a physician’s/dentist’s office - When services are due to accidental injury to sound natural teeth. 0% - After deductible 40% - After deductible Services connected to dental care when performed in an outpatient facility * 0% - After deductible 40% - After deductible Inpatient/outpatient/in your home 0% - After deductible 40% - After deductible (*) Preauthorization may be required for this service. Please see Preauthorization in Section 5 for more information. You Pay You Pay Outpatient durable medical equipment* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient medical supplies* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Outpatient diabetic supplies/equipment purchasedat licensed medical supply provider (other than a pharmacy). See the Summary of Pharmacy Benefits for supplies purchased at a pharmacy. 20% - After deductible 40% - After deductible Outpatient prosthesis* - Must be provided by a licensed medical supply provider. 20% - After deductible 40% - After deductible Enteral formula delivered through a feeding tube. Must be sole source of nutrition. 20% - After deductible 40% - After deductible Enteral formula or food taken orally * 20% - After deductible The level of coverage is the same as network provider. Hair prosthesis (wigs) - The benefit limit is $350 per hair prosthesis (wig) when worn for hair loss suffered as a result of cancer treatment. 20% - After deductible The level of coverage is the same as network provider. Coverage provided for members from birth to 36 months. The provider must be certified as an EIS provider by the Rhode Island Department of Human Services. 0% - After deductible The level of coverage is the same as network provider. Asthma management 0% - After deductible 40% - After deductible Hospital emergency room 0% - After deductible The level of coverage is the same as network provider.

  • Extended Health Care Benefits The City will provide for all employees by contract through an insurer selected by the City an Extended Health Care Plan which will provide extended health care benefits. The City shall pay one hundred per cent (100%) of the premiums, which will include any premiums payable under The Health Insurance Act, R.S.O. 1990, as amended.

  • Health Care Benefits A. Each regular, full-time employee may elect coverage for himself and his eligible dependents* under one of the following health insurance plans: 1. Blue Cross/Blue Shield of Michigan Flexible Blue 3 with Flexible Blue Rx Prescription Drug Coverage with a Health Savings Account (hereinafter collectively referred to as the “H.S.A Plan”). The Employer shall pay for the illustrated premium cost of this coverage and make an annual contribution to each participating employee’s Health Savings Account in the amount of $500 for those selecting single coverage and $1,000 for those selecting Employee & Spouse, Employee Child(ren) or Family coverage, or the maximum annual amount the Employer is permitted to pay under Section 3 of the Publicly Funded Health Insurance Contribution Act, Public Act 152 of the Michigan Public Acts of 2011, whichever results in the lesser Employer contribution to the cost of such plan. Employees may, at their option, make additional contributions through bi-weekly pre-tax payroll deduction as permitted by applicable law. 2. Blue Cross/Blue Shield of Michigan Community Blue PPO Option 3 Revised Plan with Blue Preferred Rx Prescription Drug Coverage with a 50% co-pay ($5 floor and a $50 ceiling). Employees shall pay the difference between the illustrated premium cost of this coverage and the amount of the Employer’s total contribution towards the cost of coverage under the H.S.A. Plan as described in Section 1 (a) (1), for the same level of benefit (i.e. single, employee/spouse, employee/child(ren) and family), or pay the difference between the total cost of such coverage and the maximum annual amount the Employer is permitted to pay under Section 3 of the Publicly Funded Health Insurance Contribution Act, Public Act 152 of the Michigan Public Acts of 2011, whichever results in the greater employee contribution. 3. Blue Cross/Blue Shield of Michigan Community Blue PPO Option 6 Revised Plan with Blue Preferred Rx Prescription Drug Coverage with a 50% co-pay ($5 floor and a $50 ceiling). Employees shall pay the difference between the illustrated premium cost of this coverage and the amount of the Employer’s total contribution towards the cost of coverage under the H.S.A. Plan as described in Section 1 (a) (1), for the same level of benefit (i.e. single, employee/spouse, employee/child(ren) and family), or pay the difference between the total cost of such coverage and the maximum annual amount the Employer is permitted to pay under Section 3 of the Publicly Funded Health Insurance Contribution Act, Public Act 152 of the Michigan Public Acts of 2011, whichever results in the greater employee contribution. (a) All coverage under any of the foregoing plans shall be subject to such terms, conditions, exclusions, limitations, deductibles, co-payments premium cost-sharing, and other provisions of the plans. Coverage shall commence on the employee’s ninetieth (90th) day of continuous employment. The employee’s contribution to the cost of such coverage shall be payable on a bi-weekly basis through automatic payroll deduction. (b) To qualify for health care benefits as above described each employee must individually enroll and make proper application for such benefits at the Human Resources Department upon the commencement of his regular employment with the Employer. (c) Except as otherwise provided under the Family and Medical Leave Act, when on an authorized unpaid leave of absence of more than two weeks, the employee will be responsible for paying all his benefit costs for the period he is not on the active payroll. Proper application and arrangements for the payment of such continued benefits must be made at the Human Resources Department prior to the commencement of the leave. If such application and arrangements are not made as herein described, the employee's health care benefits shall automatically terminate upon the effective date of the unpaid leave of absence. (d) Except as otherwise provided under this Agreement and/or under COBRA, an employee's health care benefits shall terminate on the date the employee goes on a leave of absence for more than two weeks, terminates, retires or is laid off. Upon return from a leave of absence or layoff, an employee's health care benefits coverage shall be reinstated commencing with the employee's return. (e) An employee who is on layoff or leave of absence for more than two weeks or who terminates may elect under COBRA to continue the coverage herein provided at his own expense. (f) The Employer reserves the right to change a carrier(s), a plan(s), and/or the manner in which it provides the above benefits, provided that the benefits and conditions are equal to or better than the benefits and conditions outlined above. (g) To be eligible for health care benefits as provided above, an employee must document all coverage available to him under his spouse's medical plan and cooperate in the coordination of coverage to limit the Employer's expense. If an employee’s spouse or eligible dependent children work for an employer who provides medical coverage, they are required to elect medical coverage with their employer, so long as the spouse’s or monthly contribution to the premium does not exceed 20% of the total premium cost of said coverage. The Monroe County Plan shall provide secondary coverage. (h) Each employee is responsible for notifying the Human Resources Department of any change in his status, which might affect his insurance coverage or benefits, such as, marriage, divorce, births, adoptions, deaths, etc.

  • Family Care and Medical Leave An unpaid Family Care and Medical Leave shall be granted, to the extent of and subject to the restrictions as set forth below, to an employee who has been employed for at least twelve (12) months and who has served for one hundred thirty days (130) workdays during the twelve (12) months immediately preceding the effective date of the leave. For purposes of this section, furlough days and days worked during off-basis time shall count as "workdays". Family Care and Medical Leave absences of twenty (20) consecutive working days or less can be granted by the immediate administrator or designee. Leaves of twenty (20) or more consecutive working days can be granted only by submission of a formal leave application to the Classified Personnel Assignments Branch.

  • Health Care Operations “Health Care Operations” shall have the same meaning as the term “health care operations” in 45 CFR §164.501.