Common use of Medically Frail Determination Clause in Contracts

Medically Frail Determination. The Contractor shall utilize the Milliman Medical Underwriting Guidelines (“Milliman Guidelines”) to determine a medically frail designation, a HIP member may be designated as medically frail at any time during the member’s twelve (12) month benefit period, provided such designation is supported by the Milliman Guidelines. In accordance with Section 7.2.3, the Contractor shall conduct an initial health needs screening of all new members within ninety (90) calendar days of a new member’s enrollment in the Contractor’s plan. The initial health needs screening shall be followed by a detailed comprehensive health assessment conducted by a health care professional in order to gather applicable information to compare against the Medical Underwriting Guidelines. The comprehensive health assessment may include a full review of important relevant clinical information such as the provider’s assessment of conditions and the severity of illness, treatment history and outcomes, other diseases, illnesses, and health conditions as well a review of the member’s available claims, including pharmacy claims. The Contractors shall apply the Milliman Guidelines to either the information obtained in the initial health needs screening and comprehensive health assessment, or the member’s claims history to generate debit points for the member. The member would qualify as medically frail based on the member’s qualifying conditions and related risk scores as follows: ▪ 150 debit points for indicated medical conditions; ▪ 150 debit points for combined indicated medical, behavioral health and substance abuse conditions; ▪ 75 debit points for indicated behavioral health conditions; ▪ 75 debit points for indicated substance abuse conditions; or ▪ Needs assistances with one of the activities of daily living. Either the member, provider or the Contractor may initiate a medically frail assessment during the member’s benefit period. The Contractor shall establish a process to allow members to self-identify as medically frail to the Contractor. If requested by the member, the Contractor shall conduct a medically frail assessment in accordance with this Section 3.3.2.2 within thirty (30) days of the member’s self-identification. If the results of applying the Milliman Guidelines supports a medically frail designation, the Contractor shall document and support the decision. Documentation may include, but is not limited to (i) output files from the Milliman Renewal MUGs tool indicating the number of debit points the member accumulated; (ii) completed comprehensive health assessment tool; (iii) documentation of attempts to make contact with their member and/or physician(s);

Medically Frail Determination. The Contractor shall utilize the Milliman Medical Underwriting Guidelines (“Milliman Guidelines”) to determine a medically frail designation, a HIP member may be designated as medically frail at any time during the member’s twelve (12) month benefit period, provided such designation is supported by the Milliman Guidelines. In accordance with Section 7.2.3, the Contractor shall conduct an initial health needs screening of all new members within ninety (90) calendar days of a new member’s enrollment in the Contractor’s plan. The initial health needs screening shall be followed by a detailed comprehensive health assessment conducted by a health care professional in order to gather applicable information to compare against the Medical Underwriting Guidelines. The comprehensive health assessment may include a full review of important relevant clinical information such as the provider’s assessment of conditions and the severity of illness, treatment history and outcomes, other diseases, illnesses, and health conditions as well a review of the member’s available claims, including pharmacy claims. The Contractors shall apply the Milliman Guidelines to either the information obtained in the initial health needs screening and comprehensive health assessment, or the member’s claims history to generate debit points for the member. The member would qualify as medically frail based on the member’s qualifying conditions and related risk scores as follows: ▪ 150 debit points for indicated medical conditions; ▪  150 debit points for combined indicated medical, behavioral health and substance abuse conditions; ▪  75 debit points for indicated behavioral health conditions; ▪  75 debit points for indicated substance abuse conditions; or ▪  Needs assistances with one of the activities of daily living. Either the member, provider or the Contractor may initiate a medically frail assessment during the member’s benefit period. The Contractor shall establish a process to allow members to self-identify as medically frail to the Contractor. If requested by the member, the Contractor shall conduct a medically frail assessment in accordance with this Section 3.3.2.2 within thirty (30) days of the member’s self-identification. If the results of applying the Milliman Guidelines supports a medically frail designation, the Contractor shall document and support the decision. Documentation may include, but is not limited to (i) output files from the Milliman Renewal MUGs tool indicating the number of debit points the member accumulated; (ii) completed comprehensive health assessment tool; (iii) documentation of attempts to make contact with their member and/or physician(s);

