Members with Special Health Care Needs. The MCO must have plans for provision of care for the special needs populations and for provision of medically necessary, specialty care through direct access to specialists. The Hoosier Healthwise managed care program uses the definition and reference for children with special health care needs as adopted by the Maternal and Child Health Bureau (MCHB) and published by the American Academy of Pediatrics (AAP): “Children with special health care needs are those who have or are at increased risk for a chronic physical, developmental, behavioral, or emotional condition and who also require health and related services of a type or amount beyond that required by children generally.” In accordance with 42 CFR 438.208(c), the State’s enrollment broker conducts a Health Needs Assessment (HNA) screening to identify members with potential special health care needs. The HNA screening tool assigns children to one of the Living With Illness Measures (LWIM) screener health domains based on the National Committee on Quality Assurance study design. The scoring for the LWIM screener identifies a child as potentially having a special health care need in one of seven different health domains: • Functional limitations only • Dependency on devices only • Service use or need only • Functional limitations and a dependency on devices • Functional limitations and a service use or need • Dependency on devices and a service use or need • Functional limitations, a dependency on devices and a service use or need The MCO will receive the HNA screening results for subsequent assessment by an MCO health care professional and to facilitate care coordination. However, not all Hoosier Healthwise enrollees complete the HNA screening tool and individuals can complete the HNA screening tool with or without the assistance of the enrollment broker. The State requires the MCO to conduct a HNA screening for its members who have not received the HNA screening at the time of enrollment. In accordance with 42 CFR 438.208(c)(2), the MCO must have a health care professional assess the member when the HNA screening identifies the member as potentially having a special health care need. When the assessment confirms the special health care need, the MCO must coordinate the member’s health care services with the member’s PMP’s plan of care. The MCO must offer continued coordinated care services to any special health care needs members transferring into the MCO’s membership from another plan. For example, M...
Members with Special Health Care Needs. (MSHCN) Given the substantial proportion of members with chronic conditions and co-morbidities in the ABD population, one of the quality of care initiatives of the ABD Medicaid managed care program focuses on case management. In order to ensure state compliance with the provisions of 42 CFR 438.208, the Bureau of Managed Health Care established Members with Special Health Care Needs (MSHCN) basic program requirements as set forth in Appendix G, Coverage and Services of the Agreement, and corresponding minimum performance standards as described below. The purpose of these measures is to provide appropriate and targeted case management services to MSHCN who have specific diagnoses and/or who require high-cost or extensive services. Given the expedited schedule for implementing the ABD Medicaid managed care program, coupled with the challenges facing a new Medicaid program in the State of Ohio, the minimum performance standards for the case management requirements for MSHCN are phased in throughout SFY 2007 and SFY 2008. The minimum standards for these performance measures will be fully phased in by no later than SFY 2009. For detailed methodologies of each measure, see ODJFS Methods for the ABD Medicaid Managed Care Program’s Case Management Performance Measures.
Members with Special Health Care Needs
