Common use of Individuals with Special Health Care Needs Clause in Contracts

Individuals with Special Health Care Needs. The plan shall implement mechanisms for identifying, assessing and ensuring the existence of an Individualized Treatment Plan for individuals with special health care needs as defined in Section I, Definitions and Acronyms. Mechanisms shall include evaluation of risk assessments, claims data, and CPT/ICD-9 codes. Additionally, the plan shall implement a process for receiving and considering provider and enrollee input. In accordance with this contract and 42 CFR 438.208(c)(3), an Individualized Treatment Plan for an enrollee determined to need a course of treatment or regular care monitoring must be: · Developed by the enrollee's direct service mental health care professional with enrollee participation and in consultation with any specialists caring for the enrollee; · Approved by the plan in a timely manner if this approval is required; and · Developed in accordance with any applicable Agency quality assurance and utilization review standards. Pursuant to 42 CFR 438.208(c)(4), for Enrollees with special health care needs determined through an assessment by appropriate mental health care professionals (consistent with 42 CFR 438.208(c)(2)) to need a course of treatment or regular care monitoring, the plan must have a mechanism in place to allow Enrollees to directly access a mental health care specialist (for example, through a standing referral or an approved number of visits) as appropriate for the Enrollee's condition and identified needs.

Individuals with Special Health Care Needs. 1. The plan Health Plan shall implement mechanisms for identifying, assessing and ensuring the existence of an Individualized Treatment Plan individualized treatment plan for individuals with special health care needs needs, as defined in Attachment II, Section I, Definitions and Acronyms. Mechanisms shall include evaluation of risk assessments, claims data, and CPT/ICD-9 codes. Additionally, the plan Health Plan shall implement a process for receiving and considering provider and enrollee input. 2. In accordance with this contract Contract and 42 CFR 438.208(c)(3), an Individualized Treatment Plan individualized treatment plan for an enrollee determined to need a course of treatment or regular care monitoring must be: · : (a) Developed by the enrollee's direct service mental health care professional with enrollee participation and in consultation with any specialists caring for the enrollee; · ; (b) Approved by the plan Health Plan in a timely manner if this approval is required; and · and (c) Developed in accordance with any applicable Agency quality assurance and utilization review standards. 3. Pursuant to 42 CFR 438.208(c)(4), for Enrollees enrollees with special health care needs determined through an assessment by appropriate mental health care professionals (consistent with 42 CFR 438.208(c)(2)) to need a course of treatment or regular care monitoring, the plan must Health Plan shall have a mechanism in place to allow Enrollees enrollees to directly access a mental health care specialist (for example, through a standing referral or an approved number of visits) as appropriate for the Enrolleeenrollee's condition and identified needs.