Medically Frail Determination. The Contractor shall utilize the Milliman Medical Underwriting Guidelines (“Milliman Guidelines”) to determine a medically frail designation, a HIP member may be designated as medically frail at any time during the member’s twelve (12) month benefit period, provided such designation is supported by the Milliman Guidelines. In accordance with Section 7.2.3, the Contractor shall conduct an initial health needs screening of all new members within ninety (90) calendar days of a new member’s enrollment in the Contractor’s plan. The initial health needs screening shall be followed by a detailed comprehensive health assessment conducted by a health care professional in order to gather applicable information to compare against the Medical Underwriting Guidelines. The comprehensive health assessment may include a full review of important relevant clinical information such as the provider’s assessment of conditions and the severity of illness, treatment history and outcomes, other diseases, illnesses, and health conditions as well a review of the member’s available claims, including pharmacy claims. The Contractors shall apply the Milliman Guidelines to either the information obtained in the initial health needs screening and comprehensive health assessment, or the member’s claims history to generate debit points for the member. The member would qualify as medically frail based on the member’s qualifying conditions and related risk scores as follows: ▪  150 debit points for indicated medical conditions; ▪  150 debit points for combined indicated medical, behavioral health and substance abuse conditions; ▪  75 debit points for indicated behavioral health conditions; ▪  75 debit points for indicated substance abuse conditions; or ▪  Needs assistances with one of the activities of daily living. Either the member, provider or the Contractor may initiate a medically frail assessment during the member’s benefit period. The Contractor shall establish a process to allow members to self-identify as medically frail to the Contractor. If requested by the member, the Contractor shall conduct a medically frail assessment in accordance with this Section 3.3.2.2 within thirty (30) days of the member’s self-identification. If the results of applying the Milliman Guidelines supports a medically frail designation, the Contractor shall document and support the decision. Documentation may include, but is not limited to (i) output files from the Milliman Renewal MUGs tool indicating the number of debit points the member accumulated; (ii) completed comprehensive health assessment tool; (iii) documentation of attempts to make contact with their member and/or physician(s);Section

Medically Frail Determination. The Contractor shall utilize the Milliman Medical Underwriting Guidelines (“Milliman Guidelines”) to determine a medically frail designation, a HIP member may be designated as medically frail at any time during the member’s twelve (12) month benefit period, provided such designation is supported by the Milliman Guidelines. In accordance with Section 7.2.3, the Contractor shall conduct an initial health needs screening of all new members within ninety (90) calendar days of a new member’s enrollment in the Contractor’s plan. The initial health needs screening shall be followed by a detailed comprehensive health assessment conducted by a health care professional in order to gather applicable information to compare against the Medical Underwriting Guidelines. The comprehensive health assessment may include a full review of important relevant clinical information such as the provider’s assessment of conditions and the severity of illness, treatment history and outcomes, other diseases, illnesses, and health conditions as well a review of the member’s available claims, including pharmacy claims. The Contractors shall apply the Milliman Guidelines to either the information obtained in the initial health needs screening and comprehensive health assessment, or the member’s claims history to generate debit points for the member. The member would qualify as medically frail based on the member’s qualifying conditions and related risk scores as follows: ▪  150 debit points for indicated medical conditions; ▪  150 debit points for combined indicated medical, behavioral health and substance abuse conditions; ▪  75 debit points for indicated behavioral health conditions; ▪  75 debit points for indicated substance abuse conditions; or ▪  Needs assistances with one of the activities of daily living. Either the member, provider or the Contractor may initiate a medically frail assessment during the member’s benefit period. The Contractor shall establish a process to allow members to self-identify as medically frail to the Contractor. If requested by the member, the Contractor shall conduct a medically frail assessment in accordance with this Section 3.3.2.2 within thirty (30) days of the member’s self-identification. If the results of applying the Milliman Guidelines supports a medically frail designation, the Contractor shall document and support the decision. Documentation may include, but is not limited to (i) output files from the Milliman Renewal MUGs tool indicating the number of debit points the member accumulated; (ii) completed comprehensive health assessment tool; (iii) documentation of attempts to make contact with their member and/or physician(s);; (iv) recorded responses and supporting information indicating member impairment in Activities of Daily Living (ADLs); (v) supplemental information gathered by the Contractor in order to make a complete decision (such as lab results, physician notes or lifestyle factors). The Contractor shall notify the State’s fiscal agent in the manner and timeframe determined by the State and established in the HIP MCE Policies and Procedures Manual when a HIP member or HIP lockout applicant (as described in Section 4.7.1.2) is determined medically frail by the Contractor. Upon receipt of the medically frail confirmation, the State will transfer the member to HIP State Plan benefits effective the first day of the month following receipt of the medically frail confirmation. If, following a medical frail assessment, the results of the claims history and/or pharmacy data review do not support a medically frail designation, the Contractor shall inform the member that they will remain in their current HIP benefit plan. The Contractor is responsible for notifying the member of the ultimate medically frail designation decision, any changes to the member’s benefits, as well as the member’s right to appeal in accordance with Section 7.9.

Medically Frail Determination. The Contractor shall utilize the Milliman Medical Underwriting Guidelines (“Milliman Guidelines”) to determine a medically frail designation, a HIP member may be designated as medically frail at any time during the member’s twelve (12) month benefit period, provided such designation is supported by the Milliman Guidelines. In accordance with Section 7.2.3, the Contractor shall conduct an initial health needs screening of all new members within ninety (90) calendar days of a new member’s enrollment in the Contractor’s plan. The initial health needs screening shall be followed by a detailed comprehensive health assessment conducted by a health care professional in order to gather applicable information to compare against the Medical Underwriting Guidelines. The comprehensive health assessment may include a full review of important relevant clinical information such as the provider’s assessment of conditions and the severity of illness, treatment history and outcomes, other diseases, illnesses, and health conditions as well a review of the member’s available claims, including pharmacy claims. The Contractors shall apply the Milliman Guidelines to either the information obtained in the initial health needs screening and comprehensive health assessment, or the member’s claims history to generate debit points for the member. The member would qualify as medically frail based on the member’s qualifying conditions and related risk scores as follows: ▪ 150 debit points for indicated medical conditions; ▪ 150 debit points for combined indicated medical, behavioral health and substance abuse conditions; ▪ 75 debit points for indicated behavioral health conditions; ▪ 75 debit points for indicated substance abuse conditions; or ▪ Needs assistances with one of the activities of daily living. Either the member, provider or the Contractor may initiate a medically frail assessment during the member’s benefit period. The Contractor shall establish a process to allow members to self-identify as medically frail to the Contractor. If requested by the member, the Contractor shall conduct a medically frail assessment in accordance with this Section 3.3.2.2 within thirty (30) days of the member’s self-identification. If the results of applying the Milliman Guidelines supports a medically frail designation, the Contractor shall document and support the decision. Documentation may include, but is not limited to (i) output files from the Milliman Renewal MUGs tool indicating the number of debit points the member accumulated; (ii) completed comprehensive health assessment tool; (iii) documentation of attempts to make contact with their member and/or physician(s);

Medically Frail Determination. The Contractor shall utilize the Milliman Medical Underwriting Guidelines (“Milliman Guidelines”) to determine a medically frail designation, a HIP member may be designated as medically frail at any time during the member’s twelve (12) month benefit period, provided such designation is supported by the Milliman Guidelines. In accordance with Section 7.2.3, the Contractor shall conduct an initial health needs screening of all new members within ninety (90) calendar days of a new member’s enrollment in the Contractor’s plan. The initial health needs screening shall be followed by a detailed comprehensive health assessment conducted by a health care professional in order to gather applicable information to compare against the Medical Underwriting Guidelines. The comprehensive health assessment may include a full review of important relevant clinical information such as the provider’s assessment of conditions and the severity of illness, treatment history and outcomes, other diseases, illnesses, and health conditions as well a review of the member’s available claims, including pharmacy claims. The Contractors shall apply the Milliman Guidelines to either the information obtained in the initial health needs screening and comprehensive health assessment, or the member’s claims history to generate debit points for the member. The member would qualify as medically frail based on the member’s qualifying conditions and related risk scores as follows: ▪  150 debit points for indicated medical conditions; ▪  150 debit points for combined indicated medical, behavioral health and substance abuse conditions; ▪  75 debit points for indicated behavioral health conditions; ▪  75 debit points for indicated substance abuse conditions; or ▪  Needs assistances with one of the activities of daily living. Either the member, provider or the Contractor may initiate a medically frail assessment during the member’s benefit period. The Contractor shall establish a process to allow members to self-identify as medically frail to the Contractor. If requested by the member, the Contractor shall conduct a medically frail assessment in accordance with this Section 3.3.2.2 within thirty (30) days of the member’s self-identification. If the results of applying the Milliman Guidelines supports a medically frail designation, the Contractor shall document and support the decision. Documentation may include, but is not limited to (i) output files from the Milliman Renewal MUGs tool indicating the number of debit points the member accumulated; (ii) completed comprehensive health assessment tool; (iii) documentation of attempts to make contact with their member and/or physician(s);; (iv) recorded responses and supporting information indicating member impairment in Activities of Daily Living (ADLs); (v) supplemental information gathered by the Contractor in order to make a complete decision (such as lab results, physician notes or lifestyle factors). The Contractor shall notify the State’s fiscal agent in the manner and timeframe determined by the State and established in the HIP MCE Policies and Procedures Manual when a HIP member or HIP lockout applicant (as described in Section 4.7.1.2) is determined medically frail by the Contractor. Upon receipt of the medically frail confirmation, the State will transfer the member to HIP State Plan benefits effective the first day of the month following receipt of the medically frail confirmation. If, following a medical frail assessment, the results of the claims history and/or pharmacy data review do not support a medically frail designation, the Contractor shall inform the member that they will remain in their current HIP benefit plan. The Contractor is responsible for notifying the member of the ultimate medically frail designation decision, any changes to the member’s benefits, as well as the member’s right to appeal in accordance with Section 7.9.

Medically Frail Determination. The Contractor shall utilize the Milliman Medical Underwriting Guidelines (“Milliman Guidelines”) to determine a medically frail designation, a HIP member may be designated as medically frail at any time during the member’s twelve (12) month benefit period, provided such designation is supported by the Milliman Guidelines. In accordance with Section 7.2.3, the Contractor shall conduct an initial health needs screening of all new members within ninety (90) calendar days of a new member’s enrollment in the Contractor’s plan. The initial health needs screening shall be followed by a detailed comprehensive health assessment conducted by a health care professional in order to gather applicable information to compare against the Medical Underwriting Guidelines. The comprehensive health assessment may include a full review of important relevant clinical information such as the provider’s assessment of conditions and the severity of illness, treatment history and outcomes, other diseases, illnesses, and health conditions as well a review of the member’s available claims, including pharmacy claims. The Contractors shall apply the Milliman Guidelines to either the information obtained in the initial health needs screening and comprehensive health assessment, or the member’s claims history to generate debit points for the member. The member would qualify as medically frail based on the member’s qualifying conditions and related risk scores as follows: ▪ 150 debit points for indicated medical conditions; ▪ 150 debit points for combined indicated medical, behavioral health and substance abuse conditions; ▪ 75 debit points for indicated behavioral health conditions; ▪ 75 debit points for indicated substance abuse conditions; or ▪ Needs assistances with one of the activities of daily living. Either the member, provider or the Contractor may initiate a medically frail assessment during the member’s benefit period. The Contractor shall establish a process to allow members to self-identify as medically frail to the Contractor. If requested by the member, the Contractor shall conduct a medically frail assessment in accordance with this Section 3.3.2.2 within thirty (30) days of the member’s self-identification. If the results of applying the Milliman Guidelines supports a medically frail designation, the Contractor shall document and support the decision. Documentation may include, but is not limited to (i) output files from the Milliman Renewal MUGs tool indicating the number of debit points the member accumulated; (ii) completed comprehensive health assessment tool; (iii) documentation of attempts to make contact with their member and/or physician(s);Section